Government Insurance Research Articles

Stroke systems of care in the Philippines: Addressing gaps and developing strategies.

In the Philippines, the mortality from stroke during the last 10 years remains high. This paper aims to describe the gaps in stroke care and the development of stroke systems of care in the Philippines. Gaps in stroke systems of care include low number of neurologist, inadequate CT scan machines, lack of stroke training among health workers, lack of stroke protocols and pathways, poor community stroke awareness, low government insurance coverage with high out of pocket medical expenses, lack of infrastructure for EMS, inadequate acute stroke ready hospitals, stroke units and rehabilitation facilities. Although there are government programs for primary stroke prevention, the strategies are inadequate to address the stroke pandemic. The Stroke Society of the Philippines has worked with the government for nationwide and regional stroke training of health care workers, community stroke awareness, setting up acute stroke ready hospitals and acute stroke units in different areas of the country and adapting stroke protocols and pathways. Stroke registries are now utilized for quality improvement. Thrombolysis rate has improved from 1.4% in 2014-2016 to 11% in 2021 based on RES-Q database. Because of government subsidy, thrombolysis in the government hospitals is higher at 7.4% (range 4.4-16.9) compared to 4.8% (range 0-10.1) rate in private hospitals. Mechanical thrombectomy rate remained low at 0.4% of all acute ischemic stroke patients because of the cost. With limited resources, infrastructures for emergency medical service is lacking. The innovations done by other LMIC can be done in the Philippines including the use of technology to reach out to geographically isolated areas and use of mobile stroke units. Non neurologist can be trained to help treat stroke patients. Upgrading of the Philhealth insurance to cover for reperfusion therapies, adequate stroke infrastructures and network, and increase in community stroke awareness are areas for improvement in the Philippine stroke systems of care.

Demographic Features, Clinical Characteristics and Survival Outcomes of Primary Cutaneous Gamma-Delta T Cell Lymphoma, a Retrospective National Cancer Database Analysis

Introduction The cytotoxic gamma delta T cells give rise to an extremely rare malignancy, known as Primary cutaneous Gamma-Delta T cell lymphoma (PCGDTCL), which represents < 1% of all lymphomas. These are considered aggressive lymphomas with a median survival of 15-31 months. Since they usually present as plaques in the extremities, they mimic nonspecific panniculitis and need a high index of suspicion for diagnosis. Using a large national cancer repository, the National Cancer Database (NCDB), we analyzed the demographic distribution, clinical characteristics, treatment strategies and survival outcomes and studied the impact of various factors on the survival of patients with PCGDTCL. Methods The 2004-2018 NCDB file was used to extract patients with a diagnosis of PCGDTCL. We included patients who had skin and lymph nodes as the primary disease sites. All patients were adults aged ≥ 18 years. Frequencies and chi-square tests were used to compare patient distribution among various demographic and clinical characteristics as shown in the table. Kaplan-Meier (KM) analysis and hazard ratios (HR) were used to compare survival outcomes. Results A total of 110 patients with PCGDTCL were identified. The table summarizes the distribution of patients by various demographic features and disease stage. The median age of our cohort was 58 years. Most of the patients were elderly males aged >60 years (>60 years: 42.73%, 41-60 years: 36.36%, <=40 years: 20.91%) (Males: 56.36%, Females: 43.64%). Caucasian race was the most common (Caucasian: 79.09%, African American: 16.36%). There was an equal distribution of patients using private and government insurance (48.18% each). Income, facility type, and area distribution is shown in the table. Most of the patients were diagnosed at stage 1 (52.33%), followed by stage 4 (30.23%). 55.88% (38/68) of Caucasians were diagnosed at stage 1 and 27.94% (19/68) were diagnosed at stage 4. Among African Americans, the distribution between stage 1 and stage 4 was 38.46% (5/13) each. On analyzing income categories, <$48,000 group had 48.15% stage 4 (13/27) and 40.74% (11/27) stage 1. Among the >=$48,000 group, 57.88% (26/45) were stage 1 and 24.14% (11/45) were stage 4. Distribution by insurance used is shown in the table. The distribution among various systemic treatment strategies used were as follows: Chemotherapy only - 47 (42.72%), Chemotherapy with Radiation - 17 (15.46%), Radiation alone -13 (11.82%), No chemotherapy or Radiation - 33 (30%). Among patients who did not receive chemotherapy or radiation, 79.17% had stage 1 disease. Overall survival of the study group at 3 years was 46.6%. The group that did not receive chemotherapy or radiation had the highest 3-year survival (74.3%). Survival rates of the other treatment groups and the survival by race, income and insurance is represented in the table. HR estimates showed that compared to the no systemic therapy group, the chemotherapy [2.994 (95% CI 1.400, 6.401)p=0.0047] and chemotherapy with radiation [2.611 (95% CI 1.048,6.5090)p=0.0394] groups had more adverse outcomes. Comparison between the other treatment groups were not significant. The African American race had a lower overall survival (37.5%), but the HR did not reach significance compared to Caucasians [1.524 (95% CI 0.779,2.984)p=0.2187]. Having an income of <$48,000 had a lower survival (27.6%) with HR [2.151 (95% CI 1.225,3.778)p=0.0077] compared to the higher incomes. Government insurance had a lower survival (38.8%), but the HR did not show significance compared to private insurance [1.708 (95% CI=0.980, 0.977)p=0.0591]. Conclusion We provide one of the first descriptive analysis of a very rare lymphoma. Although the group that did not receive any chemotherapy or radiation had better survival, majority of the patients in this group were stage 1. We hypothesized that this group may have received topical treatments which may have not been captured in NCDB. Socioeconomic disparities significantly impact access to healthcare and is of particular importance in rare lymphomas like PCGDTCL. In our analysis, patients with a lower income had a worse survival. The survival was also lower among African Americans, although the HR was not significant. A higher percentage of African American patients and those with a lower income were also diagnosed at Stage 4. Limitations of our study include the use of non-population-based data and the confounding that may arise from it. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of Patient Demographics and Neighborhood Socioeconomic Variables on Clinical Trial Participation Patterns for Non-Hodgkin Lymphoma at a Major Academic Institution

