East South Central Region Research Articles

187. Regional Distribution of Antimicrobial Resistance Among Outpatient Urine e. Coli Isolates in US Females ≥12 Years of age: a Multicenter Evaluation in 2019

BackgroundThe 2019 CDC Threats Report lists extended spectrum β-lactamase (ESBL) producing Enterobacterales as a serious health threat. While the clinical epidemiology of uncomplicated urinary tract infection (uUTI) has remained stable, there has been a notable increase in antimicrobial resistance (AMR) among community-acquired uUTIs. Urine cultures are seldom ordered for uUTI as treatment is often empiric; local surveillance data may therefore be lacking. The study objective was to determine the prevalence and geographic distribution of AMR in urine E. coli isolates from females in the US outpatient setting.MethodsA retrospective cross-sectional study of E. coli ambulatory urine isolates identified from females (≥ 12 years of age) at 296 facilities, with ≥ 1 quarter of data in 2019 (BD Insights Research Database, Franklin Lakes, NJ). Initial isolates representing each distinct susceptibility pattern within 30 days of index urine were included. E. coli isolates were identified as not-susceptible (NS) if intermediate/resistant to trimethoprim-sulfamethoxazole (TMP-SMX), fluoroquinolone (FQ), nitrofurantoin (NFT), ESBL+ (by commercial panels or intermediate/resistant to ceftriaxone, cefotaxime, ceftazidime or cefepime), and multi-drug resistant, defined as NS to ≥ 2 or ≥ 3 of FQ, TMP-SMX, NFT or ESBL+. Logistic regression models were used to evaluate resistance prevalence and variation across US census regions.ResultsOf 267,524 non-duplicate E. coli isolates evaluated, 25.1% (67,189) were TMP-SMX NS, 20.3% (54,359) were FQ NS, 7.3% (19,576) were ESBL+, 3.5% (9,453) were NFT NS, 14.0% (37,328) were NS to ≥ 2 drugs and 4.0% (10,814) were NS to ≥ 3 drugs. For all phenotypes, there was significant variation in resistance across census regions (all P< 0.001) with the highest in the East South Central region and lowest in the New England region of the US (Table). The figure shows regional prevalence of ESBL+ E. coli in 2019.Table. Antimicrobial resistance data from 30-day non-duplicate urine E. coli isolates in females ≥12 years old in 2019, by US census region. Figure. Heat map of the overall US geographic distribution of ESBL+ E. coli (30-day non-duplicate urine isolates) from females across 296 acute care facilities in 2019. ConclusionThe 2019 prevalence of AMR in non-duplicate ambulatory E. coli urine isolates was notable: TMP-SMX NS and FQ NS were > 20%. In addition, there were significant regional differences in resistance, with the highest in the East South Central region of the US, for all NS phenotypes. These analyses inform, and may optimize, empiric treatment of uUTI and patient outcomes.DisclosuresVikas Gupta, PharmD, BCPS, Becton, Dickinson and Company (Employee, Shareholder)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Aruni Mulgirigama, MBBS, GlaxoSmithKline plc. (Employee, Shareholder) Ashish V. Joshi, PhD, GlaxoSmithKline plc. (Employee, Shareholder) Nicole Scangarella-Oman, MS, GlaxoSmithKline plc. (Employee, Shareholder) Kalvin Yu, MD, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Anthony Boyles, MSc, Becton, Dickinson and Company (Employee)GlaxoSmithKline plc. (Other Financial or Material Support, Funding) Fanny S. Mitrani-Gold, MPH, GlaxoSmithKline plc. (Employee, Shareholder)

Abstract C002: Racial and geographic variation in knowledge of palliative care among American adults

Abstract Introduction Palliative care provides clinical and economic benefits for patients diagnosed with life limiting illness and their family caregivers. The extent to which variation in knowledge of palliative care exits in racial groups and geographic regions within the United States is not known. The aim of the study was to present the up-to-date data on the knowledge penetration of palliative care by racial and geographic regions. Methodology We assessed variations in knowledge of palliative care using the 2018 National Cancer Institute’s Health Information National Trends Survey. We used the Pearson chi-square test and multivariable logistic regression models to assess the association of race and having knowledge of palliative care for each census geographic region. The state-level prevalence of no knowledge of palliative care were plotted in a map. Results The study population included 3194 respondents (weighted sample size: 229,591,005; median age: 58). About 15 % of the study population was Hispanic, 10% non-Hispanic-Black, and 61% non-Hispanic White. About 84% Hispanic respondents, 75% non-Hispanic Blacks and 65% non-Hispanic Whites had no knowledge of palliative care (P &amp;lt;0.001). For Hispanic, the prevalence of no knowledge of palliative care ranged from 48% in East South Central region to 96% in East North Central and West North Central region. For non-Hispanic Blacks, the prevalence of no knowledge of palliative care ranged from 32% in New England region to 97% in West North Central region. For non-Hispanic Whites, the prevalence of no knowledge of palliative care ranged from 44% in New England region to 78% in Mountain region. Both racial group and census geographic regions were statistically significant variables in the multivariable model predicting no knowledge of palliative care. Conclusions In the United States, substantial geographic variations in the knowledge of palliative care exist. The prevalence of responders who had no knowledge of palliative care were greater in Hispanic and non-Hispanic Black than non-Hispanic White groups. This finding represents an opportunity for targeted future education to increase the knowledge gap overall and in patients of non-White decent. Citation Format: Kayanna Jacobs, Young Rock Hong, Jiang Bian, Sheri Kittelson, Diana J. Wilkie, Jinhai Huo. Racial and geographic variation in knowledge of palliative care among American adults [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 C002.

