High-quality Treatment Research Articles

Flemish network on rare connective tissue diseases (CTD): patient pathways in systemic sclerosis. First steps taken

ABSTRACT Despite the low prevalence of each rare disease, the total burden is high. Patients with rare diseases encounter numerous barriers, including delayed diagnosis and limited access to high-quality treatments. In order to tackle these challenges, the European Commission launched the European Reference Networks (ERNs), cross-border networks of healthcare providers and patients representatives. In parallel, the aims and structure of these ERNs were translated at the federal and regional levels, resulting in the creation of the Flemish Network of Rare Diseases. In line with the mission of the ERNs and to ensure equal access to care, we describe as first patient pathways for systemic sclerosis (SSc), as a pilot model for other rare connective and musculoskeletal diseases. Consensus was reached on following key messages: 1. Patients with SSc should have multidisciplinary clinical and investigational evaluations in a tertiary reference expert centre at baseline, and subsequently every three to 5 years. Intermediately, a yearly clinical evaluation should be provided in the reference centre, whilst SSc technical evaluations are permissionably executed in a centre that follows SSc-specific clinical practice guidelines. In between, monitoring can take place in secondary care units, under the condition that qualitative examinations and care including interactive multidisciplinary consultations can be provided. 2. Patients with early diffuse cutaneous SSc, (progressive) interstitial lung disease and/or pulmonary arterial hypertension should undergo regular evaluations in specialised tertiary care reference institutions. 3. Monitoring of patients with progressive interstitial lung disease and/or pulmonary (arterial) hypertension will be done in agreement with experts of ERN LUNG.

An adaptive conjugate gradient accelerated evolutionary algorithm for multi-objective spot optimization in cancer intensity modulated proton therapy

Intensity-modulate proton therapy is one of the most advanced cancer treatment techniques due to the Bragg peak characteristics of proton radiation. The personalized demand of different patients requires treatment optimization methods to quickly provide diverse treatment plans to select the best plan for a patient. However, most existing treatment optimization methods are transformed the multi-objective optimization problem into a single optimization problem. Moreover, the radiation physicists may adjust the objective weights repeatedly to produce a set of high-quality treatment plans. To address this problem, this paper proposes an adaptive conjugate gradient accelerated evolutionary algorithm (ACG-EA) to generate a set of diverse high-quality treatment plans simultaneously. The conjugate gradient method is employed as a directional mutation operator to accelerate the search process in the hybrid mutation operation. In addition, the weight parameters of the conjugate gradient are automatically updated based on the diversity and convergence of the current population. Compared with five representative multi-objective evolutionary algorithms, the experimental results have shown the competitive performance of the proposed ACG-EA on the hypervolume and dose-volume histogram indicators in six clinical cancer cases.

Association between comorbid chronic pain or prior hospitalization for mental illness and substance use treatment among a cohort at high risk of opioid overdose

IntroductionChronic pain and serious mental illness increase risk of opioid use, and opioid use can exacerbate both conditions. Substance use disorder (SUD) treatment can be lifesaving, but chronic pain and serious mental illness may make recovery challenging. We evaluated the association between current chronic pain and prior hospitalization for mental illness and 90-day SUD treatment engagement, among emergency department (ED) patients at high risk of opioid overdose. MethodsWe conducted a cohort analysis of 648 ED patients enrolled in a randomized controlled trial in Rhode Island. We linked baseline study data on chronic pain and prior hospitalization for mental illness to statewide administrative data on state-licensed treatment programs (including methadone) and buprenorphine treatment via prescription. We defined treatment engagement as initiation of a state-licensed treatment program, transfer between state-licensed programs/providers, or a buprenorphine prescription (re-)fill. We used modified Poisson models to estimate the association between each baseline comorbidity and treatment engagement within 90 days following the ED visit, adjusted for a priori potential confounders. In an exploratory analysis, models were stratified by baseline treatment status. ResultsThe mean age of participants was 37 years; 439 (68 %) were male, and 446 (69 %) had been recently unhoused. Overall, 278 participants (43 %) engaged in treatment within 90 days of the ED visit. Participants with prior hospitalization for mental illness were more likely to engage in treatment than those without (adjusted risk ratio [ARR] = 1.24, 95 % confidence interval [CI] = 1.01–1.53), although this association was only among those already accessing treatment at baseline (ARR = 1.58, 95 % CI = 1.10–2.27). Chronic pain was not associated with 90-day treatment engagement overall (ARR = 1.12, 95 % CI = 0.91–1.38) or within baseline treatment subgroups. ConclusionsAmong ED patients at high risk of opioid overdose and accessing treatment at baseline, those with prior hospitalization for mental illness (but not chronic pain) were more likely to engage in treatment following the ED visit, which may reflect disproportionate initiation of additional treatment programs, transfer between programs/providers, or ongoing buprenorphine treatment. Touchpoints within the medical system should be leveraged to ensure that everyone, including those with serious mental illness, can access high-quality SUD treatment at the desired intensity level.

