Differences In Rates Of Surgery Research Articles

Access to and Timeliness of Lung Cancer Surgery, Radiation Therapy, and Systemic Therapy in New Zealand: A Universal Health Care Context.

Lung cancer is the biggest cancer killer of indigenous peoples worldwide, including Māori people in New Zealand. There is some evidence of disparities in access to lung cancer treatment between Māori and non-Māori patients, but an examination of the depth and breadth of these disparities is needed. Here, we use national-level data to examine disparities in access to surgery, radiation therapy and systemic therapy between Māori and European patients, as well as timing of treatment relative to diagnosis. We included all lung cancer registrations across New Zealand from 2007 to 2019 (N = 27,869) and compared access with treatment and the timing of treatment using national-level inpatient, outpatient, and pharmaceutical records. Māori patients with lung cancer appeared less likely to access surgery than European patients (Māori, 14%; European, 20%; adjusted odds ratio [adj OR], 0.82 [95% CI, 0.73 to 0.92]), including curative surgery (Māori, 10%; European, 16%; adj OR, 0.72 [95% CI, 0.62 to 0.84]). These differences were only partially explained by stage and comorbidity. There were no differences in access to radiation therapy or systemic therapy once adjusted for confounding by age. Although it appeared that there was a longer time from diagnosis to radiation therapy for Māori patients compared with European patients, this difference was small and requires further investigation. Our observation of differences in surgery rates between Māori and European patients with lung cancer who were not explained by stage of disease, tumor type, or comorbidity suggests that Māori patients who may be good candidates for surgery are missing out on this treatment to a greater extent than their European counterparts.

The McKenzie Method versus guideline-based advice in the treatment of sciatica: 24-month outcomes of a randomised clinical trial

Objective To compare the effectiveness of a McKenzie Method intervention in patients with sciatica with guideline-based patient education. Design Multi-centre, assessor-blinded, parallel-group, randomised trial Setting Two tertiary hospitals providing operative spinal care. Subjects Sciatica patients with magnetic resonance imaging-confirmed lumbar disc herniation compressing a nerve root. Interventions The McKenzie group received specific back exercises for seven visits combined with an educational book, and the Control group received a single session of self-management guidance according to usual practices. Main measures The primary outcome was the number of surgical operations. Secondary outcomes were pain measured using the Visual Analogue Scale, disability using the Oswestry Disability Index and health-related quality of life using a RAND-36 questionnaire at baseline and 24-month follow-up. Results Altogether 66 patients, mean age of 43 years, of which 50% were females with long-lasting sciatica, mean 16 weeks, were randomised to two groups. Nineteen patients (29%) had surgery. There was no significant difference in surgery rates between the groups. Back and leg pain decreased, and disability improved in both groups. Health-related quality of life improved in six dimensions out of eight in both groups. There were no significant between-group changes in the patient-reported outcomes at the follow-up. Conclusions Multiple sessions of McKenzie-based back exercises with a McKenzie-specific patient's educational book produced effects equal to guideline-based advice at long-term follow-up. However, the power of these results is diminished due to the small patient population and confounding factors.

Medicaid Insurance is Associated with Treatment Disparities for Proximal Humerus Fractures in a National Database Analysis.

Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs. We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010-2019 were identified by ICD-9/10 diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, non-infectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications. We included 245,396 patients for analysis. 14% of Medicaid patients (1,789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately-insured patients and 16% (13,305/83,068) of Medicare patients (pairwise p < 0.001). TTS (Medicaid: 11.7 days, private: 10.6 days (p < 0.001), Medicare: 10.7 days (p = 0.003)) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio [OR]: 0.77 [95% confidence interval (CI): 0.63 - 0.93] for private vs Medicaid, and 0.71 [95% CI: 0.59 - 0.88] for Medicare vs Medicaid) and experienced fewer 90-day postoperative complications (adjusted ORs: 0.73 [95% CI: 0.62 - 0.85] for private vs Medicaid, 0.65 [95% CI: 0.55 - 0.77] for Medicare vs Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications. There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality-improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers patients face and minimize healthcare inequities seen in the treatment of PHFs based on insurance type.

