Charlson Comorbidity Research Articles

Abstract P2-11-09: Comparing the effects of various beta blockers on cardiovascular-related mortality in breast cancer patients

Abstract Background: Breast cancer mortality has decreased along with advances in diagnosis and treatments. However, cardiovascular (CV) disease-related mortality is a growing concern in this population. Increased risk of CV diseases is primarily contributed by chemotherapy such as anthracyclines, anti-HER2 drugs like trastuzumab, and radiotherapy in breast cancer patients in addition to increased age. While beta blockers have been investigated to manage CV complications associated with these breast cancer treatments in general, various beta blockers have not been compared for their effects on death due to CV events. The aim of this study was to compare the effects of commonly used beta-blockers (metoprolol, carvedilol and atenolol) on CV-related mortality among older patients with breast cancer. Methods: A retrospective cohort study was conducted using the multi-year Surveillance, Epidemiology, and End Results-Medicare data (2009 to 2015). Patients diagnosed with breast cancer as the 1st or only cancer were included in this study and the date of diagnosis was the index date. The primary exposure was receipt of beta blocker monotherapy (metoprolol, carvedilol and atenolol) for at least 6 months prior to the index date. CV-related mortality was the outcome and was defined as death due to diseases of the heart. Patients were followed from the index date until the outcome or were censored at: the date of death due to breast cancer, death due to other reasons, discontinuation of the index beta-blocker, switching or addition of other beta-blockers, or end of the study period (December 31st 2015), whichever occurred first. Demographic and clinical covariates were identified using the Andersen Behavioral Model conceptual framework. Descriptive statistics were used to assess the difference in covariates between the three exposure groups. The competing risk regression model, adjusted for potential confounding variables, was used to study the association between the beta-blockers and the risk of CV-related mortality. Results: The study cohort included 6,540 patients of which 3,622 (55.4%) were metoprolol users, 989 (15.1%) carvedilol users, and 1,929 (29.5%) atenolol users. The mean age was 77.9 years for metoprolol users, 78.7 years for carvedilol users, and 76.8 years for atenolol users. A majority of the patients were White (86.8%), of Non- Hispanic or Latino ethnicity (95.1%), female (99.2%), diagnosed at stage 1 breast cancer (41.8%), of HR+/HER2- breast cancer subtype (62.8%), had between 1 to 3 Charlson comorbidities (50.6%), and did not have any other cancer after the incident diagnosis (87.8%). There were 36 (1.9%) atenolol users, 40 (4.0%) carvedilol users, and 70 (1.9%) metoprolol users with the outcome. The median time to outcome was 528 days in metoprolol users, 356 days in carvedilol users, and 411 days in atenolol users. In the adjusted model, older patients, and those with more than 3 Charlson comorbidities had a higher risk of CV-related mortality. Metoprolol was associated with a 38% (adjusted hazard ratio (aHR): 0.63, 95% CI: 0.41 to 0.96, p=0.03) reduced risk of CV-related mortality compared to carvedilol users after adjusting for the covariates. There was no significant difference in the risk of CV-related mortality between atenolol and carvedilol users. Conclusion: In older patients with breast cancer, metoprolol was associated with a reduced risk of CV-related mortality compared to carvedilol. Future prospective studies are needed to confirm these findings. Citation Format: Noor M Abdulkareem, Soumya G Chikermane, Suma Gopinathan, Michael L Johnson, Meghana V Trivedi. Comparing the effects of various beta blockers on cardiovascular-related mortality in breast cancer patients [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-11-09.

Depression in psoriatic arthritis: Related to socio-demographics, comorbid loads or disease activity?

Psychological distress commonly occurs in patients with psoriatic arthritis (PsA). The primary objective of this study was to determine the prevalence of depression in PsA. The secondary objective was to explore its associated factors, including socio-demographics, disease activity data and comorbidities. Patients with PsA fulfilling the Classification Criteria for Psoriatic Arthritis were consecutively recruited from local rheumatology clinics. Depression was assessed by a self-administered Chinese-Cantonese version of the Hospital Anxiety and Depression Scale (HADS). Two hundred and eight eligible patients with PsA were recruited, with 82 females and 126 males. Depression was found in 62 (29.8%) of them. The univariate model identified these associated factors: (1) Psoriasis Area and Severity Index score; (2) disease activity measurement, that is tender and swollen joint count, erythrocyte sedimentation rate, C-reactive protein, Disease Activity in Psoriatic Arthritis (DAPSA) score, Leeds Enthesitis Index and tender dactylitis count; (3) quality of life measurement, that is Health Assessment Questionnaire - Disability Index (HAQ-DI), pain and general health perception; (4) PsA duration; and (5) body mass index. The final regression model identified DAPSA and HAQ-DI were closely associated with depression, P=.007 and P=.02 respectively. Moderate and strong correlations with HADS score were found with DAPSA (Kendall's tau-b coefficient [τb]=0.25) and HAQ-DI (τb=0.4) respectively. No associations with depression were found between age, living and employment status, gender, demographics, inflammatory markers, disease duration, skin involvement and comorbidities, in term of Charlson's Comorbidity Index. Depression was prevalent among PsA patients and it was closely correlated with disease activity and physical function impairment. Achieving low disease activity and maintaining physical function in patients with PsA may mitigate the psychological burden. The present study also highlighted the unmet needs of strategies to identify this common phenomenon.