Diagnostic workup for esophageal cancer patients can be improved with checklists and clearer protocols; a comparative study between two tertiary centers in Europe

BackgroundRapid and complete workup of newly diagnosed esophageal cancer is vital for a timely, individual and high-quality treatment strategy. The aim of this study was to uncover potential delay, inefficiencies and non-contributing investigations in the diagnostic process in two tertiary referral centers. MethodsThis retrospective cohort study included all newly diagnosed esophageal cancer patients referred to or diagnosed in the Amsterdam UMC and Karolinska University Hospital between July 2020 and July 2021. Radiology, pathological assessment and multidisciplinary team meeting reports were reviewed. To assess time interval from diagnosis to treatment, dates of diagnosis, admittance to referral hospital, MDT meeting and start of treatment were collected. ResultsIn total, 252 esophageal cancer patients were included, 187 were treated with curative intent. Curatively treated patients had a mean age of 66 years, were predominantly male (74.9 %) with an adenocarcinoma (71.1 %). Curatively treated patients had a median time from diagnosis to referral of seven days (IQR:0–11) and of 35 days (IQR:28–45) between diagnosis and start of treatment. Main reasons for the significant (P < 0.001) differences in time between diagnosis and treatment between centers, Amsterdam UMC (39 days) vs Karolinska (27 days), were need for additional diagnostics (47.8 %) and differences in referral routine. Gastroscopy was repeated in 32.2 % of patients, mainly for further anatomical mapping. ConclusionSignificant time differences between centers in the path from diagnosis to start treatment can be explained by differences in workup approach, referral routines and MDT meeting regulations. Repeat of gastroscopy can be prevented with clearer endoscopy guidelines.

Nutrition care for the adult post-intestinal transplant patient.

Intestinal transplantation has emerged as an accepted treatment choice for individuals experiencing irreversible intestinal failure. This treatment is particularly relevant for those who are not candidates or have poor response to autologous gut reconstruction or trophic hormone therapy, and who can no longer be sustained on parenteral nutrition. One of the main goals of transplant is to eliminate the need for parenteral support and its associated complications, while safely restoring complete nutrition autonomy. An intestinal transplant is a complex process that goes beyond merely replacing the intestines to provide nourishment and ceasing parenteral support. It requires an integrated management approach in the pretransplant and posttransplant setting, and high-quality nutrition treatment is one of the cornerstones leading to favorable outcomes and long-term management. Since the outset of intestinal transplant in the early 2000s, there is observed improvement of achieving nutrition autonomy sooner in the initial posttransplant phase; however, the development of nutrition complications in the chronic posttransplant period remains a long-term risk. This review delineates the decision-making process and clinical protocols used to nutritionally manage and monitor pre- and post-intestine transplant patients.

Determinants of congenital syphilis in Fortaleza, Brazil: A retrospective case-control study.