The Evolving Burden of Drug Use Associated Infective Endocarditis in the United States

The rise in the number of valve operations performed for infective endocarditis (IE) due to drug use is an important manifestation of the opioid epidemic. This study characterized national trends and outcomes of valve surgery for drug use-associated IE (DU-IE). Adults undergoing valve surgery for active IE in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database between July 2011 and June 2018 were stratified as DU-IE and non-DU-IE. Trends and clinical profiles were analyzed. Early outcomes were assessed. The association of DU-IE with outcomes was analyzed with multivariable regression, adjusting for STS Valve Risk model covariates. There were 34,905 valve operations performed for IE, of which 33.7% were for DU-IE. DU-IE operations increased 2.7-fold during the study period. There was considerable regional variability in DU-IE operations, ranging from 28% to 58% of all IE surgeries in 2018, with highest rates observed in East South Central and South Atlantic regions. DU-IE patients were younger and had fewer cardiovascular comorbidities. Risk-adjusted major morbidity and in-hospital mortality were significantly higher in the DU-IE group. Redo valve procedures in DU-IE patients were associated with worse outcomes, compared with those receiving a first valve operation. Operations for DU-IE have increased sharply in the United States during the last several years, exhibiting substantial regional variability. DU-IE patients have unique clinical profiles, and worse risk-adjusted outcomes. This demonstrates the significant impact of the opioid epidemic on endocarditis surgeries and punctuates the urgent need for multidisciplinary regional and national efforts to reverse this trend.

Cervical disc replacement: examining "real-world" utilization of an emerging technology.

Cervical disc replacement (CDR) has emerged as an alternative to anterior cervical discectomy and fusion (ACDF) for the management of cervical spondylotic pathology. While much is known about the efficacy of CDR within the constraints of a well-controlled, experimental setting, little is known about general utilization. The authors present an analysis of temporal and geographic trends in "real-world" utilization of CDR among those enrolled in private insurance plans in the US. Eligible subjects were identified from the IBM MarketScan Databases between 2009 and 2017. Individuals 18 years and older, undergoing a single-level CDR or ACDF for cervical radiculopathy and/or myelopathy, were identified. US Census divisions were used to classify the region where surgery was performed. Two-level mixed-effects regression modeling was used to study regional differences in proportional utilization of CDR, while controlling for confounding by regional case-mix differences. A total of 47,387 subjects met the inclusion criteria; 3553 underwent CDR and 43,834 underwent ACDF. At a national level, the utilization of single-level CDR rose from 5.6 cases for every 100 ACDFs performed in 2009 to 28.8 cases per 100 ACDFs in 2017. The most substantial increases occurred from 2013 onward. The region of highest utilization was the Mountain region (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming), where 14.3 CDRs were performed for every 100 ACDFs (averaged over the 9-year period of study). This is in contrast to the East South Central region (Alabama, Kentucky, Mississippi, and Tennessee), where only 2.1 CDRs were performed for every 100 ACDFs. Patient factors that significantly increased the odds of undergoing a CDR were age younger than 40 years (OR 15.9 [95% CI 10.0-25.5]; p < 0.001), no clinical evidence of myelopathy/myeloradiculopathy (OR 1.5 [95% CI 1.4-1.7]; p < 0.001), and a Charlson Comorbidity Index score of 0 (OR 2.7 [95% CI 1.7-4.2]; p < 0.001). After controlling for these factors, significant differences in utilization rates remained between regions (chi-square test = 830.4; p < 0.001). This US national level study lends insight into the rate of uptake and geographic differences in utilization of the single-level CDR procedure. Further study will be needed to ascertain specific factors that predict adoption of this technology to explain observed geographic discrepancies.

