High-volume Facilities Research Articles

Utilization of radiation therapy in multiple myeloma: trends and changes in practice.

Plasma cell disorders including plasmacytomas and multiple myeloma (MM) are exquisitely radiosensitive, and thus, radiation therapy (XRT) is used effectively in their management. The role of XRT in the setting of novel MM therapeutics has not been explored. The 2016 National Cancer Database (NCDB) for MM with patients diagnosed between 2004 and 2013 was studied. Association between utilization of XRT as part of initial therapy and patient, disease, or treating facility characteristics was studied. A total of 111,281 cases with 91.6% MM, 7% osseous plasmacytoma (PLA-O), and 1.4% extramedullary plasmacytoma (PLA-E) were identified. XRT was utilized as part of initial therapy in 25.4% cases, including 69.3% of PLA-O, 60% of PLA-E, and 21.5% of MM patients. Patients with PLA-E and MM were significantly less likely to receive XRT as compared to PLA-O (p < 0.001). A significantly decreased use of XRT was noted over time (p < 0.001), and for advancing patient age (p < 0.001), women (p < 0.001), and blacks (p < 0.001), and with increasing income (p = 0.015). Patients with Medicare were less likely to receive XRT (OR 0.86, 95% CI 0.78, 0.94) as compared to uninsured as were those with initial treatment at academic or high-volume facilities and facilities performing stem cell transplant. There was overall decreased utilization of XRT in recent years, possibly due to advent of efficacious systemic agents for MM therapy, with a higher XRT utilization for plasmacytomas. Patterns of XRT use need to be explored prospectively, so that uniform standards of healthcare delivery can be maintained and treatment heterogeneity can be minimized.

This Month in Adult Urology

This Month in Adult Urology

Prolongation of definitive head and neck cancer radiotherapy: Survival impact and predisposing factors

Background and purposeTo quantify the survival impact of prolongation of definitive radiotherapy (RT) for head and neck cancer in a national, modern cohort, and to identify predictive factors for prolongation. Materials and methodsThe National Cancer Database was queried for adults with non-metastatic cancer of the nasopharynx, oropharynx, larynx, or hypopharynx diagnosed 2004–2015, treated with definitive RT to 66–70 Gy in 30–35 fractions at 2–2.2 Gy per fraction. Multivariable Cox regression and propensity score matching were used to model the survival impact of RT prolongation, adjusting for potential confounders such as age and comorbidity. Predictors of RT prolongation were identified using multivariable multinomial logistic regression. ResultsIn total, 36,367 patients were identified. As a continuous variable, RT prolongation increased the relative hazard of death by 2% per day (P < .0001). In the matched cohorts, patients with short (4–8 days) or long prolongation (>8 days) had lower absolute 4-year overall survival by 4% and 12%, respectively (P < .0001), while prolongation of 1–3 days was not significantly adverse. Major predictors of increased risk of prolongation were administration of systemic therapy, baseline comorbidity, lack of private insurance, and tumor/nodal stage. Conversely, higher facility volume was significantly protective, with a 55% lower risk of long prolongation within the topmost quartile (>11.5 patients/year). ConclusionRT prolongation, especially >8 days, is significantly deleterious. Systemic therapy and facility volume were major predictors. Early identification of patients at increased risk of treatment interruptions may facilitate implementation of preventive measures.

Age and racial differences in the presentation of gestational trophoblastic neoplasia

ObjectiveGestational trophoblastic neoplasia are a group of diseases with few data given their rarity. The aim of this study was to determine the age and racial differences in the presentation...

Analysis of Radiation Facility Volume and Survival in Men With Lymph Node–Positive Prostate Cancer Treated With Radiation and Androgen Deprivation Therapy