Congenital syphilis (CS) is a significant public health problem in Brazil. Despite efforts to increase syphilis testing and treatment among pregnant women, rates of CS in the country remain high. We conducted a retrospective case-control study to identify potential associations between the mothers' sociodemographic characteristics, clinical factors related to the current and previous pregnancies, and the occurrence of CS among newborns in Fortaleza, a populous city with one of the highest incidences of CS in Brazil. Data from newborns diagnosed with CS between 2017 and 2020 were extracted from SINAN, the national database for notifiable diseases. Data from women who had delivered an infant with CS were extracted from SINASC, the national database for registration of live births, and linked with their infant's data. CS cases and non-CS controls were matched by year of birth at a ratio of 1:3 respectively. Potential associations were estimated using a multivariate regression model accounting for sociodemographic, obstetric, and antenatal care-related factors. Epidemiological data from 8,744 live births were included in the analysis, including 2,186 cases and 6,588 controls. The final multivariate regression model identified increased odds of delivering an infant with CS among pregnant women and girls aged below 20 years (OR 1.29), single women (OR 1.48), women who had less than 8 years of formal education (OR 2.42), women who delivered in a public hospital (OR 6.92), women who had more than 4 previous pregnancies (OR 1.60), and women who had one or more prior fetal loss (OR 1.19). The odds of delivering an infant with CS also increased as the number of antenatal visits decreased. Women who did not attend any antenatal visits had 3.94 times the odds of delivering an infant with CS compared to women who attended 7 or more visits. Our study found that increased odds of delivering an infant with CS were highly associated with factors related to socioeconomic vulnerability. These determinants not only affect the access to essential antenatal care services, but also the continuity and quality of such preventive measures. Future policies aimed at reducing the incidence of CS should not only target those pregnant women and adolescents with identifiable risk factors for testing, but also assure high quality care, treatment and follow-up for this group.

Improved Dosimetry and Plan Quality for Accelerated Partial Breast Irradiation Using Online Adaptive Radiation Therapy: A Single Institutional Study

PurposeAccelerated partial breast irradiation (APBI) is an attractive treatment modality for eligible patients as it has been shown to result in similar local control and improved cosmetic outcomes compared to whole breast radiotherapy. The use of online adaptive radiotherapy (OART) for APBI is promising as it allows for a reduction of PTV margins since breast motion and lumpectomy cavity volume changes are accounted for in daily imaging. Here we present a retrospective, single-institution evaluation on the adequacy of kV-cone beam computed tomography (CBCT) OART for APBI treatments. Methods and Materials19 patients (21 treatment sites) were treated to 30 Gy in 5 fractions between January of 2022 and May of 2023. Time between simulation and treatment, change in gross tumor (i.e. lumpectomy cavity) volume (GTV), and differences in dose volume histogram (DVH) metrics with adaption were analyzed. The Wilcoxon paired, non-parametric test was utilized to test for DVH metric differences between the scheduled plans (initial plans recalculated on daily CBCT anatomy) and delivered plans, either the scheduled or adapted plan, which was re-optimized using daily anatomy. ResultsMedian (inter-quartile range) time from simulation to first treatment was 26 days (21-32 days). During this same time, median GTV volume reduction was 16.0% (7.3-23.9%) relative to simulation volume. Adaptive treatments took 31.3 min (27.4-36.6 min) from start of CBCT to treatment session end. At treatment, the adaptive plan was selected for 86% (89/103) of evaluable fractions. In evaluating plan quality, 78% of delivered plans met all target, OAR, and conformity metrics evaluated, compared to 34% of scheduled plans. ConclusionsUse of OART for stereotactic linac-based APBI allowed for safe, high-quality treatments in this cohort of 21 treatment courses. Although treatment delivery times were longer than traditional stereotactic body treatments, there were notable improvements in plan quality for APBI using OART.

Evidence-Do Gap in Quality of Direct-To-Consumer Telemedicine: Cross-Sectional Standardized Patient Study in China.

