Higher Comorbidity Score Research Articles

The DOSE index in chronic obstructive pulmonary disease: evaluating healthcare costs

Background and objectivesThe DOSE index, which incorporates Dyspnea, Obstruction, Smoking, and Exacerbations, is a widely used tool for assessing the severity and prognosis of Chronic Obstructive Pulmonary Disease (COPD). In addition to risk assessment, it has potential clinical utility in predicting healthcare costs, which are primarily driven by exacerbations. While several indices, such as the BODE (Body-mass index, Obstruction, Dyspnea, Exercise) and ADO (Age, Dyspnea, Obstruction) indices, exist for risk prediction, there is a lack of dedicated tools for forecasting healthcare costs. This study explores the potential of the DOSE index compared to other indices, including BODE, ADO, and the Charlson Comorbidity Index (CCI), for this purpose.Materials and methodsThis cross-sectional retrospective study analyzed data from 396 COPD cases. We examined associations between the DOSE index, BODE index, ADO index, CCI, and healthcare costs, including hospitalizations and emergency room treatments. Healthcare costs were categorized as direct medical expenses.ResultsSignificant associations were observed between the DOSE index and various healthcare parameters. DOSE quartiles showed strong correlations with outpatient visits (p = 0.013) and outpatient medical expenses (p = 0.011). In addition, hospitalization frequency, duration, and associated costs were significantly correlated with higher DOSE quartiles (p < 0.001). A significant difference was found when comparing DOSE quartiles between patients with high (CCI ≥ 3) and low (CCI < 3) comorbidity scores (p = 0.018). The DOSE index outperformed other indices, likely due to its inclusion of exacerbations, a key driver of healthcare costs.ConclusionThe DOSE index demonstrates potential in predicting healthcare costs, particularly due to its inclusion of exacerbation frequency. This study highlights the importance of considering exacerbations alongside traditional risk factors for more accurate cost forecasting in COPD management. Our findings suggest that the DOSE index may be a valuable tool in both clinical and economic assessments of COPD patients, though further research is warranted to validate these findings in larger datasets.

Exploring Risk Factors for Post-operative Complications in Laparoscopic Common Bile Duct Exploration: A Literature Review.

Gallstone-related diseases, particularly common bile duct (CBD) stones, pose a significant global health challenge. The emergence of laparoscopic common bile duct exploration (LCBDE) has transformed the management of these conditions by offering a less invasive alternative to traditional open surgery. This literature review aims to analyze published literature to identify and understand the risk factors associated with LCBDE. The study aims to offer valuable insights that could potentially enhance patient care and outcomes in managing CBD stones. A comprehensive search of English-language studies from the past 20 years was conducted using PubMed, focusing on peer-reviewed primary research, systematic reviews, and meta-analyses. From 830 initial articles, 25 were selected based on relevance and availability. The review identified several key risk factors influencing LCBDE outcomes, including patient-related factors such as advanced age, high comorbidity scores, narrow bile ducts, and complex stones, which increase the likelihood of complications. Surgeon experience also plays a crucial role, with lower complication rates observed among surgeons who have performed at least 70 LCBDE procedures over a 10-year period. Additionally, procedure-related factors such as the transcystic (TC) approach, primary suture (PS) closure, and intraoperative imaging were found to reduce complication rates. LCBDE remains a promising approach for managing bile duct stones, particularly when patient, surgeon, and procedural factors are optimized.

Patients with Inflammatory Bowel Disease are at Increased Risk for Complications of Herpes Zoster

Background and aimsPatients with inflammatory bowel disease (IBD) are at an increased risk for vaccine-preventable diseases, such as herpes zoster (HZ). The aim of this study was to determine whether complications of HZ are more frequent in patients with IBD than in non-IBD controls. MethodsThis was a retrospective, cohort study using the Optum Research Database. Patients with IBD were matched 1:1 to non-IBD controls based on age, sex, and index year, which was defined as the diagnosis of HZ. We then identified the complications of HZ that occurred up to 90 days after the index date. We compared patients with IBD with non-IBD controls and evaluated the 90-day risk of HZ complications. We used a composite primary outcome for any HZ complication. Secondary outcomes were risk factors for complications. ResultsFour thousand seven fifty-six patients with IBD met the inclusion criteria and were matched to the controls. Patients with IBD were more likely to have complications of HZ than controls [738 (15.52%) vs. 595 (12.51%), p < 0.0001]. Patients with IBD with higher comorbidity scores were more likely to develop complications (1.86 vs. 1.18 p < 0.0001). In the logistic regression analysis of patients with IBD having a higher comorbidity score, above 50 years of age, on anti-TNF or corticosteroids were all at increased risk of a complication of HZ. ConclusionPatients with IBD are more likely to have complications of HZ than controls. Efforts are needed to increase HZ vaccine uptake to reduce the morbidity of HZ.

The impact of COVID-19 on time toxicity in patients with advanced cancer.