Long-term control of node-positive (N1) prostate cancer, the incidence of which is increasing, is obtainable with aggressive treatment, and definitive external beam radiation therapy (EBRT) with long-term androgen deprivation therapy (ADT) is an increasingly preferred option. Caring for these patients is complex and may require resources more readily available at high-volume centers. To evaluate the association between radiation facility case volume and overall survival (OS) in men with N1 prostate cancer. This cohort study included 1899 men diagnosed with T1N1M0 to T4N1M0 prostate cancer treated with curative-intent EBRT and ADT between January 2004 and December 2016 at US facilities reporting to the National Cancer Database. Data analysis was performed from March to June 2020. Treatment at a center with high vs low average cumulative facility volume (ACFV), defined as the total number of prostate radiation cases at an individual patient's treatment facility from 2004 until the year of that patient's diagnosis. OS was assessed between high- vs low-ACFV centers using the Kaplan-Meier method with and without propensity score-based weighted adjustment and multivariable Cox proportional hazards. The nonlinear association between continuous ACFV and OS was examined through a Martingale residual plot, and the optimal ACFV cutoff point that maximized the separation between high vs low ACFV was identified via a bias adjusted log rank test. A total of 1899 men met inclusion criteria. The median (interquartile range) age was 66 (60-72) years, 1491 (78.5%) were White individuals, and 1145 (60.3%) were treated at nonacademic centers. The optimal ACFV cutoff point was 66.4 patients treated per year. The median OS for patients treated at high-ACFV vs low-ACFV centers was 111.1 (95% CI, 101.5-127.9) months and 92.3 (95% CI, 87.7-103.9) months, respectively (P = .01). On multivariable analysis, treatment at a low-ACFV center was associated with increased risk of death (HR, 1.22; 95% CI, 1.02-1.46, P = .03) compared with treatment at a high-ACFV center. These results persisted after propensity score-based adjustment. This cohort study found a significant association of facility case volume with long-term outcomes in men with N1 prostate cancer undergoing EBRT with ADT. Specifically, treatment at a facility with high radiation case volume was independently associated with longer OS. Further studies should focus on identifying which factors unique to high-volume centers may be responsible for this benefit.

Understanding infection prevention behaviour in maternity wards: A mixed-methods analysis of hand hygiene in Zanzibar.

RationaleAlthough women in low- and middle-income countries are increasingly encouraged to give birth at facilities, healthcare-associated infection of both the mother and newborn remain common. An important cause of infection is poor hand hygiene. There is a need to understand how environmental, behavioural, and organisational factors influence hygiene practice.ObjectiveTo understand variations between facilities and between people in hygiene behaviour and to explore potential intervention targets in four labour wards in Zanzibar.MethodsSite visits including observation of deliveries and of day-to-day workings of the facilities. Thirty-three semi-structured interviews, totalling more than 46 hours, with birth attendants, orderlies, managerial staff and mothers. Transcribed interviews and observation notes were read and coded by two authors. Themes were developed and analysed in light of existing research.ResultsThe physical preconditions for hand hygiene were met more regularly in the two highvolume facilities, where soap, water, gloves were almost always available. However, in all of the facilities, hand hygiene appeared impeded by poor ergonomics, like, for example, physical distance between water taps, gloves, or delivery beds. Recontamination of gloved hands following good hand hygiene was commonly observed, a pattern that the birth attendants attributed to high and unpredictable workload and equipment shortages. Interviews and focus groups suggested that birth attendants typically understood when and why hand hygiene should be implemented, and that they were aware of low handwashing rates among co-workers. In poorer performing facilities, managers were less inclined to visit wards and more likely to perceive hand hygiene as beyond their influence.ConclusionsObservations and interviews suggest improvements in the ergonomic design of delivery rooms, including convenient availability of sinks, soap, hand gel, hand towels and gloves, may be a low-cost way to reduce the infection burden from poor hand hygiene.

Abstract PO-211: Racial disparities in the quality of surgical care among Medicare beneficiaries with prostate cancer