Background: There have been tremendous advancements in Non-Hodgkin Lymphoma (NHL) therapies and outcomes in large part due to clinical trials. Prior studies have demonstrated that certain populations including the elderly, certain racial and/or ethnic minority groups, and women are underrepresented in cancer clinical trials. Better understanding of how social context impacts clinical trial enrollment will allow us to better design tailored interventions to address barriers to clinical trial participation. We performed a retrospective analysis of patients with NHL seen at MD Anderson Cancer Center (MDACC) to systematically investigate the association between clinical trial participation patterns and sociodemographic context measured by neighborhood socioeconomic factors based on place of residence. Examining our practice patterns may then inform strategies to enhance trial recruitment of underrepresented groups. Methods: We examined 3448 patients, age ≥18 years with a diagnosis of NHL seen at MDACC between January 2017 and December 2020. Using patient address, geolocation software and American Community Survey (2015 - 2020) and 2020 census data available through data.Census.gov we ascertained 35 neighborhood level socioeconomic status (nSES) variables corresponding to each census tract including the domains of educational attainment, neighborhood median income, poverty, crowding, race composition and home values. We performed descriptive analysis to understand the demographics of the total populations and those enrolled in clinical trials. We performed univariate analysis of clinical trial enrollment patterns by sex, race, age, histology type, insurance type and nSES variables using 2-sample t-test and Mann-Whitney tests (MHT). Using exhaustive variable selection based upon minimizing the Akaike Information Criteria, including 2-way interactions, we found the set of variables that generated an optimal generalized additive logistic regression model for incidence of participation in clinical trials. We repeated this procedure for the diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) subgroups. We adjusted alpha 0.05/3=0.017 as the criteria for significance in these models to address multiple testing. Results: We excluded 130 patients with international patient addresses and 427 patients without complete address information. and found no significant difference in baseline characteristic or clinical trial enrollment between the 572 excluded patients and the study cohort of 2943 patients. The study population was 59% male, 74.6% Non-Hispanic white (NHW), 13.2% Hispanic, 6.1% black, 3.7% Asian; 29.5% had DLBCL, 22% FL, 13.2% mantle cell, 9% marginal zone, 8.3% T-cell, and 6.5% high grade B cell lymphoma. The most common insurance was managed care 47% and Medicare 45.7%; 2.5% of patients were self-pay, 1.2% had Medicaid, and 2.1% had other government insurance. There was a high overall clinical trial participation rate of 30.5% with 20.9% enrolled in therapeutic trials and participation differed by diagnosis (Table). In univariate analyses, lower participation rates were associated with lower nSES including: increasing % of populations living below poverty level, increasing % living in crowded households, increasing % above age 25 years with less than high school diploma, and decreasing median household income. Racial composition of census tract was not associated with differences in clinical trial participation. Participation did not differ by insurance type. In multivariable analysis, incidence of participation declined nonlinearly with age in the overall, FL, and DLBCL models. In the DLBCL subset Hispanic patients had lower odds of participation than Whites (odds ratio 0.34, p=0.0003). No nSES variable predicted clinical trial participation in these models. Conclusion: In a large academic cohort, age and diagnosis not race, gender, insurance type, or nSES were independent predictors of trial participation. One major limitation to the generalizability of these results is the select patient population seen at our institution are relatively well insured. Examination of multi-center datasets including community practices when underinsured patients received care and evaluation of interventions to influence access to clinical trials are needed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Why Are Patients Not Getting a Graft? an Intent-to-Transplant Analysis in the Times of Universal Coverage and Haploidentical Donors