Surgeon and Facility Volumes Are Associated With Social Disparities and Post-Operative Complications After Total Hip Arthroplasty

BackgroundThe purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA). MethodsAdults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research. ResultsIn total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities. ConclusionBoth low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.

Should total omentectomy be performed for advanced gastric cancer?: The role of omentectomy during laparoscopic gastrectomy for advanced gastric cancer.

In the era of minimally invasive surgery, laparoscopic partial omentectomy (LPO) has seen widespread use as a curative surgical procedure for early gastric cancer. However, scientific evidence of the extent of omentectomy during laparoscopic gastrectomy remains unclear for advanced gastric cancer (AGC). We analyzed 666 eligible patients who underwent laparoscopic gastrectomy for AGC with curative intent between 2014 and 2018. Surgical outcome and postoperative prognosis were compared between LPO and laparoscopic total omentectomy (LTO) groups after 2:1 propensity score matching with age, sex, body mass index, tumor size, pT stage, pN stage, gastrectomy type, and clinical T stage as covariates. After extensive matching, there was no significant difference in pathologic or clinical stages between the LPO (n = 254) and LTO (n = 177) groups. LPO provided a significantly shorter operation time than LTO (199.2 ± 64.8 vs. 248.1 ± 68.3min, P < 0.001). Pulmonary complication within postoperative 30days was significantly lower in the LPO group (4.4 vs. 10.3%, P = 0.018). In multivariate analysis, LTO was the independent risk factor for pulmonary complication (odds ratio [OR] 2.53, 95% confidence interval [95% CI] 1.12-5.73, P = 0.025), which became more obvious in patients with a Charlson's comorbidity index of 4 or higher (OR 27.43, 95% CI 1.35-558.34, P = 0.031). The 5-year overall survival rate (OS) and 3-year recurrence-free survival (RFS) rates were not significantly different between the two groups, even after stage stratification. LPO provided significantly shorter operation time and less pulmonary complication than LTO without compromising 5-year OS and 3-year RFS for AGC. LTO was the independent risk factor for pulmonary complications, which became more evident in patients with severe comorbidities.

Relation between drug therapy-based comorbidity indices, Charlson's comorbidity index, polypharmacy and mortality in three samples of older adults

BackgroundComorbidity indexes were designed in order to measure how the disease burden of a patient is related to different clinical outcomes such as mortality, especially in older and intensively treated people. Charlson's Comorbidity Index (CCI) is the most widely used rating system, based on diagnoses, but when this information is not available therapy-based comorbidity indices (TBCI) are an alternative: among them, Drug Derived Complexity Index (DDCI), Medicines Comorbidity Index (MCI), and Chronic Disease Score (CDS) are available. AimsThis study assessed the predictive power for 1-year mortality of these comorbidity indices and polypharmacy. MethodsSurvival analysis and Receiver Operating Characteristic (ROC) analysis were conducted on three Italian cohorts: 2,389 nursing home residents (Korian), 4,765 and 633 older adults admitted acutely to geriatric or internal medicine wards (REPOSI and ELICADHE). ResultsCox's regression indicated that the highest levels of the CCI are associated with an increment of 1-year mortality risk as compared to null score for all the three samples. DDCI and excessive polypharmacy gave similar results but MCI and CDS were not always statistically significant. The predictive power with the ROC curve of each comorbidity index was poor and similar in all settings. ConclusionOn the whole, comorbidity indices did not perform well in our three settings, although the highest level of each index was associated with higher mortality.

Transesophageal echocardiography and risk of respiratory failure in patients who had ischemic stroke or transient ischemic attack: an IDEAL phase 4 study

ObjectiveTransesophageal echocardiography (TEE) is sometimes used to search for cardioembolic sources after ischemic stroke or transient ischemic attack (TIA). TEE visualizes some sources better than transthoracic echocardiography, but TEE is...

Plasma 5-HIAA activity indicative of serotonergic disturbances in cognitively impaired, elderly patients experiencing postoperative delirium.