267 Background: The COVID-19 pandemic necessitated the rapid adoption of telemedicine but little is known about whether the changes in care delivery has led to differences in time toxicity for patients with advanced cancer. This study examines the impact of the pandemic on time toxicity, defined as the time burden of interacting with the healthcare system, by comparing healthcare contact days between pre-COVID and post-COVID periods. Methods: A retrospective cohort study was performed on patients with advanced (stage 4) cancer who died within one year of diagnosis at Kaiser Permanente Northern California between January 1, 2015 and June 30, 2023. Time toxicity was defined as the percentage of healthcare contact days over the course of survival period between cancer diagnosis and death (contact days/survival days). We included outpatient days (imaging, labs, treatment, provider visits), inpatient stays (emergency department, acute inpatient, non-acute institutional stays), and in-home days (in-home care, virtual care, home hospice). Differences between pre-COVID (diagnosed and died before March 1, 2020) and post-COVID (diagnosed after March 1, 2020) periods were analyzed using Wilcoxon tests. Results: The cohort included 9643 patients, with 6558 pre-COVID and 3085 post-COVID. Median age at diagnosis was 74 years, and the cohort was 46.9% female, largely white (64.5%), with a high comorbidity score (median Elixhauser score: 4). Post-COVID, there was an increase in institutional stay (8.7% vs. 9.3%) and outpatient service (imaging and labs) (4.4% vs. 3.1%), while in-person outpatient visits decreased (5.9% vs. 8.7%, p&lt;0.0001). Additionally, in-home days increased (25.0% vs. 20.8%), with a significant rise in in-home virtual care (3.9% vs. 1.8%, all p&lt;0.01). Conclusions: The COVID-19 pandemic led to notable shifts in healthcare utilization for patients with advanced cancer in the last year of life. The increase in telehealth and in-home services in the post-COVID era was accompanied by a slight increase in emergency and ancillary services. Further understanding patient experiences around these shifts is crucial for optimizing care and managing time toxicity in the evolving healthcare landscape. Description of outcomes pre and post-COVID-19 pandemic. Total Pre-COVID Post-COVID P-value Survival Days, median 86.0 84.0 89.0 0.02 Percentage of Contact, median (interquartile range) Comprehensive Contact 63.3 (41.0-92.0) 62.5 (40.7-91.0) 65.2 (41.7-94.1) 0.01 Institutional stay 9.0 (2.7-26.2) 8.7 (2.7-25.9) 9.3 (2.9-26.8) 0.11 Outpatient 12.4 (5.3-19.8) 12.9 (5.6-20.6) 11.2 (4.8-18.1) &lt;.001 Outpatient visit 7.7 (2.8-13.4) 8.7 (3.5-14.6) 5.9 (1.6-10.7) &lt;.0001 Outpatient service 3.5 (0.8-6.3) 3.1 (0.4-5.8) 4.4 (1.5-7.1) &lt;.0001 In-home 22.2 (7.4-50.0) 20.8 (6.0-48.4) 25.0 (10.4-51.7) &lt;.001 In-home care 18.1 (1.7-46.6) 17.4 (1.2-46.2) 19.2 (2.4-47.2) 0.03 In-home virtual care 2.2 (0.0-4.8) 1.8 (0.0-3.8) 3.9 (0.7-7.0) &lt;.0001

Social Risks and Health Care Use in Medically Complex Patients

Integrated health care systems have initiated major investments to identify and address social risks, particularly for patients with multiple medical conditions. To evaluate the association of social risks with health care use among patients with complex multimorbidity. This longitudinal cohort study assessed Kaiser Permanente Northern California (KPNC) patients with (1) moderate medical complexity (defined by high comorbidity score, high risk of hospitalization, and/or prior emergency department [ED] admissions) and (2) high medical complexity (eg, meeting additional criteria, such as ≥7 medications and laboratory evidence of poor disease control). Social risks (eg, requiring medical financial assistance and self-reported social barriers to care). Inpatient and outpatient health care use during 12 months of follow-up (January 15, 2023, to January 14, 2024). The sample included 97 252 KPNC patients (mean [SD] age, 69.5 [16] years; 52.1% female; 10.6% Asian, 11.1% Black, 18.3% Hispanic, 54.6% White, and 5.5% other race or ethnicity [eg, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, multiracial, or unknown race]; and 8.8% insured by Medicaid), including 27 827 with moderate medical complexity (5074 [18.2%] with social risks) and 69 425 with high medical complexity (17 343 [25.0%] with social risks). In fully adjusted models, for moderate medical complexity, social risks were associated with higher odds of inpatient admissions (odds ratio [OR], 1.2; 95% CI, 1.1-1.4), ED visits (OR, 1.2; 95% CI, 1.1-1.3), and mental health visits (OR, 1.2; 95% CI, 1.1-1.3) vs individuals without social risks. Among individuals with high medical complexity, social risks were associated with higher odds of inpatient admissions (OR, 1.2; 95% CI, 1.1-1.2), ED visits (OR, 1.2; 95% CI, 1.1-1.2), and 30-day readmissions (OR, 1.2; 95% CI, 1.1-1.3) and higher odds of mental health visits (OR, 1.3; 95% CI, 1.2-1.3) vs individuals without social risks. In this cohort study of individuals with medical complexity, coexisting social risks were associated with substantial downstream health care use. Efforts to reduce use in individuals with complex medical comorbidity could include concurrent efforts to identify and reduce social risks.

United States Veterans' Utilization of Spinal Cord Injuries and Disorders Annual Evaluation Services