Multicenter retrospective cohort study of the association between surgery for odontoid fractures in the elderly and in-hospital outcomes

Odontoid fractures are increasingly prevalent in older adults and associated with high morbidity and mortality. Optimal management remains controversial. Our study aims to investigate the association between surgical management of odontoid fractures and in-hospital mortality in a multi-center geriatric cohort. We identified patients 65 years or older with C2 odontoid fractures from the Trauma Quality Improvement Program database. The primary study outcome was in-hospital mortality. Secondary outcomes were in-hospital complications and hospital length of stay. Generalized estimating equation models were used to compare outcomes between operative and non-operative cohorts. Among the 13,218 eligible patients, 1100 (8.3%) were treated surgically. The risk of in-hospital mortality did not differ between surgical and non-surgical groups, after patient and hospital-level adjustment (OR: 0.94, 95%CI: 0.55–1.60). The risks of major complications and immobility-related complications were higher in the operative cohort (adjusted OR: 2.12, 95%CI: 1.53–2.94; and OR: 2.24, 95%CI: 1.38–3.63, respectively). Patients undergoing surgery had extended in-hospital length of stay compared to the non-operative group (9 days, IQR: 6–12 days vs. 4 days, IQR: 3–7 days). These findings were supported by secondary analyses that considered between-center differences in rates of surgery. Among geriatric patients with odontoid fractures surgical management was associated with similar in-hospital mortality, but higher in-hospital complication rates compared to non-operative management. Surgical management of geriatric patients with odontoid fractures requires careful patient selection and consideration of pre-existing comorbidities.

Association of Variation in US County-Level Rates of Liver Surgical Resection for Colorectal Liver Metastasis With Poverty Rates in 2010

Among patients with colorectal liver metastasis (CRLM) who are eligible for curative-intent liver surgical resection, only half undergo liver metastasectomy. It is currently unclear how rates of liver metastasectomy vary geographically in the US. Geographic differences in county-level socioeconomic characteristics may, in part, explain variability in the receipt of liver metastasectomy for CRLM. To describe county-level variation in the receipt of liver metastasectomy for CRLM in the US and its association with poverty rates. This ecological, cross-sectional, and county-level analysis was conducted using data from the Surveillance, Epidemiology, and End Results Research Plus database. The study included the county-level proportion of patients who had colorectal adenocarcinoma diagnosed between January 1, 2010, and December 31, 2018, underwent primary surgical resection, and had liver metastasis without extrahepatic metastasis. The county-level proportion of patients with stage I colorectal cancer (CRC) was used as a comparator. Data analysis was performed on March 2, 2022. County-level poverty in 2010 obtained from the US Census (proportion of county population below the federal poverty level). The primary outcome was county-level odds of liver metastasectomy for CRLM. The comparator outcome was county-level odds of surgical resection for stage I CRC. Multivariable binomial logistic regression accounting for clustering of outcomes within a county via an overdispersion parameter was used to estimate the county-level odds of receiving a liver metastasectomy for CRLM associated with a 10% increase in poverty rate. In the 194 US counties included in this study, there were 11 348 patients. At the county level, the majority of the population was male (mean [SD], 56.9% [10.2%]), White (71.9% [20.0%]), and aged between 50 and 64 (38.1% [11.0%]) or 65 and 79 (33.6% [11.4%]) years. The adjusted odds of undergoing a liver metastasectomy was lower in counties with higher poverty in 2010 (per 10% increase; odds ratio, 0.82 [95% CI, 0.69-0.96]; P = .02). County-level poverty was not associated with receipt of surgery for stage I CRC. Despite the difference in rates of surgery (mean county-level rates were 0.24 for liver metastasectomy for CRLM and 0.75 for surgery for stage I CRC), the variance at the county-level for these 2 surgical procedures was similar (F370, 193 = 0.81; P = .08). The findings of this study suggest that higher poverty was associated with lower receipt of liver metastasectomy among US patients with CRLM. Surgery for a more common and less complex cancer comparator (ie, stage I CRC) was not observed to be associated with county-level poverty rates. However, county-level variation in surgical rates was similar for CRLM and stage I CRC. These findings further suggest that access to surgical care for complex gastrointestinal cancers such as CRLM may be partially influenced by where patients live.

DOP56 Long-term disease progression and resective surgery rates in Crohn’s disease over different therapeutic eras – a population-based study from western Hungary between 1977–2020, data from the Veszprem county cohort