Efficacy of Chemoradiation and Patterns of Practice in the Treatment of Locally Advanced Endometrial Stromal Sarcoma: An NCDB Population-Based Study

Endometrial stromal sarcoma (ESS) is a rare neoplasm of the mesenchymal elements of the uterus. Radical surgery is the primary therapy for non-metastatic disease. The role of adjuvant therapy after surgery remains controversial and is mostly consistent with systemic therapy. Given the rarity of this disease, it was hypothesized that analysis of current patterns of practice and their efficacy, as identified in a large hospital-based registry dataset, could inform more uniform and effective approaches to management. The National Cancer Database (NCDB) was queried for patients with Stage III-IVA ESS age 18 to 90 years diagnosed from 2001-2015 and treated with surgery +/- RT +/- chemotherapy. Patients were excluded if vital status was unavailable, if they received chemotherapy or RT alone, or if they died within 90 days of surgery. Fisher’s exact test and multivariate logistic regression were performed to analyze factors associated with delivery of a particular treatment modality, with corrections made to control the family-wise error rate. A survival analysis was performed using Kaplan-Meier estimates, a Cox proportional hazards regression model, and log-rank testing. A total of 214 patients met search criteria with a median age of 50 (19-87) years; 89 (41.5%) patients received surgery alone, 35 (16.4%) received surgery + RT, 68 (31.8%) received surgery + chemotherapy, and 22 (10.3%) received tri-modality therapy. Median follow-up was ∼27 months. Overall survival for all patients was 62% at 3 years, and 56% at 5 years. Age <50 years, low grade, and administration of RT were associated with improved overall survival (p < 0.001). For patients with high grade disease, the addition of RT to surgery and chemotherapy was associated with significant survival benefit (p < 0.004). Number of nodes examined in high-grade patients was associated with improved survival. Mean time from diagnosis to the start of RT was 107 (18-399) days, and the mean time between surgery and the start of RT was 90.5 (8-379) days. These were not significant predictors of survival. Integrated Cancer Network facilities had higher rates of RT use at 40% vs. ∼20-25% at other facilities. East North Central and East South Central census regions had higher rates of RT use at 40-47% vs. 11-29% in other regions. The addition of RT to surgery for patients with locally advanced endometrial stromal sarcoma appears to provide a survival benefit, particularly in patients with high-grade histology receiving surgery and chemotherapy. The rate of RT utilization was low overall, and there was significant variability in dose delivered and timing of treatment. More robust multi-institutional studies are required to better elucidate appropriate management in this cohort.

Evolution of Excisional Surgery Practices for Melanoma in the United States

National Comprehensive Cancer Network guidelines for melanoma have consistently recommended wide local excision as the standard of care since their inception. Although surgery with more comprehensive margin assessment (eg, Mohs surgery) has been advocated for certain subsets of melanoma, how often these techniques are used in clinical practice is uncertain. To examine trends in the use of comprehensive margin assessment surgery for melanoma by tracking claims data for Mohs surgery. This national cross-sectional analysis examined claims data from the Optum Clinformatics Data Mart, a nationally representative database. The study cohort consisted of 79 108 patients undergoing surgical excision for melanoma from January 1, 2001, through December 31, 2016. Data were analyzed from January 1, 2001, through December 31, 2016. The primary outcome was the likelihood of a melanoma being treated with Mohs surgery over time, evaluated by multivariable logistic regression and expressed as the odds of treatment per additional calendar year. Among 79 108 patients with melanoma (median age, 63 years [interquartile range {IQR}, 51-73]; 47 407 men [59.9%]), 75 047 were treated with conventional excision (median age, 62 years [IQR, 50-73 years]; 44 786 men [59.7%]) and 4061 with Mohs surgery (median age, 67 years [IQR, 56-76 years]; 2621 men [64.5%]). Mohs surgery was used in 5.1% of all surgical cases, with the rate of Mohs surgery increasing 304% from 2.6% in 2001 to 7.9% in 2016. Odds of receiving Mohs surgery for melanoma increased significantly in more recent calendar years (odds ratio [OR], 1.02 per calendar year; 95% CI, 1.01-1.03; P < .001). Immunohistochemistry (IHC) use was only coded with Mohs surgery in 1087 cases (26.8%), and the odds of receiving Mohs surgery with IHC increased in more recent calendar years (OR, 1.13 per calendar year; 95% CI, 1.10-1.15; P < .001). Use of Mohs surgery and Mohs surgery with IHC for melanoma differed widely across geographic census divisions with greater than 3-fold variation between the regions with highest and lowest use in every period (eg, for 2013 through 2016, the East South Central region used Mohs surgery in 8.8% of melanoma excisions compared with 2.6 in the New England region). Despite stable guidelines for melanoma surgery, the results of this study suggest that surgical practices for melanoma are evolving. Wide variations in surgical practice patterns for melanoma are present in the United States. This study's findings suggest that the effect of variations in surgical techniques on outcomes requires scrutiny and further study.