ObjectivesDelirium frequently arises in older demented and non‐demented patients in postoperative, clinical settings. To date, the underlying pathophysiological mechanisms remain poorly understood. Monoamine neurotransmitter alterations have been linked to delirium and cognitive impairment. Our aim was to investigate if this holds true in cognitively normal and impaired patients experiencing delirium following hip surgery.MethodsMonoamines and metabolites were measured in plasma samples of 181 individuals by means of reversed‐phase ultra‐high‐performance liquid chromatography with electrochemical detection. Delirium and delirium severity were scored with the Confusion Assessment Method and Delirium Rating Scale‐Revised‐1998. Cognitive function was assessed using the Informant Questionnaire on Cognitive Decline and the Mini‐Mental State Examination, multimorbidity with the Charlson Comorbidity Index.ResultsPlasma 5‐hydroxyindoleacetic acid (5‐HIAA), the major metabolite of serotonin (5‐HT), was significantly higher in delirious and non‐delirious cognitively impaired subjects as compared to control individuals without delirium and cognitive impairment (p < 0.001 and p = 0.007), which remained highly significant after excluding patients taking psychotropic medication (p < 0.0001 and p = 0.003). No significant differences were found for cognitively normal delirious patients, although serotonergic levels were numerically higher compared to control counterparts.ConclusionsOur findings indicate a general serotonergic disturbance in delirious and non‐delirious postoperative patients suffering from cognitive impairment. We observed a similar, but less pronounced difference in delirious patients, which suggests serotonergic disturbances may be further aggravated by the co‐occurrence of delirium and cognitive impairment.

Reconstruction of post-resection chest wall defects in surgical treatment of invasive non-small cell lung cancer

To present the results of reconstruction of post-resection chest wall defects with nickel-titanium (TiNi) implants in patients with invasive NSCLC and to analyze the features of perioperative management. We enrolled 9 patients with NSCLC involving the ribs after lobectomy or pneumonectomy with chest wall reconstruction. Defects were closed used TiNi mesh and rib prostheses. We selected the shape and dimensions of artificial ribs individually before surgery according to CT data and 3D models of reinforcing elements. There were male smokers aged 64.6±4.6 years among patients (range 58-73). T3N0M0 was diagnosed in 6 patients, T3N1M0 - 2, T3N2M0 - 1. Squamous cell carcinoma was verified in 4 (44.4%) patients, adenocarcinoma - in 5 (55.6%) patients. All patients had comorbidities. Mean Charlson's comorbidity index was 6.56±4.6. Dimension of chest wall defect varied from 78 to 100 cm2. Postoperative period was uneventful without signs of respiratory failure. There were no lethal outcomes. Complications occurred in 33.3% of patients (prolonged air discharge through the drains, pleuritis and atrial fibrillation). Surgical treatment of NSCLC spreading to the chest wall is a complex task requiring further improvement. Bioadaptive TiNi implants are a promising reinforcing material that allows successful reconstruction of post-resection chest wall defects with good anatomical, functional and cosmetic results. «Sandwich» technology is advisable for extensive defects. This approach includes 2 layers of knitted mesh and rib prostheses between these layers.

Abstract PO-191: Contributions of tumor characteristics, treatment, and access to care factors on racial disparities in endometrial cancer survival

Abstract Background: Among women with endometrial cancer (EC), well-established mortality disparities between White and Black women have continued to widen over time. Hispanic, American Indian/Alaska Native (AI/AN) women, and women broadly categorized as Asian or Pacific Islander have not been the focus of many prior studies of racial disparities in EC survival. We examined racial disparities in survival and assessed the contributions of demographic, tumor, treatment, access to care, and health status factors on racial disparities in survival among women with EC. Methods: Participants were diagnosed between 2004 and 2015 with stages 1A through 4B, endometroid and non-endometroid EC in the National Cancer Database (NCDB). Race was categorized as non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, Asian, Native-Hawaiian/Pacific Islander (NH/PI), and AI/AN. We used a series of Cox regression models to estimate the relative contribution of prognostic factors to excess risk of mortality. We examined the following classes of prognostic factors: age at diagnosis, tumor characteristics (stage and histology), guideline-concordant treatment, access to care (insurance status, facility type, treatment delay), and Charlson comorbidity. Each class of factors was added individually to a baseline race-only model, and we estimated the percentage contribution of each class on changes in the hazard ratio (HR) for race using the equation: (HR0 – HRn)/(HR0 – 1), in which HR0 is from the race-only model and HRn is the HR for race categories from the model with the variables of interest. Asian women comprised the reference category in all models as mortality was lowest in this group. Changes in HRs are described as percentages. Results: Our study population included 208,112 women with EC. In the race-only model, overall HRs relative to Asians were 2.49 (95% CI, 2.32-2.67), 1.41 (95% CI, 1.18-1.69), 1.29 (95% CI, 1.20-1.38), 1.18 (95% CI, 0.97-1.43), and 1.09 (95% CI, 1.01-1.18) for NHB, NH/PI, NHW, AI/AN, and Hispanic women, respectively. Age at diagnosis was the most influential variable among NHW and NH/PI women, describing 93.1% and 75.6% of the survival disparity, respectively. Tumor characteristics were the most influential contributor for NHB women (40.9%), while among Hispanic and AI/AN women, access to care (77.8%) and comorbidities (50%) were responsible for the largest attenuation in HRs, respectively. Guideline-concordant treatment was linked with a small attenuation in HRs among NHB (2.7%), NHW (3.4%), and NH/PI (7.3%). Conclusions: Contributors to racial disparities in EC survival vary by race/ethnicity. Some factors, like age, are non-modifiable and represent poor intervention targets. Conversely, other factors, like high stage, comorbidities, and low access to care, are challenging but modifiable problems that implicate the larger societal context. Our preliminary findings suggest that interventions for reducing EC survival disparities will require a tailored approach for the particular group of women for whom we are trying to intervene. Citation Format: Jordyn A. Brown, Jennifer A. Sinnott, Kemi M. Doll, Macarius M. Donneyong, Tasleem J. Padamsee, Elyse Llamocca, David E. Cohn, Casey Cosgrove, Ashley S. Felix. Contributions of tumor characteristics, treatment, and access to care factors on racial disparities in endometrial cancer survival [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-191.

