Government-sponsored Insurance Research Articles

Abstract 4857: Contemporary hospital-based study examining demographics, treatment patterns and survival outcomes of primary effusion lymphoma in the United States, with a specific emphasis on Hispanics

Abstract Background: Primary effusion lymphoma (PEL) is a rare and aggressive non-Hodgkin lymphoma associated with HIV and human herpesvirus 8 (HHV-8). (Blood PMID: 8695812). Without treatment, patients typically survive only two to three months (Oncol Res Treat PMID: 28253516) Limited research has been conducted on PEL, particularly in minorities in the United States. Limited research, especially in minority populations (Blood PMID: 30154110), has prompted a nationwide study comparing demographics, clinical characteristics, treatment patterns, and survival outcomes between Hispanic (HI) and Non-Hispanic (NH) PEL patients. Methods: Data on PEL patients from the National Cancer Database (NCDB) between 2004 and 2019 were analyzed in the US. Demographics and treatment characteristics were compared across ethnic groups. Kaplan-Meier and Cox regression analyses were used to compare overall survival (OS) between HI and NH populations. Multivariate analysis and propensity score matching were conducted, adjusting for age, stage, co-morbidity score, insurance status, type of facility, and great circle distance. Results: Of 459 PEL patients, 18% were HI, and 79% were NH. Both groups had mostly male patients (87% vs. 86%). HI patients were younger at diagnosis (mean 49 years vs. 57 years, p=0.163). Diagnoses were mostly from 2014-2019, and the majority were white (87% vs. 69%). Government-sponsored insurance was more prevalent in both groups (62% vs. 66%). HI had a higher percentage of uninsured individuals (8% vs. 5% NH) (p-value=0.01). The median income bracket was over $46,000 for both cohorts, HI 34% and NH 37%. Advanced comorbidities were similar between HI 50% and NH 43% based on Charlson-Deyo Score. The survival probabilities at 2, 5, and 10 years for HI vs NH were (40% vs 40%), (34% vs 289%), and (34% vs 24%), respectively. The median survival time (MS) was 0.8 years for HI and 0.9 years for NH. There was no overall survival (OS) difference (p-value=0.51). On multivariate analysis, there were no independent variables associated with better or worse OS. The propensity-matched analysis showed no MS difference between HI and NH (0.80 vs 0.71 years). Conclusion: This hospital-based analysis confirmed low survival rates and revealed no statistical differences in MS or OS among HI and NH individuals with PEL. Interestingly, the disease was more prevalent in high-income subjects in both cohorts, despite HI individuals having lower insurance rates. A better understanding of intrinsic disease characteristics and biological variables can offer valuable insights into how to unveil potential targets of better and hopefully meaningful therapies that could improve survival outcomes. Citation Format: Sergio A. Vallejo Avila, Joel Michalek, Qianquian Liu, Adolfo E. Diaz Duque. Contemporary hospital-based study examining demographics, treatment patterns and survival outcomes of primary effusion lymphoma in the United States, with a specific emphasis on Hispanics [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4857.

Disparities in Eye Care Utilization Among Refugee and Migrant Populations.

In this cross-sectional study, we examined refugee/migrant participants' health and eye care utilization compared to controls in San Diego County. Data were collected from electronic health records (EHRs) at UCSD Health-affiliated medical centers. Through a manual review of EHRs, eligibility criteria to identify a cohort were developed. A total of 64 refugee/migrant participants and 95 control participants matched based on country of origin, age, and sex were included in the analysis. Demographic characteristics, insurance type, and vision/eye care utilization were compared between the two groups. A greater proportion of refugee/migrant participants were more likely to be enrolled in government-sponsored insurance programs, predominantly Medicaid when compared to controls (55% vs. 24%, P = < 0.01). When adjusting for age, history of ophthalmic procedure, and surgery, refugee status was associated with fewer encounters with ophthalmologists in a multivariable linear regression model (coefficient = -1.66 [95% confidence interval [CI] = -2.89 to -0.44], P = 0.009). This study highlights disparities in eye care utilization for refugee/migrant populations. When compared to controls, a larger proportion of refugees/migrants had government-funded insurance, and refugee status was associated with fewer encounters with ophthalmologists. These findings underscore the need for further research on this population to better understand potential healthcare barriers these individuals may encounter. This analysis of EHR data illustrates disparities in eye care experienced by refugees/migrants, highlighting potential gaps in care in a vulnerable population.

Unnecessary Hysterectomies Among Premenopausal Women in Developed and Developing Countries: A Critical Review of Steps Taken to Improve Women's Health.

