Higher Comorbidity Score Research Articles

Skilled Nursing Facility Following Hip Fracture Arthroplasty Diminishes Care “Value”

BackgroundValue is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNFs) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF). MethodsBetween October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, postoperative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-squared or t-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA and 63% HA) and 132 (69%) patients discharged to SNF (14% THA and 86% HA). Patients discharged to SNF were older (P < .01), had lower Risk Assessment and Prediction Tool scores (P < .01), had higher comorbidity scores (P = .011), and had longer posthospitalization care (P < .01). ResultsThere were no differences in rates of inpatient minor complications (P = .520), inpatient major complications (P = .119), Intensive Care Unit admissions (P = .193), or readmissions within 30 (P = .690) and 90 days (P = .176). Costs of care at a SNF were higher than HHS (P < .01). In multivariate regressions, a lower Risk Assessment and Prediction Tool score was associated with discharge to SNF (odds ratio 0.69, 95% confidence interval 0.58-0.83, P < .001). ConclusionAmong Comprehensive Care for Joint Replacement bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate patients.

Association of Frailty Status with Risk of Fall among Hospitalized Elderly Patients: A Cross-Sectional Study in an Acute Geriatric Unit.

Introduction: The objective was to study the association of frailty status in hospitalized elderly patients with risk of fall in an acute geriatric unit and to characterize elderly “fallers” using a comprehensive gerontological assessment. Patients and Methods: A cross-sectional study was conducted in patients over 65 years of age and hospitalized in an acute geriatric unit. This work was carried out in the Acute Geriatric Medicine Unit, Saint-Julien Hospital, Center Hospitalier Universitaire de Rouen from 1 June 2016 to 15 August 2016. Results: 172 patients were included during the collection period, with a female predominance of 115 patients (66.9%). The average age of the sample was 79.37 years old (65–85). The average CHARLSON score was 6.93 (3–16). Patients came from home in 81.4% of cases (i.e., 140 patients), and from a nursing home in 18.6% of cases (i.e., 32 patients). The risk of falling, as assessed by the Monopodal Support Test, returned as abnormal for 127 patients. In our series, there was a statistically strong link between the risk of falling and the presence of a dementia pathology (p = 0.009), the presence of a vitamin D deficiency (p = 0.03), the presence of frailty, as assessed by the three scales (modified SEGA scale, Fried scale and CFS/7 (<0.001), a high comorbidity score (p = 0.04), and a disturbed autonomy assessment according to IADL (p = 1.02 × 10−5) and according to ADL (p = 6.4 × 10−8). There was a statistically strong link between the risk of falling and the occurrence of death (p = 0.01). Conclusion: The consequences of the fall in terms of morbidity and mortality and the frequency of this event with advancing age and its impact on the quality of life as well as on health expenditure justify a systematic identification of the risk of falling in the elderly population. It is therefore important to have sensitive, specific, and reproducible tools available for identifying elderly people at high risk of falling.

Real-world efficacy and safety outcomes of imatinib treatment in patients with chronic myeloid leukemia: An Australian experience.

Tyrosine kinase inhibitors (TKI) have revolutionized the treatment of chronic myeloid leukemia (CML), but patients still experience treatment‐limiting toxicities or therapeutic failure. To investigate the real‐world use and outcomes of imatinib in patients with CML in Australia, a retrospective cohort study of patients with CML commencing imatinib (2001–2018) was conducted across two sites. Prescribing patterns, tolerability outcomes, and survival and molecular response were evaluated. 86 patients received 89 imatinib treatments. Dose modifications were frequently observed (12‐month rate of 58%). At last follow‐up, 62 patients (5‐year rate of 55%) had permanently discontinued imatinib treatment, of which 44 switched to another TKI (5‐year rate of 46%). Within 3 months of starting imatinib, 43% (95% CI, 32%–53%) of patients experienced imatinib‐related grade ≥3 adverse drug reactions (ADRs). Higher comorbidity score, lower body weight, higher imatinib starting dose, and Middle Eastern or North African ancestry were associated with a higher risk of grade ≥3 ADR occurrence on multivariable analysis (MVA). Estimated overall survival and event‐free survival rates at 3 years were 97% (95% CI, 92%–100%) and 81% (95% CI, 72%–92%), respectively. Cumulative incidence of major molecular response (MMR) at 3 years was 63% (95% CI, 50%–73%). On MVA, imatinib starting dose, ELTS score, BCR‐ABL1 transcript type, pre‐existing pulmonary disease, and potential drug–drug interactions were predictive of MMR. In conclusion, imatinib induced deep molecular responses that translated to good survival outcomes in a real‐world setting, but was associated with a higher incidence of ADRs, dose modifications and treatment discontinuations than in clinical trials.

