High-volume Facilities Research Articles

Disparities in Access to Oncologic Care in Pancreatic Cancer: A Systematic Review.

Pancreatic cancer care is complex, and multiple disparities in receipt of therapies have been documented. The authors aimed to conduct a systematic review of the literature to critically assess and summarize disparities in access to oncologic therapies for pancreatic cancer. A search of PubMed, Scopus, Web of Science, and Cochrane databases were performed for studies reporting disparities in access to oncologic care for pancreatic cancer. Primary research articles published in the United States from 2000 to 2020 were included. Data were independently extracted, and risk of bias was assessed using the modified Newcastle-Ottawa scale. The inclusion criteria were met by 47 studies. All the studies used retrospective data, with 70 % involving national database studies, 41 assessing the impact of race/ethnicity, 22 assessing the impact of socioeconomic status, 18 assessing the impact of insurance status, 23 assessing the impact of gender, 26 assessing the impact of age, and 3 assessing the impact of location on the delivery of cancer-directed therapies. Race, socioeconomic status, insurance status, gender, and age- based disparities in receipt of surgical resection, treatment at high-volume facilities and multimodal therapy for resectable pancreatic cancer, receipt of systemic chemotherapy for metastatic cancer, and receipt of expected standard-of-care treatment are reported. Significant sociodemographic disparities in access to equitable oncologic care exist along the continuum of pancreatic cancer care. Multiple patient, provider, and systemic factors contribute to these disparities. The ongoing study of these disparities is important to elucidate processes that may be targeted to improve access to equitable oncologic care for patients with pancreatic cancer.

Regional trends of minimally invasive radical hysterectomy for cervical cancer and exploration of perioperative outcomes

IntroductionRadical hysterectomy (RH) with bilateral pelvic lymph node dissection is the standard treatment for early stage cervical cancer which can be performed either by an abdominal or a minimally invasive (MIS) approach. In 2018, Ramirez et al. presented their randomized-controlled trial data which demonstrated that patients who were treated with minimally invasive surgical (MIS) radical hysterectomy (RH) had higher rates of locoregional disease recurrence and lower rates of overall survival when compared to patients treated with an abdominal approach. The objective of this study is to examine the trends in management of patients diagnosed with cervical cancer in New York State (NYS) and to analyze their perioperative outcomes. MethodsUsing the Statewide Planning and Research Cooperative System (SPARCS) Database, patients undergoing RH for early stage cervical cancer in NYS between the years of 2007–2015 were identified and categorized based on surgical approach. Demographic information was collected and multivariable regression was conducted to assess the impact of hysterectomy approach on perioperative outcomes. ResultsIn NYS, 5575 patients were treated with RH for early stage cervical cancer with 3257 (58.4%) treated by abdominal RH and 2318 (41.6%) treated with MIS RH. Between the years of 2007 and 2015, patients diagnosed with cervical cancer treated with MIS RH increased from 25.7% to 48.3% respectively. Surgeons performing MIS RH were more likely to be younger (average age 47.1 vs 49.2, p < 0.001) and have less time elapsed from their fellowship graduation (20.37 vs 22.64 years, p < 0.001). Patients who saw high volume doctors (OR 1.95, CI 1.65–2.31) and were seen in high volume facilities (OR 1.40, CI 1.18–1.65) were more likely to undergo MIS RH compared to abdominal RH. Patients who underwent MIS RH were more likely to be discharged home as opposed to acute rehab or nursing facility, when compared to patients treated with abdominal RH (98.5 vs 94.2% p < 0.001). When analyzing perioperativce outcomes, patient undergoing MIS RH had a 85% decrease in length of hospital stay compared to abdominal RH, a 40% reduction in 30-day readmission rates, and a 10% reduction in hospital costs respectively. DiscussionIn our study period, between the years of 2007 and 2015, the number of cervical cancer cases treated with MIS RH increased from 25.7% to 48.3%. MIS techniques led to a reduction in length of hospital stay, patient readmission rates, and hospital costs. Based on recent data from Ramirez et al., preliminary data demonstrated decrease in MIS RH for treatment of cervical cancer after presentation of the LACC trial and our data confirmed these reported trends in NYS. With this change in surgical practice, there will be associated changes in perioperative outcomes. Moreover, for patients diagnosed with cervical cancer with microscopic disease or previous treatment with an excisions procedure, MIS approach should be considered for improvement in perioperative outcomes as long as oncologic outcomes are not compromised.