ObjectiveTo evaluate Veterans’ engagement in spinal cord injury and disorder (SCI/D) specialty annual evaluations (AEs). DesignCross-sectional retrospective cohort study. SettingSCI/D System of Care, United States Department of Veterans Affairs (VA). ParticipantsVeterans with SCI/Ds (N=14,662). InterventionsNot applicable. Main Outcome MeasuresReceiving SCI/D AEs during the study period (fiscal years [FY] 2019 and 2020). ResultsA total of 14,662 Veterans with SCI/Ds were included in the sample; 32.8% (n=4811) received 2 AEs, 28.8% (n=4219) received 1 AE, and 38.4% (n=5632) received no AEs, with an average of 0.9 AEs per Veteran over the 2-year study timeframe (range, 0-2y). Black Veterans had an 8% higher number of AEs than White Veterans after adjusting for other variables (adjusted relative risk [RR], 1.08; 95% confidence interval [CI], 1.04-1.12). Veterans who lived ≥240 minutes away from a VA SCI/D System of Care Center had 45% fewer AEs than Veterans who lived within 30 minutes (adjusted RR, 0.55; 95% CI, 0.52-0.59). Veterans with more SCI/D specialty visits had 90% more AEs than those with fewer visits (adjusted RR, 1.90; 95% CI, 1.78-2.03), whereas Veterans with more outpatient visits in VA primary care had 28% fewer AEs (adjusted RR, 0.72; 95% CI, 0.69-0.76). Veterans with higher comorbidity scores had 9% more AEs than Veterans with lower scores (adjusted RR, 0.66; 95% CI, 0.61-0.70). ConclusionsMore than half (62%) of Veterans received ≥1 SCI/D AE during FY19-20. Veterans living closer to a VA SCI/D System of Care Center/Hub had more engagement in SCI/D AEs. Veterans with SCI/Ds who used VA primary care outside of the SCI/D System of Care had fewer AEs. There were no major racial, age-based, or sex disparities in SCI/D AE usage. Our findings suggest the need for targeted intervention efforts to promote AE use among Veterans.

Clinical characteristics and therapeutic outcomes after endoscopic endonasal surgery for craniopharyngioma in the elderly

OBJECTIVE Craniopharyngiomas (CPs) in adults are rare benign epithelial tumors, and few contemporary studies have explored outcomes after surgical treatment in elderly patients, especially with regard to endoscopic endonasal surgery (EES). METHODS A retrospective cohort study was conducted on patients aged ≥ 18 years with CP who were treated with EES from 2013 to 2022. The cohort was divided into nonelderly (18–64 years) and elderly (≥ 65 years) groups based on age. Various parameters, including patient and tumor characteristics, surgical outcomes, complications, and follow-up, were compared between the two age groups. RESULTS A total of 193 patients met the inclusion criteria, with 161 (83.4%) patients in the nonelderly group and 32 (16.6%) patients in the elderly group. Preoperatively, older patients were more likely to have memory impairment (4.3% vs 18.8%, p = 0.010), fatigue or decreased energy (9.3% vs 34.4%, p = 0.001), hypopituitarism (68.7% vs 90.6%, p = 0.012), or hydrocephalus (18% vs 40.6%, p = 0.005), and they were more likely asymptomatic (1.2% vs 9.4%, p = 0.033) and less likely to experience headache (57.8% vs 31.3%, p = 0.006). Patients in the elderly group had a longer symptom duration (median [IQR] 5 [10] months vs 9.5 [13] months, p = 0.001) and higher comorbidity scores (p &lt; 0.001). Postoperatively, gross-total resection was achieved in 145 (90.1%) and 28 (87.5%) patients in the nonelderly and elderly groups, respectively. Older patients were more likely to develop pneumonia (5% vs 21.9%, p = 0.004). There were no significant differences in the extent of resection (p = 0.541), pathological subtypes (88.2% vs 75.0% adamantinomatous, p = 0.089), operation time (mean ± SD 307.8 ± 68.3 minutes vs 323.5 ± 86.0 minutes, p = 0.257), estimated blood loss (median [IQR] 300 [200] ml vs 300 [238] ml, p = 0.594), length of stay (median [IQR] 15 [8] days vs 15 [22] days, p = 0.964), perioperative mortality (2.5% vs 3.1%, p &gt; 0.99), or postoperative severe hypothalamic dysfunction (37.9% vs 50.0%, p = 0.237) between the groups. Multivariate Cox regression analysis demonstrated that tumor calcification (HR 3.406, 95% CI 1.859–27.233, p = 0.038) and preoperative hydrocephalus (HR 3.688, 95% CI 1.310–10.386, p = 0.013) were independently associated with decreased survival. The median follow-up period in the elderly group was shorter (71 months vs 44 months, p = 0.001), and no recurrence was observed (7.1% vs 0%, p = 0.132). CONCLUSIONS This study demonstrates that EES is a viable treatment option for older CP patients. With appropriate perioperative management, EES does not significantly increase mortality and, in selected populations, is well tolerated by patients.

Association Between Pneumococcal Vaccination Uptake and Loneliness Among Regular Patients in Rural Community Hospitals: A Cross-Sectional Study.

Introduction Vaccination is essential for preventing infectious diseases such as pneumonia and seasonal viral infections. The COVID-19 pandemic has underscored the critical role of vaccination in public health. However, vaccination uptake can be influenced by biopsychosocial conditions. Immunocompromised individuals, for instance, face restrictions with live vaccines, and psychosocial factors like loneliness can negatively impact attitudes towards vaccination. This study aims to clarify the association between loneliness and pneumococcal vaccination rate among regular patients in a rural Japanese community. Method A cross-sectional study was conducted at Unnan City Hospital in Unnan City, a rural area in southeastern Shimane Prefecture, Japan. Participants included patients over 40 who regularly visited the general medicine department between September 1, 2023, and November 31, 2023. Data on vaccination rates for pneumococcal pneumonia and loneliness levels assessed using the Japanese version of the three-item University of California, Los Angeles (UCLA) Loneliness Scale were collected. Additional data on demographics, BMI, renal function, and comorbidities were extracted from electronic medical records. Statistical analyses were performed to identify factors associated with vaccination rates, including univariate and multivariate logistic regression. Results Out of 1,024 eligible patients, 647 participated in the study. Participants with higher loneliness had significantly lower vaccination rates for pneumococcal pneumonia (22.3% vs. 34.2%, p = 0.001). The multivariate logistic regression model showed that higher loneliness was significantly associated with lower vaccination likelihood (odds ratio (OR) = 0.54, 95% CI = 0.37-0.78, p = 0.0011). Age was positively associated with vaccination (OR = 1.08, 95% CI = 1.06-1.11, p < 0.001), whereas higher comorbidity scores (Charlson Comorbidity Index (CCI) ≥ 5) and frequent healthy eating practices were associated with lower vaccination rates. Conclusion This study demonstrates a significant association between higher loneliness levels and lower pneumococcal vaccination rates among patients in a rural Japanese community. Addressing psychosocial barriers such as loneliness could enhance vaccination uptake. Public health interventions focused on reducing loneliness and enhancing social support are essential to improving vaccination rates and preventing infectious diseases. Further research should explore the causal mechanisms and develop targeted strategies to mitigate the impact of loneliness on health behaviors.