A Novel Nomogram for Early Identification and Intervention in Colorectal Cancer Patients at Risk for Malnutrition.

Malnutrition is under-recognized in cancer patients and can lead to poor treatment outcomes. We aim to develop an outpatient-focused score based on the Malnutrition Screening Tool (MST) to help identify colorectal cancer (CRC) profiles at high risk for malnutrition. 506 CRC patients during initial outpatient oncology consultation at our tertiary referral outpatient oncology clinic completed the MST. Objective and subjective data were collected through chart review. Data gathered are as follows: demographics, anthropometrics, laboratory values, patient-reported symptoms, MST score, cancer history, performance status, socioeconomic status, and Charlson Comorbidity. Predictors of malnutrition were identified by logistic regression. Receiver operating curve (ROC), area under the curve (AUC), and our model's predictability were determined. Significant predictors of malnutrition are as follows: younger age (20-39 vs >40 years) (P = .007), normal-to-low body mass index at presentation (P = .019), Eastern Cooperative Oncology Group classification 2-3 (P = .012), metastatic disease (P = .046), albumin <3.0g/dL (P = .033), fatigue (P < .001), and change in stool/bowel habits (P = .002). In our derived malnutrition score, risk of malnutrition increased from 11% for score 0, to 100% for scores 9-10. Receiver operating curve showed AUC .745 (95% CI, .697-.793). An outpatient clinic-derived malnutrition score obtained from objective and patient-reported variables may facilitate identification of CRC patients at highest risk for malnutrition. Rapid identification and intervention in high-risk patients may improve treatment recovery, therapy tolerance, and quality of life. Our tool requires external validation before application in clinical practice.

Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores.

Objective This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design This study is a retrospective review. Setting This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien-Dindo grade IV (CDIV) criteria, and mortality. Results Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI ( p = 0.01, R 2 = 0.97) and ASA ( p = 0.04., R 2 = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality ( p = 0.03, R 2 = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35-6.83, p < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.

Prognostic Value of the Three-Dimensional Right Ventricular Ejection Fraction in Patients With Asymptomatic Aortic Stenosis.

Background: The right ventricular (RV) function is an important prognostic marker of asymptomatic aortic stenosis (AS). However, previous publications have not addressed the additive value of conventional RV parameters over left heart parameters. Whether three-dimensional echocardiography (3DE)-derived RV ejection fraction (RVEF) has prognostic utility independent of 3DE derived left heart parameters is also unknown. We investigated the prognostic utility of 3DE RVEF in patients with asymptomatic AS.Methods: We retrospectively selected 392 asymptomatic AS patients. RVEF, left ventricular ejection fraction (LVEF) and left atrial volumes (LAVs) were measured using 3DE datasets. We determined the association of those parameters, as well as of aortic valve replacement (AVR), and Charlson's comorbidity index with cardiac events. We also analyzed whether RVEF has incremental value over two-dimensional echocardiography (2DE) RV parameters.Results: During a median follow-up of 27 months, 57 patients developed cardiac events, and 68 patients received AVR. Univariate Cox proportional hazard analysis revealed that RVEF was associated with cardiac events (p < 0.001). Multivariate analysis revealed that RVEF was significantly associated with cardiac events (p < 0.001) even after adjusting for AVR, Charlson's comorbidity index, LVEF, LAV, E/e', and indexed aortic valve area (iAVA). An incremental value of RVEF over left heart parameters was also demonstrated using a nested regression model. Classification and regression-tree analysis selected RVEF first with a cut-off value of 41%. RVEF had incremental value over iAVA, LVEF, and 2DE conventional RV parameters for its association with future outcomes.Conclusions: 3DE RVEF had significant prognostic value even after adjusting for comorbidities, left heart parameters, and conventional 2DE RV parameters in asymptomatic aortic stenosis.