Background: The evidence-do gap between the availability of clinical guidelines and provider practice is well documented, resulting in low health care quality. With the rapid development of telemedicine worldwide, this study aimed to investigate the evidence-do gap and explore the factors for the evidence versus practice deficits as well as low quality in direct-to-consumer telemedicine. Methods: We adopted the standardized patient approach to evaluate the health worker performance and calculate the evidence-do gap in quality of the consultation process, diagnosis, and treatment in telemedicine based on China's national clinical guidelines. Moreover, we further explored the factors associated with the gap through multiple linear regression and logistic regressions. Results: Validated physician-patient interactions (N = 321) were included. On the one hand, the consultation process and treatment quality are less commendable with the huge evidence-do gap. More than three-quarters of the physicians provided low-quality care, as against standard clinical guidelines. On the other hand, the level I, specialized hospitals, doctor, associate chief physicians, and attending physicians, sponsored by Internet enterprises, more times of provider's responses and words were associated with high-quality processes; More total times of provider's responses, urticaria, and nonoffice hours of the visit were associated with high-quality diagnosis; Sponsored by Internet enterprises, more total words of provider's all responses, and urticaria were associated with high-quality treatment. Conclusions: Our findings have important implications in an era in which to better comprehend the evidence-do gap. Efforts to bridge the evidence-do gap should be focused on the important role of institutions and physicians.

Особливості захворюваності дорослого населення Дніпропетровської області на урологічні хвороби

Purpose: to determine the regional features of urological morbidity and its specific weight in the structure of the general morbidity of the adult population of the Dnipropetrovsk region. Materials and methods. Bibliosemantic, analytical, and medical-statistical methods were used, which make it possible to characterize the current state of health of the population and determine trends in the incidence and prevalence of diseases. The results. The average long-term indicator of the primary morbidity of the population of the Dnipropetrovsk region for all classes of diseases was 7,272.23 per 10,000 adult population, total morbidity was 22,250.84 per 10,000 adult population with a tendency to increase, hospital morbidity was 2,167.9 per 10,000 adult population, with a general tendency to decrease the level of hospitalization. Diseases of the genitourinary system rank second, fourth, and sixth in the structure of primary morbidity, prevalence of morbidity, and hospital morbidity of the adult population, respectively. The leading nosological groups of urological diseases registered for the first time in the adult population of the region are cystitis - 64.88 cases per 10 thousand population, kidney infections - 43.23 per 10 thousand population and kidney and ureter stones - 17.92 per 10 thousand population with a tendency to increase indicators during the studied period, with the exception of kidney and ureter stones. Similar trends persist for the prevalence of diseases. The level of hospitalization of the population of the region turned out to be the highest for kidney and ureter stones - 25.28 per 10 thousand population and kidney infections - 20.01 per 10 thousand population, remained relatively stable during 2012-2019, while during 2020- In 2021, a significant decrease was noted for kidney and ureter stones, kidney infections, while the indicator of hospital morbidity for kidney and ureter stones remained relatively stable. Conclusions. Significant levels of morbidity and prevalence of diseases of the genitourinary system, including urological diseases, negative trends towards their increase require improvement of monitoring of the health status of the population, prevention, timely and complete detection of urological pathology, and high-quality treatment.

Abstract B044: Avanzando Caminos (Leading Pathways): The Hispanic/Latino cancer survivorship cohort study