Surgeon and Facility Volume are Associated With Postoperative Complications After Total Knee Arthroplasty

BackgroundSurgeon and hospital volumes may affect outcomes of various orthopedic procedures. The purpose of this study is to characterize the volume dependence of both facilities and surgeons on morbidity and mortality after total knee arthroplasty.MethodsAdults who underwent total knee arthroplasty for osteoarthritis from 2011 to 2015 were identified using International Classification of Diseases-9 Clinical Modification diagnostic and procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, while controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20%.ResultsOf 113,784 identified patients, 71,827 were treated at a high- or low-volume facility or by low- or high-volume surgeon. Low-volume facilities had higher 1-month, 3-month, and 12-month rates of readmission, urinary tract infection, cardiorespiratory arrest, surgical site infection, and wound complications; higher 3- and 12-month rates of pneumonia, cellulitis, and in-facility mortality; and higher 12-month rates of acute renal failure and revision. Low-volume surgeons had higher 1-, 3-, and 12-month rates of readmission, urinary tract infection, acute renal failure, pneumonia, surgical site infection, deep vein thrombosis, pulmonary embolism, cellulitis, and wound complications; higher 3- and 12-month rates of cardiorespiratory arrest; and higher 12-month rate of in-facility mortality.ConclusionsThese results suggest volume shifting toward higher volume facilities and/or surgeons could improve patient outcomes and have potential cost savings. Furthermore, these results can inform healthcare policy, for example, designating institutions as centers of excellence.

Revisional Bariatric Surgery

Obesity can be defined as a chronic disease with a serious impact on an individual’s quality of life; moreover, it is a leading risk factor for global death. Bariatric surgery has already proven its efficacy in providing the patient with a healthier life. Nonetheless, failure of initiated treatment can occur in medical practice. We can and should offer our patients correct, patient-tailored revisional therapy conducted by an experienced surgeon in a high-volume hospital facility. In this article, current indications and strategies for secondary bariatric procedures were summarized and include type and number of cases (105 cases) that was converted from restrictive procedure (sleeve gastrectomy and gastric plication) to mal absorbative procedure (gastric bypass R en Y or MGB or to SASI or others.

Black race is independently associated with underutilization of preoperative chemotherapy in clinical stage T2 or higher gastric adenocarcinoma

BackgroundConsensus guidelines recommend for perioperative chemotherapy and surgery for patients with clinical stage (cT) T2 or greater gastric adenocarcinoma. We compared adherence to guidelines in these patients stratified by race. MethodsNon-Hispanic White and Black patients with resected ≥cT2 gastric adenocarcinoma were identified within the National Cancer Database (2008–2017). We compared administration of preoperative chemotherapy by race, adjusting for clinicodemographic variables. We performed marginal standardization of logistic regression to calculate adjusted probabilities of administration of preoperative chemotherapy in patients under the age of 80 years with insurance. ResultsA total of 13,850 patients were identified (White = 12,161; Black = 1,689). Black race was associated with lower likelihood of receiving preoperative chemotherapy than White race (odds ratio = 0.46, 95% confidence interval: 0.39–0.54). Other factors associated with lower likelihood of preoperative chemotherapy included age ≥70 years, female sex, treatment at community facilities, non-private or no health insurance, and cT4 disease. Factors associated with higher likelihood of preoperative chemotherapy included treatment at high-volume facilities, longer distance to facility, higher education and income levels, cT3 disease, and cN+ disease. In patients <80 years with insurance, marginal standardization models demonstrated that Black race was associated with a lower adjusted probability of receiving preoperative chemotherapy regardless of age, insurance payor, facility type/volume, distance to facility, cT stage, cN stage, sex, and education/income levels. ConclusionBlack race was associated with underutilization of preoperative chemotherapy for cT2 or greater gastric cancer, in discordance to published guidelines. The etiology of these disparities is multifactorial, and correcting the root causes represents a critical area for improvement.