Abstract Background: Black men in the US demonstrate a two-fold increase in prostate cancer mortality compared to men of other races/ethnicities. The aim of this analysis was to understand how access to high quality care—estimated using surgical volume— impacts disparities in prostate cancer mortality between Black and White men with localized prostate cancer. Methods: This is an analysis of a SEER-Medicare cohort of men diagnosed with localized prostate cancer (cT1-4N0M0) managed primarily by radical prostatectomy from 2005-2015. This analysis was restricted to Black and White men due to low representative numbers of men of other races/ethnicities. Social, demographic, and clinical data were obtained. Both facility and provider data were obtained using administrative data in Medicare. Surgical volume for both providers and facilities were stratified into low, medium, and high. Simple descriptive analyses were performed. Multivariable Cox regression analyses was used to assess the relationship between race, surgical volume, and various clinical and social variables. Results: Black men represented 2,070 (7.1%) of the 29,071 men in this cohort. Black men in the cohort had a higher proportion of prostate specific antigen (PSA) greater than 20 ng/mL (7.0% vs 3.6%) and a higher proportion of men with cT1 disease at diagnosis (64.6% vs 56.1%) when compared to White men. Black men were also less likely to be married/partnered (63.5% vs. 79.9%), more likely to reside in an impoverished zip code (43.9% vs. 11.1%), and more likely to have significant comorbidities (7.2% vs. 2.9%). Black men in this cohort were most likely to be treated in the Southern US (42.8% of cases). Black men were more likely to be treated at a minority serving hospital/facility (24.6% vs. 3.1%, p &amp;lt; 0.001), more likely to be treated at a very large hospital/health system (p &amp;lt; 0.001), and less likely to be treated by a high-volume surgeon or facility (7.7% vs. 19.9%, p &amp;lt; 0.001) compared to White men. On multivariable analysis adjusted for race, hospital type, NCI comorbidity index, clinical stage, and prostatectomy volume; black men demonstrated an increased risk of prostate cancer mortality (hazard ratio 1.27, 95% CI 0.94, 1.72) compared to White men. On stratified analysis, there were no racial disparities in cancer-specific mortality among men treated by a high-volume provider/facility. In contrast, Black men treated by a low/medium volume provider/facility had a higher likelihood of prostate cancer related death following surgery (hazard ratio 1.41, 95% CI 1.02, 1.95, p = 0.04). Conclusions: Black Medicare beneficiaries with prostate cancer demonstrate unique patterns of surgical care utilization, with differences noted in the types and surgical volumes—and likely surgical quality—of their health facilities and providers. Our findings suggest that access to high-quality prostate cancer care is an important mediator of racial disparities in prostate cancer, even among men with access to health insurance. Citation Format: Yaw A. Nyame, Sarah K. Holt, Ruth Etzioni, John L. Gore. Racial disparities in the quality of surgical care among Medicare beneficiaries with prostate cancer [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-211.

A four-step method to centralize pancreatic surgery, accounting for volume, performance and access to care

BackgroundAdequate criteria for pancreatic surgery centralization are debated. This retrospective study aimed to define a reproducible method for complex care centralization, accounting for hospital performance and access to care. MethodsThe method consisted in: 1. Analysis of overall outcome and mortality-related factors. 2. Assessment of volume and adjusted mortality of each hospital. 3. Definition of different centralization models. 4. Final adjustments to guarantee access to care, evaluating travel times and waiting lists. This method was tested on Lombardy, the most populous Italian region (about 10 million inhabitants, 24 000 km2). ResultsAccording to Ministry of Health data, 79 hospitals performed 3037 resections in 2014–2016. Mean overall mortality was 5.0%, increasing from 2.3%, of seven high-volume facilities (>30 resections/year) to 10.7% of 56 low-volume facilities (<10 resections/year). Five centralization models were tested (range: 7–23 hospitals): the best performing model included seven high-volume facilities, providing both low mortality (<2%), and easy access to care, namely reasonable travel time (≤60 min for >90% of the population), and limited impact on waiting list (1.1 extra-resection/hospital/week). ConclusionThe four-step method appears as a flexible tool to centralize pancreatic surgery, allowing regulatory institutions to estimate the effect of different models.

The Volume-Outcome Effect Calls for Centralization of Care in Esophageal Adenocarcinoma: Results From a Large National Cancer Registry.

Using the National Cancer Database, we assessed the relationship between facility overall esophageal adenocarcinoma (EAC) case volume and survival. We categorized facilities into volume quintiles based on annual EAC patient volume and performed a multivariable Cox proportional hazards regression between facility patient volume and survival. In a cohort of 116,675 patients, facilities with higher vs lower (≥25 vs 1-4 cases) annual EAC patient volume demonstrated improved survival (adjusted hazard ratio: 0.80. 95% confidence interval: 0.70-0.91). This robust volume-outcome effect calls for centralization of care for EAC patients at high annual case volume facilities.

Impact of geography and travel distance on outcomes in epithelial ovarian cancer: a national cancer database analysis

BackgroundAs ovarian cancer treatment shifts to provide more complex aspects of care at high-volume centers, almost a quarter of patients, many of whom reside in rural counties, will not have...