Women with pelvic organ disease often require a hysterectomy for better health. Still, in countries like India, there are many challenges for them as they are subjected many a time to unnecessary hysterectomies. Through this article, we suggest many ways to address this menace, such as proper health education and sensitization of women of premenopausal age group by health workers and mass media. Many preventable hysterectomies can be avoided if we guide women about their pathology before giving consent for surgery. Role enhancement of health agencies and nongovernmental organizations for early identification of such women in the society of all segments, stopping the greed of various health institutions using government-sponsored insurance health schemes for personal gain, and law enforcement by courts and health departments should also be our main focus. This study aims to review nonsurgical procedures adopted to decrease unnecessary hysterectomies and make suitable directions by government and lawful agencies to curb this menace. All states and union territories received the "Guidelines to Prevent Unnecessary Hysterectomies" recommendations from the Ministry of Health and Family Welfare for compliance. The recommendations suggest creating hysterectomy monitoring committees at the district, state, and federal levels. The duration of hospital stays and associated expenditures can decrease by performing minimally invasive treatments as outpatient operations. Minimally invasive options may shape the future of gynecology in developed nations.

Breaking Barriers in Classic Hodgkin Lymphoma: Unraveling Disparities between Hispanic and Non-Hispanic Patients Via the National Cancer Database (NCDB)

BACKGROUND Reducing health disparities in an increasingly diverse population with growing inequality is of paramount importance. Classic Hodgkin lymphoma (cHL), exhibits incidence variations related to socio-environmental factors, socioeconomic status, and migration (PMID 22241896). This research focuses on investigating the disparities between Hispanic (HI) and non-Hispanic (NH) patients diagnosed with cHL; utilizing an extensive dataset, this study represents the largest and most comprehensive effort to date in shedding light on the factors contributing to disparities in cHL incidence and outcomes between these two population groups. The findings from this groundbreaking study can play a crucial role in shaping healthcare policies and practices that foster inclusivity and provide equitable access to quality care, ultimately contributing to the overall health and well-being of the entire nation. METHODS Data were analyzed on cHL patients in the US reported to the National Cancer Database (NCDB) between 2004 and 2019. Demographic and treatment characteristics were compared between ethnic groups. Kaplan-Meier and Cox regression analyses were used to compare OS between HI and NH populations. Multivariate analysis and propensity score matching was performed with adjustment for age, stage, co-morbidity score, and insurance status, type of facility and great circle distance. RESULTS Out of 84,923 cHL patients, 9% were HI, and 86% NH. 56% of HI were male, compared to 54% of NH . As compared to NH at diagnosis, HI patients were younger (mean 38 years vs. 41 years) (p=&amp;lt;0.001); the majority of HI (84%) and NH (81%) were diagnosed under 65 years of age. Regarding race, most of HI and NH were White (88% vs 82%), followed by Black (2% vs 13%). When examining the stage, most of HI (33%) and NH (39%) were stage II. When examining insurance type, private insurance was the most prevalent type in HI vs NH (43% vs 60%), followed by government-sponsored insurance (39% vs 32%). The non-insured group was higher in HI (15%) vs NH (6%) (p=&amp;lt;0.001). Regarding Census Median Income (2008-2012), the most prevalent bracket for HI was $48,000 - $62,999 (28%), and for NH it was ‘$63,000+‘ (36%). When looking at median income of less than $38,000, HI were 26% vs NH 15%. Regarding Charlson-Deyo Score (comorbidities score), HI had 7% with a score of =/&amp;gt; 2 score, vs NH 5%. Academic/Research Programs were the most prevalent type of facility providing care for HI (44%) and NH (34%). Concerning the timing of treatment initiation, NH patients started receiving treatment earlier than HI, with median times of 22 days and 21 days for general treatment and 28 days and 27 days for chemotherapy, respectively (p&amp;lt;0.001). In contrast, the initiation of immunotherapy showed no significant difference between groups (median: 41 days for HI, 39 days for NH; p=0.762). Radiation therapy was initiated later among HI patients (median: 180 days) compared to NH patients (median: 166 days) (p&amp;lt;0.001). Mortality rates at 30 and 90 days were higher in the HI population at 1% and 4%, respectively, compared to 1% and 3% in NH population. On survival analysis; the survival probability at 2, 5 and 10 years of HI vs NH were (86% vs 87%), (82% vs 81%), and (74% vs 73%), respectively. There was not overall survival (OS) difference favoring HI/NH with (p=0.46) Independently, on multivariate analysis, NH ethnicity was associated with better OS (HR 0.89, CI 0.83-0.96, p&amp;lt;0.01) and private insurance type was associated with better OS (HR 0.69, CI 0.63-0.76, p&amp;lt;0.01) Interestingly, the propensity matched analysis did not demonstrate significant MS difference between HI vs NH (median 12.9 vs. 13.1 years). CONCLUSION Our evaluation of the NCDB did not demonstrate significant disparities in OS outcomes between HI and NH patients diagnosed with cHL. Despite being younger at diagnosis, HI patients exhibited lower access to insurance coverage. Additionally, treatment initiation and clinical outcomes varied among these groups, with HI individuals experiencing higher mortality rates at 30 and 90 days. These insights underscore the urgency to address and rectify the short term pervasive ethnic, socioeconomic, and healthcare inequalities present in the management of cHL. Our findings illuminate the necessity to emphasize the importance of personalizing healthcare strategies to accommodate these socio-cultural nuances, thereby fostering improved and equitable patient outcomes.

