Higher Proportion Of Black Patients Research Articles

Abstract LB139: Disparities in oral precancerous lesion surveillance in the United States upper Midwest

Abstract Objective: To determine whether geographic representation and race of patients in a regional oral cancer surveillance program (University of Minnesota Cancer Active Surveillance Population (UMN CASP)) mirror characteristics in the corresponding National Cancer Institute (NCI) designated comprehensive cancer center catchment. Introduction: Oral cancer poses a significant public health concern that may be mitigated through lesion surveillance. Representation of patients for clinical trials throughout an NCI cancer center catchment area is a crucial goal to promote improved health outcomes. This study investigates the demographic landscape of patients with preneoplastic oral lesions seen at the CASP. Methods: Through the UMN Clinical and Translational Sciences Institute, we queried 30 International Classification of Disease (ICD) 9 and 10 codes corresponding to 120 unique mucosal oral precancerous lesion descriptors of CASP patients. Automated extraction of electronic medical record (EMR) data for 4,496 patients treated by the senior author between 2011 and 2023 identified 1,375 patients with preneoplastic lesions. The proportion of patients residing in three-digit zip code regions of Minnesota were compared to 2021 American Community Survey state population data. Additionally, race data were compared between CASP patients and the UMN Masonic Cancer Center (MCC) patient catchment data. Results: CASP patients were over-represented relative to state population distributions within the Minneapolis-St. Paul metropolitan area and surrounding suburbs (region 554 p<0.0001 and region 551 p<0.0001). Under-representation of CASP patients was observed in all western and southern border regions (regions 559 p<0.0001, 560 p<0.0001, 561 p<0.0001, 562 p=0.0037, 565 p<0.0001, and 567 p=0.0006) as well as portions of central (563 p<0.0001), northern (566 p=0.0015), and north-eastern (558 p<0.0001) Minnesota. Proportional representation was observed in several regions of central (553 and 564), eastern (550), and north-eastern (557 and 556) Minnesota. Comparisons of CASP race data revealed a higher proportion of black patients (CASP 8.59% [95% CI 7.17-10.27%] vs. MCC 7.16% [95% CI 7.14-7.17%]) and a lower proportion of Asian/Pacific Islander patients (CASP 3.74% [95% CI 2.82-4.94%] vs. MCC 5.32% [95% CI 5.30-5.34%]) relative to MCC catchment patients. White, American Indian/Alaskan Native, and mixed-race groups were proportionally represented in both data sets. Conclusions: These data show that system wide EMR searches can be implemented to identify patients in an NCI cancer center catchment area with precancerous or other at-risk conditions for cancer. Importantly, Native patients were proportionally represented in the screening program while several rural locations were under-represented. This information can instruct the expenditure of additional resources for under-represented groups and permit streamlined enrollment of patients for cancer prevention clinical trials. Citation Format: Alexander J. Dwyer, Lindsey Mortensen, Beverly R. Wuertz, Frank G. Ondrey. Disparities in oral precancerous lesion surveillance in the United States upper Midwest [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB139.

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program

Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Hospital Value-Based Purchasing program HEA. Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

Racial and Ethnic Minority Patients Have Increased Complication Risks When Undergoing Surgery While Not Meeting Clinical Guidelines.