Abstract Background Few population-based studies have investigated the long-term surgery rates of Crohn’s disease (CD). The present study is a continuation of the Veszprem IBD population based cohort with a follow-up since 1977. Our aim was to analyze the long-term disease course and surgery rates over different therapeutic eras in a prospective population-based database from Veszprem Province, including incident CD patients. Methods Patient inclusion was between January 1, 1977 and December 31, 2018; follow-up ended December 31, 2020. Both in-hospital and outpatient records were collected and comprehensively reviewed at diagnosis and during clinical follow-up. Surgery rates were examined in three different eras based on time of diagnosis: cohort-A, 1977-1995; cohort-B, 1996-2008; and cohort-C, 2009-2018. Results Data of 946 incident CD patients were analyzed (male/female: 496/450; median age at diagnosis:28 years(y) [IQR: 22-40]), with a median of 15y(IQR 9-21) follow-up.Table 1. Overall immunosuppressive therapy use was increasing by time (48.0%/62.4%/65.5%), as well as the probability of biological therapy initiation within 5 years of diagnosis (0.0±0%/7.3±1.2%/22.7±2.2%) in cohorts A/B/C. Figure 1. The cumulative probability of disease behavior progression in patients with luminal (B1) behavior into stenosing or penetrating phenotype (B2/B3) was 27.1±5.3%/ 21.5±2.5%/ 11.3±2.2% in cohorts A/B/C after 5 years (pLogRank&amp;lt;0.001). Figure 2. The cumulative probability of resective surgery in the total population was 34.2±1.6% after 10 years, 44.9±2.0% after 20 years, and 61.9±4.2% after 30 years. The cumulative probability of first resective surgery between cohorts A/B/C were as follows: 28.7±3.7%/ 26.3±2.1%/ 28.1±2.4% after 5 years; 39.4±4.0%/ 32.6±2.2%/ 33.0±2.7% after 10 years; and 54.5±4.1%/ 41.4±2.6% (cohorts A/B) after 20 years. There were no statistically significant differences in surgery rates between the cohorts overall [pLogRank=0.055], however a notable decrease in long-term (20y) surgery rates was observed comparing cohorts B and C vs. cohort A.Figure 3. A cox-regression multivariate analysis showed that stenosing or penetrating disease (B2/B3) behavior (HR 4.52; 95%CI 3.60-5.68; p&amp;lt;0.001) and ileal (L1) location at diagnosis (HR 1.30; 95%CI 1.05-1.61; p=0.016) were independent predictors of resective surgery.Table 2. Conclusion Disease behavior progression decreased, however no differences in resective surgery risk at 5 and 10 years from diagnosis have been observed in incident CD patients despite the increasing use of immunosuppressives and biologicals in this population based cohort. However, a decrease is shown in long term (20y) surgery risk comparing the earliest cohort to latter ones with higher immunosuppressive and biological use.

What are the health consequences associated with differences in medical malpractice liability laws? An instrumental variable analysis of surgery effects on health outcomes for proximal humeral facture across states with different liability rules

BackgroundStates enacted tort reforms to lower medical malpractice liability, which are associated with higher surgery rates among Medicare patients with shoulder conditions. Surgery in this group often entails tradeoffs between improved health and increased risk of morbidity and mortality. We assessed whether differences in surgery rates across states with different liability rules are associated with surgical outcomes among Medicare patients with proximal humeral fracture.MethodsWe obtained data for 67,966 Medicare beneficiaries with a diagnosis of proximal humeral fracture in 2011. Outcome measures included adverse events, mortality, and treatment success rates, defined as surviving the treatment period with < $300 in shoulder-related expenditures. We used existing state-level tort reform rules as instruments for surgical treatment and separately as predictors to answer our research question, both for the full cohort and for stratified subgroups based on age and general health status measured by Charlson Comorbidity Index and Function-Related Indicators.ResultsWe found a 0.32 percentage-point increase (p < 0.05) in treatment success and a 0.21 percentage-point increase (p < 0.01) in mortality for every 1 percentage-point increase in surgery rates among patients in states with lower liability risk. In subgroup analyses, mortality increased among more vulnerable patients, by 0.29 percentage-point (p < 0.01) for patients with Charlson Comorbidity Index > = 2 and by 0.45 percentage-point (p < 0.01) among those patients with Function-Related Indicator scores > = 2. On the other hand, treatment success increased in patients with lower Function-Related Index scores (< 2) by 0.54 percentage-point (p < 0.001). However, younger Medicare patients (< 80 years) experienced an increase in both mortality (0.28 percentage-point, p < 0.01) and treatment success (0.89 percentage-point, p < 0.01). The reduced-form estimates are consistent with our instrumental variable results.ConclusionsA tradeoff exists between increased mortality risk and increased treatment success across states with different malpractice risk levels. These results varied across patient subgroups, with more vulnerable patients generally bearing the brunt of the increased mortality and less vulnerable patients enjoying increased success rates. These findings highlight the important risk-reward scenario associated with different liability environments, especially among patients with different health status.

Racial Disparities in Surgical Treatment of Obstructive Sleep Apnea.