Risk of Bowel Obstruction After Hysterectomy for Benign Indication According to Surgical Method in Denmark, 1984–2013

Study ObjectiveTo estimate the risk of bowel obstruction after hysterectomy for benign indications depending on the surgical method (abdominal, vaginal, or laparoscopic) and identify risk factors for adhesive bowel obstruction. DesignA national registry-based cohort. SettingDanish hospitals during the period 1984-2013. PatientsDanish women who underwent hysterectomy for benign indications (N=125,568). InterventionsAbdominal hysterectomies were compared with vaginal hysterectomies, laparoscopic hysterectomies, and minimally invasive (vaginal and laparoscopic) hysterectomies. Measurements and Main ResultsThe incidence of bowel obstruction according to the surgical method was compared using Cox proportional hazard regression. The covariates included were the time period, age, concomitant operations, prior abdominal surgery or disease, and socioeconomic factors. In a sub-analysis (n=35,712 women) of the period 2004-2013, detailed information from the Danish Hysterectomy Database enabled the inclusion of patient-related, surgery-related, and complication-related covariates.The overall crude incidence of bowel obstruction was 17.4/1000 hysterectomies (2196 incident cases). The 10-year cumulative incidence of bowel obstruction differed between the surgical routes (abdominal, 1.7%; laparoscopic, 1.4%; and vaginal, 0.9%). In multiple adjusted analyses, the risk of bowel obstruction was higher after abdominal hysterectomy than after vaginal (HR 1.64 [95% CI 1.39-1.93]) and minimally invasive (vaginal or laparoscopic) hysterectomy (HR 1.54 [1.33-1.79]). Additional pre-existing risk factors for bowel obstruction at the time of hysterectomy were increased age, low education, low income, smoking, high ASA comorbidity score, history of infertility, abdominal infection, and prior abdominal surgery (apart from cesarean section),penetrating lesions in abdominal organs, or operative adhesiolysis. Perioperative risk factors at the time of hysterectomy included concomitant removal of the ovaries, adhesiolysis, blood transfusion, readmission, and overall presence of perioperative complications. ConclusionAbdominal hysterectomy is associated with a 54% higher risk of bowel obstruction than minimally invasive (laparoscopic or vaginal) hysterectomy.

Presentation, management, and outcomes of older compared to younger adults with hospital-acquired bloodstream infections in the intensive care unit: a multicenter cohort study.

Older adults admitted to the intensive care unit (ICU) usually have fair baseline functional capacity, yet their age and frailty may compromise their management. We compared the characteristics and management of older (≥ 75years) versus younger adults hospitalized in ICU with hospital-acquired bloodstream infection (HA-BSI). Nested cohort study within the EUROBACT-2 database, a multinational prospective cohort study including adults (≥ 18years) hospitalized in the ICU during 2019-2021. We compared older versus younger adults in terms of infection characteristics (clinical signs and symptoms, source, and microbiological data), management (imaging, source control, antimicrobial therapy), and outcomes (28-day mortality and hospital discharge). Among 2111 individuals hospitalized in 219 ICUs with HA-BSI, 563 (27%) were ≥ 75years old. Compared to younger patients, these individuals had higher comorbidity score and lower functional capacity; presented more often with a pulmonary, urinary, or unknown HA-BSI source; and had lower heart rate, blood pressure and temperature at presentation. Pathogens and resistance rates were similar in both groups. Differences in management included mainly lower rates of effective source control achievement among aged individuals. Older adults also had significantly higher day-28 mortality (50% versus 34%, p < 0.001), and lower rates of discharge from hospital (12% versus 20%, p < 0.001) by this time. Older adults with HA-BSI hospitalized in ICU have different baseline characteristics and source of infection compared to younger patients. Management of older adults differs mainly by lower probability to achieve source control. This should be targeted to improve outcomes among older ICU patients.

Inhaled Corticosteroids and the Risk of Nontuberculous Mycobacterial Infection in Chronic Airway Disease: A Nationwide Population-Based Study.