Nationwide Outcomes After Neoadjuvant Chemotherapy for Locally Advanced Sigmoid Colon Cancer-A Propensity Score-Matched Analysis.

The role of neoadjuvant chemotherapy (NAC) in advanced sigmoid colon carcinoma remains to be further characterized. Rationale for NAC includes downstaging on final pathology and optimization of microscopically negative margins (R0 resection). We investigated rates of neoadjuvant chemotherapy use in advanced sigmoid colon cancer at academic cancer centers and assessed factors associated with likelihood of NAC administration. The National Cancer Database was queried from 2004 to 2017 for patients with clinical T3 or T4, N0-2, M0 sigmoid colon cancer who underwent surgical resection. Those with neoadjuvant radiation or metastatic disease were excluded. The outcomes of patients who did and did not receive neoadjuvant chemotherapy were evaluated for this retrospective cohort study. There were 23,597 patients of whom 364 (1.5%) received NAC. More patients received NAC at academic (41%, P < .001) and high-volume centers (27%, P < .001). Patients with Medicare/Medicaid (39%) and private insurance (52%) were more likely to receive NAC (P < .001). There was a significantly higher rate of N2 to N1 downstaging in the NAC group. Propensity-score matching demonstrated comprehensive community cancer programs (CCCP) were less likely to provide NAC (OR 0.4; 95% CI 0.23, 0.70, P < .001). There was no difference in survival (P = .20), R0 resection (P = .090), or 30-day readmission rates (P = .30) in the NAC cohort compared to the non-NAC cohort. Access to centers offering multi-disciplinary care with NAC prior to surgical resection is important. This care was associated with academic and high-volume centers and private or government-sponsored insurance. There was no difference in survival between NAC and non-NAC cohort.

Demographics and Survival Outcomes of Burkitt Lymphoma in the US: A Hospital-Based Study from the National Cancer Database with Focus on Hispanics

BACKGROUND: Burkitt lymphoma (BL) is an aggressive B cell non-Hodgkin lymphoma primarily caused by MYC gene deregulation on chromosome 8 ( BloodPMID: 33171490). In the US, both sporadic and immunodeficiency-associated variants of BL are common, and their treatment and prognosis are generally similar ( BloodPMID: 15265787). BL is typically diagnosed at a median age of 30. However, the underrepresentation of Hispanics (HI) in previous studies has led to an incomplete and inaccurate representation of this population. ( J Clin OncolPMID: 9704731) To address this knowledge gap, a comprehensive nationwide study is underway to investigate the demographic, clinical, and survival outcomes of HI and non-Hispanic (NH) patients with BL. METHODS: Data from BL patients in the US (reported to NCDB between 2004 and 2019) were analyzed. Demographics, treatments, and overall survival (OS) were compared across ethnic groups. Kaplan-Meier and Cox regression analyses OS between HI and NH. Multivariate analysis and propensity score matching adjusted for age, stage, co-morbidity score, insurance status, facility type, and great circle distance. RESULTS: Among the 11,015 BL patients analyzed, 12% were HI and 84% were NH. Most were male (HI 76%, NH 74%) and diagnosed before age 65 (83% vs.72%). HI patients were younger (mean 47 years) than NH patients (mean 52 years) (p-value &amp;lt;0.001). Both groups were predominantly white (HI 90%, NH 82%), and stage IV was the most common (HI 52%, NH 52%). HI patients had a higher comorbidity burden (22%) with Charlson-Deyo Scores ≥2 compared to NH patients (16%) (p-value &amp;lt;0.001). Both groups had more government-sponsored insurance (HI: 42%, NH: 42%), but HI had a significantly higher uninsured percentage (16%) compared to NH (5.4%) (p&amp;lt;0.001). Regarding Census Median Income (2008-2012) HI's most prevalent bracket was $35,000 - $45,999 (27%), while NH's was $46,000+ (42%). HI had more median incomes below $30,000 (24%) than NH (13%) (p&amp;lt;0.001). HI patients had a shorter median distance to the reporting hospital (7.5 miles) compared to NH patients (11.5 miles) (p&amp;lt;0.001). In survival analysis, HI had higher 2, 5, and 10-year survival rates (64%, 60%, and 53%, respectively) compared to NH (69%, 54%, and 47%, respectively). The median survival time (MS) was 11.4 years for HI and 7.7 years for NH, favoring HI (p=0.003). Independently, on multivariate analysis, private insurance type was associated with higher OS (HR 0.69, CI 0.59-0.80, p&amp;lt;0,01). Interestingly, the propensity-matched analysis showed a significant MS difference between HI vs NH (6.22 vs. 2.77 years). CONCLUSION: The survival analysis conducted in this study revealed a significant and noteworthy difference in favor of HI patients with BL, despite their lower insurance coverage and income compared to NH patients. This finding could be attributed to their younger age at diagnosis, although both groups had similar burdens of comorbidities. Additionally, for both cohorts, private insurance type emerged as a significant prognostic factor in the multivariate analysis. These findings highlight the impact of ethnic and economic variations on oncological outcomes in BL for HI. This prompts further exploration of potential protective factors, unique disease characteristics, or access to improved treatments in this population. Understanding the underlying reasons for these differences could pave the way for targeted interventions and improved care for patients from diverse ethnic and economic backgrounds.