Clinical guidelines for performing total joint arthroplasty (TJA) have not been uniformly adopted in practice because research has suggested that they may foster inequities in surgical access, potentially disadvantaging minority sociodemographic groups. The aim of this study was to assess whether undergoing TJA without meeting clinical guidelines affects complication risk and leads to disparities in postoperative outcomes. This retrospective cohort study evaluated the records of 11,611 adult patients who underwent primary TJA from January 1, 2010, to December 31, 2020, at an academic hospital network. Based on self-reported race and ethnicity, 89.5% of patients were White, 3.5% were Black, 2.9% were Hispanic, 1.3% were Asian, and 2.8% were classified as other. Patients met institutional guidelines for undergoing TJA if they had a hemoglobin A1c of <8.0% and a body mass index of <40 kg/m 2 and were not currently smoking. A logistic regression model was utilized to identify factors associated with complications, and a mixed-effects model was utilized to identify factors associated with not meeting guidelines for undergoing TJA. During the study period, 11% (1,274) of the 11,611 adults who underwent primary TJA did not meet clinical guidelines. Compared with the group who met guidelines, the group who did not had higher proportions of Black patients (3.2% versus 6.0%; p < 0.001) and Hispanic patients (2.7% versus 4.6%; p < 0.001). An increased risk of not meeting guidelines at the time of surgery was demonstrated among Black patients (odds ratio [OR], 1.60 [95% confidence interval (CI), 1.22 to 2.10]; p = 0.001) and patients insured by Medicaid (OR, 1.75 [95% CI, 1.26 to 2.44]; p = 0.001) or Medicare (OR, 1.22 [95% CI, 1.06 to 1.41]; p = 0.007). Patients who did not meet guidelines had a higher risk of reoperation than those who met guidelines (7.7% [98] versus 5.9% [615]; p = 0.017), including a higher risk of infection-related reoperation (3.1% [40] versus 1.4% [147]; p < 0.001). We found that patients who underwent TJA despite not meeting institutional preoperative criteria had a higher risk of postoperative complications. These patients were more likely to be from racial and ethnic minority groups, to have a lower socioeconomic status, and to have Medicare or Medicaid insurance. These findings underscore the need for surgery-related shared decision-making that is informed by evidence-based guidelines in order to reduce complication burden. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Racial and Ethnic Composition of Populations Served by Freestanding Children's Hospitals and Disparities in Outcomes of Pediatric Lupus.

Health disparities may be driven by hospital-level factors. We assessed whether racial and ethnic composition of populations hospitals serve explain or modify disparities in hospital outcomes of children with systemic lupus erythematosus (SLE). In this retrospective cohort study of patients 5 to 26 years old with SLE at 47 children's hospitals in the Pediatric Health Information System (2006-2021), race and ethnicity were assessed at the patient level and hospital level (proportion of total admissions composed of Black or Hispanic patients, respectively). Outcomes included intensive care unit (ICU) admission or adverse renal outcome (end-stage renal disease, dialysis, or transplant) during follow-up. We estimated racial and ethnic disparities, adjusted or stratified by hospital racial or ethnic composition. Of 8,125 patients with SLE, 2,293 (28%) required ICU admission, and 698 (9%) had an adverse renal outcome. Black and non-Hispanic White disparities in ICU admission were observed only at hospitals serving higher proportions of Black patients (odds ratio [OR] 1.29, 95% confidence interval [95% CI] 1.04-1.59 vs OR 1.07, 95% CI 0.83-1.38). Larger Black and non-Hispanic White disparities in adverse renal outcomes were observed at hospitals with higher Black racial composition (OR 2.0, 95% CI 1.4-2.8 vs OR 1.7, 95% CI 1.1-2.4). Conversely, Hispanic versus non-Hispanic disparities in renal outcomes persisted after adjustment for hospital-reported Hispanic ethnic composition but were observed only at hospitals with lower proportions of Hispanic patients. Worse Black and White disparities in SLE outcomes are observed at children's hospitals serving more Black children, whereas distinct patterns are observed for Hispanic and non-Hispanic disparities. Reporting of hospital characteristics related to populations served is needed to identify modifiable drivers of hospital-level variation.

Inpatient outcomes for lung cancer patients presenting with superior vena cava thrombosis

Background A specific cause of superior vena cava (SVC) syndrome, SVC thrombosis, is a rare but known complication in cancer patients. Early identification and management of SVC thrombosis in lung cancer patients may lead to improved patient outcomes and a reduction in healthcare costs. Methods We studied the racial and socioeconomic differences, length of stay, total hospital charges, and all-cause mortality outcomes in patients with lung cancer with and without SVC thrombosis using data from the National Inpatient Sample. Statistical analysis was performed on STATA. Results A total of 480,750 patients were hospitalized for lung cancer; 720 (0.15%) of these patients had SVC thrombosis. The lung cancer with SVC thrombosis cohort had a statistically higher proportion of Black patients. Patients with lung cancer presenting with SVC thrombosis had an increased hospital length of stay (10 vs 6 days, P < 0.001) and cost ($117,320 vs $80,806, P < 0.005) compared to those without SVC thrombosis. All-cause mortality in patients with lung cancer was 7.7% and the presence of SVC thrombosis significantly increased the odds of inpatient mortality (18.0%). Nonwhite races were associated with higher odds of mortality in lung cancer admissions. Conclusion Race, insurance type, and comorbidities impacted the likelihood of developing SVC thrombosis in patients with lung cancer. SVC thrombosis is a poor prognostic factor for patients with lung cancer. Further studies to evaluate these disparities are warranted.

