Delivery Of Care For Individuals Research Articles

Perceived Importance of Types and Characteristics of Support to Informal Caregivers among Spouse Caregivers of Persons with Dementia in Sweden: A Cross-Sectional Questionnaire-Based Study.

Informal caregivers play a crucial role in the care of individuals with dementia, and their caregiving may significantly impact their own health and well-being. This cross-sectional survey study focuses on the perceived importance of various types and characteristics of formal support in a convenience sample of caregivers aged 65 years or older (N = 175) caring for a spouse with dementia. Participants completed a questionnaire containing 17 items describing different types of support and 12 items describing different characteristics of support, rating their importance. The questionnaire also contained questions on various caregiving-related factors. Principle components analysis (PCA) was carried out on the importance ratings, separately, on the types of support items and the characteristics of support items. Each PCA produced three components. For types of support, they were Proficiency and Opportunity, Supportive Structures, Flexible Counselling. For characteristics of support, they included Respectful and Competent, Timely Support, and Accessible and Acceptable. The three characteristics of the support components all had higher mean importance ratings than the three types of support components. The content of some components indicated that while spouse caregivers rate support for their caregiving needs as important, they may not always differentiate their own needs from those of their partner with dementia. The negative impact of caregiving was the factor most strongly and consistently associated with the components' importance ratings. This study emphasizes the need for health and social care providers to address the unique needs of spouse caregivers while simultaneously ensuring the delivery of quality care for individuals with dementia.

Delta Radiomics — Potential role in Head Neck Cancer

IntroductionDelta radiomics is a tool used to assess the response of oncologic patients undergoing immunotherapy. It extracts high-dimensional quantitative features from medical images, providing information about cancer's phenotype, genotype, and tumoral microenvironment. This analysis could help avoid invasive procedures and help choose the most suitable therapeutic in multiple therapeutic options. Radiomics has gained interest as an imaging biomarker for predicting response to various immunotherapies. Delta radiomics assesses feature variations from one time point to another based on subsequent images, offering higher value for treatment-outcome prediction or patient stratification into risk categories. It has potential benefits for clinical endpoints in oncology, such as differential diagnosis, prognosis, treatment response prediction, and evaluation of side effects. Further research with prospective and multicentre studies is needed for clinical validation of delta radiomics approaches. Statement of clinical significanceIn head and neck oncology, delta radiomics can be used to enhance the precision of diagnosis, assess tumor response, forecast normal tissue toxicity, predict clinical outcome, and pinpoint characteristics for treatment modification. Patients' quality of life may be enhanced by it. It can support post-treatment surveillance. Additionally, it can support the delivery of individualized care based on a patient's reaction to medication and radiation.

Perspective] Delta Radiomics — Potential Role in Head Neck Cancer

INTRODUCTION: Delta radiomics is a tool used to assess the response of oncologic patients undergoing immunotherapy. It extracts high-dimensional quantitative features from medical images, providing information about cancer's phenotype, genotype, and tumoral microenvironment. This analysis could help avoid invasive procedures and help choose the most suitable therapeutic in multiple therapeutic options. Radiomics has gained interest as an imaging biomarker for predicting response to various immunotherapies. Delta radiomics assesses feature variations from one time point to another based on subsequent images, offering higher value for treatment-outcome prediction or patient stratification into risk categories. It has potential benefits for clinical endpoints in oncology, such as differential diagnosis, prognosis, treatment response prediction, and evaluation of side effects. Further research with prospective and multicentre studies is needed for clinical validation of delta radiomics approaches. STATEMENT OF CLINICAL SIGNIFICANCE: In head and neck oncology, delta radiomics can be used to enhance the precision of diagnosis, assess tumor response, forecast normal tissue toxicity, predict clinical outcome, and pinpoint characteristics for treatment modification. Patients' quality of life may be enhanced by it. It can support post-treatment surveillance. Additionally, it can support the delivery of individualized care based on a patient's reaction to medication and radiation.