Effects at 12 months of a primary care intervention using finger puppets to support early language promotion: A pilot study

ObjectiveTo determine if introducing finger puppets in the primary care setting during infancy improves parenting and language outcomes at 12 months. MethodsIntervention cohorts were enrolled at ages 2 (early) and 6 (late) months, given a puppet, and followed two weeks later to assess dosage. High dosage was defined as using the puppet daily. At 12 months, a usual care cohort was enrolled and outcome measures were collected for all participants, including maternal depression (PHQ-9), the cognitive home environment (StimQ-T), preverbal skills (CSBS-DP-IT), and vocabulary development (CDI SF). ResultsOf 413 families screened, 248 (60%) were eligible, 180 (73%) enrolled, and 154 (86%) completed the 12-month visit. Most children (84%) were on government-sponsored insurance. There were no differences between early and late intervention outcomes. In intention-to-treat analysis, the intervention cohorts scored better than usual care on the Availability of Learning Materials (ALM) (5.50 vs. 5.02, p = 0.04) and Parental Involvement in Developmental Advance (PIDA) (8.30 vs. 7.58, p = 0.02) StimQ-T subscales and receptive vocabulary (CDI SF English) (61.0 vs. 50.1, p = 0.05). In per protocol analysis, high dosage scored better than low dosage and usual care on the StimQ-T ALM (5.83, 5.08, 5.02, p = 0.01), preverbal communication (CSBS-DP-IT) (72.3, 57.2, 59.2, p = 0.01), and receptive vocabulary (CDI SF English) (73.4, 56.1, 50.1, p = 0.0002). ConclusionsFinger puppets distributed in infancy were associated with an enhanced cognitive home environment and better preverbal and receptive language at 12 months, especially for families using the puppet daily. Additional study should determine if impacts are generalizable and maintained.

Geographic variation in the rate and route of hysterectomy for benign disease in the USA: A retrospective cross-sectional study.

To describe population rate of hysterectomy for benign disease in the USA, including geographic variation across states and Hospital Service Areas (HSAs; areas defined by common patient flows to healthcare facilities). Cross-sectional study. Four US states including 322 HSAs. A total of 316 052 cases of hysterectomy from 2012 to 2016. We compiled annual hysterectomy cases, merged female populations, and adjusted for reported rates of previous hysterectomy. We assessed small-area variation and created multi-level Poisson regression models. Prior-hysterectomy-adjusted population rates of hysterectomy for benign disease. The annual population rate of hysterectomy for benign disease was 49 per 10 000 hysterectomy-eligible residents, declining slightly over time, mostly among reproductive-age populations. Rates peaked among residents ages 40-49 years, and declined with increasing age, apart from an increase with universal coverage at age 65 years. We found large differences in age-standardised population rates of hysterectomy across states (range 42.2-69.0), and HSAs (range: overall 12.9-106.3; 25th-75th percentile 44.0-64.9). Among the non-elderly population, those with government-sponsored insurance had greater variation than those with private insurance (coefficient of variation 0.61 versus 0.32). Proportions of minimally invasive procedures were similar across states (71.0-74.8%) but varied greatly across HSAs (27-96%). In regression models, HSA population characteristics explained 31.8% of observed variation in annual rates. Higher local proportions of government-sponsored insurance and non-White race were associated with lower population rates. We found substantial variation in rate and route of hysterectomy for benign disease in the USA. Local population characteristics explained less than one-third of observed variation.

Out‐of‐pocket expenses associated with pediatric heart transplantation

Heart transplantation in children is associated with high resource utilization. However, the financial burden on families and the association with patient and demographic factors remains unclear. This study aims to examine out-of-pocket expenses associated with pediatric heart transplantation. An anonymous REDCap survey was distributed to caregivers of children who have undergone heart transplantation using social media, national organizations, and during clinic encounters from May through August 2022. There were a total of 146 respondents. The median monthly out-of-pocket expense was $250 (IQR $75-$500) and 20 respondents (13.7%) reported monthly expenses of >$1000. Families with commercial insurance reported significantly higher out-of-pocket expenses compared to those with government-sponsored insurance (median $350 vs. $100, p < .001). Families with government-sponsored insurance were most happy with their insurance coverage, followed by commercial insurance and then coverage through the Affordable Care Act (p < .001 for all pairwise comparisons). There was no statistically significant difference in overall transplant-related out-of-pocket expenses based on total household income (p = .222). Monthly out-of-pocket expense was not associated with the number of medications, type of immunosuppressants, or post-transplant complications including rejection, PTLD, or CAV (p = NS for all). Cardiac catheterizations and unplanned admissions were reported as the events that incurred the highest out-of-pocket expense. Families of children who have undergone heart transplantation can incur significant out-of-pocket expenses and strategies to mitigate this financial burden should be investigated.