Patient characteristics and health system factors associated with adjuvant radiation therapy receipt in older women with early-stage endometrial cancer

IntroductionAmong women with early-stage endometrial cancer (EC), age, stage, grade, and histology are used to determine fitness for adjuvant radiation therapy (RT) administration. We examined non-cancer factors associated with adjuvant RT receipt in older women with early-stage EC. Materials & methodsUsing data from the Surveillance Epidemiology and End Results cancer registry program linked with Medicare claims, we identified 25,654 women (aged ≥66 years) diagnosed with first primary stage I-II EC during 2004–2017 who underwent a hysterectomy. Diagnosis and procedure codes were used to identify adjuvant RT claims filed for the seven-month period post-hysterectomy. Multivariable log-binomial regression was used to estimate adjuvant RT prevalence associated with patient characteristics and health system factors after adjustment for age, frailty, and endometrial factors. ResultsAdjuvant RT was less commonly administered to Asian American and Pacific Islander patients than non-Hispanic White patients (Prevalence ratio [PR], 0.84; 95% confidence interval [CI], 0.73 to 0.97). Compared to women treated in the Northeast region, women treated other regions of the US were less likely to undergo adjuvant RT (PR, 0.75; 95% CI, 0.71 to 0.79). Residing in rural or high neighborhood-poverty counties was associated with lower adjuvant RT administration. Higher comorbidity score was not associated with reduced prevalence of adjuvant RT receipt; however, women with high probability of predicted probability of frailty were less likely to undergo adjuvant RT (PR, 0.67; 95% CI, 0.55 to 0.81) compared to women with low probability of frailty. Women who received lymph node assessment were more likely to undergo adjuvant RT compared to women who did not (PR, 1.43; 95% CI, 1.34 to 1.51). Women treated by a gynecologic oncologist were more likely to undergo adjuvant RT compared to women treated by a non-gynecologic oncologist (PR 1.09; 95% CI, 1.04 to 1.14). Adjuvant RT was more commonly administered to women treated in larger academic hospitals. DiscussionFindings suggest that various non-cancer factors affect the delivery of adjuvant RT to older women with early-stage EC in real-world oncology practice. Advancing our understanding of factors associated with adjuvant RT administration may help expand equitable access to RT.

Factors Associated With Poor Outcomes Among Patients With SARS-CoV-2 Coronavirus Infection and Gastrointestinal Symptoms

Background & AimsGastrointestinal (GI) symptoms are present in 20% of patients with COVID-19. We studied the association of GI symptoms (in COVID-19 patients) with adverse outcomes and factors associated with poor outcomes in these patients.MethodsThe study cohort included 100,902 patients from the Cerner Real World Data (CRWD) COVID-19 Database of hospital encounters and emergency department (ER) visits with COVID-19 infection from December 1, 2019, to November 30, 2020. Multivariate analysis was used to study the effect of GI symptoms on adverse outcomes, and the factors associated with acute respiratory distress syndrome (ARDS), sepsis, and ventilator requirement or oxygen dependence in COVID-19 patients with GI symptoms.ResultsPatients with COVID-19 and GI symptoms were significantly more likely to have ARDS (OR 1.20, 95% CI 1.11, 1.29), sepsis (OR 1.19, 95% CI 1.14, 1.24), acute kidney injury (OR 1.30, 95% CI 1.24, 1.36), venous thromboembolism (OR 1.36, 95% CI 1.22, 1.52) or GI bleed (OR 1.62, 95% CI 1.47, 1.79); and less likely to experience cardiomyopathy (OR 0.87, 95% CI 0.77, 0.99) or death (OR 0.71, 95% CI 0.67, 0.75). Among those with GI symptoms, older age, higher Charlson comorbidity index scores, and use of proton pump inhibitors (PPI)/ H2 receptor antagonists (H2RA) were associated with higher mortality, ARDS, sepsis, and ventilator or oxygen requirement.ConclusionPatients with COVID-19 who have GI symptoms have overall worse in-hospital complications, but less cardiomyopathy and mortality. Older age, higher comorbidity scores, and the use of PPI and H2RA are associated with poor outcomes in these patients.

Economic and humanistic burden of ovarian cancer in the United States (392)

Economic and humanistic burden of ovarian cancer in the United States (392)

Key predictors and burden of meticillin-resistant Staphylococcus aureus infection in comparison with meticillin-susceptible S. aureus infection in an Australian hospital setting