Field Performance Evaluation of High Polymer-Modified Asphalt Concrete Overlays

The objective of this paper was to assess the viability of using high polymer (HP) modified asphalt concrete (AC) mixtures in Virginia as a reflective crack mitigation technique or when deemed appropriate as a tool for increased crack resistance on higher volume facilities. This was achieved by compiling and evaluating routine distress survey data against pre-paving distress survey data for relevant in-service HP pavements constructed between 2015 and 2018 and comparing them with several control in-service conventional polymer-modified asphalt (PMA) pavements. This is the first effort in North America to provide a detailed field performance of HP AC mixtures. In general, none of the evaluated mixtures (HP or PMA) was able to prevent reflective cracking completely. The HP sections showed the most promising performance 5 years after construction regardless of traffic level and the pre-existing pavement conditions. The pavement management system data for the reviewed sections indicated a potential controlling effect of the joint condition of the underlying jointed concrete pavement layer regardless of the asphalt mixture type employed (PMA or HP). Moreover, performance evaluations using the network-level pavement management data were conducted to estimate the life expectancy of HP AC overlays. Two different approaches and three levels of analysis were undertaken. Overall, PMA and HP AC overlays had an average predicted service life of 6.2 and 8.3 years, respectively, indicating a 34% extension of performance life of the AC overlays with high polymer modification.

The Effect of Hospital and Surgeon Volumes on Complication Rates After Fixation of Peritrochanteric Hip Fractures.

This study evaluates the relationship between hospital and surgeon volumes of peritrochanteric hip fracture fixation and complication rates. Adults (60 years of age or older) who underwent surgical fixation for closed peritrochanteric fractures from 2009 to 2015 were identified using International Classification of Diseases 9 and 10 Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperations, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes. Statistical significance was set at P < 0.05. A total of 29,656 patients were included in the study. Low-volume (LV) facilities had higher rates of readmission [hazard ratio (HR) 1.07, 95% confidence interval (CI), 1.05-1.17], pneumonia (HR 1.36, 95% CI, 1.22-1.51), wound complications (HR 1.24, 95% CI, 1.03-1.49), and mortality (HR 1.15, 95% CI, 1.04-1.27) but lower rates of acute renal failure (HR 0.90, 95% CI, 0.83-0.98), deep vein thrombosis (HR 0.66, 95% CI, 0.55-0.78), and acute respiratory failure (HR 0.77, 95% CI, 0.62-0.95) than high-volume (HV) facilities. Patients treated by LV surgeons had lower rates of readmission (HR 0.92, 95% CI, 0.87-0.97) and deep vein thrombosis (HR 0.78, 95% CI, 0.66-0.94) but higher rates of acute renal failure (HR 1.13, 95% CI, 1.04-1.22) than those treated by HV surgeons. There are increased rates of mortality, readmission, and certain complications when peritrochanteric femur fractures are surgically managed at LV hospitals compared with those managed at HV hospitals. Thus, the benefit of a high-volume surgical facility is apparent in mortality and readmissions but not all complications. There was no significant decrease in complications if fixation was performed by HV surgeons relative to LV surgeons. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes.

Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns. Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital. The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death. Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers. Therapeutic, III.

Multi-Level Laboratory Performance Evaluation of Conventional and High Polymer-Modified Asphalt Mixtures

Asphalt concrete (AC) overlays have been one of the most common treatments used by the Virginia Department of Transportation (VDOT) for maintaining/rehabilitating pavements. However, when the overlay is placed on existing composite pavements or cracked AC pavements, differential movements across any cracks or joints can result in physical tearing of the AC overlay. Thus, the long-term performance of many AC overlays will highly depend on their ability to resist cracking. The purpose of this study was to assess the viability of using high polymer-modified (HP) AC mixtures in Virginia as a crack mitigation technique or when deemed appropriate as a tool for increased resistance to rutting and cracking on higher volume facilities. Another objective was to assess the ability of various testing protocols to discern the performance of pavements through a comprehensive evaluation of three conventional polymer-modified (PMA) and five HP field-produced mixtures placed in Virginia. This included laboratory testing at multiple levels of complexity (basic, intermediate, and advanced) on collected asphalt binders, plant-produced asphalt mixtures, and field cores. The performance characteristics of PMA and HP mixes were evaluated in the laboratory in relation to durability and resistance to rutting and cracking. Based on the mixes tested, stone matrix asphalt (SMA) mixes showed better performance than dense-graded surface mixes (SM) regardless of the asphalt binder type. Moreover, HP mixes showed better performance than PMA mixes regardless of the mixture type. Overall, SMA-HP mixes showed the most promising performance among all evaluated mixes.