Using the Ages & Stages Questionnaire to assess later effects of an infant intervention promoting language in primary care

BackgroundPositive relational experiences during infancy have a profound impact on child development and are critical for future health and school readiness. We have been evaluating a simple finger puppet intervention that takes one minute and costs $1USD to deliver in the primary care setting to promote caregiver-infant interactions. We explored using developmental trajectories to determine later outcomes of our early intervention program by comparing trajectories to age 36 months to assess optimal intervention timing when delivered in early versus late infancy.MethodsThree cohorts were enrolled and given a puppet at 2 months (early intervention) and 6 or 12 months (late intervention). Child development was assessed using the Ages & Stages Questionnaires (ASQ-3), which were independently collected during well visits. Scanned ASQ-3 forms from 2 to 36 months were obtained retrospectively through the electronic medical record. To compare longitudinal scores at different ages, all raw scores were first converted to z-scores. Longitudinal mixed effects models examined the trajectories of participant ASQ-3 scores over time by comparing the average intercepts and slopes.ResultsOf 180 children enrolled, 172 (96%) completed 2 or more ASQ-3 questionnaires and were included in the analysis, with a mean of 4.9 and a total of 843 questionnaires. Most children (85%) were on government-sponsored insurance. There were no statistical differences comparing cohort intercepts, while early intervention had a significant difference in slope compared to late intervention for the Personal-Social domain (0.12, p=0.018), resulting in higher predicted scores at 36 months. Early compared to late intervention had a difference in slope approaching significance for Communication (0.14, p=0.056) and the combined non-motor score (0.33, p=0.052). There were no significant differences in slope for Problem Solving (0.05, p=0.48), Gross Motor (-0.009, p=0.84), Fine Motor (0.06, p=0.22), and total ASQ-3 (0.32, p=0.17) scores.ConclusionsFinger puppets may provide a simple and scalable way to encourage responsive caregiver-infant interactions promoting language and social-emotional development, especially when provided in early versus late infancy. Our trajectory analysis also demonstrates a useful and potentially cost-effective approach to evaluating long-term developmental outcomes of an early intervention.

Interruption of Insurance Coverage and the Risk of Amputation in Patients with Pre-Existing Commercial Health Insurance and Peripheral Artery Disease

Peripheral artery disease (PAD) is linked with an increased risk of lower extremity amputation and multiple socioeconomic factors attenuate this risk. Prior studies have demonstrated increased rates of amputation in PAD patients with suboptimal or no insurance coverage. However, the impact of insurance loss in PAD patients with pre-existing commercial insurance coverage is unclear. In this study, we evaluated the outcomes of PAD patients who lose commercial insurance coverage. The Pearl Diver all-payor insurance claims database was used to identify adult patients (>18years) with a PAD diagnosis from 2010 to 2019. The study cohort included patients with pre-existing commercial insurance and at least 3years continuous enrollment after diagnosis of PAD. Patients were stratified based on whether they had an interruption of commercial insurance coverage over time. Patients who transitioned from commercial insurance to Medicare and other government-sponsored insurance during follow up were excluded. Adjusted comparison (1:1 ratio) was performed using propensity matching for age, gender, the Charlson Comorbidity Index (CCI), and relevant comorbidities. The main outcomes were major amputation and minor amputation. Cox proportional hazards ratios and Kaplan-Meier estimate were used to examine the association between loss of insurance and outcomes. Among the 214,386 patients included, 43.3% (n=92,772) had continuous commercial insurance coverage and 56.7% (n=121,614) had interruption of coverage (transition to uninsured or Medicaid coverage) during follow up. In the crude cohort and matched cohort, interruption of coverage was associated with lower major amputation-free survival on Kaplan Meier estimate (P<0.001). In the crude cohort, interruption of coverage was associated with 77% increased risk of major amputation (OR 1.77, 95% CI 1.49-2.12) and a 41% high risk of minor amputation (OR 1.41, 95% CI 1.31-1.53). In the matched cohort, interruption of coverage was associated with 87% increased risk of major amputation (OR 1.87, 95% CI 1.57-2.25) and a 104% increased risk of minor amputation (OR 1.47, 95% CI 1.36-1.60). Interruption of insurance coverage in PAD patients with pre-existing commercial health insurance was associated with increased risks of lower extremity amputation.