Perspective] Delta Radiomics — Potential Role in Head Neck Cancer

INTRODUCTION: Delta radiomics is a tool used to assess the response of oncologic patients undergoing immunotherapy. It extracts high-dimensional quantitative features from medical images, providing information about cancer's phenotype, genotype, and tumoral microenvironment. This analysis could help avoid invasive procedures and help choose the most suitable therapeutic in multiple therapeutic options. METHOD: Radiomics has gained interest as an imaging biomarker for predicting response to various immunotherapies. Delta radiomics assesses feature variations from one time point to another based on subsequent images, offering higher value for treatment-outcome prediction or patient stratification into risk categories. CONCLUSION: It has potential benefits for clinical endpoints in oncology, such as differential diagnosis, prognosis, treatment response prediction, and evaluation of side effects. Further research with prospective and multicentre studies is needed for clinical validation of delta radiomics approaches. STATEMENT OF CLINICAL SIGNIFICANCE: In head and neck oncology, delta radiomics can be used to enhance the precision of diagnosis, assess tumor response, forecast normal tissue toxicity, predict clinical outcome, and pinpoint characteristics for treatment modification. Patients' quality of life may be enhanced by it. It can support post-treatment surveillance. Additionally, it can support the delivery of individualized care based on a patient's reaction to medication and radiation.

Understanding multiple sclerosis as a disease spectrum: above and below the clinical threshold.

Research in multiple sclerosis (MS) has long been predicated on clinical groupings that do not reflect the underlying biologic heterogeneity apparent within patient populations. This review explicates the various levels of explanation through which the spectrum of disease is described and investigated both above and below the clinical threshold of detection, as framed by the topographical model of MS, to help advance a cogent mechanistic framework. Contemporary evidence has amended the view of MS as consisting of sequential disease phases in favor of a spectrum of disease with an admixture of interdependent and dynamic pathobiological axes driving tissue injury and progression. Recent studies have shown the presence of acute and compartmentalized inflammation and mechanisms of neurodegeneration beginning early and evolving throughout the disease continuum. Still, the gap between the understanding of immunopathologic processes in MS and the tools used to measure relevant molecular, laboratory, radiologic, and clinical metrics needs attention to enable better prognostication of disease and monitoring for changes along specific pathologic axes and variable treatment outcomes. Aligning on a consistently-applied mechanistic framework at distinct levels of explanation will enable greater precision across bench and clinical research, and inform discourse on drivers of disability progression and delivery of care for individuals with MS.

Palliative Intent Treatment and Palliative Care Delivery for Individuals With Advanced Nonsmall Cell Lung Cancer and Melanoma: A Patterns of Care Study.

Introduction: This study aimed to describe the patterns of palliative intent treatment and/or palliative care (PC) delivery among a population-based sample of individuals diagnosed with advanced nonsmall cell lung cancer (NSCLC) or advanced melanoma. Methods: Data from 655 advanced-stage melanoma patients and 2688 advanced-stage NSCLC patients included in the National Cancer Institute's 2017/2018 Patterns of Care study were analyzed. Bivariate and multivariate logistic regression analyses examined factors associated with (1) receipt of PC (including palliative surgery, radiation, and/or systemic therapy after cancer diagnosis, and PC consultations); and (2) timing from diagnosis to receipt of PC. Proportional hazards models also examined factors associated with timing of receipt of PC after diagnosis. Results: A total of 23.5% of those with melanoma and 52.6% of those with NSCLC received some type of PC. For melanoma, stage 4 (vs. stage 3) was associated with higher receipt of PC and receipt within three months of diagnosis. For NSCLC, stage 4 (vs. stage 3) and a diagnosis of depression or psychosocial distress within three months of diagnosis were significantly associated with receipt of PC and receipt within three months of diagnosis. Conclusion: Study findings indicate that those with advanced-stage cancer or who report distress are more likely to receive palliative intent treatment and/or PC. Given that individuals with advanced cancers are living longer and often experience long-lasting symptoms, it is critical to identify and overcome barriers for broadly delivering comprehensive palliative and supportive care.

Placebo effects in children with autism spectrum disorder.

Placebo responses are frequently observed in research studies and clinical contexts, yet there is limited knowledge about the placebo effect among children with neurodevelopmental disorders. Here, we review the placebo effect in autism spectrum disorder (ASD). Placebo responses are widely evident in ASD clinical trials and could partly operate via so-called placebo-by-proxy, whereby caregivers or clinicians indirectly shape patient outcomes. Understanding the role of placebo effects in ASD may help discern genuine treatment effects from contextual factors in clinical trials. The much less studied nocebo effect, or negative placebo, might contribute to the experience of side effects in ASD treatments but empirical data is missing. Better knowledge about placebo and nocebo mechanisms may contribute to the development of more effective research designs, such as three-armed designs that account for natural history, and improved treatments for ASD symptoms. At a clinical level, deeper knowledge about placebo and nocebo effects may optimize the delivery of care for individuals with ASD in the future. WHAT THIS PAPER ADDS: Placebo responses are evident in autism spectrum disorder (ASD) clinical trials. Placebo responses in ASD are likely dependent on a placebo-by-proxy mechanism.

