Disparities In Administration Research Articles

Understanding Racial and Ethnic Disparities in Perioperative Pain Management After Routine Pediatric Tonsillectomy

ABSTRACTBackgroundHispanic/Latino (H/L) patients are often excluded from studies addressing pain management. Limited data suggests disparities in administration of perioperative opioid analgesia. We hypothesize that H/L patients are less likely to have their pain assessed and managed appropriately with opioids following routine pediatric tonsillectomy.AimsOur primary outcome was to compare the proportion of H/L patients who receive perioperative opioids to their non‐H/L counterparts. Secondarily, we studied the proportion of H/L patients who had their pain score assessed.MethodsA retrospective medical record review of patients receiving routine tonsillectomy from October 2017 to March 2022 was performed. Descriptive statistics, univariate, and multivariate analyses were conducted with levels of significance at 0.05 and calculation of adjusted odds ratios (aORs).ResultsOf 6553 patients included, 582 (9%) of those self‐identified as H/L. The median age of the cohort was 5.6 years (IQR 3.4–9.1) and 53.3% identified as male. H/L patients were more likely to have a higher BMI (p < 0.001), have an income level of < $100 000/year (p < 0.001), and utilize public insurance (p < 0.001) than non‐H/L patients. On multivariate analysis, non‐H/L patients were less likely to receive opioids (aOR 0.78 [0.66, 0.93], p = 0.006). They were also more likely to have their pain assessed (aOR 2.38 [1.75, 3.21], p < 0.001).ConclusionsDisparities in perioperative pain management following routine pediatric tonsillectomy exist. In contrast with current literature and our prior hypothesis, children of non‐H/L ethnicity were less likely to receive opioids and more likely to have their pain assessed. Given H/L patients received fewer pain assessments, they are at risk for inferior pain management. Further understanding of factors driving differences in pain management may improve perioperative patient experience, quality of care, and aid in the creation of more standardized protocols.

A meta-analysis on racial disparity in administration of tissue plasminogen activator (tPA) in stroke patients.

A meta-analysis on racial disparity in administration of tissue plasminogen activator (tPA) in stroke patients.

789 The Impact of Social Determinants on Adjuvant Radiation Following Atypical Meningioma Surgery

INTRODUCTION: WHO grade 2 meningiomas or ‘atypical meningiomas’ are a subset of meningioma associated with higher morbidity and mortality. Adjuvant radiotherapy is increasingly shown to improve survival and reduce recurrence in these tumors. METHODS: The National Cancer Database was queried for patients receiving atypical meningioma surgery between 2004 and 2019. Univariate association, univariate regression and multivariate regression were performed on 8,654 patients to assess the association between receipt of adjuvant radiation and social determinants. Secondarily, KM curves were used to compare overall patient survival between those that received radiation and those that did not. RESULTS: Adjuvant radiation was less likely to be administered to patients over age 65 (95% CI = 0.53-0.77) and more likely to be administered to males (95% CI = 1.07–1.38). Compared to the Southern USA, patients were more likely to receive radiotherapy in the Northeastern (95% CI = 1.40–2.05), Midwestern (95% CI =1.06–1.54), and Western parts of the United States (95% CI = 1.31–2.00). Patients residing furthest from the reporting facility were less likely to receive radiation (95% CI = 0.65–0.98). Patients with any kind of insurance were more likely to receive radiation (p = 0.048) than those without insurance. On multivariate analysis, no differences were found between racial groups regarding adjuvant radiation, however the univariate analysis demonstrated that compared to non-hispanic whites, non-hispanic blacks were less likely to receive radiation (95% CI = 0.64-0.94) and Asian/Pasic Islanders were more likely to receive radiation (95% CI = 1.03–1.79). CONCLUSIONS: We reveal that disparities in administration of adjuvant RT exist based on female sex, age > 65, uninsured status, distance from the treating facility, and facility regional location.