Staphylococcus aureus is associated with significant mortality and increased burden on the healthcare system. Relatively few reliable estimates are available regarding the impact of meticillin-resistant S.aureus (MRSA) infection compared with meticillin-susceptible S.aureus (MSSA) infection. To compare patients with MRSA infection and MSSA infection to identify differences in inpatient mortality, length of stay and costs of hospital services, and identify predictors of MRSA as a cause of S.aureus infection. An analytical, retrospective, longitudinal study using non-identifiable linked data on adults admitted to hospitals of a health district in Australia with a diagnosis of S.aureus infection over a 10-year period. The main outcome measure was 30-day inpatient mortality. Secondary endpoints included total overnight stays, all-cause inpatient mortality, and hospitalization costs within 1 year of index admission. Inpatient mortality at 30, 100 and 365 days was estimated to be significantly greater for patients with MRSA infection. The mean additional cost of MRSA infection when controlling for additional factors was $5988 and 4 nights of additional hospital stay per patient within 1 year of index admission. Key predictors of MRSA infection were: date of index admission; higher comorbidity score; greater socio-economic disadvantage; admission to hospital other than via the emergency department; older age; and prior admission to hospital within 28 days of index admission. MRSA infection is associated with increased inpatient mortality, costs and hospital length of stay compared with MSSA infection. Efforts are required to alleviate the additional burden of MRSA infection on patients and healthcare systems.

Effect of Electronic and Mail Outreach From Primary Care Physicians for COVID-19 Vaccination of Black and Latino Older Adults

COVID-19 morbidity is highest in Black and Latino older adults. These racial and ethnic groups initially had lower vaccination uptake than others, and rates in Black adults continue to lag. To evaluate the effect of outreach via electronic secure messages and mailings from primary care physicians (PCPs) on COVID-19 vaccination uptake among Black and Latino older adults and to compare the effects of culturally tailored and standard PCP messages. This randomized clinical trial was conducted from March 29 to May 20, 2021, with follow-up surveys through July 31, 2021. Latino and Black individuals aged 65 years and older from 4 Kaiser Permanente Northern California (KPNC) service areas were included. Data were analyzed from May 27, 2021, to September 28, 2021. Individuals who had not received COVID-19 vaccination after previous outreach were randomized to electronic secure message and/or mail outreach from their PCP, similar outreach with additional culturally tailored content, or usual care. Outreach groups were sent a secure message or letter in their PCP's name, followed by a postcard to those still unvaccinated after 4 weeks. The primary outcome was time to receipt of COVID-19 vaccination during the 8 weeks after initial study outreach. KPNC data were supplemented with state data from external sources. Intervention effects were evaluated via proportional hazards regression. Of 8287 included individuals (mean [SD] age, 72.6 [7.0] years; 4665 [56.3%] women), 2434 (29.4%) were Black, 3782 (45.6%) were Latino and preferred English-language communications, and 2071 (25.0%) were Latino and preferred Spanish-language communications; 2847 participants (34.4%) had a neighborhood deprivation index at the 75th percentile or higher. A total of 2767 participants were randomized to culturally tailored PCP outreach, 2747 participants were randomized to standard PCP outreach, and 2773 participants were randomized to usual care. Culturally tailored PCP outreach led to higher COVID-19 vaccination rates during follow-up compared with usual care (664 participants [24.0%] vs 603 participants [21.7%]; adjusted hazard ratio (aHR), 1.22; 95% CI, 1.09-1.37), as did standard PCP outreach (635 participants [23.1%]; aHR, 1.17; 95% CI, 1.04-1.31). Individuals who were Black (aHR, 1.19; 95% CI, 1.06-1.33), had high neighborhood deprivation (aHR, 1.17; 95% CI, 1.03-1.33), and had medium to high comorbidity scores (aHR, 1.19; 95% CI, 1.09-1.31) were more likely to be vaccinated during follow-up. This randomized clinical trial found that PCP outreach using electronic and mailed messages increased COVID-19 vaccination rates among Black and Latino older adults. ClinicalTrials.gov Identifier: NCT05096026.

Population-Based Disparities in Inferior Vena Cava Filter Procedures Among Medicare Enrollees With Acute Venous Thromboembolism.

Venous thromboembolism (VTE) imposes a significant clinical and financial burden on patients and society. Inferior vena cava filters (IVCFs) are considered for patients with absolute contraindications or failures of anticoagulation. However, studies examining the population-based disparities of IVCF placement and retrieval are limited. The association between patient and clinical characteristics in the likelihood of and time to IVCF placement and retrievals in a nationally representative cohort was examined. Medicare patients aged ≥65 years with index VTE claims between 2015 and 2018 were followed through 2019 to identify IVCF placements and retrievals. Rates were compared using survival analysis methods. Of the 516,978 patients with VTE diagnoses, 5,864 (1.1%) had IVCFs placed, and 1,884 (32.1%) of those underwent retrieval procedures. Placement and retrieval rates varied significantly by demographics, comorbidity burden, and geographic region. From Cox regression, older age (hazard ratio [HR], 1.26; P < .0001), higher baseline comorbidity (Elixhauser) score (HR, 1.07; P < .0001), and outpatient (vs inpatient) site of VTE service (HR, 2.11; P < .0001) were associated with increased frequency of IVCF placement. The rate of retrieval was significantly lower for men (HR, 0.83; P= .0393), patients with higher comorbidity scores (HR, 0.95; P= .0037), and those with outpatient (vs inpatient) VTE sites of service (HR, 0.77; P= .0173). Neither facility- nor county-level characteristics were significantly associated with placements or retrievals. This large cohort of Medicare beneficiaries with newly diagnosed VTE demonstrated inequities in IVCF placement and retrieval.