Examining rehabilitation access disparities: an integrated analysis of electronic health record data and population characteristics through bivariate choropleth mapping.

Despite efforts to view electronic health records (EHR) data through an equity lens, crucial contextual information regarding patients' social environments remains limited. Integrating EHR data and Geographic Information Systems (GIS) technology can give deeper insights into the relationships between patients' social environments, health outcomes, and geographic factors. This study aims to identify regions with the fastest and slowest access to outpatient physical therapy services using bivariate choropleth maps to provide contextual insights that may contribute to health disparity in access. This was a retrospective cohort study of patients' access timelines for the first visit to outpatient physical therapy services (n = 10,363). The three timelines evaluated were (1) referral-to-scheduled appointment time, (2) scheduled appointment to first visit time, and (3) referral to first visit time. Hot and coldspot analyses (CI 95%) determined the fastest and slowest access times with patient-level characteristics and bivariate choropleth maps that were developed to visualize associations between access patterns and disadvantaged areas using Area Deprivation Index scores. Data were collected between January 1, 2016 and January 1, 2020. EHR data were geocoded via GIS technology to calculate geospatial statistics (Gi∗ statistic from ArcGIS Pro) in an urban area. Statistically significant differences were found for all three access timelines between coldspot (i.e., fast access group) and hotspot (i.e., slow access group) comparisons (p < .05). The hotspot regions had higher deprivation scores; higher proportions of residents who were older, privately insured, female, lived further from clinics; and a higher proportion of Black patients with orthopaedic diagnoses compared to the coldspot regions. Our study identified and described local areas with higher densities of patients that experienced longer access times to outpatient physical therapy services. Integration of EHR and GIS data is a more robust method to identify health disparities in access to care. With this approach, we can better understand the intricate interplay between social, economic, and environmental factors contributing to health disparities in access to care.

Clinical Characteristics and Histopathology in Adults With Focal Segmental Glomerulosclerosis

Rationale & ObjectiveFew data are available regarding histological features at the time of focal segmental glomerulosclerosis (FSGS) diagnosis among diverse real-world populations. This study describes clinical and histological characteristics, and correlates of histological disease severity, in adults with FSGS who underwent a clinical kidney biopsy. Study DesignReal-world cohort study with data derived from health records. Setting& Participants: Adults with FSGS by kidney biopsies from Arkana Laboratories during 1 January 2016 to 31 May 2020. ExposuresRace, CKD stage, nephrotic proteinuria, age, sex, and hypertension. OutcomesSevere histological disease, defined as global glomerulosclerosis in >50% of glomeruli and >25% interstitial fibrosis and tubular atrophy (IFTA). Analytical ApproachDemographic, clinical, and histological characteristics were compared between race groups. Correlates of severe disease were analyzed by multiple logistic regression. ResultsAmong 2,011 patients with FSGS, 40.6% were White and 23.6% Black. White patients were older (52.8 versus 45.5 years, P < 0.001) with higher estimated glomerular filtration rate (eGFR) than Black patients (53.5 versus 43.1 ml/min/1.73 m2, P < 0.001). A higher proportion of Black patients had global glomerulosclerosis ≥50% (32.1% versus 14.6%, P < 0.001) or IFTA >50% (34.6% versus 14.7%, P < 0.001). Severe histological disease was more likely in Black patients (odds ratio 2.46; 95% confidence interval 1.59, 3.79; P < 0.001). A higher proportion of patients with nephrotic than non-nephrotic proteinuria exhibited diffuse foot process effacement. LimitationsUnequal representation across United States (US) regions, missing demographic and clinical data, and lack of data on primary versus secondary FSGS, treatments, or outcomes. ConclusionsBlack patients were more frequently diagnosed at younger age with lower eGFR and more severe histological disease compared with White patients. Timelier identification of FSGS could increase the opportunity for therapeutic intervention, especially for high-risk patients, to mitigate disease progression and complications.