Can Regionalization of Care Reduce Socioeconomic Disparities in Breast Cancer Survival?

Background:Breast cancer patients of low socioeconomic status (SES) have worse survival than more affluent women and are also more likely to undergo surgery in low-volume facilities. Since breast cancer patients treated in high-volume facilities have better survival, regionalizing the care of low SES patients toward high-volume facilities might reduce SES disparities in survival.Objective:We leverage a natural experiment in New York state to examine whether a policy precluding payment for breast cancer surgery for New York Medicaid beneficiaries undergoing surgery in low-volume facilities led to reduced SES disparities in mortality.Research Design:A multivariable difference-in-differences regression analysis compared mortality of low SES (dual enrollees, Medicare-Medicaid) breast cancer patients to that of wealthier patients exempt from the policy (Medicare only) for time periods before and after the policy implementation.Subjects:A total of 14,183 Medicare beneficiaries with breast cancer in 2006–2008 or 2014–2015.Measures:All-cause mortality at 3 years after diagnosis and Medicaid status, determined by Medicare administrative data.Results:Both low SES and Medicare-only patients had better 3-year survival after the policy implementation. However, the decline in mortality was larger in magnitude among the low SES women than others, resulting in a 53% smaller SES survival disparity after the policy after adjustment for age, race, and comorbid illness.Conclusion:Regionalization of early breast cancer care away from low-volume centers may improve outcomes and reduce SES disparities in survival.

Association of Highly Restrictive State Abortion Policies With Abortion Rates, 2000-2014

Although abortion is common in the United States, patients face substantial barriers to obtaining an abortion. Recently enacted abortion restrictions pose such barriers. To assess the association between a state legislative climate that is highly restrictive toward abortion provision and the abortion rate and to evaluate whether distance to a facility providing abortion care mediates the association between legislative climate and the abortion rate. This cohort study examined county-of-residence abortion rates from all states that publicly provided them and used data on abortion restrictions, facility locations, and county demographic characteristics for the years 2000 to 2014. The association between legislative climate and abortion rates was evaluated using propensity score-weighted, linear regression difference-in-difference analysis. All models included state and year fixed effects and standard errors adjusted for state-level clustering. Highly restrictive legislative climate, defined as having at least 3 of 4 types of abortion restrictions; distance to a high-volume facility providing abortion care (ie, performing ≥395 abortions per year) in miles. County-level abortion rate, defined as abortions per 1000 women per year. Abortion rate data were obtained from 1178 counties in 18 states for a median of 12.5 years (range, 5-14). The median abortion rate was 2.89 per 1000 women (interquartile range, 1.71-4.46 per 1000 women). A highly restrictive legislative climate, when compared with a less restrictive one, was associated with 0.48 fewer abortions per 1000 women (95% CI, -0.92 to -0.04 abortions per 1000 women; P = .03). Adjusted for distance to a facility providing abortion care, a highly restrictive legislative climate was associated with 0.44 fewer abortions per 1000 women (95% CI, -0.85 to -0.03; P = .04). Each mile to a facility was associated with 0.02 fewer abortions per 1000 women (95% CI, -0.03 to -0.01 abortions per 1000 women; P = .003). Legislative climate was not significantly associated with distance to a facility providing abortion care (change in distance associated with highly restrictive climate, -2.73 [95% CI, -6.02 to 0.57] miles; P = .10). This study provides evidence that a state legislative climate that is highly restrictive toward abortion provision is associated with a lower abortion rate. The cumulative effect of restrictive policies may pose a barrier to abortion access.

Impact of Treatment Facility Chracteristics on Patient (Pt) Outcomes in Acute Myeloid Leukemia (AML) Using Data from the National Cancer Database (NCDB)