Impact of Early versus Late Referral to Nephrologists on Outcomes of Chronic Kidney Disease Patients in Northern India.

Background CKD patients are often asymptomatic in the early stages and referred late to nephrologists. Late referred patients carry a poor prognosis. There is a lack of data on outcomes associated with referral patterns in CKD patients from northern India. Methods In this observational cohort study, all CKD patients who visited the nephrology OPD of the institute between Nov 1, 2018, and Dec 31, 2020, were classified as early referral (ER) if their first encounter with a nephrologist occurred more than one year before initiation of dialysis and education about dialysis (from a nurse or nephrologist). The remaining others were considered late referrals (LRs). The outcomes impact of early and late referrals was analyzed. Results A total of 992 (male 656) CKD patients (ER, n = 475 and LR, n = 517) were enrolled. Patients referred early were older and diabetic and had higher BMI, better education, occupation, and socioeconomic status as compared to those referred late. The mean eGFR at first contact with the nephrologist was (25.4 ± 11.5 ml/min) in ER and 9.6 ± 5.7 ml/min in the LR group and had a higher comorbidity score. The CKD-MBD parameters, hemoglobin, and nutritional parameters were worse in LR. Only a few patients had AVF, and the majority required emergency dialysis in the LR group. A total of 91 (9.2%) patients died, 17 (1.7% ER and 74 (7.5%) patients in the LR group patients. There was significantly lower survival at 6 months (ER 97.1% vs. LR 89.7%), 12 months (ER 96.4% vs. LR 85.7%), 18 months (ER 96.4% vs. LR 85.7%), and 24 months (ER 96.4% vs. LR 85.7%) in late referral group as compared to early referral group (P=0.005). Conclusions LR to nephrologists has the risk of the emergency start of dialysis with temporary vascular access and had a higher risk of mortality. The timely referral to the nephrologist in the predialysis stage is associated with better survival and reduced mortality.

Clinical characteristics and outcomes of COVID-19 disease in patients with cancer.

e18678 Background: The Coronavirus Disease 2019 (COVID- 19) has been nominated as a pandemic by the World Health Organization short after has spreaded globally. Unfortunately, even after several effective vaccines approved by FDA, COVID-19 cases are still surging. Compared to the general population, patients with cancer are more susceptible to COVID-19 for many aspects. Therefore, better understanding of the clinical characteristics of cancer patients with COVID-19 is urgently needed to spare these vulnerable patients from severe disease course. Methods: This retrospective study was completed in Capital Health Regional Medical Center, New jersey, USA. Adult patients with COVID-19 diagnosed between March 2020 and May 2021 were included in this study. All selected COVID-19 patients were stratified as two groups: Patients with cancer and patients without cancer. Other variables were included as age at diagnosis, gender, race/ethnicity, insurance status, obesity, comorbidity score, treatment of COVID-19, oxygen requirement and vital status. The Charlson Comorbidity Index was used to calculate the comorbidity score. Results: A total of 562 COVID-19 patients were included in this study; 67 (12%) patients diagnosed with cancer. Patients with cancer were more likely to be older (73 vs. 62 years, p &lt; 0.001), overweight (BMI 25-29.9) (39% vs 28%, p = 0.02), and have higher comorbidity score &gt; 3 (58% vs 15%, p &lt; 0.001) than patients without cancer. Patients with cancer more frequently received steroid therapies (52% vs. 34%, p = 0.003), remdesivir (21% vs. 4%, p &lt; 0.001), and convalescent plasma (21% vs. 10%, p = 0.009). The rate of high flow oxygen therapy was higher in patients with cancer than patients without cancer (30% vs. 16%, p = 0.02). The days of mechanic ventilation, hospital stay, ICU admission were similar between two groups. Patients without cancer had better survival rate compared to patients with cancer (77% vs. 64%, p = 0.02). Patients with cancer had increased D-dimer level (2.4 vs. 1.6 mg/L, p = 0.08) compared to patients without cancer but it was not significantly different. Other laboratory findings were also similar between two groups, including WBC, neutrophils, lymphocytes, lactate, lactate dehydrogenase, creatine kinase, d-dimer, C-reactive protein, procalcitonin, fibrinogen, BNP, troponin, sodium, AST, ALT, and ferritin. Multivariable logistic regression analysis showed that patients with cancer were associated with increased odds of higher than 3 comorbidity score (OR 7.09 [3.85-13.05], p &lt; 0.001) and oxygen therapy with nasal cannula up to 6 liters (OR 3.7 [1.04-13.5], p = 0.04). Conclusions: This present analysis showed that patients had increased risk of mortality compared to counterpart. Our results emphasize that cancer patients as a group are at higher risk due to advanced age and preexisting conditions.