Abstract 17110: Racial Differences in the Performance of the Transthyretin Amyloid Cardiomyopathy Risk Score

Introduction: Early diagnosis of transthyretin cardiac amyloidosis is crucial, particularly with the availability of disease-modifying therapies. Tc-99m pyrophosphate scintigraphy (PYP scan) is widely used for diagnosis. A previously validated score derived from a nearly all Caucasian cohort has shown promise in predicting PYP scan positivity in patients with HFpEF; but further assessment in a racially diverse cohort is needed. Aims: To evaluate the performance of the ATTR-CM score in predicting PYP scan positivity overall, and across racial groups. Methods: We included all patients referred for PYP with SPECT/CT at the Cleveland Clinic between 1/2012 and 1/2020 who had undergone echocardiography within one year of PYP scan. The ATTR-CM score was calculated, consisting of the following variables: Age (if 60-69, +2; if 70-79, +3; if ≥80, +4), Sex (if Male, +2), Hypertension diagnosis (if present, -1), Ejection Fraction (if &lt;60%, +1), Posterior Wall Thickness (if ≥12 mm, +1) and Relative Wall Thickness (if &gt;0.57, +2). A score ≥6 was considered high-risk. Results: The cohort consisted of 540 patients (64% white; 33% black). The overall prevalence of ATTR-CM was 28.5%, with no significant difference between racial groups (27.5% vs 29.9%; p = 0.52). A higher proportion of black patients had an EF &lt; 40% (23.3% vs 35.4%, p = 0.01). The score showed good discrimination with an AUC of 0.816, with similar performance between racial groups (0.824 vs. 0.824; p &lt; 0.001; Figure 2). For a score ≥6, sensitivity was 77.3% (82.7% white; 67.3% black), specificity was 70.2% (64.3% white; 80.6% black), PPV was 50.9%, and NPV was 88.6%. Similar findings were observed when considering only patients with EF ≥ 40%. Conclusions: The overall performance of the ATTR-CM risk score by AUC was consistently good across races. However, it was less sensitive for detecting disease in black patients. Efforts to scale ATTR-CM diagnosis tools should be mindful of racial differences in risk prediction models.

Characteristics and Predictors of Apparent Treatment Resistant Hypertension in Real-World Populations Using Electronic Health Record-Based Data.

Apparent treatment-resistant hypertension (aTRH) is defined as uncontrolled blood pressure (BP) despite using ≥3 antihypertensive classes or controlled BP while using ≥4 antihypertensive classes. Patients with aTRH have a higher risk for adverse cardiovascular outcomes compared to patients with controlled hypertension (HTN). Although there have been prior reports on the prevalence, characteristics, and predictors of aTRH, these have been broadly derived from smaller datasets, randomized controlled trials, or closed healthcare systems. We extracted patients with HTN defined by ICD 9 and 10 codes during 1/1/2015-12/31/2018, from two large electronic health record databases: the OneFlorida Data Trust (n=223,384) and Research Action for Health Network (REACHnet) (n=175,229). We applied our previously validated aTRH and stable controlled HTN computable phenotype algorithms and performed univariate and multivariate analyses to identify the prevalence, characteristics, and predictors of aTRH in these populations. The prevalence of aTRH among patients with HTN in OneFlorida (16.7%) and REACHnet (11.3%) was similar to prior reports. Both populations had a significantly higher proportion of Black patients with aTRH compared to those with stable controlled HTN. aTRH in both populations shared similar significant predictors, including Black race, diabetes, heart failure, chronic kidney disease, cardiomegaly, and higher body mass index. In both populations, aTRH was significantly associated with similar comorbidities, when compared with stable controlled HTN. In two large, diverse real-world populations, we observed similar comorbidities and predictors of aTRH as prior studies. In the future, these results may be used to improve healthcare professionals' understanding of aTRH predictors and associated comorbidities.

Provider care segregation and hospital-region racial disparities for carotid interventions in the USA

BackgroundReasons for racial disparities in the utilization and outcomes of carotid interventions (carotid endarterectomy (CEA) and carotid artery stenting (CAS)) are not well understood, especially segregation of care associated with...