Influence of Treatment Facility Type and Annual Patient Volume on Overall Survival in Patients with Mantle Cell Lymphoma: A National Cancer Database Analysis

Influence of Treatment Facility Type and Annual Patient Volume on Overall Survival in Patients with Mantle Cell Lymphoma: A National Cancer Database Analysis

Impact of Treating Facility on Overall Survival and Treatment in Multiple Myeloma (MM) Using National Cancer Database (NCDB)

Introduction:Prior studies have shown poorer outcomes in Black and Hispanic patients and in patients with lower median household income and education 1-5. In MM, we hypothesize that facility affiliation and case volume affects overall survival (OS) and rates of frontline treatment (including chemotherapy, immunotherapy, autologous stem cell transplant [ASCT] and palliative care).Methods:This is a retrospective analysis of 174,551 MM patients in the NCDB database, over the age of 18 years, between 2004-2016. Facility types include community cancer programs, comprehensive community cancer programs, academic/research cancer programs and integrated network cancer programs. High volume facilities had new MM cases per year ≥ 99 th percentile, and all other facilities were classified as low volume. Multivariable analyses used Cox proportional hazard analysis for OS and logistic regression for use of treatment, adjusted for age, sex, race, Hispanic origin, education, great circle distance, CCI score, and type of county (depending on population size). Kaplan-Meier method was used to estimate median OS, and the log rank test was used to compare OS across predictor variables.Results:The median age was 67 years (range 18-90) with 55% males, and 76% White vs 20% Black. In academic/research cancer programs, the median OS in high volume centers was 75.5 mo vs 50.2 mo in low volume centers (p<0.01). In community cancer programs, the median OS in high volume centers was 55.2 mo vs 35.5 mo in low volume centers (p<0.01). In multivariable analyses, the OS was higher in academic/research cancer programs vs community cancer programs (hazard ratio of 0.87 p<0.01). There was no significant difference in OS at integrated network cancer programs or comprehensive community cancer programs vs community cancer programs. The odds of utilizing chemotherapy were higher in academic/research cancer programs compared to community cancer programs (p<0.01 for both), whereas the odds of receiving palliative care were similar between both facility types (p=0.25). The odds of utilizing ASCT were higher in all facilities when compared to community cancer programs (p<0.01). The odds of utilizing palliative care were higher at integrated network cancer programs and comprehensive community cancer programs compared to community cancer programs (p<0.01 for both). Facilities with low volume of cases had significantly lower odds of utilizing chemotherapy, immunotherapy and ASCT when compared to high volume facilities; however had significantly increased odds of receiving palliative care.Discussion:Our results show that academic/research cancer programs with high volumes have the best OS in MM. Additionally, academic/research cancer programs are more likely to give chemotherapy, immunotherapy, and ASCT, but less likely to give palliative care. We theorize that academic/research cancer programs with a high volume of cases likely have increased resources, which optimizes outcomes. Given that ~25% of patients with MM die in the first year 6, there is a recognized need to identify strategies to improve early outcomes in patients treated at community cancer programs and low volume facilities. [Display omitted] DisclosuresLai: Jazz Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Daiichi-Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees; Astellas: Speakers Bureau; Macrogenics: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz Pharma: Speakers Bureau; Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Understanding the Role of the Otolaryngology Hospitalist: Tracheostomies and Tracheostomy Care.

The concept of a hospitalist has been well established. This model has been associated with reduced length of stay contributing to reduction in healthcare costs. Minimal literature is available assessing the effects of an otolaryngology (ENT) hospitalist at a tertiary medical center. The aim of this study is to assess the role of an ENT hospitalist on (1) performing tracheostomies and (2) providing care as part of the tracheostomy care team (TCT). Retrospective chart review of all tracheostomies performed by the ENT service over 2 years (July 2015-June 2017), and prospective data collection of all tracheostomy care consults over 1 year (July 2016-June 2017). In year 1 (from July 2015 to June 2016), no ENT hospitalist was employed, and in year 2 (from July 2016 to June 2017), an ENT hospitalist was employed. Compared to other Ear, Nose, and Throat (ENT) surgeons, the ENT hospitalist performed tracheostomies with shorter patient wait times, and performed a greater proportion of percutaneous tracheostomies at the bedside versus open tracheostomies in the operating room. The tracheostomy care team (TCT) received 91 consults over the course of 1 year with an average of 1.1 billable procedures generated per consult. In this study, an ENT hospitalist was decreased patient wait time to tracheostomy and increased bedside percutaneous tracheostomies, which has positive implications for resource utilization and healthcare cost. The average wait time to receive a tracheostomy was reduced when calculated across the entire department due to the availability of the ENT hospitalist to see and perform tracheostomies. The TCT generated many billable bedside procedures in addition to encouraged decannulation of patients. This study highlights the fact that the ENT hospitalist contributes to providing expedient tracheostomies and provides valuable consulting services as part of a TCT at a high-volume tertiary care facility.