A Population-Based Study Evaluating Retention in Rheumatology Care Among Patients With Rheumatoid Arthritis.

ObjectiveThe study objective was to assess adherence to system‐level performance measures measuring retention in rheumatology care and disease modifying anti‐rheumatic drug (DMARD) treatment in rheumatoid arthritis (RA).MethodsWe used a validated health administrative data case definition to identify individuals with RA in Ontario, Canada, between 2002 and 2014 who had at least 5 years of potential follow‐up prior to 2019. During the first 5 years following diagnosis, we assessed whether patients were seen by a rheumatologist yearly and the proportion dispensed a DMARD yearly (in those aged ≥66 for whom medication data were available). Multivariable logistic regression analyses were used to estimate the odds of remaining under rheumatologist care.ResultsThe cohort included 50,883 patients with RA (26.1% aged 66 years and older). Over half (57.7%) saw a rheumatologist yearly in all 5 years of follow‐up. Sharp declines in the percentage of patients with an annual visit were observed in each subsequent year after diagnosis, although a linear trend to improved retention in rheumatology care was seen over the study period (P < 0.0001). For individuals aged 66 years or older (n = 13,293), 82.1% under rheumatologist care during all 5 years after diagnosis were dispensed a DMARD annually compared with 31.0% of those not retained under rheumatology care. Older age, male sex, lower socioeconomic status, higher comorbidity score, and having an older rheumatologist decreased the odds of remaining under rheumatology care.ConclusionSystem‐level improvement initiatives should focus on maintaining ongoing access to rheumatology specialty care. Further investigation into causes of loss to rheumatology follow‐up is needed.

PD13-04 TRENDS IN DIAGNOSIS AND TREATMENT OF T1A, T1B PROSTATE CANCER IN THE UNITED STATES, 2010-2017

You have accessJournal of UrologyCME1 May 2022PD13-04 TRENDS IN DIAGNOSIS AND TREATMENT OF T1A, T1B PROSTATE CANCER IN THE UNITED STATES, 2010-2017 Eyal Kord, Hannah Koenig, On Ho, John Paul Flores, and Christopher Porter Eyal KordEyal Kord More articles by this author , Hannah KoenigHannah Koenig More articles by this author , On HoOn Ho More articles by this author , John Paul FloresJohn Paul Flores More articles by this author , and Christopher PorterChristopher Porter More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002545.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Currently, there is no consensus regarding optimal treatment for incidental prostate cancer (PCa) finding after surgical treatment for benign prostate obstruction. In addition, changing recommendations regarding PCa screening in the US during the last decade, have led to changes in incidence patterns of PCa. We aimed to assess recent trends in diagnosis and treatment of T1a, T1b PCa in the US. METHODS: Using the National Cancer Database, we identified patients diagnosed with T1a, T1b, and T1c PCa between 2010-2017. We described rates of diagnosis, change in clinically significant disease, and patients risk stratification over the time-period studied. Use of treatment modalities was compared between the risk stratified groups. We used the two-way ANOVA and Tukey post Hoc Tests to examine significant changes in incidence and treatment. RESULTS: We identified 24,679 patients diagnosed with T1a (15,186) or T1b (9,493) PCa between 2010-2017. Newly diagnosed T1a/b cases represented an average of 3.54% of all PCa cases without a significant change in incidence over the years. The chance of T1a/b being clinically significant (CS) increased steadily and significantly over time representing 38.7% in 2010 and 44.1% in 2017 (p <0.001). Low, intermediate, and high-risk disease comprised 72.3%,20.9%, and 6.8% of T1a, and 27.3%,33.5%, and 39.2% of T1b diagnosis, respectively. In comparison to T1c, patients diagnosed with T1a/b disease were older (62.2 Vs 70.3 for Low, 64.4 Vs 72.3 for intermediate, and 67.1 Vs 76.4 for high risk, p <0.001) and had a higher comorbidity score across all risk groups. (0.18 Vs 0.42 for Low, 0.23 Vs 0.46 for intermediate, and 0.27 Vs 0.45 for high risk, p <0.001) Across all risk groups, patients diagnosed with T1a/b disease were significantly less likely to be treated definitively with surgery or radiation, and more likely to be treated with active surveillance/watchful waiting or androgen deprivation therapy in comparison to T1c patients (Table 1). CONCLUSIONS: Although the incidence of T1a/b PCa remained stable, the chance of CS disease diagnosis increased between 2010-2017. In comparison to T1c, men diagnosed incidentally with T1a/b disease are less likely to receive definitive treatment by surgery or radiation. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e252 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eyal Kord More articles by this author Hannah Koenig More articles by this author On Ho More articles by this author John Paul Flores More articles by this author Christopher Porter More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP24-01 RACE BASED EQUATIONS FOR ESTIMATING KIDNEY FUNCTION MAY CONTRIBUTE TO RACIAL DISPARITIES IN PARTIAL NEPHRECTOMY UTILIZATION AMONG BLACK PATIENTS WITH KIDNEY TUMORS