Introduction The literature suggests a widespread reduction in the availability and accessibility of newer treatment options among marginalized groups in AML. Studies from large national databases point to lower socio-economic status, Hispanic and African American race, Medicare or no insurance, being unmarried, treatment at non-academic centers, and rural residence as negatively impacting overall survival (OS) and rates of chemotherapy utilization in AML patients (Patel et al. 2015, Jaco et al. 2017, Bhatt et al. 2018, Master et al. 2016). We hypothesized that facility affiliation and pt volume would also have important effects on time to treatment (TTT) and OS in AML, even when these socioeconomic disparities were accounted for. Methods For this retrospective analysis, we used NCDB data that included 124,988 pts over the age of 18 with AML between the years 2004-2016. Variables analyzed included facility types described as community cancer programs (CP), comprehensive community cancer programs (CCP), academic/research center cancer programs (AC) and integrated network cancer programs (IN), and volume of facilities defined as high volume (HV) and low volume (LV). HV facilities had case volumes of ≥ 99th percentile and all other facilities were classified as LV. Multivariate analyses (MVA) included demographic and socioeconomic covariables. We used Cox proportional hazard analysis for both TTT and OS MVA. The Kaplan-Meier method was used to estimate median TTT and OS, and the log rank test used to compare TTT and OS across predictor variables. Results The median age of AML patients was 63 yrs (range 18-90) with 54% males, and 86% Caucasian. Five percent of patients were treated at CP, 30% at CCP, 44% at AC, and 10% at IN. 21% at HV facilities and 79% at LV facilities. Median TTT in days at CP facilities was 7, compared to 5 days in CCP and AC facilities versus 4 days at IN (p&amp;lt;0.0001). TTT was 5 days at HV facilities versus 4 days at LV facilities (p&amp;lt;0.0001). Kaplan-Meier curves showed that TTT was similar between HV and LV facilities(figure 1). The median OS was 3.25 months in CP compared to 4.34 months at CCP, 5.06 months at IN and 9.53 months at AC (p&amp;lt;0.0001). For facility volume, the median OS was 13.11 months in HV facilities compared to 6.93 months in LV facilities (p&amp;lt;0.0001). When sex, race, age, Hispanic Origin, education, urban/rural residence, Charlson-Deyo Comorbidity score and Great Circle Distance were adjusted for in MVA (table 1), the OS was higher in AC versus CP facilities (hazard ratio [HR] of 0.90 (0.87-0.93, p&amp;lt;0.0001), and there was no statistically significant difference with comparison of other facility types to CP. Similarly, there was a lower OS at LV versus HV facilities with a HR of 1.14 (1.12-1.16, p&amp;lt;0.0001). CCP facilities had a shorter TTT compared to CP with a HR of 1.21 (1.17-1.26, p&amp;lt;0.0001). AC had a shorter TTT than CP with a HR of 1.17 (1.13-1.22, p&amp;lt;0.0001), and IN had a shorter TTT compared to CP with a HR of 1.29 (1.24-1.34, p&amp;lt;0.0001). Additionally, TTT in the MVA for facility volume was shorter in LV facilities compared to HV facilities with HR of 1.05 (1.04-1.07, p&amp;lt;0.0001) [table 1]. Conclusion When adjusting for various socioeconomic factors, we found that TTT was longest in CP compared to CCP, AC, and IN. Treatment at a LV facility resulted in a decreased overall survival. LV facilities may be less familiar with treatment regimens for AML, less likely to use novel treatment options, and be less familiar with the disease. We showed that treatment at an AC compared to CP, CCP and IN facilities improved survival. Given poor outcomes for AML, these results show the importance of going to AC and HV facilities with more experience in treating AML for improved outcomes. Disclosures Lai: Astellas: Speakers Bureau; Jazz: Speakers Bureau; Abbvie: Consultancy; Agios: Consultancy; Macrogenics: Consultancy.

Effect of Treatment Center Experience on Survival after Diagnosis of Stage I-III Merkel Cell Carcinoma Treated with Surgery with or without Postoperative Radiation Therapy

Treatment center volume (TCV) is associated with improved outcomes across different cancers. Prior work suggested that TCV is associated with overall survival (OS) for Merkel cell carcinoma (MCC). This study characterizes the relationship between TCV and OS for stage I-III MCC treated with surgery with or without postoperative radiation therapy (RT). Retrospective large database study including 11, 119 patients diagnosed with stage I-III MCC from 2004-2015. Treatment at a high TCV center, defined as ³90th percentile (³5 cases/year) was associated with a statistically significant improvement in OS in stage I-III MCC (2-year OS 70.9% vs. 63.6%, p <0.0001). For every 9 patients treated per year, there was a 3% improvement in OS (adjusted hazard ratio [AHR], 0.974; 95% CI: 0.959 - 0.989, P < 0.0010). Treatment at high TCV centers was associated with improved 2-year OS (69.8% vs. 59.4%, p <0.0001) for patients treated with surgery alone, and for patients treated with postoperative RT (2yr OS 73.1% vs. 68.4%, p <0.0001). A sensitivity analysis identified a significant OS benefit for treatment at centers with TCV at the 75th percentile (3 patients/year) or above. Survival after curative-intent treatment of MCC is higher in high-volume facilities for stage I-III MCC treated with surgery-alone with or without postoperative RT. Due to the rarity of the condition, providers at cancer centers with low volume of MCC patients, should consider referring their patients to a high-volume center, where there also may be enhanced access to clinical trials and specialty expertise.