Abstract Background: Advances in prevention, early detection, and treatment have resulted in a 29% reduction in cancer mortality since 1990 and unprecedented increases in the number of cancer survivors. There are more than 16.9M survivors living in the US today and 22.1M are expected by 2030. Cancer survivorship outcomes vary by race/ethnicity, socioeconomic status (SES), and more. Cancer is the leading cause of deaths in Hispanics/Latinos (H/Ls), a critical issue given that H/Ls are the largest ethnic minority group in the US and will account for 30% of the US population by 2060. H/Ls are disproportionately impacted by cancer due to inequities in SES and healthcare access, which leads to differences in risk factors/exposures and barriers to high-quality cancer prevention, early detection, and treatment. Although H/Ls have lower incidence rates for most common cancer types, significant disparities exist in prevalence, invasiveness, and mortality in specific cancers and across multiple patient-reported outcomes, such as quality of life and symptom burden. However, there is limited work documenting survivorship experiences among H/Ls. Purpose: The Avanzando Caminos multisite cohort study was established to address critical gaps in the science of H/L survivorship. It aims to examine the influence of sociocultural, medical, stress, psychosocial, lifestyle, behavioral, and biological factors on symptom burden, health-related quality of life, and clinical outcomes among H/Ls who have been previously treated for cancer. Methods: Avanzando Caminos, a collaboration between the Sylvester Comprehensive Cancer Center at the University of Miami and the Mays Cancer Center at UT Health San Antonio, is a 6-year prospective, cohort-based study of 3,000 H/Ls (1,500 in South Florida and 1,500 in South Texas) who completed primary cancer treatment within the past five years for stomach, liver, cervical, colorectal, lung, breast, kidney, or prostate cancers. Participants will complete self-report measures at baseline, 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years. Blood draws to assess leukocyte gene expression, cardiometabolic markers, and genetic admixture will be collected at baseline, 1 year, 3 years, and 5 years. Medical and cancer characteristics and clinical outcomes will be extracted from the electronic medical record and/or state cancer registry at each time point. Data analysis will include general latent variable modeling with maximum likelihood robust variance estimation. Results: So far, we have recruited 398 H/L participants with a mean age of 59.49 years, 62% are female, 35% are Mexican, 57% Cuban, 24% Central/South American, 78% Puerto Rican, and 7% other. Preliminary results will include sociocultural, quality of life, stress, and other factors impacting H/Ls survivors. Conclusions: Avanzando Caminos is expected to fill critical gaps in knowledge to guide future secondary and tertiary prevention efforts to mitigate cancer disparities and optimize health-related quality of life among Hispanic/Latino cancer survivors. Citation Format: Amelie G. Ramirez, Patricia Chalela, Stephanie Rowan, Ysabel R. Lew, Victoria C. Garza, Natalie Rodriguez, Myriam N. Gonzalez, Britney E. Ortiz, Dorothy Long Parma, Edgar Muñoz, Yidong Chen, Chen-Pin Wang, Adolfo E. Diaz Duque, Luz M. Garcini, Dolores M. Perdomo, Stefanie V. Beltran, Gabrielle Montes de Oca, Maria Baraya, Akina Natori, Madeline H. Krause, Paulo S. Pinheiro, Patricia I. Moreno, Michael H. Antoni, Carmen Calfa, Olveen Carrasquillo, Gilberto Lopes, Steve Cole, Frank J. Penedo. Avanzando Caminos (Leading Pathways): The Hispanic/Latino cancer survivorship cohort study [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B044.

Randomised controlled trial of automated VR therapy to improve positive self-beliefs and psychological well-being in young people diagnosed with psychosis: a study protocol for the Phoenix VR self-confidence therapy trial

IntroductionThe confidence of young people diagnosed with psychosis is often low. Positive self-beliefs may be few and negative self-beliefs many. A sense of defeat and failure is common. Young people...

Opportunities to improve opioid use disorder care for hospitalised patients with endocarditis

BackgroundDriven by increased injection opioid use, rates of hospitalisation for infective endocarditis, an infection associated with injection drug use, are increasing. In the USA, 1 in 10 hospitalised patients for...

Evaluation of the effectiveness of a nationwide precision medicine program for patients with advanced non-small cell lung cancer in Germany: a historical cohort analysis