Analgesic use in ED patients with long-bone fractures: A national assessment of racial and ethnic disparities

BackgroundIt is vital to ensure equitable care is given to all patients and to eliminate any disparities in administration of analgesics and opioids in emergency department (ED) patients with long-bone fractures. Our objective was to determine whether sex, ethnic, or racial disparities still exist in administration and prescription of analgesics and opioids in ED patients with long-bone fractures using a current nationally representative database. MethodsThis was a retrospective, cross-sectional analysis of ED patients ages 15–55 years with long-bone fractures included in the National Hospital and Medical Care Survey (NHAMCS) database from 2016 to 2019. Our primary and secondary outcomes were administration of analgesics and opioids in the ED and our exploratory outcomes were prescription of analgesics and opioids in discharged patients. Outcomes were adjusted for age, sex, race, insurance, fracture location, number of fractures, and pain severity. ResultsOf the estimated 2.32 million ED patient visits analyzed, 65% received analgesics and 50% received opioids in the ED. On multivariable analyses, administration of analgesics was associated with female sex (OR 2.11; 95% CI 1.08–4.12) and Black race (OR 2.84; 95% CI 1.03–7.80), but not with Hispanic/Latino ethnicity (OR 2.09; 95% CI 0.72–6.04). No associations were found between opioid administration or analgesic or opioid prescription and female sex, Hispanic/Latino ethnicity, or Black race. ConclusionsBetween 2016 and 2019 there were no significant sex, ethnic, or racial disparities in administration or prescription of analgesics or opioids in ED adult patients with long-bone fractures.

Trends and disparities in the utilization of systemic chemotherapy in patients with metastatic hepato-pancreato-biliary cancers

BackgroundWe described trends and disparities in utilization of systemic chemotherapy in metastatic hepato-pancreato-biliary (HPB) cancers. MethodsWe queried the National Cancer Database for metastatic HPB cancers [hepatocellular carcinoma (HCC), biliary tract cancers (BTC), pancreatic adenocarcinoma (PDAC)]. We used multivariable analysis to examine the factors associated with utilization of systemic chemotherapy. We utilized marginal structural logistic models to estimate the effect of health insurance, facility type, or facility volume on utilization of systemic chemotherapy. ResultsWe identified 162,283 patients with metastatic HPB cancers: 23,923 (14.7%) had HCC, 26,766 (16.5%) had BTC, and 111,594 (68.8%) had PDAC.A total of 37.2% patients with HCC, 55.6% with BTC, and 56.4% with PDAC received chemotherapy. Age ≥70 years and Charlson-Deyo score ≥2 were associated with lower likelihood of receiving chemotherapy across all cancers.Patients with private health insurance had higher receipt of chemotherapy. Receiving treatment at academic facilities had no effect on the receipt of chemotherapy. Treatment of patients with HCC or PDAC at high-volume facilities resulted in higher receipt of chemotherapy. ConclusionA significant proportion of patients with metastatic HPB cancers do not receive systemic chemotherapy. Several disparities in administration of chemotherapy for metastatic HPB cancers exist.

Racial Disparities in Administration of Venous Thromboembolism Prophylaxis After Severe Traumatic Injuries.

Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients. We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders. A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed. While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.

Does Preferred Spoken Language Affect Time to Epidural for Nulliparous Patients? [A203