Racial and ethnic differences in tumor characteristics among endometrial cancer patients in an equal-access healthcare population

PurposeThere are racial and ethnic differences in endometrial cancer incidence and mortality rates; compared with Non-Hispanic White women, Black women have a similar incidence rate for endometrial cancer, but their mortality is higher. Pacific Islander women may also have worse outcomes compared to their White counterparts. We assessed tumor characteristics and adjuvant therapy by racial and ethnic group among endometrial cancer patients treated within the Military Health System, an equal access healthcare organization.MethodsWe retrospectively identified women diagnosed with invasive endometrial cancer among US Department of Defense beneficiaries reported in the Automated Central Tumor Registry database (year of diagnosis: 2001–2018). We compared tumor characteristics and receipt of adjuvant therapy across racial and ethnic groups using Chi-square or Fisher tests. Hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of all cause mortality were calculated using Cox proportional hazards regression models adjusting for age at diagnosis, adjuvant therapy, histology and stage.ResultsThe study included 2574 endometrial cancer patients [1729 Non-Hispanic White, 318 Asian, 286 Black, 140 Pacific Islander and 101 Hispanic women]. Among all cases, a higher proportion of Black patients had non-endometrioid histology (46.5% versus ≤ 29.3% in other groups, P < 0.01) and grade 3–4 tumors (40.1% versus ≤ 29.3% in other groups, P < 0.01). In multivariable Cox models, compared with Non-Hispanic White cases, Black endometrial cancer patients had a higher mortality risk (HR 1.43, 95% CI, 1.13–1.83). There was no difference in mortality risk for other racial and ethnic groups.ConclusionBlack patients with endometrial cancer presented with more aggressive tumor features and they had worse overall survival compared with patients in other racial and ethnic groups. Further study is needed to better direct preventive and therapeutic efforts in order to correct endometrial cancer disparities in the future.

Assessing inpatient outcomes for patients with small cell lung cancer presenting with superior vena cava thrombosis.

8589 Background: Superior Vena Cava Syndrome (SVCS) is a condition characterized by obstruction of the SVC that can commonly be caused by thrombus formation in the SVC. Small cell lung cancer (SCLC) frequently results in obstruction of the SVC. When severe enough, SVCS can present as a life-threatening oncological emergency. In this study we aim to explore baseline characteristics of SVC thrombosis (SVCT) in patients with SCLC, the prevalence of US hospitalizations, and disparities with regards to race and socioeconomic status. Methods: National Inpatient Sample was utilized to obtain pertinent data. Total hospitalizations with coexistent comorbidities of SCLC were extracted from the 2016 to 2019 database. Adult patients with a secondary diagnosis of SVC thrombosis were determined by using ICD-10 codes. We studied the racial and socioeconomic differences as well as length of stay (LOS), total hospital charges (THC), and all-cause mortality outcomes in cancer patients with and without SVC thrombosis. Statistical analysis was performed on STATA, with logistic regression analyses and chi-square tests. Results: A total of 480,750 patients were hospitalized for SCLC. 720 of these patients had SVC thrombosis (0.15% of SCLC patients). The mean age of those with thrombi was significantly lower compared to those without thrombi (64 vs. 69, p &lt; 0.001). The SCLC with SVCT cohort had statistically higher proportion of black patients than the other cohort. Charlson index was significantly higher in SCLC with SVCT cohort (5.8 vs. 5, p &lt; 0.001). Average income between the two cohort groups were similar. Medicaid and private insurance utilization were more common in SCLC with SVCT admissions compared to without SVCT. Patients presenting with SVC thrombosis had an increased hospital LOS (10 vs. 6 days, p &lt; 0.001) and cost compared to other cohorts ($117,320 vs. $80,806, p &lt; 0.005). All-cause mortality in patients with SCLC was 7.7% and the presence of SVC thrombosis significantly increased the odds of inpatient mortality (18.0%). Non-White races were associated with higher odds of mortality in SCLC admissions. In addition, patients with SVC thrombus also had greater odds of having a concomitant pulmonary embolism during hospitalization. Conclusions: In this study we found that race, insurance type, and comorbidities impacted the likelihood of developing thrombosis in the superior vena cava in patients with SCLC. Though the incidence is rare, SVC thrombosis indicates a poor prognostic factor for patients with SCLC. Further studies to evaluate these disparities in race and socioeconomic factors are warranted. The development of thrombosis and subsequent SVC syndrome is a potentially life-threatening condition; addressing potential reversible risk factors could improve mortality in a large subgroup of hospitalizations related to SCLC.