The national Network Genomic Medicine (nNGM) Lung Cancer provides comprehensive and high-quality multiplex molecular diagnostics and standardized personalized treatment recommendation for patients with advanced non-small cell lung cancer (aNSCLC) in Germany. The primary aim of this study was to investigate the effectiveness of the nNGM precision medicine program in terms of overall survival (OS) using real-world data (RWD). A historical nationwide cohort analysis of patients with aNSCLC and initial diagnosis between 04/2019 and 06/2020 was conducted to compare treatment and OS of patients with and without nNGM-participation. Patients participating within the nNGM (nNGM group) were selected based on a prospective nNGM database. The electronic health records (EHR) of the prospective nNGM database were case-specifically linked to claims data (AOK, German health insurance). The control group was selected from claims data of patients receiving usual care without nNGM-participation (non-nNGM group). The minimum follow-up period was six months. Overall, n=509 patients in the nNGM group and n=7213 patients in the non-nNGM group met the inclusion criteria. Patients participating in the nNGM had a significantly improved OS compared to the non-nNGM group (median OS: 10.5 months vs. 8.7 months, p=0.008, HR=0.84, 95% CI: 0.74-0.95). The 1-year survival rates were 46.8% (nNGM) and 41.3% (non-nNGM). The use of approved tyrosine kinase inhibitors (TKI) in the first-line setting was significantly higher in the nNGM group than in the non-nNGM group (nNGM: 8.4% (43/509) vs. non-nNGM: 5.1% (366/7213), p=0.001). Overall, patients receiving first-line TKI treatment had significantly higher 1-year OS rates than patients treated with PD-1/PD-L1 inhibitors and/or chemotherapy (67.2% vs. 40.2%, p<0.001). This is the first study to demonstrate a significant survival benefit and higher utilization of targeted therapies for aNSCLC patients participating within nNGM. Our data indicate that precision medicine programs can enhance collaborative personalized lung cancer care and promote the implementation of treatment innovations and the latest scientific knowledge into clinical routine care. The study was funded by the AOK Federal Association Germany.

OGC P65 Diagnostic workup for esophageal cancer patients can be improved with checklists and clearer protocols; a comparative study between two tertiary centers in Europe

Abstract Background Rapid and complete workup of newly diagnosed esophageal cancer is vital for a timely, individual and high-quality treatment strategy. The aim of this study was to uncover potential delay, inefficiencies and non-contributing investigations in the diagnostic process. Methods This retrospective cohort study included all newly diagnosed esophageal cancer patients referred to or diagnosed in the Amsterdam UMC and Karolinska University Hospital between July 2020 and July 2021. Radiology, pathological assessment and multidisciplinary team meeting reports were reviewed. To assess time interval from diagnosis to treatment, dates of diagnosis, admittance to referral hospital, MDT meeting and start of treatment were collected. Results In total, 252 esophageal cancer patients were included, of which 187 were treated with curative intent. Curatively treated patients had a mean age of 66 years, were predominantly male (74.9%) with an adenocarcinoma (71.4%). Curatively treated patients had a median time from diagnosis to referral of seven days (IQR:0-11) and a median of 35 days (IQR:28-45) between diagnosis and start treatment. 69 patients had a prolonged time, defined as 40 days or more, between diagnosis and treatment. Main reasons for differences in time between diagnosis and treatment between centers, Amsterdam UMC (39 days) vs Karolinska (27 days), were additional diagnostics (47.8%) and differences in referral routine. For 27 out of 67 patients (40.3%) only logistical reasons were found for prolonged time between diagnosis and treatment. Conclusions Time between diagnosis and treatment can be improved, possibly with alterations in workup protocol, referral routines, MDT meeting regulations and workup checklists.

Racial Disparities in Periprosthetic Joint Infections after Primary Total Joint Arthroplasty: A Retrospective Study.

In the United States, racial disparities have been observed in complications following total joint arthroplasty (TJA), including readmissions and mortality. It is unclear whether such disparities also exist for periprosthetic joint infection (PJI). The clinical data registry of a large New England hospital system was used to identify patients who underwent TJA between January 2018 and December 2021. The comorbidities were evaluated using the Elixhauser Comorbidity Index (ECI). We used Poisson regression to assess the relationship between PJI and race by estimating cumulative incidence ratios (cIRs) and 95% confidence intervals (CIs). We adjusted for age and sex and examined whether ECI was a mediator using structural equation modeling. The final analytic dataset included 10,018 TJAs in 9681 individuals [mean age (SD) 69 (10)]. The majority (96.5%) of the TJAs were performed in non-Hispanic (NH) White individuals. The incidence of PJI was higher among NH Black individuals (3.1%) compared with NH White individuals (1.6%) [adjusted cIR = 2.12, 95%CI = 1.16-3.89; p = 0.015]. Comorbidities significantly mediated the association between race and PJI, accounting for 26% of the total effect of race on PJI incidence. Interventions that increase access to high-quality treatments for comorbidities before and after TJA may reduce racial disparities in PJI.