ObjectiveDetermine risk factors for failure to receive surgical treatment among patients with obstructive sleep apnea.Study DesignPopulation-based observational longitudinal cohort study.SettingPopulation-based database.MethodsMultivariate analysis of 500,792 individuals with obstructive sleep apnea from Optum’s deidentified Clinformatics Data Mart database (2004-2018).ResultsBlack race, increased age, diabetes, atrial fibrillation, obesity, and congestive heart failure were independently associated with a decreased rate of surgery for obstructive sleep apnea. Asian race, hypertension, arrhythmias other than atrial fibrillation, pulmonary disease, and liver disease were independently associated with an increased rate of surgery for obstructive sleep apnea.ConclusionRacial disparities in health outcomes related to health care access and in economic resources have an enormous impact on public health and social equity. We found differences in rates of surgery for obstructive sleep apnea based on race. These data are consistent with others demonstrating disparities in medical treatment of sleep apnea with positive pressure and underline a need for a change in awareness and treatment in these populations.

State medical malpractice laws and utilization of surgical treatment for rotator cuff tear and proximal humerus fracture: an observational cohort study

BackgroundHow much does the medical malpractice system affect treatment decisions in orthopaedics? To further this inquiry, we sought to assess whether malpractice liability is associated with differences in surgery rates among elderly orthopaedic patients.MethodsMedicare data were obtained for patients with a rotator cuff tear or proximal humerus fracture in 2011. Multivariate regressions were used to assess whether the probability of surgery is associated with various state-level rules that increase or decrease malpractice liability risks.ResultsStudy results indicate that lower liability is associated with higher surgery rates. States with joint and several liability, caps on punitive damages, and punitive evidence rule had surgery rates that were respectively 5%-, 1%-, and 1%-point higher for rotator cuff tears, and 2%-, 2%- and 1%-point higher for proximal humerus fractures. Conversely, greater liability is associated with lower surgery rates, respectively 6%- and 9%-points lower for rotator cuff patients in states with comparative negligence and pure comparative negligence.ConclusionsMedical malpractice liability is associated with orthopaedic treatment choices. Future research should investigate whether treatment differences result in health outcome changes to assess the costs and benefits of the medical liability system.

Medicaid expansion and the management of pancreatic cancer.

Medicaid expansion under the Affordable Care Act has improved access to screening and treatment for certain cancers. It is unclear how this policy has affected the diagnosis and management of pancreatic cancer. Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during two time periods: pre-expansion (2011-2012) and postexpansion (2015-2016). We investigated changes in cancer staging, treatment decisions, and surgical outcomes. In this national cohort, pancreatic cancer patients in expansion states had increased Medicaid coverage relative to those in nonexpansion states (DID = 17.49, p < 0.01). Medicaid expansion also led to an increase in early-stage diagnoses (Stage I/II, DID = 4.71, p = 0.03), higher comorbidity scores among surgical patients (Charlson/Deyo score 0: DID = -13.69, p = 0.02), a trend toward more neoadjuvant radiation (DID = 6.15, p = 0.06), and more positive margins (DID = 11.69, p = 0.02). There were no differences in rates of surgery, postoperative outcomes, or overall survival. Medicaid expansion was associated with improved insurance coverage and earlier stage diagnoses for Medicaid and uninsured pancreatic cancer patients, but similar surgical outcomes and overall survival. These findings highlight both the benefits of Medicaid expansion and the potential limitations of policy change to improve outcomes for such an aggressive malignancy.

Evolution of epidemiological characteristics of infective endocarditis in Greece

ObjectiveThe clinical profile, management and outcome of infective endocarditis (IE) may be influenced by socioeconomic issues. MethodsA nationwide prospective study evaluated IE during the era of deep economic crisis in Greece. Epidemiological data and factors associated with 60-day mortality were analyzed through descriptive statistics, logistic and Cox-regression models. ResultsAmong 224 patients (male 72.3%, mean age 62.4 years), Staphylococcus aureus (n = 62; methicillin-resistant S. aureus (MRSA) 33.8%) predominated in the young without impact on mortality (p = 0.593), whilst Enterococci (n = 36) predominated in the elderly. Complications of IE were associated with mortality: heart failure [OR 2.415 (95% CI: 1.159–5.029), p = 0.019], stroke [OR 3.206 (95% CI: 1.190–8.632), p = 0.018] and acute kidney injury [OR 2.283 (95% CI: 1.085–4.805), p = 0.029]. A 60-day survival benefit was solely related to cardiac surgery for IE during hospitalization [HR 0.386 (95% CI: 0.165–0.903), p = 0.028] and compliance with antimicrobial treatment guidelines [HR 0.487 (95% CI: 0.259–0.916), p = 0.026]. Compared with a previous country cohort study, history of rheumatic fever and native valve predisposition had declined, whilst underlying renal disease and right-sided IE had increased (p < 0.0001); HIV infection had emerged (p = 0.002). No difference in rates of surgery and outcome was assessed. ConclusionsA country-wide survey of IE highlighted emergence of HIV, right-sided IE and predominance of MRSA in the youth during a severe socioeconomic crisis. Compliance with treatment guidelines promoted survival.