Regional Variation in 90-Day Postoperative Costs Among Patients Undergoing Posterior Lumbar Fusion (PLF): Insights From the Optum Labs Data Warehouse (OLDW)

Abstract INTRODUCTION Lumbar spine surgery has been reported to be associated with extremely high direct and associated costs and has thus been prioritized as a target for several quality improvement interventions. We aimed to identify factors associated with higher 90-d costs following elective posterior lumbar fusion (PLF) for degenerative lumbar spine disease among patients with commercial insurance and those on Medicare Advantage, using an administrative database. METHODS Optum Labs Data Warehouse was queried for patients undergoing PLF for degenerative lumbar spine disease between 2012 and 2015. Patients were stratified by insurance status (commercial or Medicare Advantage) and by the 9 US census regions. The primary outcome was all postoperative 90-d costs. RESULTS A total of 25 556 patients underwent a PLF, of which 67.6% had commercial insurance and 32.4% had Medicare Advantage. Regional 90-d adjusted mean costs per patient varied significantly between the 2o insurance groups, most notably for patients with commercial insurance ($123,950.38 for Mid-Atlantic region to $59,213.52 for patients in East South Central region). Multivariable regression analyses revealed that geographic region where surgery was performed, the number of operated levels, number of readmissions and number of ED visits were significantly associated with higher costs for each procedure. CONCLUSION There is significant regional variation in 90-d postoperative adjusted costs for patients on commercial and Medicare insurance undergoing PLF. These analyses are important to help surgeons develop region-specific interventions to alleviate the cost burden for patients and assist policy makers in designing more effective reimbursement policies for providers and hospitals.

Disparities in Rates of Fusions in Single-Level Lumbar Disc Pathologies

Abstract INTRODUCTION Single-level lumbar disc pathologies are managed surgically through decompression (lumbar discectomy or laminectomy) and a potential fusion. However, there is a lack of evidence for or against fusion after decompression in specific patient populations. This study seeks to observe disparities in the rates of fusion after decompression. METHODS Patients requiring surgical treatment for single-level disc herniation or degeneration were queried from the National Inpatient Sample datasets spanning 2012 to 2015. Multivariate logistic regression (with a Holm-Bonferroni correction) was performed to assess effects of patient demographics, temporality of admission, and hospital characteristics on rates of lumbar fusion while controlling for patient-level medical comorbidities. RESULTS A total of 84 336 patients were included in the analysis of indicators for fusion after elective and nonelective surgical intervention for lumbar disc pathologies. Patients in private for-profit and not-for-profit hospitals were more likely to receive a fusion compared to those in public hospitals for elective cases (OR 1.20, P &lt; .001; OR 1.21, P &lt; .001, respectively). Nonelective patients in urban teaching and nonteaching hospitals were less likely to receive a fusion compared to those in rural hospitals (OR 0.49, P &lt; .001; OR 0.54, P &lt; .001, respectively). In both elective and nonelective cases, weekend admissions were less likely to receive fusions than weekday admissions (OR 0.35, P &lt; .001; OR 0.46, P &lt; .001, respectively). Compared to hospitals in New England, hospitals in East North Central, South Atlantic, and East South Central regions had higher rates of elective fusion (OR 1.29, 1.50, and 2.09, respectively; P &lt; .001 for all), while hospitals in the Pacific and West South Central regions had lower rates of fusion (OR 0.56, P &lt; .001; OR 0.50, P &lt; .001, respectively). CONCLUSION The results of this study illustrate disparities that exist in fusion after the surgical intervention of lumbar disc pathologies in terms of patient demographics and hospital characteristics.

Environmental and individual predictors of medication adherence among elderly patients with hypertension and chronic kidney disease: A geospatial approach.

Few studies have examined how adherence to antihypertensive medications varies across different regions or how neighborhood-level factors were related to individuals' medication-taking behaviors in patients. To explore local variation in medication adherence and examine environmental and individual influences on adherence to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) among elderly hypertensive patients with chronic kidney disease (CKD) in the United States. The Medicare 5% sample claim data (2006-2013), American Community Survey 5-Year Data (2005-2009) and the Health Resources and Services Administration Primary Care Service Area data (2007). The primary outcome was medication adherence, measured by Proportion of Days Covered (PDC). Geographically weighted regression (GWR) and linear mixed-effects models were used to investigate the relationship between environmental factors, individual risk factors and medication adherence. A total of 70,201 hypertensive CKD patients residing in 2,981 counties of the US were selected. Significant spatial autocorrelation was observed in ACEIs/ARBs PDC. The West North Central and New England regions demonstrated higher adherence compared to the East South Central and West South Central regions. Residing in Medically Underserved Areas, counties with high deprivation scores, and not receiving Part D Low-income Subsidy were associated with poor medication adherence. Medication adherence is geographically differentiated across the US. Environmental and individual factors identified may be helpful in the design of local interventions focused on improving patient outcomes from a population perspective.