Introduction: allogeneic hematopoietic stem cell transplantation (alloHSCT) is a potentially curable option for patients with hematologic diseases. When considered candidates, patients face barriers to receive a transplant such as disease activity, education, financial constraints, donor availability, among others. These factors are particularly harder to overcome for patients in low- and middle-income countries. Therefore, we aimed to analyze factors that limit or favor access to an alloHSCT in a population that has been HLA typed and therefore with a potential intent-to-transplant. Methods: we retrospectively reviewed records from 2015 until the start of the COVID19 pandemic in two of the largest Mexican government-funded transplant centers in two geographic regions in Mexico with in-house HLA typing, in one of them, an outpatient transplant strategy is followed for most patients. HLA-typed patients who were potentially eligible for transplantation were included and their outcomes were assessed in an intent-to-transplant basis. We compared the outcomes of patients who underwent transplantation to those who did not and evaluated contributing barriers to access alloHSCT with multivariate logistic regression. This study was performed on behalf of the TCTMX working group. Results: we screened 391 patients, 42 were excluded as they had no indication for alloHSCT with a total of n=349 patients analyzed. The median age at HLA-typing was 34 years (IQR 22-46); n=211 (60.5%) had acute leukemia (AL), n=61 (17.5%) bone marrow failure (BMF), n=45 (12.9%) lymphoma, n=25 (7.2%) myeloproliferative neoplasms (MPN), n=4 (1.1%) chronic lymphocytic leukemia (CLL) and n=3 (0.9%) multiple myeloma (MM). Most patients (n=209, 59.9%) had government insurance coverage. Median time from diagnosis to HLA-typing was 8 months (IQR 3-19). The majority had a potential donor (95.1%): n=191 haploidentical (54.7%), n=139 a matched sibling donor (39.8%) and 2 an unrelated donor (0.6%). Almost half of them eventually received a transplant (n=170, 48.7%), the median time to HLA-typing to alloHSCT was 3 months (IQR 1-6). Sex, age and diagnoses were similar between transplanted and non-transplanted patients, while non-transplanted patients had a higher proportion of not compatible and haploidentical donors. Disease activity or progression was the biggest barrier for transplantation, followed by waiting for a hospital bed and comorbidities (Table 1). Donor availability limited transplant access for only 11.7% of patients. Access to transplantation was favored by private/out-of-pocket payment (OR 2.1 95% CI 1.3-3.4), and receiving care in the outpatient center (OR 6.4 95% CI 4-10.5), while HLA matching was not (OR 1.1 95% CI 0.8-1.7). Non-relapse mortality (NRM) in alloHSCT was 22.3%. Median overall survival (OS) from the intent-to-transplant cohort was 15 months (CI 95% 11.4-18.5). An OS landmark analysis for patients alive at or beyond 3 months (the median time from HLA-typing to alloHSCT) showed prolonged survival in alloHSCT (35 vs 13 months, p <.001), figure 1. By the time of the analysis 139 patients (39.8%) were still alive and 132 (37.8%) were event-free. Conclusion: the most frequent barrier to transplantation was the disease itself, followed by the transplant waiting list and comorbidities. Access to out-of-pocket resources and an outpatient strategy or center effect favored alloHSCT. In the era of haploidentical transplantation, donor availability was a smaller issue. An approach to overcome barriers could be to implement outpatient transplantation and eliminate the waiting list barrier without increasing NRM, to improve the health policy in the direction of more patients get coverage, patient education to diminish the rates of rejection and improve their comorbidities. To our knowledge, this is the largest intent-to-transplant analysis in a population that has been HLA-typed. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 10283: Socioeconomic Disparities in Overall and Morbidity Free Survival of Infants With Single Ventricle Heart Disease

Prior studies have demonstrated higher odds of mortality for non-white and lower socioeconomic status patients with single ventricle (SV) heart disease. However, these studies have not examined survival through staged surgical palliation or rates of morbidity in this patient population. We hypothesized that non-white race/ethnicity and lower socioeconomic status were associated with lower overall survival and increased morbidity through 1 st birthday in patients undergoing SV palliation. Patients with SV heart disease, live birth, and planned SV palliation in the National Pediatric Cardiology Quality Improvement Collaborative between January 1, 2016, and December 31, 2020, were included. Race/ethnicity, payer, and neighborhood characteristics were analyzed. Morbidity was defined as acute neurological events, unplanned procedures, renal support, cardiac arrest, extracorporeal life support, necrotizing enterocolitis, or surgical site infection. Morbidity-free survival was defined as survival through each stage of palliation without experiencing one of the above morbidities. Cox proportional hazards and multivariable regression modeling were performed to evaluate the association between socioeconomic variables, race/ethnicity, and overall morbidity-free survival to 1st birthday. There were 2,184 live births with an overall survival to 1st birthday of 76%. There was no difference in survival to 1st birthday between non-Hispanic White, non-Hispanic Black, and Hispanic patients. Patients with government insurance had decreased survival prior to their 1st birthday (HR 0.79, 95% CI 0.64, 0.98 vs commercial insurance). Infants with government insurance had lower morbidity-free survival during stage 1 (OR 0.72, 95% CI 0.59, 0.87) and stage 2 (OR 0.67, 95% CI 0.52, 0.85) hospitalizations. Patients with “Other” race/ethnicity had lower odds of morbidity-free survival to one year of age (OR 0.68 95% CI 0.47, 0.98). Household income and deprivation index were not associated with survival or morbidity. Infants with government insurance experienced decreased survival to 1st birthday, and those of “Other” race/ethnicity had lower morbidity-free survival. Addressing disparities in these patient populations is an area of ongoing need.

Abstract 13910: Racial/Ethnic Outcomes Following Percutaneous Coronary Intervention