Obesity may be associated with adjacent-segment degeneration after single-level transforaminal lumbar interbody fusion in spinopelvic-mismatched patients with a minimum 2-year follow-up.

In this study, the authors' aim was to investigate whether obesity affects surgery rates for adjacent-segment degeneration (ASD) after transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis. Patients who underwent single-level TLIF for spondylolisthesis at the University of California, San Francisco, from 2006 to 2016 were retrospectively analyzed. Inclusion criteria were a minimum 2-year follow-up, single-level TLIF, and degenerative lumbar spondylolisthesis. Exclusion criteria were trauma, tumor, infection, multilevel fusions, non-TLIF fusions, or less than a 2-year follow-up. Patient demographic data were collected, and an analysis of spinopelvic parameters was performed. The patients were divided into two groups: mismatched, or pelvic incidence (PI) minus lumbar lordosis (LL) ≥ 10°; and balanced, or PI-LL < 10°. Within the two groups, the patients were further classified by BMI (< 30 and ≥ 30 kg/m2). Patients were then evaluated for surgery for ASD, matched by BMI and PI-LL parameters. A total of 190 patients met inclusion criteria (72 males and 118 females, mean age 59.57 ± 12.39 years). The average follow-up was 40.21 ± 20.42 months (range 24-135 months). In total, 24 patients (12.63% of 190) underwent surgery for ASD. Within the entire cohort, 82 patients were in the mismatched group, and 108 patients were in the balanced group. Within the mismatched group, adjacent-segment surgeries occurred at the following rates: BMI < 30 kg/m2, 2.1% (1/48); and BMI ≥ 30 kg/m2, 17.6% (6/34). Significant differences were seen between patients with BMI ≥ 30 and BMI < 30 (p = 0.018). A receiver operating characteristic curve for BMI as a predictor for ASD was established, with an AUC of 0.69 (95% CI 0.49-0.90). The optimal BMI cutoff value determined by the Youden index is 29.95 (sensitivity 0.857; specificity 0.627). However, in the balanced PI-LL group (108/190 patients), there was no difference in surgery rates for ASD among the patients with different BMIs (p > 0.05). In patients who have a PI-LL mismatch, obesity may be associated with an increased risk of surgery for ASD after TLIF, but in obese patients without PI-LL mismatch, this association was not observed.

Association of Living in Urban Food Deserts with Mortality from Breast and Colorectal Cancer.

Food deserts are neighborhoods with low access to healthy foods and are associated with poor health metrics. We investigated association of food desert residence and cancer outcomes. In this population-based study, data from the 2000-2012 California Cancer Registry was used to identify patients with stage II/III breast or colorectal cancer. Patient residence at time of diagnosis was linked by census tract to food desert using the USDA Food Access Research Atlas. Treatment and outcomes were compared by food desert residential status. Among 64,987 female breast cancer patients identified, 66.8% were < 65years old, and 5.7% resided in food deserts. Five-year survival for food desert residents was 78% compared with 80% for non-desert residents (p < 0.0001). Among 48,666 colorectal cancer patients identified, 50.4% were female, 39% were > 65years old, and 6.4% resided in food deserts. Five-year survival for food desert residents was 60% compared with 64% for non-desert residents (p < 0.001). Living in food deserts was significantly associated with diabetes, tobacco use, poor insurance coverage, and low socioeconomic status (p < 0.05) for both cancers. There was no significant difference in rates of surgery or chemotherapy by food desert residential status for either diagnosis. Multivariable analyses showed that food desert residence was associated with highermortality. Survival, despite treatment for stage II/III breast and colorectal cancers was worse for those living in food deserts. This association remained significant withoutdifferencesin use of surgery or chemotherapy, suggesting factors other than differential care access may link food desert residence and cancer outcomes.