Association of age with treatment at high-volume hospitals and distance traveled for care, in patients with rectal cancer who seek curative resection

BackgroundThe association between volume and outcomes has led to recommendations that patients undergo surgery at high-volume centers. We aimed to determine if older patients with rectal cancer are undergoing operations at high-volume centers. MethodsWe identified patients ≥50 years old who underwent rectal cancer resection using the NCDB (2004–2015). Tertiles were used to categorize facility volume and distance traveled. ResultsHigher facility volume was associated with improved outcomes. Patients >75 years old were less likely than patients 50–59 years old to be treated at high-volume centers. Traveling >16.8 miles was associated with treatment at high-volume facilities, however patients >75 years old were less likely to travel >16.8 miles. ConclusionsHigher facility volume is associated with improved outcomes after rectal cancer resection. However, older patients are less likely to be treated at high-volume facilities. Older patients travel shorter distances for care, suggesting that care integration across networks must be optimized.

Implementation of Minimally Invasive Pancreaticoduodenectomy at Low and High-Volume Centers

BackgroundThere is a need to better define the safety of implementing the use of minimally invasive pancreaticoduodenectomy (MIPD) in order to provide evidence for safe application. The objective of this study was to evaluate the mortality associated with the implementation of MIPD across low and high-volume facilities using the National Cancer Database (NCDB). MethodsPatients in the NCDB with pancreatic cancer diagnosed from 2010-2016 undergoing MIPD were selected. Cumulative MIPD volume for each facility was calculated from the number of MIPD cases performed each year prior to and including the year of a patient's operation. A random effects logistic regression model was used to examine the adjusted association between log-transformed cumulative MIPD volume and 90-day mortality. ResultsAfter controlling for patient, tumor and facility-related variables, there was decreased 90-day mortality as the cumulative MIPD volume increased (OR 0.81; 95% CI 0.69-0.95; P = 0.009). Average annual open pancreaticoduodenectomy (PD) volume was independently protective throughout the implementation phase (OR 0.98; 95% CI 0.97-0.99; P = 0.049). This equates to an average predicted probability of 90-day mortality for the first 5 cumulative MIPD cases of 7.51% at a low-volume facility (5 open PDs per year) versus 4.39% at a high-volume facility (50 open PDs per year). ConclusionsUsing the NCDB, 90-day mortality following MIPD decreased with higher cumulative facility MIPD case volume. Although higher cumulative MIPD case volume was associated with reduced 90-day mortality at both low and high-volume facilities, the higher mortality during the implementation of MIPD is magnified at low-volume facilities. This retrospective analysis demonstrates that MIPD can be safely implemented with low mortality at facilities with high-volume open PD programs.

Retrospective comparison of three antivenoms for the treatment of dogs with crotalid envenomation.

To retrospectively compare clinical outcomes associated with 3 commercially available antivenom products (2 F[ab']2 products and 1 IgG product) in dogs with crotalid envenomation. 282 dogs with evidence of crotalid envenomation treated with antivenom at a single high-volume private emergency facility in southwestern Arizona from 2014 to 2018. Data were collected on all dogs regarding signalment, coagulation test results, snakebite characteristics, type and number of units of antivenom received (1 of 3 products), survival to hospital discharge (yes or no), and complications following discharge. Survival rates and other variables were compared among antivenoms by means of bivariable analyses. 271 of 282 (96.1%) dogs survived to discharge; 11 (3.9%) were euthanized or died in the hospital. No significant difference in survival rates was found among the 3 antivenom products. Infusion reaction rates were higher for the IgG product than for each F(ab')2 product. A higher percentage of dogs treated with the IgG product (vs either F[ab']2 product) received only 1 unit of antivenom. Variables associated with a lower probability of survival included older age and lower body weight, thoracic (vs other) location of snakebites, and presence of an antivenom infusion reaction. Given that survival rates were high for all 3 antivenom products, clinicians may consider other factors when selecting an antivenom, such as preference for a fractionated versus whole immunoglobulin product, risk of infusion reaction, cost, shelf life, availability, ease of use and administration, species of crotalids used for antivenom production, approval by federal regulatory bodies, and clinical preference.