Chronic airway diseases, such as asthma and chronic obstructive pulmonary disease (COPD), are increasingly being treated with inhaled corticosteroid (ICS). However, ICSs carry potential infection risks, particularly nontuberculous mycobacteria (NTM). This study investigated the association between ICS use and NTM infection risk using national insurance data, particularly for individuals with chronic airway diseases. We conducted a nationwide population-based study using data from the National Health Insurance Service-National Sample Cohort in South Korea from 2002 to 2019. The cohort included 57,553 patients diagnosed with COPD or asthma. To assess the risk of NTM infection, we used Cox proportional hazards models and propensity score-based inverse probability of treatment weighting (IPTW) to ensure a balanced analysis of covariates. Of the 57,553 patients (mean age 56.0 years, 43.2% male), 16.5% used ICS and 83.5% did not. We identified 63 NTM infection cases, including nine among ICS users and 54 among non-users. Before and after IPTW, ICS use was associated with a higher risk of NTM infection (adjusted hazard ratio [HR], 4.01; 95% confidence interval [CI], 1.48 to 15.58). Higher risks were significant for patients ≥65 years (adjusted HR, 6.40; 95% CI, 1.28 to 31.94), females (adjusted HR, 10.91; 95% CI, 2.24 to 53.20), never-smokers (adjusted HR, 6.31; 95% CI, 1.49 to 26.64), systemic steroid users (adjusted HR, 50.19; 95% CI, 8.07 to 312.19), and those with higher comorbidity scores (adjusted HR, 6.64; 95% CI, 1.19 to 37.03). ICS use in patients with chronic airway diseases might increase the risk of NTM infection, particularly in older females, never-smokers, and systemic steroid users.

Early blast clearance during sequential conditioning prior to allogeneic stem cell transplantation in patients with acute myeloid leukaemia.

For patients with relapsed or refractory AML, sequential conditioning prior to allogeneic stem cell transplantation (alloSCT) is an established and potentially curative treatment option. Early response to treatment during conditioning indicates chemotherapy-responsive disease and may have prognostic value. We retrospectively evaluated blast clearance on day 5 after melphalan, administered 11 days prior to alloSCT as part of a sequential conditioning in 176 patients with active AML. Overall survival (OS) was 52% (95% confidence interval [CI] 45%-60%), and relapse-free survival (RFS) was 47% (95% CI 40%-55%) at 3 years. Patients who achieved early blast clearance did not show a significant improvement in OS and RFS (OS, hazard ratio [HR] HR 0.75, p 0.19; RFS, HR 0.71, p 0.09, respectively), but had a significantly lower non-relapse mortality rate (HR 0.46, p 0.017). HLA-mismatched donor, older age, adverse genetic risk and higher comorbidity scores were associated with inferior survival outcomes. A high initial blast count was only associated with inferior prognosis in patients receiving chemotherapy-only compared to total body irradiation containing conditioning therapy. These results indicate that for patients transplanted with active AML, sensitivity to chemotherapy might be of less importance, compared to other disease- and transplant-related factors.

Impact of boarding time on in-hospital mortality in patients with cancer presenting to the emergency department.

11036 Background: Longer emergency department (ED) boarding times for admitted patients is associated with increased morbidity and mortality.1 While research over the years has shown an association between boarding time to mortality in a variety of patient demographics, no specific research has been explored in a cancer population. Patients with cancer visit the emergency department frequently and have a high rate of admission compared to other patients.2 This study evaluates boarding times and mortality rates in patients presenting to an oncologic ED. Methods: A retrospective analysis was performed on 183,524 ED visits located at a comprehensive cancer center between March 2016 and December 2022. Eligibility criteria included patients 19 years and older admitted to the hospital excluding direct intensive care unit admission. Boarding time was defined from the time the physician made an order to admit to the hospital to the time of ED departure. Demographics and clinical characteristics were examined using descriptive statistics. Categorical data was analyzed using chi-square test and continuous variables employed the nonparametric Mann–Whitney U test. Boarding time was grouped into quartiles. Univariate and multivariable logistic regression analyses examined clinical factors, including boarding time and in-hospital mortality. Results: The eligible number of visits supporting the study equaled 83,629. Overall median boarding time was 2.7 hours (interquartile range: 1.5–5.1 hours) and in-hospital mortality was 5.5% (n=4607). Longer boarding time was significantly associated with in-hospital mortality. Patients with boarding time ≥5.1 hours had 1.19 (95% confidence interval [95%CI]: 1.09-1.30; P&lt;0.001) odds of in-hospital mortality when compared to the reference group (boarding time &lt;1.5 hours) when controlling for other risk factors including comorbidities and emergency severity index (ESI) between 1 through 5. Similar results were observed for patients with boarding times of ≥1.5- &lt;2.7 hours and ≥2.7- &lt;5.1 hours with odds ratio of 1.12 (95%CI: 1.02-1.22; P=0.013) and 1.11 (95%CI: 1.02-1.21; P=0.020), respectively. Higher Charlson comorbidity index and levels 1 and 2 ESI were also associated with poor survival outcome (P&lt;0.001 for both). Conclusions: This study found an association between boarding time and in-hospital mortality in cancer patients presenting to the ED. Patients with longer boarding times were likely to experience mortality during their hospital admission. High comorbidity score and high-risk ESI were also identified as risk factors for poor survival outcome. These results emphasize the need for improved strategies to expedite the admission process and optimize care for cancer patients in the ED to reduce mortality rates. Further research and interventions targeting reduction in boarding times are warranted to improve outcomes for this vulnerable population.

In search of strategies to mitigate financial toxicity in survivorship care: A survey of 347 head and neck cancer survivors.