Introduction: Asian-American/Pacific Islanders (AAPIs) and Hispanics are two of the most rapidly growing minorities, but both are poorly represented in the cardiovascular literature. In light of national quality improvement efforts to ensure adherence to cardiovascular therapy guidelines, this study examines guideline adherence and outcomes in AAPIs and Hispanics compared to non-Hispanic Whites (NHW) in a quaternary care center after percutaneous coronary intervention (PCI). Methods: 1,896 AAPI, Hispanics, and NHW adults from February 28, 2012 to December 30, 2020 who underwent emergent or elective PCI were included. The primary endpoint was the prescription of post-PCI guideline-directed medical therapy including aspirin, statins, P2Y12 receptor blockers, and cardiopulmonary rehabilitation. Secondary endpoints included comorbidity burden, post-PCI morbidity and mortality, and prior PCI. Analyses were adjusted for age, sex, and insurance type. Results: Hispanics had the lowest median age and the highest rates of government insurance. Hispanics had lower odds of either ACE inhibitor or ARB prescription versus NHW (OR = 0.75, p = 0.03). Odds of ticagrelor prescriptions were lower for both Hispanics (OR = 0.56, p = 0.01) and AAPIs (OR = 0.62, p = 0.02) versus NHW. However, odds of clopidogrel prescriptions were higher for Hispanics than NHW (OR = 1.57, p = 0.01), while AAPIs trended towards the same (OR = 1.42, p = 0.05). No differences were found for statin or cardiopulmonary rehabilitation prescriptions. AAPIs and Hispanics had significantly higher risks of diabetes (OR = 2.28 and 1.8 respectively, p &lt; 0.01) and of being on dialysis (OR = 2.25 and 2.52 respectively, p &lt; 0.01) than NHW. AAPIs also had higher odds of hypertension than NHW (OR = 1.51, p = 0.01). Hispanics had significantly higher risk of post-PCI mortality versus NHW (OR = 2.12, p &lt; 0.01). Conclusions: AAPIs and Hispanics had lower odds of ticagrelor prescription than NHW, and Hispanics had higher odds of clopidogrel prescription. Hispanics also had higher odds of mortality post-PCI. Further, AAPIs and Hispanics had higher comorbidity burdens. This study suggests that despite quality improvement efforts, work remains to be done to narrow health disparities.

Prevalence and risks of reproductive tract infections among women of urban slums in North India

Objective: To identify the prevalence, determinants of reproductive tract infection, and healthcare seeking behavior among ever married women of reproductive age residing in an urban slum of Faridabad, Haryana, North India. Methods: This community based cross-sectional study was conducted among ever married women aged between 15 and 49 years insured under employees state insurance scheme and residing in an urban slum of Faridabad. Simple random sampling technique was used to interview 149 eligible women using a predesigned structured questionnaire. Study variables included sociodemographic profile, family planning methods, menstrual absorbent usage, and symptoms of reproductive tract infection. Binary logistic regression was used to investigate the determinants of reproductive tract infection. Results: Of the women, 46.3% had at least one reproductive tract infection or sexually transmitted infection symptom and 28.9% among them sought treatment for the symptom. Vaginal discharge, itching (14.1%) and lower abdominal pain (30.2%) were the major symptoms reported. Non-usage of condoms as contraceptive was significantly associated with a higher rate of symptoms (50.4% vs. 20.0%). Abortion had a significantly high odds of having reproductive tract infection symptoms (aOR 3.71, 95% CI 1.59-8.62; P&lt;0.01). Less frequent change in absorbent during menstruation was also reported to have a higher rate of symptoms. The majority of those who took treatment sought it from government or employees state insurance dispensary. 2% also went to faith healers. Conclusions: Nearly half of the study population have reproductive tract infection symptom. Abortions and non-usage of condom increase the risk of reproductive tract infection. Menstrual hygiene and condom usage are the significant interventions, which may reduce the prevalence of these symptoms.

Refusal of Surgery in Pituitary Adenoma Patients: A Population-Based Analysis.

We characterized the clinical and sociodemographic factors predictive of surgery refusal in pituitary adenoma (PA) patients. We queried the National Cancer Database (NCDB) to identify adult PA patients treated from 2004-2015 receiving or refusing surgery. Multivariate logistic regression and Cox proportional-hazards analysis identified clinical and/or sociodemographic factors predictive of surgery refusal or mortality, respectively. Of the 34,226 patients identified, 280 (0.8%) refused surgery. On multivariate logistic regression, age &gt; 65 (OR: 2.64; p &lt; 0.001), African American race (OR: 1.70; p &lt; 0.001), Charlson-Deyo Comorbidity (C/D) Index &gt; 2 (OR: 1.52; p = 0.047), and government insurance (OR: 2.03; p &lt; 0.001) or being uninsured (OR: 2.16; p = 0.03) were all significantly associated with surgery refusal. On multivariate cox-proportional hazard analysis, age &gt; 65 (HR: 2.66; p &lt; 0.001), tumor size &gt; 2 cm (HR: 1.30; p &lt; 0.001), C/D index &gt; 1 (HR: 1.53; p &lt; 0.001), having government insurance (HR: 1.66; p &lt; 0.001) or being uninsured (HR: 1.67; p &lt; 0.001), and surgery refusal (HR: 2.28; p &lt; 0.001) were all significant predictors of increased mortality. Macroadenoma patients receiving surgery had a significant increase in overall survival (OS) compared to those who refused surgery (p &lt; 0.001). There are significant sociodemographic factors that influence surgery refusal in PA patients. An individualized approach is warranted that considers functional status, clinical presentations, and patient choice.