Abstract D105: Differences in receipt of surgery contribute to survival disparities in esophageal and gastric cancers

Abstract Introduction: Mortality disparities for gastrointestinal cancers are well described. Differences in rates of surgery across race and ethnicity may contribute to this phenomenon. In order to evaluate this, we assessed the extent to which the mortality disparity among racial/ethnic groups for gastrointestinal cancers are due to differences in operative rates. Methods: Data for patients with stage I-III esophageal and gastric cancer diagnoses between 2004-2015 were obtained from National Cancer Database. Cancers were categorized in 3 groups: mid-esophageal (ME) cancers, distal third of esophagus and cardia gastric cancers (DEC), and non-cardia gastric (NCG) cancers. Variables included demographics, receipt of surgery, tumor stage and characteristics, and hospital factors. The racial disparity in survival was measured as the hazard ratio (HR) for Black, Latinx, and Asian/Pacific Islander patients compared to White patients. A mediation analysis was performed to quantify the contribution of variables to the observed disparity between minority and White patients. The magnitude of the contributions was estimated using two methods: the change in HR with (1) the addition of each variable of interest to a model only adjusted by age and year, and (2) the removal of each variable from a multivariate model that included all variables. Factors associated with undergoing surgery were also examined using a logistic regression model. Results: A total of 124,862 patients were included (20,852 with ME, 74,427 with DEC, and 29,583 with NCG). Black patients were more likely to be from lower-income and urban areas and had lower operative rates in all cancers. The observed HRs for Black patients compared to White patients were 1.42 (95% CI 1.36-1.49) for ME, 1.36 (1.31-1.43) for DEC and 1.01 (0.97-1.05 – no observed disparity) for NCG tumors, adjusting for age and year of diagnosis. Only Black race/ethnicity was associated with a mortality disadvantage compared to White patients. Without adjustment for any additional variables, receipt of surgery accounted for more than half of the observed survival disparity for tumors of the esophagus and cardia (ΔHRs for ME: 0.27, DECS: 0.25 and NCG: 0.07). After adjustment for tumor, patient and hospital factors, receipt of surgery remained the single strongest contributor to the Black/White disparity in survival for all cancers (ΔHRs for ME: 0.070, DEC: 0.091 and NCG: 0.07). On logistic regression, Black patients were less likely to have received surgery after adjusting for other variables compared to White patients (ME aOR: 0.41 (0.37-0.46), DECS aOR: 0.42 (0.39-0.46), and NCG aOR: 0.79 (0.73-0.86)). Conclusions: Observed survival disparities in upper GI cancers may be due to fewer surgeries being performed for Black patients. Addressing differences in receipt of surgery for stage I through III esophageal and proximal stomach cancer has potential to mitigate cancer mortality disparities. Citation Format: John Bliton, Peter Muscarella, Michael Parides, Katia Papalezova, John McAuliffe, Haejin In. Differences in receipt of surgery contribute to survival disparities in esophageal and gastric cancers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D105.

Abstract A105: Racial disparities in reasons for not receiving surgery for gastrointestinal cancer

Abstract Introduction: Differences in rates of surgery performed for gastrointestinal (GI) cancers contribute to racial disparities in cancer mortality. The National Cancer Database (NCDB) contains data obtained from Commission on Cancer-accredited hospital cancer registries and collects reasons for nonreceipt of surgery as a registry item. This study aims to examine whether racial disparities exist in this provided reason for not receiving surgery. Methods: The NCDB was used to obtain data for patients diagnosed with gastric, pancreatic, and colorectal cancer in years 2004-2015. Analysis was limited to patients who were Black or White, and cancers stages 1-3. Unadjusted and adjusted differences between Black and White patients were examined for all variables in the model. Variables included demographics, receipt of surgery, reason for not having surgery, tumor stage and characteristics, and hospital factors. Reasons for patients' not receiving surgery were evaluated with Generalized Linear Modeling regression to see if certain responses, such as “contraindicated due to patient risk factors,”, “not part of the planned first course treatment,” and “refused by the patient” were more frequently assigned to Black compared to White patients. Results: 540,205 patients with stage 1-3 gastrointestinal cancer were included in the study. 43% of the cohort had colon cancer, 24% rectal cancer, 11% gastric cancer, and 22% pancreatic cancer. For stage 1-3 disease, the raw operative rate for Black patients was 0.3%, 6.6%, 2.0%, and 6.7% lower than in White patients for stomach, pancreas, colon, and rectum cancers, respectively. These gaps widened when adjusted for age, comorbidities, and stage. On multivariate regression, Black patients were more likely to be recorded as being denied surgery due to patient risk factors even after controlling for age, stage, comorbidities, tumor characteristics, demographics, and hospital factors: OR 1.03 (95% CI 0.91-1.16), 1.25 (1.18-1.33), 1.43 (1.22-1.66), 1.63 (1.41-1.88) for stomach, pancreas, colon, and rectum cancer, respectively. Similarly, Black patients were more likely to reportedly not receive surgery due to surgery “not being the first course of treatment”: OR 0.99 (0.93-1.05), 1.14 (1.09-1.19), 1.30 (1.21-1.39), 1.33 (1.26-1.41). These two factors explain more than 80% of the difference in operative rates. Lastly, Black patients were disproportionately more likely to be recorded as having refused surgery: OR 1.84 (1.61-2.12), 1.07 (0.96-1.19), 1.59 (1.45-1.75), 1.81 (1.61-2.02). Conclusion: Compared to White patients, Black patients are more likely to be described as not receiving surgery due to patient risk factors, surgery not being part of their first course of treatment, and their having refused surgery. Further studies are needed to evaluate whether the differences in operative rates are attributable to factors not captured in cancer registries, such as frailty and lack of social support. Citation Format: John Bliton, Michael Parides, John McAuliffe, Peter Muscarella, Haejin In. Racial disparities in reasons for not receiving surgery for gastrointestinal cancer [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A105.