Impact on Maternal Postpartum Depressive Symptoms of a Primary Care Intervention Promoting Early Language: A Pilot Study.

Maternal depressive symptoms are an important risk factor for adverse child outcomes, especially in the perinatal period. We studied whether introducing finger puppets in the primary care setting to promote infant language improves maternal postpartum depressive symptoms. An intervention cohort was enrolled and given a finger puppet at the 2-month infant well visit. Two usual care cohorts were enrolled at either the 6- or 12-month well visit as part of a larger study. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), which was administered by clinic providers as part of routine screening done at both the 2- and 4-month well visits. EPDS scores were obtained retrospectively through the electronic medical record. Included mothers (n = 127) completed the EPDS at 2 and 4 months postpartum. Most children (83%) were on government-sponsored insurance. Mean EPDS scores and scores classified as possible depression (≥ 10) did not differ between cohorts. However, the change in scores between visits was significantly different for intervention (n = 46) compared to usual care (n = 81) participants (-1.1 vs. +0.4, p = 0.001). More intervention scores improved (n = 17, 37%) compared to usual care (n = 14, 17%), while more usual care scores worsened (n = 28, 35%) compared to intervention (n = 6, 13%) (p = 0.008). Finger puppets introduced during infant primary care visits to support language-rich maternal-infant interactions may provide a simple, low-cost way to improve maternal postpartum depressive symptoms. Larger studies with more diverse populations are needed to determine if effects are replicable, generalizable, and translate into better clinical outcomes.

Systemic risk and CO2 emissions in the U.S.

We provide both a theoretical framework and empirical results for the relationship between CO2 emissions and systemic risk in the U.S. Based on a modified structural distance-to-default model that integrates physical risk effects, a theoretical framework is developed, documenting a positive link between CO2 emissions and systemic risk. Network VAR analysis, Diebold and Yilmaz variance decomposition, and conditional Granger causality provide empirical support for this positive link. Bank assets are found to be negatively related to CO2 emissions, which indicates an adjustment of the banking sector’s assets towards a lower-carbon economy. Policy implications include government-sponsored insurance support for banks facing insured losses.

Real-World Evidence Supporting Tandem Control-IQ Hybrid Closed-Loop Success in the Medicare and Medicaid Type 1 and Type 2 Diabetes Populations.

Background: The Tandem Control-IQ (CIQ) system has demonstrated significant glycemic improvements in large randomized controlled and real-world trials. Use of this system is lower in people with type 1 diabetes (T1D) government-sponsored insurance and those with type 2 diabetes (T2D). This analysis aimed to evaluate the performance of CIQ in these groups. Methods and Materials: A retrospective analysis of CIQ users was performed. Users age ≥6 years with a t:slim X2 Pump and >30 days of continuous glucose monitoring (CGM) data pre-CIQ and >30 days post-CIQ technology initiation were included. Results: A total of 4243 Medicare and 1332 Medicaid CIQ users were analyzed among whom 5075 had T1D and 500 had T2D. After starting CIQ, the Medicare beneficiaries group saw significant improvement in time in target range 70-180 mg/dL (TIR; 64% vs. 74%; P < 0.0001), glucose management index (GMI; 7.3% vs. 7.0%; P < 0.0001), and the percentage of users meeting American Diabetes Association (ADA) CGM Glucometrics Guidelines (12.8% vs. 26.3%; P < 0.0001). The Medicaid group also saw significant improvement in TIR (46% vs. 60%; P < 0.0001), GMI (7.9% vs. 7.5%; P < 0.0001), and percentage meeting ADA guidelines (5.7% vs. 13.4%; P < 0.0001). Patients with T2D and either insurance saw significant glycemic improvements. Conclusions: The CIQ system was effective in the Medicare and Medicaid groups in improving glycemic control. The T2D subgroup also demonstrated improved glycemic control with CIQ use. Glucometrics achieved in this analysis are comparable with those seen in previous randomized controlled clinical trials with the CIQ system.

A two statewide population based study evaluating ethnic patterns, differences in treatment and survival between Hispanics and non-Hispanics with peripheral T cell lymphoma.