Access to Minimally Invasive Gynecologic Surgery for Adnexal Surgery: Impact of Race and Payer Mix

Study Objective To determine racial and social disparities regarding adnexal surgery. Design Retrospective cohort. Setting Data was obtained from the Statewide Planning and Research Cooperative System (SPARCS) for New York State. The database was reviewed from 2011 - 2015 for ovarian cystectomy with or without salpingectomy for benign indications. Patients or Participants There were 68,029 patients included in this analysis. Average age was 43 years, with 81.3% between 18-55 and 17.7% older than 55. Racial composition comprised of 68.7% Caucasian, 4.8% Asian, 11.2% Black, and 15.3% as other. Payor mix included 79.6% insured, 7.4% Medicaid, 8.3% Medicare, and 4.7% other or self-payment. Majority resided in metropolitan areas (90.6%) and did not travel greater than 15 miles for care. Interventions Adnexal surgery performed via laparotomy or laparoscopy. Measurements and Main Results Of the 68,029 patients included, 54,829 were performed via laparoscopy (80.6%) while 13,200 were via laparotomy (19.4%). Compared to Caucasian, odds ratio of having a laparoscopy was 0.68 for Black, 0.81 for Hispanic, and 0.80 for other. Compared to commercial insurance, odds ratio of having a laparoscopy was 0.69 for Medicaid, 0.72 for Medicare, 0.92 self. At high-volume surgical facilities, the odds ratio for utilizing laparoscopy was 1.83 compared to low volume facilities and 1.49 compared to medium volume facilities. At institutions with major teaching affiliation, the odds ratio was 0.91 compared to non-teaching and 1.0 for minor affiliation. Conclusion Race is not the only factor associated with a lower likelihood of laparoscopy for adnexal surgery. Other factors such as institution type and payer mix also impact likelihood.

Survival Outcomes in Sinonasal Poorly Differentiated Squamous Cell Carcinoma.

Sinonasal squamous cell carcinoma (SCC) is rare with no consensus on treatment regimen. Our goal is to analyze treatment outcomes in poorly differentiated SCC (PDSCC) using a large national database. Retrospective database study. The National Cancer Database was queried for sinonasal invasive SCC, grade 3 (poorly differentiated) from 2004 to 2014. Patient demographics and tumor and treatment characteristics were tabulated. Kaplan-Meier (KM) analysis was performed to compare overall survival (OS) between histology subtype and primary site. Multivariable Cox proportional hazards regression was performed for statistical analysis of treatment regimen on OS. A total of 1,074 patients were identified. The maxillary sinus was the most common site (45%). T4 tumors were observed in 50% of patients, with most patients treated at high-volume facilities (77%). In KM analysis, spindle cell SCC histological subtype, primary tumors of the maxillary sinus, and poorly differentiated grade had worse OS. In our Cox-PH model, higher T stage and age were associated with worse OS. Those treated at a high-volume facility and those who underwent surgical resection followed by adjuvant radiation had improved OS. Chemotherapy within the treatment regimen did not confer survival benefit except in surgical patients when positive margins were present, and surgery with adjuvant chemoradiation trended toward improved survival. Sinonasal PDSCC appears to be best treated at high-volume centers with surgical resection followed by adjuvant radiation. Poorly differentiated grade has worse OS compared to more differentiated tumors. Chemotherapy along with adjuvant radiation may have a role in patients with positive surgical margins. 4 Laryngoscope, 131:E1040-E1048, 2021.