Population simulation modeling of disparities in US breast cancer mortality.

Populations of African American or Black women have persistently higher breast cancer mortality than the overall US population, despite having slightly lower age-adjusted incidence. Three Cancer Intervention and Surveillance Modeling Network simulation teams modeled cancer mortality disparities between Black female populations and the overall US population. Model inputs used racial group-specific data from clinical trials, national registries, nationally representative surveys, and observational studies. Analyses began with cancer mortality in the overall population and sequentially replaced parameters for Black populations to quantify the percentage of modeled breast cancer morality disparities attributable to differences in demographics, incidence, access to screening and treatment, and variation in tumor biology and response to therapy. Results were similar across the 3 models. In 2019, racial differences in incidence and competing mortality accounted for a net ‒1% of mortality disparities, while tumor subtype and stage distributions accounted for a mean of 20% (range across models = 13%-24%), and screening accounted for a mean of 3% (range = 3%-4%) of the modeled mortality disparities. Treatment parameters accounted for the majority of modeled mortality disparities: mean = 17% (range = 16%-19%) for treatment initiation and mean = 61% (range = 57%-63%) for real-world effectiveness. Our model results suggest that changes in policies that target improvements in treatment access could increase breast cancer equity. The findings also highlight that efforts must extend beyond policies targeting equity in treatment initiation to include high-quality treatment completion. This research will facilitate future modeling to test the effects of different specific policy changes on mortality disparities.

EXPLORING MEDICAL TOURISM COMPETITIVENESS IN MALAYSIA, THAILAND, AND SINGAPORE: THE INDONESIAN TOURISTS’ PERSPECTIVES

Malaysia, Thailand, and Singapore are popular destinations for affordable and high-quality medical treatment in Southeast Asia. However, there is limited research on the competitive advantages of these countries as medical tourism destinations. This study compares the competitive advantages of Malaysia, Thailand, and Singapore as medical tourism destinations. The interviews were conducted among 49 Indonesian patients who patronised Malaysia, Thailand, and Singapore for medical tourism services. Based on the study’s findings, Malaysia, Thailand, and Singapore have several competitive advantages as medical tourism destinations. Malaysia’s main competitive advantage is its affordability. In contrast, Thailand’s main competitive advantage is its reputation as a hub for medical tourism, with a well-established and extensive network of hospitals and medical facilities. Meanwhile, Singapore’s main competitive advantage is its reputation for offering world-class medical services, with advanced medical technologies and highly trained medical professionals. At the same time, limited availability of halal foods is their limitation. Policymakers and healthcare providers could consider the study findings in developing and implementing strategies to enhance their competitiveness as medical tourism destinations. Notbaly, the identified contrasts between Malaysia, Singapore, and Thailand could be marketed to help prospective medical tourists make informed decisions when choosing a destination for medical treatment.