Multidimensional Item Response Theory for Factor Structure Assessment in Educational Psychology Research

This study demonstrates the use of multidimensional item response theory (MIRT) to investigate an instrument’s factor structure. For didactic purposes, MIRT was used to assess the factor structure of the 9-item Effort Beliefs Scale (Blackwell, Trzesniewski, & Dweck, 2006), based on data obtained from 1,127 undergraduate engineering students (20.9% female) across two academic years attending a large, metropolitan university in the east south-central region of the United States at the beginning and end of the first semester of freshman year. MIRT results supported the scale’s multidimensional structure, which were compared to those based on confirmatory factor analysis. Specifically, comparisons of competing models supported the scale’s bifactor structure in which the collective item set related to a primary dimension and each item related to one of two domain-specific factors: Positive Relationship, Inverse Relationship. Furthermore, the utility of item response theory for assessing effort beliefs changes across the first semester and the relationship of IRT and observed scores is provided. The paper concludes with an overview of MIRT for scale development and dimensionality assessment to advance the reader’s awareness of its use as a psychometric tool.

Otolaryngology Resident Well-Being and Perceptions of the Clinical Learning Environment

To measure the current state of organizational and well-being factors in otolaryngology residency programs and associate these perceptions with demographics, pursuit of subspecialty fellowships, and performance on the Otolaryngology Training Examination (OTE). Anonymous mail and online survey study of otolaryngology residents from the Southern, Mid-Atlantic, and East South-Central Regions of the United States. A total of 46 otolaryngology residents across 14 residency training programs (22% resident response rate) completed our survey. Residents who scored above the 80th percentile on the OTE perceived greater organizational support (median = 3.84) than residents who scored below the 40th percentile (median = 3.31), U = 48.00, P = .047, η2 = 0.14. Residents interested in fellowship reported less burnout (median = 2.44) compared to those who did not plan to pursue fellowship (median = 3.56), U = 105.00, P = .010, η2 = 0.05. Residents pursuing fellowship also reported less work-life strain (median = 2.56) than those forgoing fellowship (median = 2.89), U = 126.00, P = .044, η2 = 0.10. Residents with children reported greater work-life strain (median = 3.11) compared to those without (median = 2.56), U = 60.50, P = .008, η2 = 0.15. For otolaryngology residents in this survey sample, the perception of organizational support and well-being may influence resident performance (on OTE examinations) and ultimate career goals (fellowship applications). Program directors and coordinators can use this information to strengthen the perceptions of organizational support as well as improve the clinical learning environment to optimize training conditions for their residents. Residency program directors can also use the identified study measures to assess resident perceptions of the clinical learning environment and well-being for annual evaluation and improvement purposes.

Effect of adoption of neoadjuvant chemotherapy for advanced ovarian cancer on all cause mortality: quasi-experimental study

ObjectiveTo estimate the causal effect of increased use of neoadjuvant chemotherapy (NACT) on all cause mortality in advanced epithelial ovarian cancer.DesignQuasi-experimental fuzzy regression discontinuity design and cross sectional analysis. SettingCancer...

Geographic Variability in Diagnosis and Antibiotic Prescribing for Acute Respiratory Tract Infections.

IntroductionAntibiotic prescribing rates vary substantially across regions in the USA. Whether these differences are driven primarily by a greater tendency to treat certain infections (i.e., overtreatment) in certain regions or differences in the tendency to diagnose certain infections (i.e., overdiagnosis) is poorly understood.MethodsWe examined data from 2012 to 2013 using the National Ambulatory Medical Care Survey, which is a nationally representative sample of visits to office-based physicians. For each of nine geographic regions, we examined the relationship between the visit rate/1000 population for respiratory diagnoses for which antibiotics were prescribed to the visit rate/1000 population for selected respiratory diagnoses where antibiotic therapy may be warranted.ResultsThe visit rate for all respiratory conditions resulting in an antibiotic prescription was lowest (109/1000 population) in the Pacific Region and highest (176/1000, 95% CI 138–213) in the East South Central Region. The diagnosis rate for selected respiratory conditions where antibiotic therapy may be warranted was also lowest (119/1000, 95% CI 91–147) in the Pacific Region and highest (189/1000, 95% CI 153–225) in the East South Central Region.ConclusionAntibiotic prescribing rates for respiratory conditions vary by region and are strongly associated with the rate with which selected respiratory conditions are diagnosed.