Trends in the Delivery of Accelerated Partial Breast Irradiation Therapy

<h3>Purpose/Objective(s)</h3> Accelerated partial breast irradiation (APBI) has been utilized as an alternative to whole breast irradiation (WBI) therapy for selected patients with early-stage breast cancer. The purpose of this investigation is to determine trends in the delivery of APBI based on racial and socioeconomic demographics. <h3>Materials/Methods</h3> The National Cancer Database (NCDB) was utilized to identify patients eligible for APBI based on consensus statements. Eligibility criteria included: ≥50 years old, stage I-II (T1-2N0, M0), tumor size ≤ 3 cm, ER+, LVSI-, invasive disease or DCIS, and receipt of radiation therapy (RT). For this analysis, partial breast irradiation (PBI) was defined as regimens with ≤10 fractions of external beam (EBRT), radioisotope, and brachytherapy, with an understanding that IMPORT LOW PBI would be excluded while 5 fraction WBI would be included. 2,981,732 breast cancer patients, diagnosed from 2004-2017, were initially identified in this analysis. Exclusion criteria include patients ≤49 years (n=635,461), tumors ≥3.1cm (n=875,558), LN+ (n=550,481), ER- (n=166,135), positive surgical margins (n=28,703), those with LVSI (n=369,236), those not receiving RT (n=147,543), those undergoing a mastectomy (n=3,139), those receiving neoadjuvant chemotherapy (n=32, 365), those without invasive disease or DCIS (n=11,727), and those with stage 3/4 disease (n=15,216). All patients with unknown data were excluded (n=39,863). Patients were separated by those who received APBI (n=16,200) and who received ≥11 fractions which were classified as WBI (n= 90,105). <h3>Results</h3> 106,305 (3.6%) patients were identified as APBI candidates. Of those, 15.2% (mean age 66, range 50-90) received APBI while 84.8% (mean age 65, range 50-90) patients received WBI. Black and Asian patients were significantly less likely to receive APBI (Black: 12.0% OR, 0.70 [95% CI, 0.64-0.77], p <.001]; Asian: 10.1% OR, 0.59 [95% CI, 0.52-0.68], p<.001]) compared to white patients (15.7 %). Similarly, Latinx/Hispanic patients were less likely to receive APBI [11.0% OR, 0.73 [95% CI, 0.65-0.83], p <.001] when compared to non-Hispanic individuals (15.4 %). Patients with Medicare/other government insurance (16.7%) were also more likely than those with Medicaid/ not insured (9.3% OR, 0.68 [95% CI, 0.61-0.77], p<.001]) to receive APBI. Compared to urban areas (13.7%), patients living in rural locations (19.5% OR, 1.37 [95% CI, 1.0-1.86], p<.05]) were more likely to receive APBI. On univariate analysis, zip codes with higher high school graduation rates, and incomes >$63,000 were also associated with increased receipt of APBI (p<.001). <h3>Conclusion</h3> Despite similar candidacy, minority patients and those with Medicaid/ uninsured are less likely to receive APBI; while, higher SES and high school graduation rates is associated with receipt of APBI. Further study is needed to identify methods to increase availability for all appropriate patients.

Relationship Between Neighborhood Socioeconomic Disadvantage and Severe Maternal Morbidity and Maternal Mortality.

Rates of severe maternal morbidity and maternal mortality (SMM/MM) in the United States are rising. Disparities in SMM/MM persist by race, ethnicity and geography, and could partially be attributed to social determinants of health. Utilizing data from the largest, statewide referral hospital in Alabama, we investigated the relationship between residence in disadvantaged neighborhoods and SMM/MM. Data on all pregnancies between 2010 and 2020 were included; SMM/MM cases were identified using CDC definitions. Area deprivation index (ADI) available at the census-block group was geographically linked to individual records and categorized using quintile cutoffs; higher ADI score indicated higher socioeconomic disadvantage. Generalized estimating equation models were used to adjust for spatial autocorrelation and ORs were computed to evaluate the relationship between ADI and SMM/MM, adjusted for covariates including age, race, insurance, residence in medically underserved areas/population (MUAP), and urban/rural residence. Overall, 32,909 live-birth deliveries were identified, with a prevalence of 9.8% deliveries with SMM/MM with blood transfusion and 5.3% without blood transfusion, respectively. Increased levels of ADI were associated with increased odds of SMM/MM. Compared to women in the lowest quintile, the adjusted OR for SMM/MM among women in highest quintile was 1.78 (95%CI, 1.22-2.59, P=.0027); increasing age, non-Hispanic Black, government insurance and residence in MUAP were also significantly associated with increased odds of SMM/MM. Our results suggest that residence within disadvantaged neighborhoods may contribute to SMM/MM even after adjusting for patient-level factors. Measures such as ADI can help identify the most vulnerable populations and provide points to intervene.

Comparison of Long-Term Complications of COVID-19 Illness among a Diverse Sample of Children by MIS-C Status.

Most pediatric COVID-19 cases are asymptomatic; however, a small number of children are diagnosed with multisystem inflammatory syndrome in children (MIS-C), a rare but severe condition that is associated with SARS-CoV-2 infection. Persistent symptoms of COVID-19 illness in children diagnosed with/without MIS-C is largely unknown. A retrospective EHR review of patients with COVID-19 illness from one pediatric healthcare system to assess the presence of acute (<30 days) and chronic (≥30, 60–120, and >120 days) long-term COVID symptoms was conducted. Patients/caregivers completed a follow-up survey from March 2021 to January 2022 to assess the presence of long COVID. Results showed that non-MIS-C children (n = 286; 54.49% Hispanic; 19.23% non-Hispanic Black; 5.77% other ethnicity; 79.49% government insurance) were younger (mean age 6.43 years [SD 5.95]) versus MIS-C (n = 26) children (mean age 9.08 years, [SD 4.86]) (p = 0.032). A share of 11.5% of children with MIS-C and 37.8% without MIS-C reported acute long COVID while 26.9% and 15.3% reported chronic long COVID, respectively. Females were almost twice as likely to report long symptoms versus males and those with private insurance were 66% less likely to report long symptoms versus those with government insurance. In conclusion, a substantial proportion of ethnically diverse children from low resource backgrounds with severe COVID illness are reporting long-term impacts. Findings can inform pediatric professionals about this vulnerable population in post-COVID-19 recovery efforts.