INTRODUCTION: Some studies have observed sociodemographic disparities in administration of intrapartum epidural anesthesia. Our objective was to determine whether preferred spoken language was associated with time to epidural administration. METHODS: This was a retrospective cohort study of all nulliparous patients admitted for labor or induction at one academic hospital in New York who received intrapartum epidural analgesia prior to delivery from January to December 2019. The outcome was time to epidural, which was evaluated for English-speaking and non-English-speaking patients. For patients undergoing scheduled induction, time to epidural was defined as the interval from induction agent to epidural administration. For patients admitted in spontaneous labor, time to epidural was defined as the time interval from hospital presentation to epidural administration. Demographic and clinical data were collected. Patients in the induction and spontaneous labor groups were analyzed separately. RESULTS: A total of 417 patients were included: 215 (52%) inductions and 202 (48%) presenting in spontaneous labor. Overall, 264 (63%) patients preferred English and 153 (47%) preferred another language (primarily Spanish). In the spontaneous labor group, there was no difference in time to epidural between English-speaking and non-English-speaking patients (307 versus 272 minutes, respectively). Among scheduled inductions, time to epidural was lower for English speakers than non-English speakers (869 versus 1,100 minutes, respectively; P&lt;.01). English-speaking patients were more likely to be induced (56% versus 43%, P&lt;.01). Sociodemographic factors such as age, race/ethnicity, and marital status were not associated with time to epidural. CONCLUSION: Preferred language was not associated with time to epidural in the spontaneous labor group, but a significant difference was noted for patients undergoing induction. Non-English-speakers may experience delayed analgesic interventions.

Racial and Socioeconomic Disparities in the Delivery of Immunotherapy for Metastatic Melanoma in the United States.

Immunotherapy for metastatic melanoma has rapidly expanded, but racial and/or socioeconomic factors often impact the type of therapies delivered for cancer care. This study addressed a crucial public health priority by evaluating disparities in administration of immunotherapy for metastatic melanoma. The National Cancer Database was queried for newly diagnosed metastatic melanoma. Patients were dichotomized based on receipt of immunotherapy based on National Cancer Database coding. Multivariable logistic regression ascertained factors associated with immunotherapy delivery. Subgroup analysis evaluated the interaction between race, insurance status, and income. Secondarily, Cox multivariate and propensity-matched Kaplan-Meier analyses assessed overall survival based on immunotherapy receipt. Of 15,941 patients meeting the selection criteria, 2448 (15.4%) received immunotherapy, and 13,493 (84.6%) did not. Temporal trends showed that utilization of immunotherapy was 8%-12% of patients between 2004 and 2010, with utilization increasing to 29.7% of patients in 2014. Immunotherapy was more likely administered to younger and healthier patients, at academic centers, and in the absence of chemotherapy and brain metastases (P<0.05 for all). African Americans, along with patients with Medicaid and lower incomes were less likely to receive immunotherapy (P<0.05 for all). As expected, immunotherapy was associated with improved overall survival (median 16.3 vs. 8.3 mo, P<0.001). Although immunotherapy for metastatic melanoma is markedly escalating, not all populations experience this rise equally. Because immunotherapy utilization is expected to amplify even further in the future, these public health and economic issues are essential to identify and address appropriately, and have implications on public health policy, pharmaceutical and insurance companies, and value-based oncology. Methods to address these inequalities are also discussed.

Racial and Insurance-related Disparities in Delivery of Immunotherapy-type Compounds in the United States.

Racial and/or socioeconomic factors affect the type of therapies delivered for non-small cell lung cancer (NSCLC). Given the rapid expansion of immunotherapy for NSCLC, it is a crucial public health priority to evaluate disparities in administration thereof. The National Cancer Database (NCDB) was queried for newly diagnosed metastatic NSCLC. Patients were dichotomized based on receipt of immunotherapy-type compounds (ICs) based on NCDB coding. Multivariable logistic regression ascertained factors associated with IC delivery. Subgroup analysis, performed by univariate logistic regression modeling, evaluated the effect of race while stratifying for insurance type. Of 504,447 patients, 11,420 (2.3%) received ICs, and 493,027 (97.7%) did not. From 2004 to 2012, ≤1% of patients received ICs; however, 4.9% did so in 2013, 6.6% in 2014, and 8.7% in 2015. ICs were more likely administered to younger and healthier patients, those living farther from treating facilities, and in more educated areas (P<0.05 for all). ICs were more often delivered to adenocarcinomas, and patients who received chemotherapy but not radiotherapy (P<0.05 for all). In addition to geographic differences, uninsured and Medicaid populations received ICs less often, along with African Americans. On subgroup analysis, African Americans were less likely to receive ICs even when stratified for Medicare, Medicaid, or private insurances. Because IC utilization is expected to amplify even further going forward, these public health and economic issues are essential to identify and address appropriately, and have implications on pharmaceutical/insurance companies, value-based oncology, and public health policy. Methods to address these inequalities are also discussed.