Impact of the COVID-19 epidemic at a high-volume facility in gynecological oncology in Tokyo, Japan: a single-center experience

BackgroundThe number of cases of novel coronavirus disease 2019 (COVID-19) in Japan have risen since the first case was reported on January 24, 2020, and 6225 infections have been reported as of June 30, 2020. On April 8, 2020, our hospital began screening patients via pre-admission reverse transcriptase-polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and chest computed tomography (CT). Although no patients exhibited apparent pneumonia, treatment delay or changes in treatment plans were required for a few patients based on the results of screening tests. During an emerging infectious disease pandemic, the likelihood of being infected, as well as the disease itself, affects clinical decision making in several ways. We summarized and presented our experience.Case presentationAfter the introduction of pre-admission screening, RT-PCR and CT were performed in 200 and 76 patients, respectively, as of June 30, 2020. The treatment of five patients, including two patients with cervical cancer, two patients with ovarian tumors, and one patient with ovarian cancer, was affected by the results. Two asymptomatic RT-PCR-positive patients did not develop COVID-19, but their treatment was delayed until the confirmation of negative results. The other three patients were RT-PCR-negative, but abnormal CT findings suggested the possibility of COVID-19, which delayed treatment. The patients receiving first-line preoperative chemotherapy for ovarian cancer had clinically evident exacerbations because of the treatment delay.ConclusionDuring the epidemic phase of an emerging infectious disease, we found that COVID-19 has several other effects besides its incidence. The postponing treatment was the most common, therefore, treatment of ovarian tumors and ovarian cancer was considered to be the most likely to be affected among gynecological diseases. Protocols that allow for easy over-diagnosis can be disadvantageous, mainly because of treatment delays, and therefore, the protocols must be developed in light of the local infection situation.

Certificate-of-Need State Laws and Elective Posterior Lumbar Fusions: Is It Time to Repeal the Mandate?

Our study aimed to assess whether elective posterior lumbar fusions (PLFs) performed in states with Certificate-of-Need (CON) laws versus states without CON laws had lower utilization rates, lower costs, and better quality of care. The 2005-2014 100% Medicare Standard Analytical File was queried to identify patients undergoing elective 1- to 3-level PLF. Differences in per-capita utilization, 90-day reimbursements, and proportion of high-volume between CON and No-CON states were reported. Multivariate analyses were used to analyze 90-day complications and readmissions. A total of 188,687 patients underwent an elective 1- to 3-level PLF in a CON state and 167,642 patients in a No-CON state during 2005-2014. The average per capita utilization of PLFs was lower in CON states as compared with No-CON states (14.5 vs. 15.4 per 10,000 population; P < 0.001). Average 90-day reimbursements between CON and No-CON states differed by a small amount ($22,115 vs. $21,802). CON states had a higher proportion of high-volume facilities (CON vs. No CON-40.9% vs. 29.9%; P < 0.05) and lower proportion of low-volume facilities (CON vs. No-CON-37.2% vs. 45.0%; P < 0.05). PLFs performed in CON states had slightly lower odds of 90-day complications (odds ratio 0.97 [95% confidence interval 0.96-0.99]; P < 0.001) and readmissions (odds ratio 0.95 [95% confidence interval 0.93-0.97]; P < 0.001). The presence of CON laws was associated with lower utilization of elective 1- to 3-level PLFs and a greater number of high-volume facilities. However, their effect on quality of care, via reduction of 90-day readmissions and 90-day complications, is minimally significant.