Association of Medicaid Expansion with Pancreatic Cancer Treatment and Outcomes: Evidence from the National Cancer Database.

Socioeconomic- and demographic-based disparities exist in the treatment of pancreatic adenocarcinoma (PDAC). Medicaid expansion (ME) may have an impact on these disparities. Analyses of patients with PDAC from the National Cancer Database (NCDB) were performed to examine the impact of ME on access to treatment and outcomes. Patients with non-metastatic PDAC diagnosed between 2006 and 2016 were identified. Multiple logistic regression analyses were performed to evaluate factors associated with curative-intent surgical resection, multimodal therapy, treatment at a high-volume facility (HVF), and survival. The study identified 41,876 patients who met the criteria. Medicaid expansion was independently associated with curative-intent resection (odds ratio [OR] 1.54; 95 % confidence interval [CI] 1.43-1.67; p < 0.001). In a multivariable analysis, ME was independently associated with multimodal therapy (OR 1.60; 95 % CI 1.44-1.76; p < 0.001) and treatment at an HVF (OR 1.57; 95 % CI 1.42-1.74; p < 0.001). Medicaid expansion was independently associated with improved 30-day mortality (OR 0.49; 95 % CI 0.34-0.79) and 90-day mortality (OR 0.48 95 % CI 0.35-0.59). Cox regression analysis demonstrated that after adjustment for other variables, ME status was associated with improved overall survival (hazard ratio [HR], 0.82; 95 % CI 0.73-0.90; p < 0.001). Medicaid expansion is associated with increased use of care processes that improve outcomes in PDAC, operative outcomes, and overall survival. The study data suggest that ME has helped to improve disparities in PDAC in ME states.

Factors that influence healthcare service utilization during COVID-19 pandemic among pregnant women and caregivers with children under two years in Rongo sub-county, Migori County, Kenya

Background: Health systems have failed in past epidemics to maintain delivery of routine health essential services. Most resources including human and essential supplies are all diverted to address health emergency, sometimes resulting in lack of important basic and routine health services.Methods: This was a retrospective cross-sectional study with mixed data collection methods, where respondents were asked questions on how COVID-19 affected them with regard to utilization of MCH healthcare during the first peak of the COVID-19 in Kenya. Two high volume facilities were selected purposively based on volume and capacity of services offered. A random sample was drawn from the stratum using a list generated by community health workers (CHWs) attached to the health facilities. Key informant interviews were used to collect data among health care providers and structured questionnaire was used for pregnant women and caregivers. Independent variables, social distancing, social stigma, communication and human mobility restriction were associated with health care service utilization and significant at 0.05 p value.Results: Correlation analysis indicated social stigma (r-0.407, p&lt;0.512), social distancing (r-0.324, p&lt;0.001) and human mobility restrictions (r-0.606, p&lt;0.001) negatively influenced service utilization. Whereas COVID-19 related communication (0.631, p&lt;0.001) was protective and thus promoted service utilization. The hierarchical linear regression model explained 67.73% of the total variations in the health care service utilization, which was r=0.6773.Conclusions: From the findings social stigma, communication, social distancing and human mobility restrictions influence health care service utilization. Ministry of health should strengthen targeted community outreaches for pregnant women and caregivers with children under two years.

Impact of Treatment Parameters on Racial Survival Differences in Oropharyngeal Cancer: National Cancer Database Study.

To investigate how differences in treatment parameters account for survival differences between races of patients with oropharyngeal squamous cell carcinoma (OPSCC). Retrospective cohort study. National Cancer Database. Data of patients with OPSCC undergoing radiation therapy (RT) or concurrent chemoradiation therapy as primary treatment were obtained from the National Cancer Database from 2004 to 2016. We analyzed 4 treatment-related time intervals to determine their impact on survival between races when controlling for human papilloma virus (HPV) status. Cox proportional hazards models, stepwise logistic regressions, covariate adjustments, and propensity score matching were performed. A total of 3152 patients were identified (2877 White, 275 Black). In HPV- cases, Black patients with prolonged radiation duration had a significantly worse overall survival as compared with White patients (hazard ratio, 1.77; 95% CI, 1.03-3.05; P = .039). In a logistic regression model, the only covariate that was significantly associated with prolonged RT was facility type. When further adjusted for facility type, the survival difference between Black and White patients with HPV- status and prolonged RT times was no longer significant (hazard ratio, 1.55; 95% CI, 0.90-2.69; P = .116). There is a significant disparity in overall survival between Black and White patients with HPV- OPSCC when RT duration is prolonged. Clinicians should be aware of the negative impact of prolonged RT, especially in Black patients, so that they can attempt to decrease treatment-related time intervals. Facility type was also found to affect the outcomes of patients with OPSCC, and efforts should be made to improve patient access to well-equipped, high-volume facilities.