11060 Background: High costs of cancer treatment exert substantial financial toxicity for patients undergoing treatment. Growing literature suggests lasting financial toxicity (FT) after treatment completion. This calls for the development and integration of mitigating strategies in survivorship care to reduce FT; thereby improving the overall well-being of survivors. Methods: Cross-sectional survey data from 347 head and neck cancer survivors were analyzed to explore the relationship between FT and potential targets for intervention. We measured FT using the COmprehensive Score for financial Toxicity (COST, v1), and defined severe, moderate, and mild-to-no FT as having COST score ≤13, 14 to 25, and ≥26, respectively. The survey also collected information on demographics, quality of life, work and activity impairment, and cancer care coordination (CCC) communication and navigation subscales. We conducted logistic regression to examine which COST item is most predictive of severe FT, and mediation analysis using structural equation model to explore potential targets for interventions to reduce FT. Results: The average age of respondents was 65.5 yrs (SD=11.3). 334 completed COST; 6.3%, 22.2% reported severe and moderate FT, respectively. Study cohort included 20% diagnosed within 2 yrs, 45% 3-4 yrs and 35% ≥5 yrs; the proportion of patients reporting severe FT did not decrease by year since diagnosis (6%, 5.3%, and 7.7%, respectively, P=0.73). Of the 11 items in COST, financial stress was most predictive of severe FT. Survivors who rated financial stress as “very much” or “quite a bit” were 92.8 (P=0.02) times more likely to have severe FT. Higher financial stress was significantly associated with being &lt; age 65, having higher comorbidity score, lower CCC-navigation score, higher activity impairment; navigation and activity impairment are potentially actionable. None of these four variables were statistically significantly associated with severe FT. Mediation analysis showed financial stress has strong mediation effect on severe FT, and survivors with low CCC-navigation scores and high activity impairment were 3.2 times (95% CI: 1.3 – 7.8; P=0.01) and 2.5 (95% CI: 1.1 – 5.2; P=0.02) more likely, respectively, to report high financial stress. Survivors with high financial stress were significantly more likely to be interested or very interested in receiving resources covering financial issues compared to those without (63.4% vs 17.8%, P&lt;0.01). Conclusions: Survivorship care that incorporates interventions designed to improve coordination and navigation and decrease activity impairment can potentially mitigate FT for cancer survivors through reducing their financial stress. The Centers for Medicare and Medicaid Services began paying for navigation services in 2024, opening the opportunity to integrate these interventions into covered navigation services.

#3034 Therapeutic compliance: another challenge for patients on chronic hemodialysis

Abstract Background and Aims Therapeutic compliance corresponds to the degree of concordance between the patient's behavior and the recommendations of his doctor. Non-adherence to treatment predispose to high risk of mortality and increases health costs. The objective of our study was to assess the level of compliance in chronic hemodialysis patients and to identify the predictive factors of poor compliance. Method A cross-sectional study was conducted in the hemodialysis center at Taher Sfar Hospital in Mahdia. Medication adherence was assessed using a “compliance assessment test” quiz comprising six questions to which the patient must answer yes or no. Results Sixty-one patients were enrolled. The mean age was 50 ± 13 years (26 - 79 years) with a sex ratio M/F of 1.27. The patients have diabetes mellitus and hypertension in 35% and 68% of cases. They were dialyzed for a long duration (37 ± 15 months) that reaches a maximum of 280 months. The main initial nephropathies were diabetic nephropathy (35.5%) and chronic interstitial nephropathy (23.5%). Adherence was poor in 16.9 % of patients, average in 55.9% of patients while 27.1% were good adherents. Polymedication and missing of treatment were the leading causes of non-adherence. In univariate analyses, the socio-economic level affected significantly the compliance in elderly group as well as high comorbidity score (Charlson) (p&amp;lt;0.04) and diabetes status (p=0.04). No significant difference was found between elderly and young group in term of compliance to treatment. Conclusion Compliance is a dynamic behavior that is difficult to predict and requires constant monitoring. In our hemodialysis center it turned out to be good; we must insist on the therapeutic education of patients and minimize the list to the necessary.

Patterns of Care Following a Positive Fecal Blood Test for Colorectal Cancer: A Mixed Methods Study.

Multilevel barriers to colonoscopy after a positive fecal blood test for colorectal cancer (CRC) are well-documented. A less-explored barrier to appropriate follow-up is repeat fecal testing after a positive test. We investigated this phenomenon using mixed methods. This sequential mixed methods study included quantitative data from a large cohort of patients 50-89years from four healthcare systems with a positive fecal test 2010-2018 and qualitative data from interviews with physicians and patients. Logistic regression was used to evaluate whether repeat testing was associated with failure to complete subsequent colonoscopy and to identify factors associated with repeat testing. Interviews were coded and analyzed to explore reasons for repeat testing. A total of 316,443 patients had a positive fecal test. Within 1year, 76.3% received a colonoscopy without repeat fecal testing, 3% repeated testing and then received a colonoscopy, 4.4% repeated testing without colonoscopy, and 16.3% did nothing. Among repeat testers (7.4% of total cohort, N = 23,312), 59% did not receive a colonoscopy within 1year. In adjusted models, those with an initial positive test followed by a negative second test were significantly less likely to receive colonoscopy than those with two successive positive tests (OR 0.37, 95% CI 0.35-0.40). Older age (65-75 vs. 50-64years: OR 1.37, 95% CI 1.33-1.41) and higher comorbidity score (≥ 4 vs. 0: OR 1.75, 95% CI 1.67-1.83) were significantly associated with repeat testing compared to those who received colonoscopy without repeat tests. Qualitative interview data revealed reasons underlying repeat testing, including colonoscopy avoidance, bargaining, and disbelief of positive results. Among patients in this cohort, 7.4% repeated fecal testing after an initial positive test. Of those, over half did not go on to receive a colonoscopy within 1year. Efforts to improve CRC screening must address repeat fecal testing after a positive test as a barrier to completing colonoscopy.

Overall Survival and Prognostic Factors in Metastatic Triple-Negative Breast Cancer: A National Cancer Database Analysis.