You have accessJournal of UrologyCME1 May 2022MP24-01 RACE BASED EQUATIONS FOR ESTIMATING KIDNEY FUNCTION MAY CONTRIBUTE TO RACIAL DISPARITIES IN PARTIAL NEPHRECTOMY UTILIZATION AMONG BLACK PATIENTS WITH KIDNEY TUMORS Nour Abdallah, Tarik Benidir, Martin Hofmann, Eiftu Haile, Diego Aguilar Palacios, Venkatesh Krishnamurthi, Samuel Haywood, Mohamed Eltemamy, Jihad Kaouk, Robert Abouassaly, Steven Campbell, and Christopher Weight Nour AbdallahNour Abdallah More articles by this author , Tarik BenidirTarik Benidir More articles by this author , Martin HofmannMartin Hofmann More articles by this author , Eiftu HaileEiftu Haile More articles by this author , Diego Aguilar PalaciosDiego Aguilar Palacios More articles by this author , Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author , Samuel HaywoodSamuel Haywood More articles by this author , Mohamed EltemamyMohamed Eltemamy More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Robert AbouassalyRobert Abouassaly More articles by this author , Steven CampbellSteven Campbell More articles by this author , and Christopher WeightChristopher Weight More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002563.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Population based studies have found that black Americans with renal tumors are less likely to undergo a partial nephrectomy (PN) compared to non-black Americans despite their increased risk for chronic kidney disease (CKD). Guidelines suggest assessment of renal function, tumor size and location to determine whether to perform a PN or radical nephrectomy (RN). However, commonly used equations to predict renal function are racialized and estimate a 15-20% higher glomerular filtration rate (eGFR) if the patient is black compared to non-black patients. We hypothesize that these racialized estimates of eGFR may contribute to the lower utilization of PN in blacks. METHODS: From 2005 to 2020, we included 6476 consecutive patients undergoing either PN or RN with known self-reported race and preoperative (preop) creatinine at Cleveland Clinic. Data was dichotomized into Black (n=668) and non-Black patients (n=5808) and compared across preop variables and surgery types. Multivariable regression analysis was used to identify predictors of PN. We also stratified PN rates across CKD stages for blacks and non-blacks. RESULTS: The cohorts’ preop variables are listed in Table 1. Black patients had higher rates of diabetes, hypertension, had higher comorbidity scores and lower baseline eGFR. On multivariable logistic regression analysis, black patients were less likely to be treated via PN (Odds Ratio (OR)=0.75, Confidence interval (CI)=[0.63-0.89], p=0.001), even when controlling for body mass index, age-adjusted Charlson comorbidity index, hypertension, preop eGFR, tumor size and complexity. When comparing PN rates across CKD stages, PN utilization was similar for all stages except stage 1, where the odds of getting a PN were 39% lower for black patients compared to non-blacks (OR 0.61, [0.46-0.82], p=0.01). CONCLUSIONS: Black patients were less likely to undergo PN, despite lower baseline kidney function and higher comorbidity rates. This disparity was most marked in patients with high estimated renal function. Racialized kidney function equations may contribute, along with access and other unknown factors to the disparity seen in the use of kidney preservation strategies for black patients with renal masses. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e392 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nour Abdallah More articles by this author Tarik Benidir More articles by this author Martin Hofmann More articles by this author Eiftu Haile More articles by this author Diego Aguilar Palacios More articles by this author Venkatesh Krishnamurthi More articles by this author Samuel Haywood More articles by this author Mohamed Eltemamy More articles by this author Jihad Kaouk More articles by this author Robert Abouassaly More articles by this author Steven Campbell More articles by this author Christopher Weight More articles by this author Expand All Advertisement PDF downloadLoading ...

Utilization of Mammography During the Last Year of Life Among Older Breast Cancer Survivors.