Government Insurance and Out-of-Pocket Healthcare Expenditure in Ghana

The relationship between membership in Ghana’s national health insurance scheme and out-of-pocket healthcare expenditure (OOPHE) was quantified using data from two rounds of the Ghana Living Standards Survey for 2013 and 2017. Censored quantile regressions were evaluated with and without instrumental variables. The results show that going from having no insured household member to all insured predicted less OOPHE (by 19% at the median). We find statistically significant differences between the 2013 and 2017 estimates. Insurance reduced OOPHE in 2013 but had a statistically insignificant effect in 2017. The effect on spending on outpatient care was greater than that related to medicine and medical supplies. There was no statistically significant relationship with hospitalisation fees. Falling government health spending and growing reliance on private healthcare financing have been observed. The insurance scheme has become less generous, and it was therefore less effective in 2017.

Factors predicting pathological complete response in patients with localized breast cancer receiving neoadjuvant chemotherapy.

165 Background: Pathological Complete Response (pCR) after Neoadjuvant Chemotherapy (NAC) is associated with improved survival outcomes in early-stage breast cancer. However, data regarding the factors predicting pCR are limited. We analyzed the clinical and pathological factors associated with the attainment of pCR after NAC. Methods: We queried National Cancer Database for non-metastatic breast cancer patients who received NAC between 2010 and 2016. All associations were compared using Kruskal-Wallis, Pearson’s Chi-Squared, and Fisher’s Exact Tests. Multivariate logistic models were used to analyze association of race, sub-type, age, clinical stage, grade, histology, insurance, comorbidity index with pCR. Odds ratios, 95% confidence intervals, and p-values for each predictor were recorded and adjusted for confounders. All analyses were conducted in RStudio v4.0.2 at a significance level of 0.05. Results: A total of 137140 female and 741 male patients were identified. Majority of the patients were Whites (n = 95909) followed by Blacks (n = 23736), and Hispanics (n = 11023). 58.4% (n = 80556) patients were &gt; 55 years. 64% of the patients had private insurance, 31.1% (n = 42930) had government insurance (Medicare and Medicaid) and 3.6% (n = 4904) were uninsured. Majority of the patients had Charlson comorbidity index (CCI) equal to 0 (87%). Hormone-receptor positive and HER2 negative (HR+HER2-) comprised 37.9% (n = 51283), HER2+ were 35.2% (n = 47794) and triple-negative breast cancer (TNBC) were 26.9% (n = 36401). Compared to TNBC, HER2+ had higher and HR+HER2- had lower chance of attaining pCR. Blacks had lower (OR = 0.95, p &lt; 0.001) and Hispanics had higher chance of pCR (OR = 1.1 p &lt; 0.001) when compared to Whites in the overall population which includes all subtypes. Younger patients had lower chance of attaining pCR compared to elderly. Stage I and II patients had more chance of PCR compared to stage III. Patients with government insurance had lower odds of attaining PCR compared to those with private insurance. Patients with CCI 0 had higher chance of pCR when compared to those with CCI &gt; = 3 (OR = 1.15, 95% CI = 1.08-1.2, p &lt; 0.001). Conclusions: Patient and tumor factors play an important role in response to NAC in breast cancer patients. Identifying modifiable factors associated with odds of lower pCR rates such as, government insurance would help us intervene to improve the quality of care of breast cancer patients.[Table: see text]

Evolving Trends in the Management of Low-Risk Prostate Cancer.

Deferred treatment is a growing management strategy for low-risk prostate cancer. However, it is unknown whether this growth is mediated by patient factors. In this study, we sought to evaluate factors associated with deferred treatment in patients with low-risk prostate cancer and shifts in these factors after recent incorporation of active surveillance into national guidelines. We identified 137,915 men diagnosed with low-risk prostate cancer (prostate-specific antigen <10 ng/mL, Gleason score ≤6, stage cT1-cT2a) in the National Cancer Database from 2010 to 2017. Multivariate logistic regression models were used to determine factors associated with deferred treatment. Interaction variables were added to determine whether trends in use of deferred treatment over time depend on race, income, education, and insurance status. The use of deferred treatment among men with low-risk prostate cancer increased from 14.7% in 2010-2011 to 46.3% in 2016-2017 (P < .001). On multivariate analysis, deferred treatment was associated with older age, more contemporary year of diagnosis, black race, lower income, higher educational attainment, government insurance, being uninsured, treatment at an academic/research facility, and treatment at a facility in New England (each P < .05). Incorporation of interaction variables showed that black race, belonging to the two lowest income quartiles, government insurance, and being uninsured became less associated with deferred treatment in recent years. The use of deferred treatment among men with low-risk prostate cancer increased significantly from 2010 to 2017. However, patients who were black, low-income, and not privately insured experienced smaller increases in deferred treatment. Interventions to increase uptake in these groups present opportunities to improve quality of care.

Can Sociodemographic Factors be Used to Help Predict Outcomes in Charcot Neuroarthropathy?