Geographic and Demographic Variation in Use of Ranibizumab Versus Bevacizumab for Neovascular Age-related Macular Degeneration in the United States

To examine demographic and geographic variation in the use of ranibizumab and bevacizumab for the treatment of neovascular age-related macular degeneration (AMD) among Medicare beneficiaries. Retrospective cohort study. Using a 100% sample of Medicare claims data, we evaluated Medicare beneficiaries (N= 195 812) with an index claim for neovascular AMD between July 1, 2006, and June 30, 2009, to determine whether beneficiaries first received ranibizumab or bevacizumab following initial diagnosis. The overall proportion of beneficiaries that first received ranibizumab for neovascular AMD was 35%, and varied significantly (0.9%-84.6%) across the 306US hospital referral regions (median= 33%, interquartile range=17%-49%). Based on hierarchical logistic regression models, the likelihood of receiving ranibizumab declined over time (adjusted odds ratio (aOR) comparing treatment in 2009 vs 2006= 0.39, P < .001). After we controlled for year of treatment, black beneficiaries were 45% less likely to receive ranibizumab compared to non-blacks (P < .0001). Beneficiaries residing in urban areas (aOR vs isolated rural towns=1.12, P < .001), in zip codes with higher median incomes, and in the New England and East South Central census regions (aOR vs Pacific census region= 5.57, P<.001; aOR= 3.58, P < .001, respectively) had increased odds of receiving ranibizumab. The odds of receiving bevacizumab vs ranibizumab as initial therapy for neovascular AMD among US Medicare beneficiaries varied substantially across geographic and demographic groups. Relatively fewer patients received ranibizumab for initial neovascular AMD treatment in 2009 vs 2006. Future research should study the drivers of variation in utilization of these interventions, the extent this variation indicates differential access to these agents, and whether treatment choice impacts patient outcomes.

Impact of CALGB 9343 Trial and Sociodemographic Variation on Patterns of Adjuvant Radiation Therapy Practice for Elderly Women (≥70 Years) with Stage I, Estrogen Receptor-positive Breast Cancer: Analysis of the National Cancer Data Base.

The Cancer and Leukemia Group B (CALGB) 9343 trial demonstrated that adjuvant radiation therapy (RT) can be omitted in women 70 years or older, with small (≤2 cm), negative lymph nodes, estrogen receptor (ER)-positive breast cancer. We examined whether RT usage following the CALGB publication had decreased over time and evaluated sociodemographic and clinical factors associated with RT omission. From the National Cancer Data Base, we analyzed a cohort of 120,308 women aged 70 years or older with stage I, ER-positive breast cancer who underwent lumpectomy. Patients were classified into two groups based on the time of CALGB 9343 publication: (i) pre-CALGB (up to 2004), and (ii) post-CALGB (2005-2012). Clinicopathological and sociodemographic variables were compared between pre- and post-CALGB groups. Chi-square and multivariable logistic regression were employed, with the omission of adjuvant RT as the primary outcome in the regression analysis. Radiation therapy usage decreased by 4.1% after CALGB publication (on average 71.6% pre-CALGB vs. 67.5% post-CALGB; p<0.0001). Almost one-third of women aged ≥85 years received RT in the post-CALGB group. In a multivariable model, the variables significantly associated with increased odds for omission of RT in the post-CALGB group were: advanced age, African-American, increased great circle distance, therapy under academic research program, residents of East South-Central region, living in a rural population <2,500 not adjacent to a metropolitan area, low income level, Medicaid recipients, high comorbidity index, small tumor, well-differentiated histology, residual tumor, and lack of receipt of chemotherapy and anti-hormonal therapy. During the study period, the CALGB trial publication had a minimal impact on the rate of adjuvant RT use among elderly women with small, ER-positive breast cancers. Significant variation in RT usage existed across sociodemographic strata.

Results of a national survey of high-frequency fish consumers in the United States