Background: Mammography is generally recommended for breast cancer survivors. However, discussion is ongoing about stopping surveillance mammography when life expectancy is <5-10 years as the benefit of screening might be diminished toward the end of life. The utilization pattern of mammography in the last year of life among this population has not been well studied. Methods: We identified 58,736 females diagnosed with breast cancer between January 2002 and December 2015, who died at the age of at least 67, from the SEER-Medicare database. We examined the utilization patterns of mammography during their last year of life and investigated factors associated with the use of mammography at the end of life using a multivariable logistic regression model. Results: Overall, 28.5% of the patients received mammography during the last year of life. Multivariable logistic regression showed that older age (OR = 0.31, 95% CI = 0.29-0.34, p < 0.001 for 95 vs. 85 years old), more advanced cancer stage (OR = 0.22, 95% CI = 0.20-0.24 p < 0.001 for distant vs. localized disease), and higher comorbidity score (OR = 0.92, 95% CI = 0.91-0.93, p < 0.001 for every 1-point increase) were associated with less mammography use. Age was nonlinearly associated with mammography use, with a steady proportion of patients receiving a mammography until approximately age 80 and then a sharp decrease thereafter. Conclusion: This population-based study found that a sizable proportion of older breast cancer survivors received mammography during the last year of life.

Health Care Disparities in Surgical Management of Pelvic Organ Prolapse: A Contemporary Nationwide Analysis.

Our objective was to compare the rate of native tissue repair (NTR) versus sacrocolpopexy (SCP) and reconstructive (RECON) versus obliterative repair (OBR) for the treatment of pelvic organ prolapse (POP), evaluating for health care disparities based on race, socioeconomic, and geographic factors. The National Inpatient Sample database was queried for patients older than 18 years undergoing POP surgery from 2008 to 2018. Baseline demographics, comorbidity index, socioeconomic, and hospital variables were extracted. The weighted t test, Wilcoxon test, and χ2 test were used to compare the rate of (1) NTR versus SCP and (2) RECON vs OBR. Multivariate weighted logistic regression was used to compare while controlling for confounders. Reference groups were White race, Medicare patients, northeast region, small hospital size, and rural location. Of 71,262 patients, 67,382 (94.6%) underwent RECON. Patients undergoing OBR were older and had a higher comorbidity score. Multivariate analysis showed the following: (1) Black, Hispanic, and other races; (2) Medicaid patients; (3) patients at urban teaching hospitals are less likely to receive RECON. Patients in the midwest were more likely to receive RECON. Among 68,401 patients, 23,808 (34.8%), and 44,593 (65.19%) underwent SCP and NTR, respectively. Hysterectomy was more common in the NTR group. Multivariate analysis showed the following:(1) Black, Hispanic, and "other" races; (2) uninsured and Medicaid patients; (3) patients in the midwest, south, and west were at higher odds of receiving NTR. Patients in large and urban hospitals were less likely to undergo NTR. Racial, socioeconomic, and geographic disparities exist in surgical management for POP warranting further study to seek to eliminate these disparities.

Risk and economic burden of surgical site infection following spinal fusion in adults.

Spinal fusion surgery (SFS) is one of the most common operations in the United States, >450,000 SFSs are performed annually, incurring annual costs >$10 billion. We used a nationwide longitudinal database to accurately assess incidence and payments associated with management of postoperative infection following SFS. We conducted a retrospective, observational cohort analysis of 210,019 patients undergoing SFS from 2014 to 2018 using IBM MarketScan commercial and Medicaid-Medicare databases. We assessed rates of superficial/deep incisional SSIs, from 3 to 180 days after surgery using Cox proportional hazard regression models. To evaluate adjusted payments for patients with/without SSIs, adjusted for inflation to 2019 Consumer Price Index, we used generalized linear regression models with log-link and γ distribution. Overall, 6.6% of patients experienced an SSI, 1.7% superficial SSIs and 4.9% deep-incisional SSIs, with a median of 44 days to presentation for superficial SSIs and 28 days for deep-incisional SSIs. Selective risk factors included surgical approach, admission type, payer, and higher comorbidity score. Postoperative incremental commercial payments for patients with superficial SSI were $20,800 at 6 months, $26,937 at 12 months, and $32,821 at 24 months; incremental payments for patients with deep-incisional SSI were $59,766 at 6 months, $74,875 at 12 months, and $93,741 at 24 months. Corresponding incremental Medicare payments for patients with superficial incisional at 6, 12, 24-months were $11,044, $17,967, and $24,096; while payments for patients with deep-infection were: $48,662, $53,757, and $73,803 at 6, 12, 24-months. We identified a 4.9% rate of deep infection following SFS, with substantial payer burden. The findings suggest that the implementation of robust evidence-based surgical-care bundles to mitigate postoperative SFS infection is warranted.

Comorbidity is not associated with dialysis modality choice in patients with end-stage kidney disease.