259. Hospital mark-up and outcomes following lumbar fusions: moving towards the era of transparency in prices

BACKGROUND CONTEXT Even though charges levied by hospitals for provision of surgical services has broad financial implications on insurance contracts, pricing is not subject to regulation. As a result, hospital mark-ups (1/charge-to-cost ratio (CCR)) are known to vary significantly across the nation. While hospital administrators argue that higher hospital mark ups are reflective of high-quality care, no study have evaluated the impact of undergoing surgery in high markup hospitals on 90-day outcomes following lumbar fusions. PURPOSE To evaluate whether hospitals with higher mark-up ratios for lumbar fusions is associated with improved/better outcomes. STUDY DESIGN/SETTING Retrospective review of 100% Medicare Standard Analytical Files (SAF100) database. PATIENT SAMPLE The 2014 100% Medicare Standard Analytical Files (SAF100) was queried using DRG code 469 (SPINAL FUSION EXCEPT CERVICAL W/O MCC) to identify patients undergoing lumbar fusions. Hospital mark-up of facilities was calculated using a previously validated formula: (1/CCR). Hospital were divided into three groups – 1) low mark-up (0-2.99), 2) medium mark-up (3.00-5.49) and 3) high mark-up (>5.49). OUTCOME MEASURES Ninety-day complications and readmissions. METHODS Multivariate logistic regression analyses were used to assess for differences in 90-day outcomes between high, medium and low markup hospitals, while controlling for age, gender, region, Elixhauser Comorbidity Index, diagnosis (fracture or degenerative lumbar pathology), approach (anterior or posterior), type of fusion (primary vs revision), extent of fusion (1-3 level or 4-8 level), use of interbody, BMP, neuromonitoring, concurrent laminectomy or discectomy, hospital bed size, teaching status, hospital location (urban or rural), ownership (government, proprietary or voluntary), and whether hospital was a high volume facility (≥ 70 cases/year). A p-value of less than 0.025 was considered significant, due to comparison being carried out between three groups. RESULTS A total of 75,707 patients undergoing surgery in 1,365 hospitals were included – out of which 17,466 (23.1%) received surgery in high mark-up hospitals (N=341), 36,888 (48.7%) received surgery in medium mark-up hospital (N=805) and 21,353 (28.2%) received surgery in low mark-up hospitals (N=341). Following adjustment for baseline demographics, hospital-level factors and clinical characteristics, undergoing surgery at high mark-up hospital (vs low mark-up hospital) was not associated with significant differences in wound complications (p=0.935), sepsis (p=0.139), revision fusion (p=0.139), acute renal failure (p=0.098), myocardial infarction (p=0.774), deep venous thrombosis (p=0.046), pulmonary embolism (p=0.442), and urinary tract infections (p=0.739). High mark-up hospitals, vs low mark-up hospitals, had slightly lower odds of pneumonia (OR 0.76 [95% CI 0.64-0.92]; p=0.004) and readmissions (0.91 [95% CI 0.84-0.98]; p=0.012). Similarly, no significant differences in outcomes were noted between medium mark-up hospitals (vs low mark-up hospitals), with the exception of slightly lower odds of urinary tract infections (p=0.009). CONCLUSIONS Based on the findings of the study, it appears that hospital markup is not largely correlated with the quality of surgical care following lumbar fusions. Moving forward, price transparency in billings will be essential for controlling the ever-increasing cost burden associated with spinal fusions. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Low Rates of Chemotherapy Use for Primary, High-Grade Soft Tissue Sarcoma: A National Cancer Database Analysis.

There is conflicting evidence regarding the role of chemotherapy for high-grade soft tissue sarcoma (STS) in adults. We sought to characterize patterns of chemotherapy use, including multiagent and neoadjuvant chemotherapy, in the United States. Using the National Cancer Database, we identified 19,969 adult patients who underwent surgical resection for primary high-grade STS from 2004 to 2016. Using logistic regression, we examined factors associated with overall, multiagent, and neoadjuvant chemotherapy use. Chemotherapy was administered to 22% (n=4,377) of the study population. Among patients treated using chemotherapy, 85% received multiagent treatment and 47% received neoadjuvant treatment. On multivariate analysis, factors associated with chemotherapy use included tumor size, depth, histology, and primary site; receipt of radiation treatment; younger age; higher patient income; and academic treatment facility. Factors associated with multiagent chemotherapy use included tumor histology, tumor primary site, and younger age. Factors associated with neoadjuvant chemotherapy use included tumor size, depth, margin status, and primary site; receipt of radiation treatment; higher patient income; academic treatment facility type; and distance to treatment facility. Treatment at a high-volume facility was the only factor associated with overall, multiagent, and neoadjuvant chemotherapy use. No significant temporal trend was seen in overall, multiagent, or neoadjuvant chemotherapy use. Overall chemotherapy use was low (22%). The variability in chemotherapy use was driven by clinical, patient, demographic, and facility factors. Among patients treated with chemotherapy, the use of multiagent chemotherapy was high (85%), and nearly half received neoadjuvant therapy. There was a discrepancy in the use of chemotherapy-including neoadjuvant and multiagent chemotherapy-between high- and low-volume treatment centers.