Exposure to contaminants in fish may be associated with adverse health outcomes even as fish consumption is generally considered beneficial. Risk assessments conducted to support regulatory analyses rely on quantitative fish consumption estimates. Here we report the results of a national survey of high-frequency fish consumers (n = 2099) based on a survey population statistically representative of ~17.6 million U.S. individuals consuming three or more fish meals per week. The survey was conducted during 2013 using an on-line survey instrument. Total fish consumption averaged 111 g/day from market, restaurant and self-caught sources. Depending on the season, the incidence of individuals reporting consumption of self-caught species ranged between 10–12% of our high-frequency fish consuming demographic, averaging approximately 30 g/day and comprising 23% of total fish consumption from all sources of fish. Recreational or self-caught consumption rates vary regionally and are poorly understood, particularly for high-frequency consumers, making it difficult to support national-scale assessments. A divergence between sport-fishing and harvesting of fish as a food-staple is apparent in survey results given differences in consumption patterns with income and education. Highest consumption rates were reported for low income respondents more likely to harvest fish as a food staple. By contrast, the incidence of self-caught fish consumption was higher with income and education although overall consumption rates were lower. Regional differences were evident, with respondents from the East-South Central and New England regions reporting lowest consumption rates from self-caught fish on the order of 12–16 g/day and those from Mountain, Pacific and Mid-Atlantic regions reporting highest rates ranging from 44 to 59 g/day. Respondent-specific consumption rates together with national-level data on fish tissue concentrations of PCBs, MeHg, and PFOS suggest that 10–58% of respondents reporting self-caught fish consumption are exposed to concentrations of these contaminants that exceed threshold levels for health effects based on a target hazard index of one, representing 2.3 M to 19 M individuals. The results of this nationwide survey of high-frequency fish consumers highlights regional and demographic differences in self-caught and total fish consumption useful for policy analysis with implications for distributional differences in potential health impacts in the context of both contaminant exposures as well as protective effects.

Effect of adoption of neoadjuvant chemotherapy for advanced ovarian cancer on all-cause mortality.

5537 Background: Use of neoadjuvant chemotherapy followed by surgery for advanced epithelial ovarian cancer is controversial in the United States. Methods: Use of neoadjuvant chemotherapy for stage IIIC and IV ovarian cancer has increased gradually in the United States since 2007, but rates of adoption vary by region. Between 2011 and 2012, use of neoadjuvant chemotherapy increased by 27% in the New England and East South Central regions, but remained unchanged in three control regions (South Atlantic, West North Central, and East North Central regions). Employing prospectively collected data from Commission on Cancer-accredited cancer programs in the United States, we used this discontinuity in treatment approach to assess the causal impact of neoadjuvant chemotherapy on all-cause mortality in a quasi-experimental fuzzy regression discontinuity design. Kaplan-Meier curves and proportional hazard models were estimated to compare mortality differences between rapidly-adopting regions and controls. We also conducted a cross-sectional analysis of the relationship between regional use of neoadjuvant chemotherapy and survival. Results: We identified 1,156 women treated for advanced epithelial ovarian cancer during 2011 and 2012 in the two rapidly-adopting regions and 4,878 women in the three control regions. In the rapidly-adopting regions, patients treated in 2012 compared with 2011 had a mortality hazard ratio (HR) of 0.81 (95%CI=0.71-0.94) after adjusting for mortality time trends, while no difference was observed in control regions (HR=1.02, 95%CI=0.93-1.12). Compared with control regions, we observed larger declines in 90-day surgical mortality (7.0% to 4.0% versus 5.0 to 4.3%, p=0.01) and in the proportion of women not receiving surgery and chemotherapy (20.0% to 17.4% versus 19.0 to 19.5%, p=0.04) in rapidly adopting regions. Cross-sectional analysis confirmed that treatment in regions with greater use of neoadjuvant chemotherapy was associated was lower mortality (p=0.001). Conclusions: Adoption of neoadjuvant chemotherapy for advanced epithelial ovarian cancer in New England and East South Central regions led to a sizable reduction in mortality within three years after diagnosis.

Abstract P5-08-10: Stage-at-presentation and time-to-treatment for American Indian patients diagnosed with breast cancer