AimOver the past years the proportion of home dialysis patients has decreased in the Netherlands. In addition, the home dialysis use varies significantly among centres. It is unclear whether this is the result of differences in comorbidity, or other factors. Our aim was to investigate the association between comorbidity and dialysis modality choice.MethodsThe multi‐centre DOMESTICO cohort study collected comorbidity data of patients who started dialysis in 35 Dutch centres from 2012 to 2016. Comorbidity was assessed by the Charlson comorbidity index. Home dialysis was defined as any peritoneal dialysis or home haemodialysis treatment during follow‐up. Multivariable logistic regression analysis was used to assess the association between comorbidity and dialysis modality, with a mixed model approach to adjust for clustering of patients within dialysis centres.ResultsA total of 1358 patients were included, of whom 628 were treated with home dialysis. In crude mixed model analyses, the probability of receiving home dialysis was lower when comorbidity score was higher: having a high comorbidity score resulted in an odds ratio of 0.74 (95% CI 0.54–1.00) when compared with patients without comorbidities. After adjustments for age, sex, ethnic background, body mass index and dialysis vintage, there was no association between comorbidity and home dialysis.ConclusionComorbidity was not significantly associated with home dialysis choice, after adjustment for several confounding factors including age and body mass index. Future studies should aim at unravelling the centre‐specific characteristics that probably play a role in dialysis modality choice.

Outcomes of patients with ischemic colitis causing severe hematochezia managed medically or surgically.

To compare short- and long-term outcomes of hospitalized patients with ischemic colitis (IC) presenting with severe hematochezia and treated medically or colectomy and also those with inpatient vs. outpatient start of hematochezia. A retrospective analysis of prospectively collected data for IC patients hospitalized for severe hematochezia from two teaching hospitals was done from 1994 to 2020, with the diagnosis of IC made colonoscopically and confirmed histologically. Ninety-seven patients initially all had medical management for IC. Seventy-two (74.2%) were stable and had no further bleeding; 17 (17.5%) had colon resection; and 8 were critically ill and not surgical candidates. Surgical patients and non-surgical candidate had higher comorbidity scores; received more red blood cell (RBC) transfusion (median (IQR) 5 (3-10) vs. 4.5 (3-6.5) vs. 1 (0-4) units, p < 0.001); had significantly longer hospital and ICU days; had higher severe complication rates (35.3% vs. 100%. vs. 5.6%, p < 0.001); and had higher 30-day all-cause mortality rates (23.5% vs. 87.5% vs. 0, p < 0.001). Inpatients developing IC hemorrhage had more RBC transfusions, more complications, longer hospital stays, and higher mortality than patients whose IC bleeding started as outpatients. The majority of IC patients hospitalized for severe hematochezia were successfully treated medically. Patients who were not surgical candidate had the highest rates of severe complications and mortality. Surgical patients and those who were not surgical candidate had worse outcomes than the medical group. Patients with inpatient start of bleeding from IC had significantly worse outcomes than those with outpatient start of bleeding.

Client and service factors associated with changes in health-related quality of life following community rehabilitation

Purpose To identify client and service factors associated with changes in health-related quality of life following community rehabilitation. Methods We conducted a retrospective observational cohort study within a community rehabilitation program. Health-related quality of life was measured using the EuroQol five Dimensions, five response level version (EQ-5D-5L). Our primary outcome was the Visual Analogue Scale (VAS) rating of overall health. Analyses were stratified by diagnostic group: traumatic orthopaedic, elective orthopaedic, neurological, medical, and other. The association between client and service factors and discharge VAS scores, adjusted for baseline scores were determined using multivariable regression. Results EQ-5D-5L data were available for 981 of 1350 participants. Treatment intensity was associated with a seven-point increase (β = 7.22, 95%CI 2.28–12.2, p = 0.004) in VAS scores for traumatic orthopaedic participants. For neurological participants, there was a positive interaction between comorbidities and intensity of therapy (β = 7.9, 95%CI 2.75–13.1, p = 0.003), indicating that greater therapy intensity in those with higher comorbidity scores was associated with an improvement in VAS scores. Age was negatively associated with VAS scores for traumatic orthopaedic participants and socioeconomic status was positively associated with VAS scores for elective orthopaedic participants. Conclusions Treatment intensity is a modifiable service factor that may positively influence health-related quality of life. Implications for rehabilitation In addition to providing information on client progress towards attainment of individual treatment goals, routine collection of patient reported outcome measures within a community rehabilitation program can elicit information that can inform rehabilitation service improvement. Clients of a community rehabilitation program with a neurological or medical condition demonstrate the least improvement in overall health profile and may require additional rehabilitation or supports. Across all diagnostic groups, problems with anxiety and depression were least likely to improve following receipt of community rehabilitation. Improving access to psychological services and associated referral pathways in community rehabilitation services could improve these outcomes. Initiatives aimed at increasing intensity of therapy such as targeted triage and resource allocation, may improve health-related quality of life for clients of a community rehabilitation program with traumatic orthopaedic conditions. For clients with a neurological condition, initiatives aimed at increasing intensity of therapy may improve health-related quality of life in more complex patients with comorbid health conditions.