Do Decision Aids Benefit Patients with Chronic Musculoskeletal Pain? A Systematic Review.

To review the effect of patient decision aids for adults making treatment decisions regarding the management of chronic musculoskeletal pain. We performed a systematic review of randomized controlled trials of adults using patient decision aids to make treatment decisions for chronic musculoskeletal pain in the outpatient setting. Of 477 records screened, 17 met the inclusion criteria. Chronic musculoskeletal pain conditions included osteoarthritis of the hip, knee, or trapeziometacarpal joint and back pain. Thirteen studies evaluated the use of a decision aid for deciding between surgical and nonsurgical management. The remaining four studies evaluated decision aids for nonsurgical treatment options. Outcomes included decision quality, pain, function, and surgery utilization. The effects of decision aids on decision-making outcomes were mixed. Comparing decision aids with usual care, all five studies that examined knowledge scores found improvement in patient knowledge. None of the four studies that evaluated satisfaction with the decision-making process found a difference with use of a decision aid. There was limited and inconsistent data on other decision-related outcomes. Of the eight studies that evaluated surgery utilization, seven found no difference in surgery rates with use of a decision aid. Five studies made comparisons between different types of decision aids, and there was no clearly superior format. Decision aids may improve patients' knowledge about treatment options for chronic musculoskeletal pain but largely did not impact other outcomes. Future efforts should focus on improving the effectiveness of decision aids and incorporating nonpharmacologic and nonsurgical management options.

Effects of Social Disparities on Management and Surgical Outcomes for Patients with Secondary Hyperparathyroidism.

Nearly 80% of chronic renal failure patients have secondary hyperparathyroidism. Cinacalcet is used to lower parathyroid hormone; however, it is expensive and has side effects. When secondary hyperparathyroidism is resistant to medication or medications are inaccessible, parathyroidectomy is performed. Race and socioeconomic status influence access to care and surgical outcomes. We sought to evaluate the effect of race and socioeconomic status on parathyroidectomy rate as well as surgical outcomes of patients with secondary hyperparathyroidism. We undertook cross-sectional analysis of adults diagnosed with secondary hyperparathyroidism in the USA between 2012 and 2014, using the National Inpatient Sample. Univariate and multivariate analyses were used to determine associations between social disparities, likelihood to undergo parathyroidectomy, and surgical outcomes. Between 2012 and 2014, a national estimate of 724,170 hospitalizations wereidentified where patients had a diagnosis of secondary hyperparathyroidism. Operative rate was 0.67%. By socioeconomic status, differences in rates of surgery in the poorest compared to the richest were not significant (0.74% vs. 0.55%, OR 1.08, p = 0.5). African-American patients had higher rates of parathyroidectomy compared to Caucasians (1 vs. 0.74%, OR 1.49, p < 0.001). African-American patients also had a trend toward more complications and greater length of stay. According to a large administrative dataset, parathyroidectomy for secondary hyperparathyroidism is seldom used in the USA. African-American patients have higher rates of surgical management. Surgical outcomes may be affected by race. Clinicians treating secondary hyperparathyroidism should be aware of existing disparities within their health system.

Epidemiology of Glenohumeral Instability Related to Sporting Activities Using the FEDS (Frequency, Etiology, Direction, and Severity) Classification System: A Multicenter Analysis.