Attributable mortality of candidemia at a German tertiary hospital from 1997 to 2001 before the introduction of echinocandins.

The relevance of candidemia has increased over the last decades due to higher incidence rates in an ageing society. Studies on amphotericin B and fluconazole have shown high attributable mortality rates of 38% and 49% in the United States. Incidence rates and locational factors might have an impact on the mortality rates at the University Hospital of Cologne (UHC), Germany. We performed a matched case-control study including 57 patients with candidemia, hospitalised at the UHC between 1 July 1997 and 30 June 2001. Controls were matched by age, sex, admission date, treatment on intensive care unit (ICU), number of days at risk, underlying diseases, surgical procedures and the Charlson Comorbidity Index. The incidence of candidemia was 3.5 per 10000 admissions. For cases and controls, we observed in-hospital-mortality rates of 33.3% and 11.8%, and a 30-day mortality of 23.5% and 7.8% respectively. The attributable mortality rate to candidemia was 21.5%, and at 30days, it was 15.7%. Underlying conditions were more frequent in cases than in controls, especially central venous catheter (80% vs 33%, P<.001), chronic cardiovascular disease (39.2% vs 25.5%, P=.138), treatment on ICU (31.4% vs 13.7%, P=.033) and chronic liver disease (21.6% vs 0%, P<.001). The attributable mortality of candidemia at the UHC between 1997 and 2001 was lower compared to studies performed in the United States with a similar design. Contributing factors might be lower incidence rates and less comorbidities in our study.

The association of asthma, atopic dermatitis, and allergic rhinitis with peripartum mental disorders.

BackgroundAtopic diseases are characterized by dysregulated inflammatory response, which may incur the onset of peripartum mental disorders, but the impact remains unknown. This study examined whether and to what extent the history of atopic diseases is associated with newly onset peripartum mental disorders.MethodsUsing population‐based registries, we identified all primiparous women who gave birth to live singletons in Denmark during 1978–2016 (n = 937,422). The exposure was hospital contact due to the three major types of atopic diseases—asthma, atopic dermatitis, and allergic rhinitis—before conception. The primary outcome was any hospital contact for mental disorder during pregnancy and 1‐year postpartum, which was further classified into affective disorders, neurotic, stress‐related and somatoform disorders, and substance abuse. The follow‐up started from the date of conception and ended at the date of the first diagnosis of mental disorders, 1‐year postpartum, death, emigration, or December 31, 2016, whichever came first. Cox regression was used, adjusted for calendar year, age at childbirth, education, residence, and Charlson comorbidity index.ResultsA total of 24,016 (2.6%) women received diagnosis of at least one of the three atopic diseases before conception (asthma, 1.7%; atopic dermatitis, 0.6%; and allergic rhinitis, 0.8%). Exposure to asthma, atopic dermatitis, or allergic rhinitis was associated with a 37% increased overall risk of peripartum mental disorders (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.27–1.49). Higher risks were observed among women with more frequent hospital contacts for atopic disease (HR, 1.80; 95% CI, 1.37–2.35; ≥5 times), and with recent hospital contacts for atopic disease (HR, 1.74; 95% CI, 1.48–2.06; within 2 years before conception). Specific associations were observed between asthma and neurotic, stress‐related and somatoform disorders (HR, 1.40; 95% CI, 1.21–1.62), and between atopic dermatitis and substance abuse (HR, 1.62; 95% CI, 1.12–2.34).ConclusionsHistory of asthma, atopic dermatitis, and allergic rhinitis before conception was associated with increased risks of peripartum mental disorders. Women who have atopic diseases before pregnancy may benefit from systematic mental health monitoring.