e19567 Background: Peripheral T-cell lymphomas (PCTLs) are an aggressive group of lymphomas that comprise less than 15% of all non-Hodgkin lymphomas in adults. There is limited literature regarding differences in outcomes for Hispanics (H). Some studies indicate worse outcomes in H compared to non-Hispanics (NH), whereas others have shown comparable outcomes. The purpose of this study is to evaluate demographics, treatment patterns and survival outcomes of PCTLs among H vs. NH in Texas (TX) and Florida (FL). Methods: This is a retrospective analysis of patients with PTCLs from the Texas Cancer Registry (TCR) and the Florida Cancer Data System (FCDS), from 2006-2017. Inclusion criteria was histopathologic proven PTCLs. Patients were divided into H and NH for comparison. Standard demographic, socioeconomic, clinical, and survival variables were reviewed. All statistical testing was determined using Fisher’s Exact test, Pearson’s Chi-square test, T-test or Wilcoxon test, as appropriate. Survival time was measured using the day of diagnosis to last date of follow up or death. Survival distributions were calculated based on Kaplan-Meier curves. Results: We identified 3358 patients. In TX 51% were H, and 49% were NH. In FL 27% were H, and 73% were NH. Median age at diagnosis of H was 70-79 years (y) (19%) and NH was 60-69 (23%) in TX (p &lt; 0.001). Median age at diagnosis of H was 50-59 y (26%) and NH was 70-7 y (26%) in FL (p &lt; 0.001). Most frequent poverty index was 20-100% for H vs 10-19.9% for NH (p &lt; 0.001) in TX and 10-19% for both H and NH (p &lt; 0.001) in FL. Government-sponsored insurance (GSI) was 40% in H vs 46% in NH (p &lt; 0.001) in TX and 35% vs 31% in NH (p &lt; 0.001) in FL. Most common stage at diagnosis for both groups was III/IV with 50% in H vs 49% in NH (p = 0.01) in TX; and stage I with 53% H vs 42% in NH (p = 0.05) in FL. Median overall survival (MOS) in TX for H was 1.4 years vs 1.5 in NH; survival probability (SP) for H vs NH at 2 y was 0.42 vs 0.44, at 5 y 0.32 vs 0.31, and at 10 y 0.21 vs 0.14 with no statistically significant difference in overall survival (OS). MOS in FL for H was 1.9 y vs 1.8 y in NH; SP for H vs NH at 2 y was 0.48 vs 0.47, at 5 y 0.36 vs 0.33, and at 10 y 0.24 vs 0.20 with no statistically significant difference in OS. Conclusions: Amongst the population of TX and FL, H with PTCLs have similar outcomes when compared to NH. There were no statistically significant differences in MOS or SP at 2, 5, and 10 y among the H cohorts. There were statistically significant differences between H and NH patients in median age of diagnosis, poverty index, and insurance status at diagnosis. These disparities were observed in both states and may be a direct reflection of the significantly higher rates of poverty and lack of insurance among H. Within the context of healthcare equality, we ascertained similar outcomes amongst groups, which agrees with previous reports claiming homogeneity of medical care.

Insurance Payer Type Affects Outcomes after Revision Total Joint Arthroplasty: A Matched Cohort Analysis.

The aim of this study is to evaluate the potential effects of insurance payer type on the postoperative outcomes following revision TJA. A single-institution database was utilized to identify 4,302 consecutive revision THA and TKA. Patient demographics and indications for revision were collected and compared based on patient insurance payer type: (1) Medicaid, (2) Medicare, and (3) private. Propensity score matching and, subsequent, multivariate regression analyses were applied to control for baseline differences between payer groups. Outcomes of interest were rates of complications occurring perioperatively and 90 days post-discharge. After propensity-score-based matching, a total of 2,328 patients remained for further multivariate regression analyses (300 [12.9%] Medicaid, 1022 [43.9%] Medicare, 1006 [43.2%] private). Compared to privately insured patients, Medicaid and Medicare patients had 71% (P<0.01) and 53% (P=0.03) increased odds, respectively, for developing an in-hospital complication. At 90 days post-discharge, compared to privately insured patients, Medicaid and Medicare patients had 88% and 43% odds, respectively, for developing overall major complications. Our propensity-score-matched cohort study found that, compared to privately insured patients, patients with government-sponsored insurance were at an increased risk for developing both major or minor complications perioperatively and at 90-days post-discharge for revision TJA. This suggests that insurance payer type is an independent risk factor for poor outcomes following revision TJA.

Disparities in Mantle Cell Lymphoma Outcomes in Hispanics: A Population Based Analysis in Texas and Florida

Disparities in Mantle Cell Lymphoma Outcomes in Hispanics: A Population Based Analysis in Texas and Florida

Secondary Interpretations of Diagnostic Imaging Examinations: Patient Liabilities and Out-of-Pocket Costs.