Metastatic triple-negative breast cancer (TNBC) is aggressive with poor median overall survival (OS) ranging from 8 to 13 months. There exists considerable heterogeneity in survival at the individual patient level. To better understand the survival heterogeneity and improve risk stratification, our study aims to identify the factors influencing survival, utilizing a large patient sample from the National Cancer Database (NCDB). Women diagnosed with metastatic TNBC from 2010 to 2020 in the NCDB were included. Demographic, clinicopathological, and treatment data and overall survival (OS) outcomes were collected. Kaplan-Meier curves were used to estimate OS. The log-rank test was used to identify OS differences between groups for each variable in the univariate analysis. For the multivariate analysis, the Cox proportional hazard model with backward elimination was used to identify factors affecting OS. Adjusted hazard ratios and 95% confidence intervals are presented. In this sample, 2273 women had a median overall survival of 13.6 months. Factors associated with statistically significantly worse OS included older age, higher comorbidity scores, specific histologies, higher number of metastatic sites, presence of liver or other site metastases in those with only one metastatic site (excluding brain metastases), presence of cranial and extra-cranial metastases, lack of chemotherapy, lack of immunotherapy, lack of surgery to distant sites, lack of radiation to distant sites, and receipt of palliative treatment to alleviate symptoms. In the multivariate analysis, comorbidity score, histology, number of metastatic sites, immunotherapy, and chemotherapy had a statistically significant effect on OS. Through NCDB analysis, we have identified prognostic factors for metastatic TNBC. These findings will help individualize prognostication at diagnosis, optimize treatment strategies, and facilitate patient stratification in future clinical trials.

Abstract PO3-03-07: Patterns of Chemotherapy Utilization among Elderly Patients with Early-Stage Triple-Negative Breast Cancer

Abstract Background: Patterns of adjuvant and neoadjuvant chemotherapy use among patients with breast cancer have changed over time. Historically, adjuvant chemotherapy has been the standard treatment approach for patients with triple-negative breast cancer after surgical resection, aiming to eliminate any remaining cancer cells and reduce the risk of recurrence. Advancements in treatment strategies, research findings, and clinical guidelines have contributed to shifts in cancer care approaches, with an increase in the use of neoadjuvant chemotherapy. In this study, we explore chemotherapy utilization in a large cohort of elderly patients diagnosed with early-stage triple-negative breast cancer (TNBC). Methods: Data were obtained from the SEER- and Texas Cancer Registry (TCR)-linked Medicare databases. We identified female patients aged 66 years or older, diagnosed with early-stage (localized or regional disease) TNBC between 2010 and 2017 with claims until 2019. We identified the use of chemotherapy using HCPCS codes from outpatient and physician’s carrier claims. We used descriptive statistics and analyzed overall chemotherapy utilization and time trends of neoadjuvant versus adjuvant use via the Cochran-Armitage trend test, and evaluated factors associated with chemotherapy use via logistic regression models. This study adhered to the STROBE reporting guidelines for cohort studies. Results: Among 8,848 patients with localized or regional stage TNBC (median age 74) a total of 5,159 (58%) were treated with chemotherapy. The rate of chemotherapy utilization increased yearly from 52% in 2010 to 66% in 2017 (p&amp;lt; 0.001). After multivariable adjustment, any chemotherapy use was associated with recent year of diagnosis (OR=1.77; 95%CI 1.54-2.04), regional stage compared to localized (OR=3.78; 95%CI 3.34-4.27), and Northeastern region compared to South (OR=1.2; 95%CI 1.06-1.37). Conversely, decreased chemotherapy use was associated with age ≥76 (OR=0.24; 95%CI 0.2-0.27), being single (OR=0.76; 95%CI 0.67-0.86), and higher comorbidity score (OR=0.69; 95%CI 0.61-0.78). Among chemotherapy-treated patients, 3,808 (73.8%) received it in the adjuvant setting, 722 (14.0%) received it in the neoadjuvant setting, and 629 (12.2%) received chemotherapy both preoperatively and postoperatively. Among those who were treated with any chemotherapy, the percentage of patients treated with neoadjuvant chemotherapy increased from 15.2% in 2010 to 37.4% in 2017 (p&amp;lt; 0.001). Among patients treated with chemotherapy, neoadjuvant chemotherapy use was associated with recent year of diagnosis (OR=3.38; 95%CI 2.77-4.12), regional stage (OR=3.28; 95%CI 2.86-3.77), and inversely associated with older age (OR=0.77; 95%CI 0.64-0.94), non-White, non-Hispanic, non-Black race or ethnicity (OR=0.64 95%CI 0.45-0.94), non-metro area (OR=0.61; 95%CI 0.5-0.74), and Northeastern region (OR=0.66; 95%CI 0.56-0.78). Conclusion: Our study highlights the significant changes in patterns of adjuvant and neoadjuvant chemotherapy use among elderly patients with early-stage TNBC. We observed an increasing trend in chemotherapy utilization, with a notable shift from adjuvant to neoadjuvant treatment. This transition reflects the evolving landscape of cancer care and the adoption of more personalized approaches to treatment, with increased utilization of neoadjuvant chemotherapy offering opportunities for better risk assessments and tailored treatment strategies. Citation Format: Catalina Malinowski, Xiudong Lei, Sharon Giordano, Marianna Chavez. Patterns of Chemotherapy Utilization among Elderly Patients with Early-Stage Triple-Negative Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-07.