INVESTIGATION INTO THE ORGANIZATION OF MEDICAL CARE PROVISION IN CARDIOVASCULAR SURGERY DURING MARTIAL LAW

The aim of this study is to examine the organization of cardio-surgical medical care during martial law for offering qualified medical assistance to servicemen classified as temporary casualties, through bed allocation planning and bed-day calculation. Materials and methods: This research encompassed military personnel actively engaged in combat operations (n=473), with an average age of 44.1±2.2. The primary data source for analysis was the foundational medical records, including medical histories and initial medical records. Results. The article presents the results of the analysis of the needs aimed at providing a cardiac surgery hospital with an adequate number of inpatient beds and substantiates the duration of treatment - inpatient stay (bed days). Determining these factors holds exceptional importance as it facilitates the delivery of high-quality specialized treatment to the ill and/or injured, ensuring their timely rehabilitation and return to active duty within the Armed Forces of Ukraine. It was observed that the study groups exhibited no significant distinctions in terms of nosological categories of circulatory system diseases, average age, and the number of bed-days, with no statistical significance identified. The analysis revealed that during the full-scale invasion of the Russian Federation into Ukraine's territory in 2022, the demand for cardiac surgery hospital beds surged by 266.3% when compared to the 2014 bed capacity. Notably, the number of bed-days saw only a modest 6.3% increase during inpatient treatment for servicemen. Conclusions. The study has shown that the number of bed days did not increase significantly in the inpatient treatment of military personnel, only by 6.3%. Due to the increase in the number of patients/wounded, the State Institution "Amosov National Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine" opened a Military Cardiac and Major Vessel Surgery Department. This department specializes in providing highly specialized medical care to servicemen with combat-related heart injuries, major vessel wounds, and chest trauma.

"I Wasn't Presented With Options": Perspectives of Black Veterans Receiving Care for Uterine Fibroids in the Veterans Health Administration.

Black women with uterine fibroids experience greater symptom severity and worse treatment outcomes compared with their White counterparts. Black veterans who use Veterans Health Administration (VA) health care experience similar disparities. This study investigated the experiences of Black veterans receiving care for uterine fibroids at VA. We identified Black veterans aged 18 to 54years with newly diagnosed symptomatic uterine fibroids between the fiscal years 2010 and 2012 using VA medical record data, and we recruited participants for interviews in 2021. We used purposive sampling by the last recorded fibroid treatment in the data (categorized as hysterectomy, other uterine-sparing treatments, and medication only/no treatment) to ensure diversity of treatment experiences. In-depth semistructured interviews were conducted to gather rich narratives of veterans' uterine fibroid care experiences. Transcribed interviews were analyzed using content analysis. Twenty Black veterans completed interviews. Key themes that emerged included the amplified impact of severe fibroid symptoms in male-dominated military culture; the presence of multilevel barriers, from individual to health care system factors, that delayed access to high-quality treatment; insufficient treatments offered; experiences of interpersonal racism and provider bias; and the impact of fertility loss related to fibroids on mental health and intimate relationships. Veterans with positive experiences stressed the importance of finding a trustworthy provider and self-advocacy. System-level interventions, such as race-conscious and person-centered care training, are needed to improve care experiences and outcomes of Black veterans with fibroids.

ФАКТОРЫ, ОПРЕДЕЛЯЮЩИЕ ИСПОЛЬЗОВАНИЕ МОБИЛЬНЫХ ПРИЛОЖЕНИЙ ЛЮДЬМИ СТАРШЕГО ВОЗРАСТА КАК ИНСТРУМЕНТА ДОСТУПНОСТИ ЛЕКАРСТВЕННОЙ ПОМОЩИ

To provide high-quality medication treatment to seniors using mobile applications, expand and develop the market for applications of this functional group, it is necessary to conduct a study of the factors influencing the attitude of older people to these applications. The aim is to study the factors determining the acceptance and use of mobile applications for the provision of medication treatment by seniors. Materials and methods. The survey involved 368 older mobile app consumers. Healthcare applications (mHealth), applications of pharmacy chains and individual pharmacies, medicine search applications (aggregators of medicines and their prices) were investigated. The survey was conducted by personal oral survey (24.5%) and online survey (75.5%) using a structured questionnaire. Results and discussion. 14 shaping factors and 13 maintaining factors of mobile app adoption and use by seniors were identified and studied. A special attitude of seniors towards various groups of mobile applications has been established. The main motivational incentives and barriers to the selection and use of mobile applications (10 parameters each) were identified and studied. Personal reasons that prevent the use of applications are shown. Particular attention is paid to personal motivational barriers in the age groups of older people from 65 to 80 years and 80 years and older. Conclusion. The results allowed to outline the main vectors for further improvement of mobile applications for the provision of medication treatment to seniors.