Secondary interpretations of diagnostic imaging examinations are increasingly performed to improve care for complex patients. We sought to determine associated patient-billed liabilities and out-of-pocket payments and to identify patient and imaging study characteristics that correlate with higher patient bills and out-of-pocket payments. Data extracted for 7,740 secondary imaging interpretations performed across our large metropolitan health system over 25 months included total professional charges, insurance payments, patient-billed liabilities, and patient out-of-pocket payments. Multivariable linear regression analyses were performed to identify patient and imaging factors associated with higher patient bills and out-of-pocket payments. Mean secondary interpretation professional charges, insurance payments, patient-billed liabilities, and patient out-of-pocket payments were $306.50, $108.02, $27.80, and $14.55, respectively. Patients received bills for 47.5% of services and made out-of-pocket payments for 17.1%. Patient-billed liabilities and out-of-pocket payments were higher for patients who were younger and uninsured and for secondary interpretations requested for patients seen in outpatient (versus inpatient) settings. Patient-billed liabilities and out-of-pocket payments were lower for patients who were Black (versus White) and had government-sponsored (versus commercial) insurance and for secondary interpretations performed during the second, third, or fourth (versus first) quarter of each calendar year. Observed differences between patient-billed liabilities and out-of-pocket payments suggest that secondary interpretations of diagnostic imaging examinations can result in small but real patient financial burdens. Improved price transparency and enhanced patient communication about the value of secondary interpretations could reduce potential surprises when patients receive these bills.

The impact of payer status on hospital admissions: evidence from an academic medical center

BackgroundThere are plenty of studies investigating the disparity of payer status in accessing to care. However, most studies are either disease-specific or cohort-specific. Quantifying the disparity from the level of facility through a large controlled study are rare. This study aims to examine how the payer status affects patient hospitalization from the perspective of a facility.MethodsWe extracted all patients with visiting record in a medical center between 5/1/2009-4/30/2014, and then linked the outpatient and inpatient records three year before target admission time to patients. We conduct a retrospective observational study using a conditional logistic regression methodology. To control the illness of patients with different diseases in training the model, we construct a three-dimension variable with data stratification technology. The model is validated on a dataset distinct from the one used for training.ResultsPatients covered by private insurance or uninsured are less likely to be hospitalized than patients insured by government. For uninsured patients, inequity in access to hospitalization is observed. The value of standardized coefficients indicates that government-sponsored insurance has the greatest impact on improving patients’ hospitalization.ConclusionAttention is needed on improving the access to care for uninsured patients. Also, basic preventive care services should be enhanced, especially for people insured by government. The findings can serve as a baseline from which to measure the anticipated effect of measures to reduce disparity of payer status in hospitalization.

Barriers to Access to Hematopoietic Cell Transplantation among Patients with Acute Myeloid Leukemia in Virginia

Allogeneic hematopoietic cell transplantation (HCT) is a standard therapy for patients with intermediate to high-risk acute myeloid leukemia (AML) and is associated with improved long-term disease-free survival. Disparity exists in access to HCT among different patient populations and requires further study.In this study, we compared HCT rates for AML among different regions in the state of Virginia and identified geographic and socioeconomic factors associated with the likelihood of receiving HCT.We conducted a retrospective, cohort study of patients 18 to 74 years of age diagnosed with AML in Virginia from 2013 to 2017 as reported to the Virginia Cancer Registry (VCR); the VCR was further linked with the Center for International Blood and Marrow Transplant Research database for identification of patients who had undergone HCT within 2 years of diagnosis. Socioeconomic data were generated from the VCR and the American Community Survey. Univariate and multivariable logistic regression models were used to examine selected socioeconomic factors of interest, including patient-level information such as sex, age, race, marital status, and primary insurance payer, as well as factors associated with geography, including the Social Vulnerability Index (SVI) and percentage of African Americans residing in the region.In Virginia, 818 patients were diagnosed with AML from 2013 to 2017, and, of these, 168 patients (21%) underwent HCT within 2 years of diagnosis. Median age was lower in the HCT cohort (55 years) versus the non-HCT cohort (64 years) (P < .001). There was a higher proportion of married patients in the HCT cohort (67%) versus the non-HCT cohort (53%) (P = .005). The rate of HCT varied by geographic region (P = .004). The multivariable analyses (without including SVI) showed decreased likelihood of HCT with increasing age (odds ratio [OR], .96; 95% confidence interval [CI], .95 to .98). Patients from regions that had a greater than 25% African American population were less likely to undergo HCT (OR, .58; 95% CI, .38 to .89). Patients who were not married were less likely to undergo HCT compared with married patients (OR, .56; 95% CI, .36 to .88). Patients with government-sponsored insurance as the primary payer were less likely to undergo HCT compared with patients with private insurance (OR, .49; 95% CI, .32 to .77). Patients living in Zip Code areas with a greater percentage of population with a bachelor's or graduate degree were more likely to undergo HCT (OR, 1.02; 95% CI, 1.00 to 1.03). In a separate multivariate model with SVI, patients residing in a Zip Code with higher SVI were less likely to undergo HCT (OR, .37; 95% CI, .16 to .82).From 2013 to 2017, we found that the likelihood of a patient undergoing HCT in Virginia for AML within 2 years of diagnosis was negatively associated with increasing age, percent of African Americans residing in the region, not-married relationship status, government-sponsored insurance as primary payer, higher SVI, and decreased percent of population with a bachelor's or graduate degree. Resources should be directed toward at-risk patient populations to remove barriers to improve access to HCT. The SVI can be used to identify communities at risk nationwide.