Abstract 13706: Expanded Coverage for Cardiac Rehabilitation in Heart Failure Patients Accelerated Annual Rates of Use

Introduction: Cardiac rehabilitation (CR) reduces morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF). In an effort to improve enrollment, Medicare expanded coverage for CR to include HFrEF patients in 2014, but the impact of this policy change is unknown. Methods: A 20% sample of Medicare inpatient, outpatient, and carrier claim files (2008 to 2017) were used to identify 849,054 patients with HFrEF, defined as having ≥ 2 outpatient claims or ≥ 1 inpatient hospitalization for chronic systolic heart failure during a calendar year. Patients who died within the calendar year of diagnosis were excluded. CR participation was identified using CPT and revenue center codes. We performed an interrupted time-series analysis to estimate annual rates of CR use over the ten year period, annual changes in CR use in the pre- (2008-2013) and post-policy (2014-2017), and the differences in annual trends pre- vs. post-policy. Results were risk adjusted by age, sex, race, dual eligibility, and Charlson comorbidities. Results: A total of 34,179 (4.0%) beneficiaries with HFrEF attended CR during the study period. Annual trends in CR enrollment are shown in Figure 1 . From 2008 to 2014, CR utilization increased from 3.30% to 4.30% at an annual absolute change of 0.15% per year (p&lt;0.001). After Medicare expanded coverage, rates of CR enrollment went from 4.30% in 2014 to 5.54% in 2017, at an annual absolute change of 0.31% (p&lt;0.001). Comparing trends in participation before and after the change in policy, the annual rate of change in CR enrollment was 0.16% higher on an absolute scale (p&lt;0.001). Conclusions: Although the absolute enrollment rate of patients with HFrEF in CR remains low, expanding coverage in 2014 was associated with a doubling in the annual rate of increase of CR use. Interventions beyond coverage changes, at the individual, provider, and system level, are needed to improve CR participation in HFrEF patients.

Experiences and priorities of older adults during the COVID-19 pandemic.

BackgroundThroughout the COVID-19 pandemic, older adults have been prioritized in public health campaigns to limit social interactions and ‘cocoon’ in their homes. This limits the autonomy of older people and may have unintended adverse consequences.AimsTo ascertain the self-reported physical and psychological effects of ‘cocooning’ and the expressed priorities of older adults themselves during the pandemic.MethodsThis is a cross-sectional, survey-based study involving 93 patients aged 65 and older, attending geriatric medicine out-patient and ambulatory day hospital services or our in-patient rehabilitation units. Demographic data was obtained from the medical records. Frailty level was calculated using the Clinical Frailty Scale (CFS), and disease burden was calculated with the Charlson Comorbidity Index.ResultsMean age was 79.1 (range 66–96), 24% had dementia, and most were mildly frail (CFS < 5). One-third reported new feelings of depression, decreased mobility, and loss of enjoyment as a consequence ‘cocooning’. Loneliness was more prevalent amongst in-patients (38% vs 9%, p > 0.001). Respondents worried more about the risks of COVID-19 to their family than themselves. Expressed priorities varied from ‘enjoying life as much as possible’ to ‘protecting the development of children’.ConclusionsAdverse consequences of ‘cocooning’ were commonly expressed amongst older adults. Public health policy should take into account the heterogeneity of this population and be sensitive to their self-expressed wishes and priorities.Supplementary informationThe online version contains supplementary material available at 10.1007/s11845-021-02804-y.

Impact of Dosing Frequency of Oral Oncolytics on Refill Adherence Among Patients with Hematological Malignancies