Category: Diabetes; Other Introduction/Purpose: The diabetic Charcot foot, or Charcot neuroarthropathy, is a devastating condition that arises secondary to longstanding diabetes, peripheral neuropathy, and trauma. One of the many challenges associated with the Charcot patient is the lack of data exploring factors that may predict long-term outcomes. Therefore, the purpose of this study was to evaluate how certain sociodemographic factors may influence mortality and the need to undergo lower extremity amputation in patients with Charcot. Methods: Following institutional board approval, all patients from 2015-2021 with a diagnosis of Charcot Foot were queried using hospital electronic medical records. Demographics collected included sex, age, race, and insurance coverage. Outcomes recorded were the need to undergo major amputation and mortality rate. Statistical analysis was then run to determine if sex, age, race, and insurance coverage was associated with increased risk of needing a major amputation or death. Results: From 2015-2021, 80 Charcot patients with a mean age of 60 (Range, 84-32) were identified. Of these patients, 58 were male, 26 were female, 71 were white, 3 were African American, and 6 were identified as other. In our cohort, 47 patients had government funded insurance and 33 had private insurance. Amputation occurred in 22 patients and death in 15. Government funded insurance (RR: 9.8, 95% CI:1.4-71.1, P = 0.0236) and age over 65 was associated with an increased risk of death (RR: 2.5, 95% CI: 1.02 to 6.17; P = 0.044). No statistically significant increased risk of death or amputation was found in white, African American, male, or female patients. Government insurance was also not associated with an increased risk for amputation (Table 1). Conclusion: Charcot Neuroarthropathy is associated with high rates of morbidity and mortality. In our cohort, there was an increased risk of mortality in patients with government funded insurance and patients over the age of 65. Further investigation exploring the role of sociodemographic factors is warranted.

Palliative care usage in metastatic thyroid cancer: An analysis of the National Cancer Database.

196 Background: Metastatic thyroid cancer portends a poor prognosis, especially in patients over the age of 55 or in more aggressive histologies, such as anaplastic. Palliative care (PC), which focuses on improving the quality of life in patients with severe disease, may be beneficial to these patients. To our knowledge, there has yet to be a study describing the demographic and usage factors associated with PC in metastatic thyroid cancer. Methods: We conducted a retrospective analysis of the National Cancer Database (NCDB) from 2004-2017 for subjects with metastatic thyroid cancer (n = 5,229) of all histologies. Analysis was completed between patients who utilized PC (n = 826) and patients who did not use PC (n = 4,403). The NCDB defines palliative care as care provided to alleviate or palliate symptoms, including radiation therapy, surgery, pain management, and/or systemic therapy. PC usage and survival were compared between cancer subtypes. Demographic factors were analyzed using Pearson chi-squared tests and t-tests, while survival was estimated using Kaplan-Meier curves. Results: Of the subjects with metastatic thyroid cancer, 50.6% had papillary, 25.2% had anaplastic, 15.9% had follicular, and 8.3% had medullary thyroid cancer. Anaplastic, medullary, follicular, and papillary metastatic cancers had median survivals of 2.4, 19.9, 49.5, and 55.3 months, respectively (p &lt; 0.001). PC usage increased between 2004 (3.4%) and 2017 (11.4%) across all subtypes. The mean age at diagnosis of PC patients was 69.2 years old compared to 66.9 years old for non-PC patients (p &lt; 0.001). Anaplastic thyroid cancer made up the greatest proportion of PC usage (42.5%) compared to other histologies (p &lt; 0.001). Subjects of Spanish/Hispanic origin received PC at lower proportions (p &lt; 0.001). In addition, Asian patients made up a smaller fraction of the PC cohort (4.2%) compared to the non-PC cohort (6.7%) (p = 0.028). Patients with private insurance made up a smaller proportion of PC users (26.5%) compared to non-PC users (35.6%), while subjects with government insurance or no insurance made up a greater proportion of PC usage (p &lt; 0.001). Less PC usage was seen by patients who lived in an area where greater than 17.6% of individuals did not attain a high school degree; these patients made up 25.3% and 19.9% of the non-PC and PC cohorts, respectively (p = 0.006). Patients who received PC tended to live closer to the reporting hospital (p = 0.007). No statistically significant difference was seen between PC and non-PC cohorts for income and facility type. Conclusions: In this study, we highlighted several disparities in PC usage across common types of thyroid cancer. We also compared usage between categories and noted a greater proportion of PC usage in recent years. Our study is a valuable baseline as PC continues to be integrated in cancer care.

The association between adverse birth outcomes and smoking cessation during pregnancy across the United States-43 States and New York City, 2012-2017.