Abstract Purpose: To review the stage of presentation and time-to-treatment for American Indian (AI) patients diagnosed with breast cancer (BC) and compare them to White (W), Black (B), Asian (AS) and Hawaiian/Polynesian (HP) population across the US and by geographic region using a large national database. Methods: The NCDB, a joint project of the American Cancer Society and the Commission on Cancer, is a comprehensive national database that registers approximately 70% of cancer patients in the US. Data for patients with BC was extracted from the NCDB 2013 PUF file (2004-2013). Categorical data were compared using the chi-square test. Time-to-treatment (TtT) analysis was performed in patients with non-metastatic breast cancer. All interval parameters were evaluated as continuous variables and compared using ANOVA analysis. Results: Table 1 shows the number of patients, median age and stage at presentation by race. The median age was lowest for AS and largest for W patients. Compared to W patients, AI patients were less likely to present with stage 0/I disease and more likely to present with stage II/III disease. Similarly, AI patients were 25% more likely to present with metastatic disease when compared to W patients. Table 1 also shows the mean intervals (in days) from diagnosis to treatment. This analysis revealed significant differences amongst the races, with AI patients tending to have the second shortest TtT. Evaluation of the interval to treatment amongst the 9 geographic regions also revealed significant differences. The West North Central and East South Central regions had the shortest TtT and the Pacific and North East regions had the longest. For AI patients, the shortest TtT occurred in the West North Central and South Atlantic while the longest TtT occurred in the North East and West South Central regions. In general, the magnitude of these differences was under 20%, but varied greatly depending on the variables and regions evaluated. These differences were statistically significant (p-value &amp;lt; 0.01). Conclusion: AI patients presented with later stage disease and longer interval to treatment for all modalities compared to White race, but did better overall than Black patients, both for stage at diagnosis and time to treat. There was considerable regional variation in time intervals across all races. Efforts to improve outcomes should be focused on addressing regional variations in time to treat, and in earlier diagnosis of breast cancer for at risk populations. Table 1Clinical ParametersAmerican IndianWhiteBlackAsianHawaiin / Polynesianp-valueN4,6341,623,175217,69655,9423,473 Age (Median)5761585556&amp;lt; 0.001Stage 0 (%)17.420.521.425.519.5&amp;lt; 0.001I35.942.031.137.335.8 II31.525.129.025.829.5 III10.78.712.48.510.8 IV4.63.76.12.94.3 Inverval from Diagnosis to: [Mean(Std Dev) in days]Treatment Start32.3 (38.8)27.8 (39.3)35.0 (39.4)31.1 (31.9)31.2 (32.9)&amp;lt; 0.001Definitive Surgical Procedure52.7 (62.8)44.5 (52.5)61.6 (71.1)51.4 (57.3)52.0 (60.6)&amp;lt; 0.001Start of Radiotherapy152.9 (90.5)128.0 (83.7)165.4 (99.7)144.2 (90.0)151.0 (93.2)&amp;lt; 0.001Start of Chemotherapy76.0 (53.1)68.8 (47.8)77.7 (56.1)72.9 (52.6)78.8 (50.2)&amp;lt; 0.001Start of HT160.7 (103.7)144.3 (101.4)171.2 (117.8)160.4 (106.9)171.5 (115.2)&amp;lt; 0.001 Citation Format: Algan O, Campbell JE, Algan SM. Stage-at-presentation and time-to-treatment for American Indian patients diagnosed with breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-10.

State and Regional Prevalence of Diagnosed Multiple Chronic Conditions Among Adults Aged ≥18 Years - United States, 2014.

The prevalence and care management of multiple (two or more) chronic conditions (MCC) are important public health concerns (1). Approximately 25% of U.S. adults have diagnoses of MCC (2). Care management of MCC presents a challenge to both patients and providers because of the substantial costs associated with treating more than one condition and the traditional care strategies that focus on single conditions as opposed to enhanced care coordination (3,4). Maintaining surveillance, targeting service delivery, and projecting resources are all important to meet this challenge, and these actions can be informed by identifying state and other regional variations in MCC prevalence (5,6). Data from the 2014 National Health Interview Survey (NHIS) were used to estimate prevalence of MCC (defined as two or more of 10 diagnosed chronic conditions) for each U.S. state and region by age and sex. Significant state and regional variation in MCC prevalence was found, with state-level estimates ranging from 19.0% in Colorado to 38.2% in Kentucky. MCC prevalence also varied by region, ranging from 21.4% in the Pacific region to 34.5% in the East South Central region. The prevalence of MCC was higher among women than among men within certain U.S. regions, and was higher in older persons in all regions. Such findings further the research and surveillance objectives stated in the U.S. Department of Health and Human Services (HHS) publication, Multiple Chronic Conditions: A Strategic Framework (1). Furthermore, geographic disparities in MCC prevalence can inform state-level surveillance programs and groups targeting service delivery or allocating resources for MCC prevention activities.

How fast will the registered nurse workforce grow through 2030? Projections in nine regions of the country

BackgroundAfter an unprecedented increase in nursing school enrollment and graduates in the past 10 years, projected shortages of nurses have been erased at a national level. However, nursing markets are local, and an uneven distribution of health care providers of all types is a longstanding feature of health care in the United States. PurposeThe purpose of this study was to understand how the outlook for future registered nurse (RN) supply varies regionally across the United States. MethodsWe apply our nursing supply model to the nine U.S. Census Divisions to produce separate supply forecasts for each region. DiscussionWe find dramatic differences in expected future growth of the nursing workforce across U.S. regions. These range from zero expected growth in the number of RNs per capita in New England and in the Pacific regions between 2015 and 2030 to 40% growth in the East South Central region (Mississippi, Alabama, Tennessee, Kentucky) and in the West South Central region (Texas, Oklahoma, Arkansas, Louisiana). ConclusionAssuming growth in the demand for RNs per population, some regions of the United States are expected to face shortfalls in their nursing workforce if recent trends do not change.