Implementing digital systems to facilitate genetic testing for hereditary cancer syndromes: An observational study of 4 clinical workflows

PurposeNational efforts have prioritized the identification of effective methods for increasing case ascertainment and delivery of evidence-based health care for individuals at elevated risk for hereditary cancers. MethodsThis study examined the uptake of genetic counseling and testing following the use of a digital cancer genetic risk assessment program implemented at 27 health care sites in 10 states using 1 of 4 clinical workflows: (1) traditional referral, (2) point-of-care scheduling, (3) point-of-care counseling/telegenetics, and (4) point-of-care testing. ResultsIn 2019, 102,542 patients were screened and 33,113 (32%) were identified as at high risk and meeting National Comprehensive Cancer Network genetic testing criteria for hereditary breast and ovarian cancer, Lynch syndrome, or both. Among those identified at high risk, 5147 (16%) proceeded with genetic testing. Genetic counseling uptake was 11% among the sites with workflows that included seeing a genetic counselor before testing, with 88% of patients proceeding with genetic testing after counseling. Uptake of genetic testing across sites varied significantly by clinical workflow (6% referral, 10% point-of-care scheduling, 14% point-of-care counseling/telegenetics, and 35% point-of-care testing, P < .0001). ConclusionStudy findings highlight the potential heterogeneity of effectiveness attributable to different care delivery approaches for implementing digital hereditary cancer risk screening programs.

Hypertension management in sub-Saharan Africa: an overview of challenges and opportunities for telemedicine

Hypertension is the leading contributor to cardiovascular disease (CVD)-related deaths globally, with Africa being one of the World Health Organization regions with the highest prevalence of elevated blood pressure (BP). In sub-Saharan Africa (SSA), awareness, treatment, and control levels of hypertension remain low in both men and women and in different settings, including rural and urban areas. Important barriers to the management of hypertension in SSA are within health systems, usually overburdened by communicable and non-communicable diseases, acute medical conditions, and child and maternal healthcare. Health system-related challenges include the availability and cost of essential medicines and healthcare workforce constraints. At the patient level, individual barriers such as sociodemographic, economic, and psychosocial factors contribute significantly to the poor control of hypertension. Telemedicine presents a promising approach to improve the delivery of optimal care for individuals living with hypertension by serving as a connection between healthcare providers and patients. This may enhance access to isolated people living with hypertension, such as in rural areas. However, there is a concern that telemedicine may exacerbate some of the barriers to the management of hypertension in disadvantaged groups, such as those with limited access to digital technology, low education and literacy levels, and the ageing population. Therefore, the objective of this review is to summarize the current state of telemedicine use in the management of hypertension in SSA and discuss the challenges and opportunities to provide cost-effective, equitable, and sustainable access to digital health technology for people living with hypertension in SSA.

Pecha Kucha: An Innovative Pedagogy to Cultivate Cultural Competency in 21 st Century Nursing Students.

Pecha Kucha: An Innovative Pedagogy to Cultivate Cultural Competency in 21 st Century Nursing Students.

Application of Next Generation Sequencing for Diagnosis and Clinical Management of Drug-Resistant Tuberculosis: Updates on Recent Developments in the Field.

The World Health Organization’s End TB Strategy prioritizes universal access to an early diagnosis and comprehensive drug susceptibility testing (DST) for all individuals with tuberculosis (TB) as a key component of integrated, patient-centered TB care. Next generation whole genome sequencing (WGS) and its associated technology has demonstrated exceptional potential for reliable and comprehensive resistance prediction for Mycobacterium tuberculosis isolates, allowing for accurate clinical decisions. This review presents a descriptive analysis of research describing the potential of WGS to accelerate delivery of individualized care, recent advances in sputum-based WGS technology and the role of targeted sequencing for resistance detection. We provide an update on recent research describing the mechanisms of resistance to new and repurposed drugs and the dynamics of mixed infections and its potential implication on TB diagnosis and treatment. Whilst the studies reviewed here have greatly improved our understanding of recent advances in this arena, it highlights significant challenges that remain. The wide-spread introduction of new drugs in the absence of standardized DST has led to rapid emergence of drug resistance. This review highlights apparent gaps in our knowledge of the mechanisms contributing to resistance for these new drugs and challenges that limit the clinical utility of next generation sequencing techniques. It is recommended that a combination of genotypic and phenotypic techniques is warranted to monitor treatment response, curb emerging resistance and further dissemination of drug resistance.