This cross-sectional study aimed to estimate the risks of adverse birth outcomes among pregnant smokers and the benefits of smoking cessation during pregnancy on birth outcomes across the United States. We performed an analysis of 203,437 pregnant women using data collected by the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2012 to 2017. PRAMS uses questionnaires and birth certificates to collect information about the socio-demographic characteristics of pregnant women, smoking status before and during pregnancy, and birth outcomes. We assessed the relationship between self-reported smoking status during pregnancy and preterm birth, low birth weight, and small-for-gestational-age using multivariable logistic regression models. In our study population, 80.43% of pregnant women never smoked, 10.55% of pregnant women quit smoking during pregnancy, and 9.02% continued smoking during pregnancy. Puerto Rico had the highest prevalence of non-smokers (94.12%), while West Virginia had the lowest prevalence of non-smokers (60.54%). Pregnant women who had a higher education level, were married, had less than 5 types of stress, and had government or private insurance before pregnancy had a higher prevalence of smokers who quit during pregnancy (quit smokers) than those that continued smoking (continuous smokers). Compared to non-smokers, continuous smokers had a significantly higher risk of low birth weight (AOR: 1.91, 95% CI 1.80, 2.03), preterm birth (AOR: 1.31, 95% CI 1.21, 1.41), and small-for-gestational-age (AOR: 2.22, 95% CI 2.07, 2.39). However, the relationships between quitting smoking and preterm birth and small-for-gestational-age were not significant. Our models suggest that smoking cessation during pregnancy can prevent adverse birth outcomes by significantly reducing the risk of preterm birth and small-for-gestational-age to almost comparable to not smoking.

Treatment selection towards active surveillance over definitive treatment for pituitary adenomas is influenced by sociodemographic factors

BackgroundClinical and sociodemographic predictors of pituitary adenoma (PA) patients undergoing active surveillance (AS) versus definitive treatment (DT) are poorly understood. ObjectiveThis population-based analysis aims to identify clinical and sociodemographic predictors of undergoing AS versus DT. MethodsThe National Cancer Database (NCDB) was utilized to query PA patients diagnosed from 2010 to 2015 undergoing AS or DT. Independent-samples t-test and chi-squared test were used to compare differences in patient baseline characteristics and a stepwise binary logistic regression was performed to elucidate factors implicated in undergoing AS. ResultsThe cohort consisted of 30,233 PA patients, with 5147 (17.0%) patients undergoing AS. On multivariable logistic regression, patients aged ≥ 65 years (OR=1.65; p < 0.001), African American race (OR=1.12; p = 0.035), having government insurance (OR=1.45; p < 0.001) or those uninsured (OR=1.58; p < 0.001) were significantly more likely to undergo AS compared to DT, while patients with larger tumors (OR=0.90; p < 0.001), receiving treatment at academic facilities (OR=0.75; p < 0.001), and living in West regions of the United States (OR=0.59; p < 0.001) were significantly less likely to undergo AS compared to DT. ConclusionsSignificant sociodemographic disparities exist in patient selection for undergoing AS versus DT, which may modify patient clinical outcomes.

Assessing Patient-Reported Financial Hardship in Patients With Cancer in Routine Clinical Care.

Financial hardship (FH) in cancer care is a growing challenge for patients, their caregivers, and health care providers with impact on morbidity and mortality. In this study, we report on a standardized approach to describe the prevalence and predictors for FH as part of routine clinical workflow. We also report on the association of FH with survival in our cancer patient population. This study includes patients who completed a FH screen at least once between 2018 and 2020. Demographics, disease state, and mortality data were extracted from the medical records. Multivariable logistic regression models were used to examine association of sociodemographic and disease variables with FH. By using propensity score weighting to account for differences in demographic and clinical factors between patients with and without FH, we then fit Cox proportional hazards models to examine the relationship between FH and survival. The study cohort included 31,154 patients. FH was reported by 14% (n = 4,250) of the patients. A significantly higher likelihood of having FH (P < .001 for all) was reported by racial/ethnic minority patients; those who were unemployed/disabled, single, or divorced; patients from disadvantaged neighborhoods; and those who were self-pay or had government insurance. Older age, being retired, and living farther from the cancer center were associated with significantly less likelihood of endorsing FH. Patients who endorsed FH had a lower survival (hazard ratio for mortality 1.46). Our study identified key groups more likely to report FH in a relatively affluent population at a large cancer center and showed an adverse association between FH and survival. Further research is needed to develop clinical care pathways for patients at high risk for worse financial and clinical outcomes.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) community survey: 1. population-based design, methodology and cohort profile

Study designCross-sectional survey.ObjectivesTo describe design and methods of Australian arm of International Spinal Cord Injury (Aus-InSCI) community survey, reporting on participation rates, potential non-response bias and cohort characteristics.SettingSurvey of community-dwelling people with SCI at least 12 months post-injury, recruited between March 2018 and January 2019, from state-wide SCI services, a government insurance agency and not-for-profit consumer organisations across four Australian states.MethodsThe Aus-InSCI survey combined data for people with SCI from nine custodians, using secure data-linkage processes, to create a population-based, anonymised dataset. The Aus-InSCI questionnaire comprised 193 questions. Eligibility, response status and participation rates were calculated. Descriptive statistics depict participant characteristics. Logistic regression models were developed for probability of participation, and inverse probability weights generated to assess potential non-response bias.Results1579 adults with SCI were recruited, a cooperation rate of 29.4%. Participants were predominantly male (73%), with 50% married. Mean age was 57 years (range 19–94) and average time post-injury 17 years (range 1–73). Paraplegia (61%) and incomplete lesions (68%) were most common. Males were more likely than females to have traumatic injuries (p < 0.0001) and complete lesions (p = 0.0002), and younger age-groups were more likely to have traumatic injuries and tetraplegia (p < 0.0001). Potential non-response bias evaluated using selected outcomes was found to be negligible in the Aus-InSCI cohort.ConclusionsThe Aus-InSCI survey made efforts to maximise coverage, avoid recruitment bias and address non-response bias. The distributed, linked and coded (re-identifiable at each custodian level) ‘virtual quasi-registry’ data model supports systematic cross-sectional and longitudinal research.