Background:Glenohumeral instability is common in athletes. There are an estimated 0.12 episodes of instability per 1000 sporting exposures. Instability can lead to time away from sport and an increased risk of shoulder arthritis.Purpose:To determine the prevalence, demographic data, anatomic features, and likelihood of surgery for the different types of instability as defined by the FEDS (frequency, etiology, direction, and severity) classification system for different sports.Study Design:Cohort study; Level of evidence, 3.Methods:Databases at 3 institutions (University of Iowa, Vanderbilt University, and University of Pennsylvania) were searched for International Classification of Diseases--Ninth Revision codes related to shoulder instability in 2010. Demographic data, symptoms, causes, imaging findings, and operative reports were obtained. Data were entered into a custom-designed REDCap online survey. Patients with subjective instability related to sporting activities were included for analysis.Results:A total of 184 athletes had glenohumeral instability; 20.1% were female. The mean age at the time of the first instability episode was 19.0 years for both male and female patients. The most common sports were football (29.3%), basketball (19.0%), and wrestling (9.8%). The most common type of instability based on the FEDS system was occasional, traumatic, anterior dislocation. Surgery was performed on 69.6% of athletes, and 14.1% had a recurrence of instability after surgery overall. Football had the highest rate of recurrence postoperatively at 23.8%. There was no difference in surgery rates between athletes with subluxations versus dislocations (P = .8458). Surgery was significantly more likely in those with frequent dislocations (P < .0001) and posterior instability (P = .027). There was a 10.7% recurrence rate overall with conservative treatment.Conclusion:Glenohumeral instability most commonly occurs in contact sports, affects male more than female patients, and is most frequently in the anterior direction. Recurrent instability is most common in football players. Attention should be turned to the specific characteristics of each type of instability to determine the best treatment for each athlete.

The Epilepsy Surgery Grading Scale: Validation in an independent population with drug-resistant focal epilepsy.

The Epilepsy Surgery Grading Scale (ESGS) is a simple tool that predicts a patient's likelihood of progressing to resective surgery and becoming seizure-free. The aim of our study was to validate the ESGS in an independent patient cohort. We retrospectively calculated the ESGS score for adult patients with drug-resistant focal epilepsy undergoing presurgical evaluation at two reference centers for drug-resistant epilepsy in Belgium. We classified patients into ESGS grade 1 (most favorable), grade 2 (intermediate), and grade 3 (least favorable). We assessed progression to surgery and postsurgical seizure freedom. A total of 238 patients underwent presurgical evaluation (presurgical cohort), of whom 140 progressed to surgery (surgical cohort). In the presurgical cohort, we observed significant differences in rates of surgery and in rates of seizure freedom between grades 1, 2, and 3. In the surgical cohort, we observed significant differences in rates of seizure freedom between grades 1 and 2 and between grades 1 and 3. We confirm the usefulness of the ESGS for the prognostic stratification of patients with drug-resistant focal epilepsy undergoing presurgical evaluation. Our results support the use of the ESGS in the decision process of presurgical evaluation in clinical practice.

Mandated health insurance increases rates of elective knee surgery.

BACKGROUNDThe recent federal ruling to against Affordable Care Act (ACA), specifically the mandate requiring people to buy insurance, has once again brought the healthcare reform debate to the spotlight. The ACA increased the number of insured Americans through the development of subsidized healthcare plans and health insurance exchanges. Insurance-based differences in the rate of upper extremity elective orthopaedic surgery have been described before and after healthcare reform in Massachusetts, where a similar mandate was put into place years before the ACA was passed. However, no comprehensive study has evaluated insurance-based differences of knee elective surgery before and after reform.AIMTo investigate how an individual mandate to purchase health insurance affects rates of knee surgery.METHODSA retrospective review was performed within an orthopaedic surgery department at a tertiary-care, academic medical center in Massachusetts. The rate of elective knee surgery performed before and after the healthcare reform (2005-2006 and 2007-2010, respectively) was calculated. The patients were categorized by insurance type (Commonwealth Care, Medicare, Medicaid, private insurance, Workers’ Compensation, TriCare, and Uninsured). Using χ2 testing, differences in rates of surgery between the pre-reform and post-reform period and among insurance subgroups were calculated.RESULTSRate of surgery increased in the post-reform period (pre-reform 8.07% (95%CI: 7.03%-9.11%), post-reform 9.38% (95%CI: 8.74%-10.03%) (P = 0.04) and was statistically significant. When the insurance groups and insurance types were compared, the rates of surgery are not significantly different before or after reform.CONCLUSIONThe increase in the rate of elective knee surgery in the post-reform period suggests that health care reform in Massachusetts has been successful in decreasing the uninsured population and may increase health care expenditures. This is a hypothesis generating study that suggests further avenues of study on how mandated coverage may change healthcare utilization and cost.