Lived experiences of people with or at risk for aortic dissection: A qualitative assessment

Aortic dissection (AD) is a life-changing event that is often accompanied by a loss of normal quality of life. Survivors of AD go on to have a chronic disease that requires lifestyle modification, medical management, and surgical repair of the aorta. Clinical care includes multiple disciplines, health care settings, and often different geographic locations. This qualitative assessment examined the experiences of people with and at risk for AD. The following four themes emerged: "unnecessary drama" at diagnosis, unmet needs for information and support, the burden of self-advocacy and care coordination, and living with unaddressed mental health impacts. Our findings inform recommendations to advance patient-centered care delivery for individuals with and at risk for AD, improving communication of timely and relevant information, and an approach to care that acknowledges the whole person in clinical decision making.

Competencies for Nurses Regarding Psychosocial Care of Patients With Cancer in Africa: An Imperative for Action.

Psychosocial care is considered an important component of quality cancer care. Individuals treated for cancer can experience biologic or physical, emotional, spiritual, and practical consequences (eg, financial), which have an impact on their quality of living. With the establishment of cancer centers in Africa, there is growing advocacy regarding the need for psychosocial care, given the level of unmet supportive care needs and high emotional distress reported for patients. Nurses are in an ideal position to provide psychosocial care to patients with cancer and their families but must possess relevant knowledge and skills to do so. Across Africa, nurses are challenged in gaining the necessary education for psychosocial cancer care as programs vary in the amount of psychosocial content offered. This perspective article presents competencies regarding psychosocial care for nurses caring for patients with cancer in Africa. The competencies were adapted by expert consensus from existing evidenced-based competencies for oncology nurses. They are offered as a potential basis for educational program planning and curriculum development for cancer nursing in Africa. Recommendations are offered regarding use of these competencies by nursing and cancer program leaders to enhance the quality of care for African patients with cancer and their family members. The strategies emphasize building capacity of nurses to engage in effective delivery of psychosocial care for individuals with cancer and their family members.

Internet-delivered Cognitive Behavioural Therapy for Persons with Mild Traumatic Brain Injury: A Multi-Method Feasibility Trial

<h3>Research Objectives</h3> To deliver a feasibility pilot trial to evaluate the acceptability and limited effectiveness of the internet-delivered cognitive behavioural therapy (ICBT) program that has been designed for persons with mild traumatic brain injury (mTBI) to improve overall well-being. <h3>Design</h3> A mixed-methods feasibility trial will be conducted to evaluate ICBT among persons with mTBI. Data will be collected at three time points, baseline, post-treatment and 3-month follow-up. Post-treatment, participants will complete a brief semi-structured interview examining the barriers and facilitators of the program. <h3>Setting</h3> Participants will be recruited from outpatient brain injury and stroke clinics by their health care providers. <h3>Participants</h3> A priori sample size of 20 has been calculated to be sufficient to detect a power of 90% and alpha at .05 with an effect size of 0.8 and accounted for a potential dropout of 30%. Potential participants will undergo an extensive screening process involving interviews to assess suicide risk and cognitive status. <h3>Interventions</h3> The ICBT program consists of six modules, including lessons on psychoeducation on the mTBI symptoms, managing symptoms of depression and anxiety, with a registered mental health professional contacting them once per week for up to 12 weeks, leading to personalized care. <h3>Main Outcome Measures</h3> The primary outcomes for the study include the feasibility and acceptability of the ICBT program. Secondary outcome measures include depression and anxiety. <h3>Results</h3> It is hypothesized that the ICBT program will be acceptable to participants and improve patient-reported outcomes from baseline to follow-up. Additionally, participants will provide valuable information on the strengths and challenges of the ICBT program to further improve and better serve this population's needs. <h3>Conclusions</h3> This research is expected to significantly improve health outcomes and mental health care delivery for individuals with mTBI and for those with other neurological conditions. The results of this study will guide larger studies to evaluate the program's effectiveness in a community setting. <h3>Author(s) Disclosures</h3> No conflict between any of the authors.

Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions

Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions

Telehealth sounds a bit challenging, but it has potential: participant and physiotherapist experiences of gym-based exercise intervention for Achilles tendinopathy monitored via telehealth

BackgroundAlthough telehealth is becoming more popular for delivery of care for individuals with musculoskeletal pain, to our knowledge telehealth has not been used to manage Achilles tendinopathy. This research aimed to explore the experience of participants and physiotherapists with gym-based exercise interventions for Achilles tendinopathy monitored via videoconference.MethodsA qualitative, interpretive description design was performed using semi-structured interviews (8 participants) and a focus group (7 physiotherapists). Participants and physiotherapists were interviewed about their experiences of the use of telehealth during a gym-based exercise intervention incorporating different calf load parameters for Achilles tendinopathy. We employed an inductive thematic analysis approach to analyse the data.ResultsThree themes identified from both participants and physiotherapists included i) acceptability of telehealth; ii) enablers to adherence with telehealth; and iii) barriers to adherence with telehealth. Two extra themes arose from participants regarding adherence with gym-based exercise, including enablers to adherence with the exercise intervention, and barriers to adherence with the exercise intervention. Both participants and physiotherapists expressed overall satisfaction and acceptability of telehealth monitoring of gym-based exercise.ConclusionGym-based exercise intervention for Achilles tendinopathy involving weekly telehealth monitoring was acceptable to both participants and physiotherapists. Potential enablers and barriers were identified that may improve adherence to this type of intervention.

Models of Palliative Care Delivery for Individuals with Cystic Fibrosis: Cystic Fibrosis Foundation Evidence-Informed Consensus Guidelines.

Cystic fibrosis (CF) affects more than 70,000 individuals and their families worldwide. Although outcomes for individuals with CF continue to improve, it remains a life-limiting condition with no cure. Individuals with CF manage extensive symptom and treatment burdens and face complex medical decisions throughout the illness course. Although palliative care has been shown to reduce suffering by alleviating illness-related burdens for people with serious illness and their families, little is known regarding the components and structure of various delivery models of palliative care needed to improve outcomes for people affected by CF. The Cystic Fibrosis Foundation (CFF) assembled an expert panel of clinicians, researchers, individuals with CF, and family caregivers, to develop consensus recommendations for models of best practices for palliative care in CF. Eleven statements were developed based on a systematic literature review and expert opinion, and address primary palliative care, specialty palliative care, and screening for palliative needs. These recommendations are intended to comprehensively address palliative care needs and improve quality of life for individuals with CF at all stages of illness and development, and their caregivers.

Using Claims Data to Assess Treatment Quality of First-Episode Psychosis.

Coordinated specialty care (CSC) has become the standard of care for first-episode psychosis (FEP). The gap between CSC best practices and the actual care delivered is unknown. This longitudinal study aimed to measure that gap by using a large Medicaid claims database and 10 quality indicators (QIs) reflecting aspects of CSC and to study the relationship between these QIs and future health care utilization. Individuals with FEP were identified in a Missouri Medicaid claims database. Participants were required to have been eligible for Medicaid benefits for at least 10 months in the year prior to and the year after their first episode of psychosis and to have had no evidence of a prior psychosis diagnosis. Descriptive statistics were generated for each of the QIs, and a stratified Cox regression was used to identify predictors of subsequent health care utilization. Data were obtained for 6,246 participants, and follow-up lasted a mean of 4.24 years. Significant practice gaps were found in the use and monitoring of antipsychotic medications. Of those prescribed antipsychotic medication, 5% received prescriptions above recommended daily doses, 16% received two or more antipsychotics, and 20% were treated with olanzapine or clozapine. Among the QIs, lack of monitoring for smoking (hazard ratio [HR]=2.71, 95% confidence interval [CI]=2.47-2.97) and lack of integrated care delivery in treatment (HR=2.00, 95% CI=1.92-2.08) were most associated with psychiatric hospitalization. In most cases, treatment was far from meeting CSC recommendations, suggesting that implementation of CSC requires substantial modifications to delivery of care for individuals with FEP.

Who should care for children with Down syndrome?