Regional, racial/ethnic, and socioeconomic disparities and treatment outcomes in patients with hepatocellular carcinoma (HCC) in the United States.

424 Background: Racial/ethnic (R/E) minorities and patients of low socioeconomic (SE) status are reported to have higher mortality related to HCC than their counterparts. However, prior studies are limited to administrative datasets without annotation for clinical covariates or represent single-center data with limited generalizability. The aim of this analysis was to characterize geographic, R/E, and SE disparities in HCC presentation, treatment, and survival among a representative sample of HCC patients in the US. Methods: TARGET-HCC is an observational, retrospective/prospective study of patients with HCC from academic and community sites. Complete medical records from consented patients are abstracted into a secure database. Multivariable logistic regression with random intercepts for site and Cox proportional hazard models with frailty adjustment were fit with adjustment for age, sex, BMI, liver disease etiology (LDE) and history of alcohol abuse to identify factors associated with early HCC detection, receipt of curative-intent therapy (CIT) and overall survival. Results: 925 patients with HCC (63% non-Hispanic white, 21% black, and 8% Hispanic) were consented from 42 sites in the US (22% Northeast, 27% Southeast, 21% Midwest, 14% South, and 16% West). Median age was 64 years and 76% were men. The most common LDE was hepatitis C (72%), and 72% had Child Pugh A cirrhosis. Most patients were diagnosed with early-stage HCC (72% Barcelona Clinic Liver Cancer 0/A). CIT was the initial therapy in 249 (32%), including 32% of BCLC 0/A. Although early tumor detection and CIT did not differ by region or R/E, there were SE disparities in CIT. Among those with early stage HCC, patients with private insurance [OR = 0.51, 95% CI (0.29, 0.91)] or Medicaid [OR = 0.50, 95% CI (0.25, 0.97)] were significantly less likely to undergo CIT. Overall survival was associated with BCLC stage and type of HCC treatment, with no significant association with region, R/E, or insurance. Conclusions: In this sample of HCC patients, there were no geographic or R/E disparities in early detection, treatment, and survival although SE disparities in administration of CIT were identified and warrant further study.

The Role of HIV in Race-Based Differences in Diffuse Large B-Cell Lymphoma(DLBCL) Treatment and Outcomes