Background: With advances in oral oncolytics for hematologic malignancies, it is important to consider dosing frequency and treatment (tx) adherence, as prior data have shown poor adherence to oral cancer medications may result in inferior tx outcomes (Huang WC, Expert Rev Anticancer Ther, 2016; Muluneh B, J Oncol Pract, 2018). There is limited evidence regarding the impact of dosing frequency on tx adherence among patients with hematological malignancies treated with oral oncolytics. The objective of this study was to characterize real-world demographic and clinical characteristics, and compare refill adherence, among patients with hematological malignancies receiving once-daily (QD) versus twice-daily (BID) oral oncolytics.Methods: This retrospective cohort study used multi-year (2012-2020) commercial claims data from Optum's de-identified Clinformatics ® Data Mart Database and included adults (≥18 yr) with a diagnosis of a hematological malignancy identified using ICD-9-CM and ICD-10-CM codes. The exposure of interest was receipt of an oral oncolytic, and the date of the first observed oral oncolytic (QD or BID) was considered the index date. All patients were required to have continuous health plan enrollment for ≥6 mo prior and ≥6 mo after the index date. The 6-mo period prior to the index date was considered the baseline period for determining patient demographics, clinical characteristics, and prior medication use. To minimize the effect of the differences in observable baseline patient characteristics between the QD and BID groups on refill adherence, 1:1 propensity score (PS) matching was used. Tx refill adherence to QD and BID oral oncolytics was measured using two established metrics: proportion of days covered (PDC) and medication possession ratio (MPR). PDC, a conservative measure of refill adherence, was considered for primary analysis as it measures total days of drug coverage within a pre-specified follow-up period; whereas MPR which was included for sensitivity analysis, measures total drug supplied within the pre-specified follow-up period. PDC and MPR were measured at pre-defined time periods of 3 and 6 mo, and from the index date until the end of the follow-up period (variable-length follow-up). Patients with drug coverage for ≥80% (PDC or MPR ≥0.8) of pre-defined time periods were considered tx refill adherent.Results: The study identified 5,874 adults with hematological malignancies, of whom 4,938 (84.1%) received QD oral oncolytics and 936 (15.9%) received BID oral oncolytics. Before 1:1 PS matching, there were significant differences between the two groups in terms of mean age (67.5 yr QD vs 61.6 yr BID, P<0.001), insurance type (Medicare, 65.4% QD vs 46.8% BID, P<0.001), being previously untreated (67.6% QD vs 63.7% BID, P=0.019), and Charlson's comorbidity score (mean: 1.61 QD vs 1.44 BID, P<0.001). After 1:1 PS matching, demographics, baseline comorbidities, cancer histology, and line of therapy were well-balanced. The matched cohort comprised 936 patients receiving QD oral oncolytics and 936 patients receiving BID oral oncolytics. Table 1 summarizes refill adherence among patients with hematological malignancies receiving QD versus BID oral oncolytics. The proportion of patients with ≥80% of drug coverage during follow-up was higher for QD versus BID recipients at 3 mo: numerically higher by PDC (70.8% vs 66.9%, P=0.065) and statistically significantly higher by MPR (72% vs 67.8%, P=0.049). The proportion of adherent patients was significantly higher for QD vs BID for both PDC and MPR at 6 mo (PDC: 62% vs 56.8%, P=0.024; MPR: 62.7% vs 57.5%, P=0.021) and at variable-length follow-up (PDC: 82.4% QD vs 77.7% BID, P=0.011; MPR: 84.9% QD vs 80.9%, P=0.020). These results suggest QD dosing is associated with improved tx adherence to oral hematological oncolytics compared to BID dosing.Conclusions: This study demonstrates significantly higher refill adherence in patients receiving QD versus BID oral hematological oncolytics at 6 mo and variable-length follow-up, highlighting the potential benefit of dosing convenience in improving adherence to oral oncolytics in the real-world setting. As suboptimal tx adherence may result in reduced tx effectiveness, real-world characterization of refill adherence rates of oral oncolytics can better inform on tx effectiveness outside of a controlled clinical trial environment. [Display omitted] DisclosuresChallagulla: Pharmacyclics LLC, an AbbVie Company: Current Employment; AbbVie: Current equity holder in publicly-traded company. Kebede: Pharmacyclics LLC, an AbbVie Company: Consultancy; ObsEva: Other. Rege: Pharmacyclics LLC, an AbbVie Company (paid to institution): Consultancy. Volodarsky: AbbVie: Current equity holder in publicly-traded company; Pharmacyclics LLC, an AbbVie Company: Current Employment. Osei-Bonsu: AbbVie: Current equity holder in publicly-traded company; Pharmacyclics LLC, an AbbVie Company: Current Employment. Karve: AbbVie: Current Employment, Current equity holder in publicly-traded company.

The influence of sex on ischemic stroke incidence, therapeutic procedures and in-hospital mortality: Results of the Spanish National Hospital Discharge.

Previous research has revealed sex-related differences in outcomes for people admitted to hospitals for ischemic stroke. We aimed to analyse the incidence, use of invasive procedures and in-hospital outcomes of ischemic stroke in Spain (2016-2018) using the Spanish National Hospital Discharge Database. We sought sex-related differences in incidence and in-hospital outcomes over time. We estimated the incidence of ischemic stroke in men and women. We analysed comorbidities (Charlson's comorbidity index, cardiovascular risk factors, alcohol abuse and atrial fibrillation), procedures (mechanical ventilation, endovascular thrombectomy and thrombolytic therapy) and outcomes. We matched each woman with a man with identical age, type of ischemic stroke and year of hospitalisation. We built Poisson regression models to obtain adjusted incidence rate ratios (IRRs). We tested in-hospital mortality (IHM) with logistic regression analyses. Ischemic stroke was coded in 172255 patients aged ≥35years (92524 men 53.7%). Men showed higher incidence rates (216.9 vs. 172.3/105 ; P<.001; IRR=1.57 (95% CI:1.55-1.59) than women. After matching, the use of endovascular thrombectomy (5.1% vs. 4.0%; P<.001) and thrombolytic therapy (7.6% vs. 6.8%; P<.001) was higher among women. IHM was significantly higher in women than in matched men (11.2% vs. 10.4%; P<.001). Women had a lower IHM than matched men when endovascular thrombectomy (9.4% vs. 12.1%; P=.001) or thrombolytic therapy (6.7% vs. 8.3%; P=.003) was coded. Patients of both sexes admitted for ischemic stroke who received thrombolytic therapy had lower IHM (OR=0.76; 95% CI:0.68-0.85 among men; and OR=0.58; 95% CI:0.52-0.64 among women), but endovascular thrombectomy was associated with a lower IHM only among women (OR=0.58; 95% CI:0.51-0.66). After multivariable adjusting, women admitted to the hospital for ischemic stroke had a significantly higher IHM than men (OR=1.16; 95% CI:1.12-1.21). Men had higher incidence rates of ischemic stroke than women. Women more often underwent thrombolytic therapy and endovascular thrombectomy but had a higher IHM.