Abstract PO3-03-08: Use of adjuvant Capecitabine after neoadjuvant chemotherapy: A Cohort Study among Elderly Patients with Early-Stage Triple-Negative Breast Cancer

Abstract Background: The use of capecitabine in the adjuvant setting in patients with residual disease after neoadjuvant chemotherapy has been incorporated into practice based on the results of the CREATE-X trial. We evaluate utilization patterns of adjuvant capecitabine use, its association with outcomes, and subsequent hospitalizations and emergency room (ER) visits among elderly patients with early-stage triple-negative breast cancer (TNBC). Methods: We identified patients aged ≥66, diagnosed with early-stage TNBC between 2010 and 2017 in the SEER and Texas Cancer Registry (TCR)-linked Medicare databases. All patients were treated with neoadjuvant chemotherapy for localized or regional-stage disease. All patients had continuous enrollment in Medicare Parts A &amp; B without a Health Maintenance Organization enrollment 12 months before cancer diagnosis and 12 months after cancer diagnosis. Chemotherapy administration was identified using HCPCS codes from outpatient and physician’s carrier claims. We analyzed the patterns of capecitabine use, its association with survival outcomes, and the frequency of ER visits and hospitalizations during treatment (between the first capecitabine claim and 30 days after the last claim for capecitabine). Descriptive statistics were used. Primary analyses included logistic regression, Kaplan-Meier estimates, and Cox regression models with propensity score adjustments. This study adhered to the STROBE guidelines for cohort studies. Results: 1,239 patients with localized or regional TNBC treated with neoadjuvant chemotherapy were included (median 72 years). Of them, 96 (7.7%) were prescribed adjuvant capecitabine. Treatment with capecitabine was associated with recent year of diagnosis, regional disease, and residing in non-metropolitan areas. Specifically, the use of capecitabine increased from 1% in 2010 to 10% in 2016 and 21% in 2017. The median duration of capecitabine treatment was 4 cycles. In multivariable logistic regression analyses, older age was associated with decreased odds of receiving ≥4 cycles of capecitabine (OR=0.25; 95% CI: 0.11–0.60; p =0.002). Among capecitabine users, 3-year OS was 46% and 78% for patients who received 1-3 and ≥4cycles of capecitabine, respectively (p&amp;lt; 0.001). The 3-year estimate of BCSS was 43% and 85% respectively (p&amp;lt; 0.001). After multivariable adjustment for comorbidity score, stage, and propensity score, receiving ≥4 cycles of capecitabine was associated with decreased risk of death (HR=0.29; 95%CI 0.13–0.63, p=0.002) and breast cancer-specific death (HR=0.15; 95%CI: 0.05–0.51, p=0.002) compared to receiving 1-3 cycles. Twenty-seven (28%) patients had ER/hospitalization during capecitabine treatment; median time from initial capecitabine claim to ER/hospitalization was 24 days (IQ 13-39). The median number of capecitabine cycles was 3 (IQR 2-5) and 5 (IQR 3-8) for those with and without ER/hospitalization (p=0.02). The most common diagnosis codes associated with ER/hospitalization included pleural effusion, GI symptoms, pneumonia, and acute kidney failure. A higher comorbidity score at diagnosis was associated with an increased risk of ER/hospitalization (HR=2.76; 95%CI 1.05-7.28, p=0.04). Conclusion: We demonstrate an increasing trend in capecitabine utilization among elderly patients with early-stage TNBC. Although the limited sample size hindered a conclusive analysis, more cycles of capecitabine were associated with improved survival outcomes. Notably, a significant proportion of patients undergoing capecitabine treatment experienced ER/hospitalizations. These findings contribute valuable information on the risks and benefits of capecitabine treatment, aiding evidence-based decision-making to prevent serious complications. Citation Format: Marija Sullivan, Xiudong Lei, Catalina Malinowski, Sharon Giordano, Marianna Chavez. Use of adjuvant Capecitabine after neoadjuvant chemotherapy: A Cohort Study among Elderly Patients with Early-Stage Triple-Negative Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-03-08.

Treatment selection and real-world analysis of immunotherapy with or without chemotherapy in PD-L1-high metastatic non-small cell lung cancer.

Lung cancer is the leading cause of cancer death in Australia. Immunotherapy has improved outcomes in patients with metastatic non-small cell lung cancer (NSCLC). Pembrolizumab is approved in first-line treatment as single-agent immunotherapy (SAI) or combination chemoimmunotherapy (CIT). In metastatic NSCLC programmed death-ligand 1 (PD-L1) ≥50% either regimen may be used. We aim to identify patient and tumour characteristics that influence treatment selection. This is a retrospective observational study. Pharmacy records identified patients with metastatic/recurrent NSCLC receiving pembrolizumab at two metropolitan centres in Victoria, Australia, since 2018. Demographics, tumour characteristics, Charlson Comorbidity Index (CCI) and treatment data were collected. Descriptive and multivariate analyses were performed. Sixty-one patients had metastatic NSCLC PD-L1 ≥50% and received pembrolizumab with median age of 65.6 years, Eastern Cooperative Oncology Group 0-1 in 82%. CIT was administered to 23% (14) with no difference in rate of delivery between centres (P = 0.808). CCI mean score differed (3.38 SAI vs 2.36 CIT, P = 0.042). Patients with high CCI score (≥2) were less likely to receive CIT (OR = 0.15, P = 0.003, 95% confidence interval (CI) 0.04-0.57). Primary tumours over 5 cm were more likely to receive CIT (OR = 3.74, P = 0.043, 95% CI = 1.04-13.42). Site-specific metastases of liver, brain and pericardial effusion were not associated with CIT. Patients with higher comorbidity score were less likely to receive CIT, suggesting chemotherapy avoidance in comorbid patients. Larger tumours are associated with CIT use, indicating that oncologists may use tumour size as a surrogate of disease burden. Limitations include small sample size and data cut-off. Future prospective studies could incorporate comorbid status and a validated disease burden score to stratify patients.