Introduction: African American (AA) race is associated with inferior survival in DLBCL compared to white (W) race (Shenoy, Cancer, 2011). This has been attributed to a disparity in administration of chemo-immunotherapy (Flowers, Cancer Epidemiol Biomarkers Prev 2012). Prevalence of human immunodeficiency virus (HIV) in AA with DLBCL is 8-fold higher than in W with DLBCL (Centers for Disease Control, 2014). We hypothesized that HIV infection is associated with a reduction in both administration of chemo-immunotherapy (rituximab) and overall survival (OS) in patients with DLBLC. We examined the relationship between race, HIV status, treatment with rituximab, and overall survival (OS) in a large cohort of United States Veterans with DLBCL with equal insurance access..Methods We identified 3,227 DLBCL pts between 1998 and 2008 in the Veterans Health Administration Central Cancer Registry. We excluded pts with primary cutaneous or central nervous system DLBCL and pts treated with unknown agents outside the VHA, 2,163 met this inclusion criterion. Given Rituximab did not become standard of care in aggressive lymphomas until approximately 2002; we did a planned sub-analysis of the 1,672 patients diagnosed and treated after January 1, 2002. Data on stage, lactate dehydrogenase (LDH), medical co-morbidities (Charlson Comorbidity Index), date of death, treatment and supportive care medications were obtained for each patient. OS was defined as time from DLBCL diagnosis to date of death. Univariate comparisons were performed to identify differences in treatment and other prognostic variables between race groups, where appropriate. Multivariable analyses were performed using logistic regression and Cox proportional hazards modeling, producing odds-ratios (OR) or hazard ratios (HR), respectively.Results: Of the 2,163 pts that met inclusion criteria, 88% were W and 12% AA. There was a higher prevalence of HIV in AA patients versus W patients (21% v. 4%, p <0.0001). Consistent with previous reports, African American race was associated with a higher frequency of elevated LDH (64% vs. 54%, p = 0.003) and younger age at diagnosis (57.6 years vs. 66 years, p=0.0001). There was no significant difference between AA race and use of rituximab compared to W race (70.4% vs. 73.7%, P= 0.271). Patients who were HIV positive were significantly less likely to receive rituximab (OR = 0.1, 95% CI 0.06 - 0.18). Patients who were HIV positive had an increased risk of death (HR = 1.67, 95% CI 1.27 - 2.2) compared to those who were HIV negative. After adjusting for HIV status in a multivariable Cox analysis, there was no racial disparity in overall survival (HR = 1.02, 95% CI 0.83 - 1.25). Kaplan-Meier analysis of age-adjusted overall survival stratified by race and HIV status is presented in Figure 1.Conclusions: Prior studies have shown detrimental survival outcomes in patient with HIV receiving Rituximab. Previously, it was also common practice to exclude Rituximab in treatment plans in HIV positive DLBCL patients (Kaplan, Blood, 2005).In this population of veterans with health insurance coverage, the observed racial disparity in survival after DLBCL diagnosis is largely explained by differences in the prevalence of HIV in the AA and W patient population. Thus, in order to reduce the racial outcome disparity among patients with DLBCL, public health efforts should focus on decreasing HIV transmission and enhancing HIV treatment in the AA community. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Sociodemographic disparities in administration of antiepileptic drugs to adults with epilepsy in Germany: a retrospective, database study of drug prescriptions.

Large epidemiological databases facilitate the study of medical care in different subgroups of the population and how such care compares with standard treatment guidelines. This study aimed for such analyses regarding utilization of antiepileptic drugs (AEDs) for epilepsy in Germany. The data source was the Disease Analyzer(®) database that is representative for the German population and assembles anonymous demographic and medical (diagnoses, prescriptions) data obtained from the practice computer system of general practitioners and specialists throughout Germany. A total of 43,712 adult patients with an epilepsy diagnosis (International Classification of Diseases, 10th edition [ICD10] code: G40.X) seen in 2010-2012 by 346 neurologists were retrospectively analysed according to sociodemographic characteristics, comorbidity, and AED treatment. Multivariate logistic regression was applied to calculate adjusted odds ratios (ORs) with 95 % confidence intervals (CIs). As compared with women, men were less likely to receive lamotrigine (OR 0.68; 95 % CI 0.65-0.72; p < 0.001) and were treated preferably with carbamazepine (OR 1.29; 95 % CI 1.23-1.35; p < 0.001). As compared with patients covered by private health insurance (PHI), patients with statutory health insurance (SHI) were treated more often with valproate (OR 1.19; 95 % CI 1.07-1.31; p < 0.001) and showed a higher rate of obesity (SHI: 3.1 %; PHI: 1.6 %; p < 0.001), while PHI was associated with administration of levetiracetam (OR 1.27; 95 % CI 1.16-1.4; p < 0.001). Carbamazepine (OR 1.25; 95 % CI 1.17-1.31; p < 0.001) and primidone (OR 1.23; 95 % CI 1.08-1.38; p < 0.001) were administered to a larger extent in rural versus urban areas. Lamotrigine (OR 1.31; 95 % CI 1.23-1.39; p < 0.001) was used more often in West than in East Germany. Living in an urban community raised the likelihood of being treated with levetiracetam (OR 1.23; 95 % CI 1.17-1.28; p < 0.001). In spite of common guidelines, AED treatment differed significantly among adults with epilepsy in Germany. Besides gender, type of health insurance and place of residence strongly influenced AED administration.