Medicaid Expansion Through the Affordable Care Act and Receipt of Guideline Recommended Brachytherapy for Locally Advanced Cervical Cancer

Brachytherapy is a critical component of definitive chemo-radiation for locally advanced cervical cancer. However, studies have shown that a large portion of patients do not received brachytherapy as part of their treatment. We hypothesized that access to care due to lack of insurance might prevent patients from receiving brachytherapy as part of their treatment, and patients in states that expanded Medicaid under the affordable care act would therefore be more likely to receive brachytherapy after expansion.The National Cancer Database was queried for cases from 2004 to 2016 of women with stage IIb-IVa cervical cancer treated with definitive radiation and chemotherapy. Patients were excluded if they received primary directed surgery, did not receive chemotherapy, had missing or incomplete radiation information, or had their Medicaid expansion status censored due to age < 40. A difference in difference (DID) analysis was performed to compare the uninsured rate and the rate of brachytherapy before and after expansion of Medicaid in states that did vs states that did not expand Medicaid. Multivariable analysis (MVA) for lack of insurance and completion of brachytherapy was adjusted for stage, race, facility type, median income, Charlson comorbidity and insurance (brachy analysis only).A total of 12,409 patients were included with a median age of 55. Most patients were treated at an academic center (50%) and 74% were white. Overall, 56% of patients lived in states that expanded Medicaid early (2010-2013, 21%) or late (2014, 35%). The proportion of patients without insurance significantly decreased in early and late expansion states (-3.2%, -6.6% respectively, P < 0.001) with no significant change in non-expansion states. The decrease in uninsured patients remained significant on multivariable analysis (DID MVA -5.2% early expansion, -6.8% late expansion, P < 0.05). The overall rate of brachytherapy usage increased in expansion states (+8.4% early, +5.0% late expansion, P < 0.001) and in states that did not expand coverage (+4.4%, P < 0.001). However, there was no increase in usage of brachytherapy in expansion states compared to non-expansion states on univariate or multivariate analysis (DID MVA 0.6% [-3.9-5.3] early expansion, -0.2% [-4.6-4.0] late expansion).Medicaid expansion and a subsequent decrease in the uninsured population did not increase the proportion of patients receiving brachytherapy as part of their definitive chemo-radiation for cervical cancer. Our study suggests that lack of insurance, while important, is not the only factor limiting access to standard of care treatment for cervical cancer. Further research into access and availability of brachytherapy is needed.S. Freije: None. E.M. Steele: None. S.E. Robertson: None. O. Ishaq: None. J.A. Holmes: None.

Comparison of a polypharmacy-based scale with Charlson comorbidity index to predict 6-month mortality in chronic complex patients after an ED visit.

The aim of this study was to test whether a newly designed polypharmacy-based scale would perform better than Charlson's Comorbidity Index (CCI) to predict outcomes in chronic complex adult patients after a reference Emergency Department (ED) visit. We built a polypharmacy-based scale with prespecified drug families. The primary outcome was 6-month mortality after the reference ED visit. Predefined secondary outcomes were need for hospital admission, 30-day readmission, and 30-day and 90-day mortality. We evaluated the ability of the CCI and the polypharmacy-based scale to independently predict 6-month mortality using logistic regression, receiver operating characteristic (ROC) curves, and cumulative survival curves using Kaplan-Meier estimates and the log-rank test for three-category distributions of the polypharmacy-based scale and the CCI. Finally, we sought to replicate our results in two different external validation cohorts. We included 201 patients (53.7% women, mean age = 81.4years), 162 of whom were admitted to the hospital at the reference ED visit. In separate multivariable analyses accounting for gender, age and main diagnosis at discharge, both the polypharmacy-based scale (P < .001) and the CCI (P = .005) independently predicted 6-month mortality. The polypharmacy-based scale performed better in the ROC analyses (area under the curve [AUC] = 0.838, 95% confidence interval [CI] = 0.780-0.896) than the CCI (AUC = 0.628, 95% CI = 0.548-0.707). In the 6-month cumulative survival analysis, the polypharmacy-based scale showed statistical significance (P < .001), whereas the CCI did not (P = .484). We replicated our results in the validation cohorts. Our polypharmacy-based scale performed significantly better than the CCI to predict 6-month mortality in chronic complex patients after a reference ED visit.