Impact of radiation therapy facility volume on survival in patients with cancer.

This study examined whether radiation therapy facility volumes correlate with survival after curative intent treatment of solid tumors. The National Cancer Database was queried for patients with solid tumors treated with curative-intent radiation therapy from 2004-2013. Facilities were stratified into 4 volume categories: low, intermediate, high, and very high. Primary cancer sites were divided into neoadjuvant, adjuvant, or definitive radiation subgroups. Kaplan-Meier curves of 5-year postradiation survival probability, stratified by facility volume, were generated with log-rank tests for group comparisons. Cox proportional hazard models were used to evaluate the effect of facility volume on survival, adjusted for multiple covariates. There were 253,422 patients treated at 1289 facilities: 6231 received neoadjuvant radiation, 147,980 received adjuvant radiation, and 99,211 received definitive radiation without surgery. Among patients receiving neoadjuvant radiation, survival correlated with facility volume for patients with rectal cancer (hazard ratio [HR], 0.75; 95% CI, 0.6-0.94; P = .01). For cancers of the breast and uterus, patients receiving adjuvant radiation at very high-volume facilities (vs low volume) had improved survival (HR, 0.83; 95% CI, 0.77-0.90; P < .001 and HR, 0.77, 95% CI, 0.62-0.97; P = .03, respectively). For patients receiving definitive radiation for prostate, non-small cell lung, pancreas, and head and neck cancer, there was an improvement in survival for patients treated at very high-volume centers (P < .05). For select cancer patients, treatment with curative radiation at higher volume facilities is associated with improved survival. In particular, patients receiving radiation therapy in the definitive setting without surgery may benefit most from treatment at high-volume centers.

Impact of facility-volume on the oncologic outcomes of premenopausal patients with early-stage cervical cancer undergoing trachelectomy

<h3>Objectives:</h3> Investigate the impact of trachelectomy facility-volume on the outcomes of patients with early-stage cervical carcinoma. <h3>Methods:</h3> Patients aged <50 years diagnosed between 2004 and 2016 with cervical carcinoma, who underwent trachelectomy at the reported facility were identified in the National Cancer Database. Facility-volume was calculated, and high-volume centers were defined as those who reported at least 10 procedures. Impact of facility-volume on peri-operative outcomes (hospital stay, unplanned readmission rate) and overall survival (OS) was evaluated for patients with known tumor histology, and stage I disease who underwent lymphadenectomy. <h3>Results:</h3> A total of 774 trachelectomies were performed for patients with cervical cancer at 269 institutions. Ten (3.3%) institutions reported at least 10 cases between 2004 and 2016, while most institutions (190, 70.6%) reported one or two cases. Outcomes were evaluated for 514 patients with known histology, stage I disease who underwent lymphadenectomy; 29.4% were managed at a high-volume facility. Patients who underwent trachelectomy at a high-volume center were more likely to have private insurance (88.1% vs 77.7%, p=0.023) while there were no differences in terms of race, presence of comorbidities and tumor histology (p>0.05) between high and low volume facilities. Patients who underwent surgery at a high-volume center had lower 30-day re-admission rate (1.3% vs 6.4%, p=0.013) but comparable rate of prolonged (>5 days) hospitalization (8.2% vs 6.5%, p=0.48). There was no difference in OS between high and low-volume centers, p=0.47; 5-year OS rates were 93.8% and 95.4% respectively. After controlling for the presence of comorbidities and tumor histology, performance of trachelectomy at a high-volume facility was not associated with better survival (HR: 1.21, 95% CI: 0.48, 3.05). <h3>Conclusions:</h3> Given the low incidence of cervical cancer in this age group, and possible de-centralization, facility-volume for trachelectomy is very low with no clear detrimental effect on survival or perioperative outcomes. Further research is needed to determine if centralization to high volume centers is associated with superior reproductive and survival outcomes.