Children with Down syndrome are known to have intellectual disability and a wide variety of malformations, such as congenital heart defects, small ears, small mouths, and other physical findings, along with medical conditions such as hypothyroidism, hip dislocation, hearing loss, cataracts, atlantoaxial instability, and leukemia. In 2011, the American Academy of Pediatrics (AAP) updated its guidelines for health supervision of the child with Down syndrome to assist the pediatrician to care for the child with Down syndrome (https://pediatrics.aappublications.org/content/128/2/393). These guidelines seem straightforward, but they do not take into account the practicality of delivering that care. Two studies in this volume of The Journal should make us pause and re-consider who should care for children with Down syndrome, and how that care should be delivered. Joslyn et al used application programming interfaces in a population-based US sample of individuals with Down syndrome to determine the distances between an individual and a set of comprehensive Down syndrome specialty care clinics. One in 5 individuals was found to have significant geographic obstacles to receiving this specialty care. In another retrospective, population-based Hong Kong cohort of live births with Down syndrome from 1995 to 2014, Chua et al found that 1- and 5-year survival in Down syndrome were 94.4% and 92.6%, respectively, now similar to that which is seen in Western countries; the mortality rate in Hong Kong decreased significantly in the early 2000s. Meanwhile the live birth rate of children with Down syndrome declined steeply in Hong Kong over the past decades, from 11.8 per 10 000 live births in 1995 to 3.4 per 10 000 in 2014. With declining birth rates, yet a higher prevalence of childhood and adult survivors with Down syndrome, what is the optimal model to deliver care for the individual with Down syndrome? The inaccessibility to comprehensive clinics for American families is likely a larger problem worldwide. However, primary care providers are not positioned either to deliver optimal care to individuals with Down syndrome. A 2016 study showed that pediatricians adhere poorly to AAP guidelines for health supervision in Down syndrome, though compliance could be improved by an educational intervention (J Pediatr 2016;171:262-8.e1-2). Clearly, there is a need to improve the overall delivery of health care for individuals with Down syndrome. Some potential solutions might include telehealth, implementation of pathways in electronic medical records to track the required comprehensive care, and novel partnerships of specialists and primary care providers in both pediatric and adult medicine to deliver complex care. Although Down syndrome is indeed an incredibly complex, multi-system condition, affected individuals, their families, and primary care physicians and specialists in both pediatric and adult medicine have an opportunity to partner to provide a uniquely new model for complex care delivery in the 21st century. Article page 138 and 146▸

The impact of underinsurance on bladder cancer diagnosis, survival, and care delivery for individuals under the age of 65years.

Health insurance is a key mediator of health care disparities. Outcomes in bladder cancer, one of the costliest diseases to treat, may be especially sensitive to a patient's insurance status. The Surveillance, Epidemiology, and End Results registry and the National Cancer Data Base were used to identify individuals younger than 65years who were diagnosed with bladder cancer from 2007 to 2014. The associations between the insurance status (privately insured, insured by Medicaid, or uninsured) and the following outcomes were evaluated: diagnosis with advanced disease, cancer-specific survival, delay in treatment longer than 90days, treatment in a high-volume hospital, and receipt of neoadjuvant chemotherapy (NAC). Compared with those with private insurance, uninsured and Medicaid-insured individuals were nearly twice as likely to receive a diagnosis of muscle-invasive bladder cancer (odds ratio [OR] for uninsured individuals, 1.90; 95% confidence interval [CI], 1.70-2.12; OR for Medicaid-insured individuals, 2.03; 95% CI, 1.87-2.20). They were also more likely to die of bladder cancer (adjusted hazard ratio [AHR] for uninsured individuals, 1.49; 95% CI, 1.31-1.71; AHR for Medicaid-insured individuals, 1.61; 95% CI, 1.46-1.79). Delays in treatment longer than 90days were more likely for uninsured (OR, 1.36; 95% CI, 1.12-1.65) and Medicaid-insured individuals (OR, 1.22; 95% CI, 1.03-1.44) in comparison with the privately insured. Uninsured patients had lower odds of treatment at a high-volume facility, and Medicaid-insured patients had lower odds of receiving NAC (P<.001 for both). Compared with privately insured individuals, uninsured and Medicaid-insured individuals experience worse prognoses and poorer care quality. Expanding high-quality insurance coverage to marginalized populations may help to reduce the burden of this disease.