Outcomes among hospitalized patients with dementia and behavioral disturbances when physical restraints are introduced.

Physical restraint use among patients hospitalized with dementia and behavioral disturbances has not been studied nationally in the United States. National Inpatient Sample database years 2016 through 2020 were used to compare physically restrained and unrestrained patients with dementia and behavioral disturbances. Multivariable regression analyses were used to assess patient outcomes. There were 991,605 patients coded for dementia with behavioral disturbances. Among these, physical restraints were used with 64,390 (6.5%) and not with 927,215 (93.5%). Patients in the restrained group were younger (mean age standard error: 78.7 0.25 vs. ; p < 0.01) and more often male (59.0% vs. 45.8%; p < 0.01) compared to the unrestrained group. A higher proportion of Black patients were in the restrained group (15.2% vs. 11.8%; p < 0.01). Larger hospitals also made up a more significant proportion of restrained versus unrestrained patients (53.3% vs. 45.1%; p < 0.01). Those with physical restraints had longer lengths of stays (adjusted mean difference [aMD] = 2.6 days CI [2.2-3.0]; p < 0.01) and higher total hospital charges (aMD = $13,150 CI [10,827-15,472]; p < 0.01). There were similar adjusted odds for in-hospital mortality (adjusted odds ratio [aOR] = 1.0 [CI 0.95-1.1]; p = 0.28) and lower odds of being discharged to home after hospitalization (aOR = 0.74 [0.70-0.79]; <0.01) for patients with physical restraints compared to those without. Among patients hospitalized with dementia and behavioral disturbances, those with physical restraints had greater hospital resource utilization outcomes. Attempts to limit physical restraint use whenever possible may improve outcomes in this vulnerable population.

Focus on Equitable Delivery of Neurologic Care: from ED to Clinic (P6-9.011)

<h3>Objective:</h3> Our goal was to examine the impact of various demographic and socioeconomic variables on attendance at neurology referral appointments from an ED visit in a large tertiary care center. We hypothesized that healthcare inequities would impact neurologic care after an ED visit. <h3>Background:</h3> Neurologic disorders are a growing burden on public health and are significant contributors to mortality and disability worldwide. Unequal access to and utilization of neurologic care has been shown for multiple neurologic diseases. Neurology referrals can be unreliable with high degree of loss-to-follow-up, leading to worse neurologic health outcomes. Neurologic disorders have also been shown to disproportionately affect. <h3>Design/Methods:</h3> We examined a retrospective cohort of adult patients evaluated in the ED over a 24-month period (January 2019–December 2020). Patient demographics were collected from all (991) patients who were subsequently referred to the outpatient neurology clinics from the ED. Chart records were reviewed to examine the primary outcome of outpatient Neurology follow-up. Univariate and multivariate regression models were used to assess the impact of age, sex, race-ethnicity, insurance status, and social vulnerability index (SVI) on outpatient follow-up. <h3>Results:</h3> Our cohort had a significantly higher proportion of Black patients, whereas a similar proportion of female patients when compared to city census data. Different insurance types were well represented in our cohort. Most common referral diagnoses included: seizures, headache, neuropathy, and stroke. There was a high proportion of patients with poor outcomes (lost to follow-up or never followed-up). In univariate and multivariate logistic regression models, <b>Black</b> and <b>uninsured</b> patients were less likely to follow-up. <h3>Conclusions:</h3> Disparities in neurological care exist. Identifying groups with higher risk of non-adherence can help clinicians identify at-risk individuals/groups. Our goal is to work with the healthcare systems to implement structural changes, including more efficient and equitable resource allocation, to assure equal access to neurological care. <b>Disclosure:</b> Ms. Giang has nothing to disclose. Dr. Perez Martinez has nothing to disclose.

Abstract PD1-09: Associations between the 21-gene Oncotype DX Recurrence Score (RS), Ki67, and Race in Early Breast Cancer (EBC) Using the National Cancer Database (NCDB)

Abstract Background: The 21-gene RS (Oncotype DX) is a validated genomic signature that provides prognostic information for distant recurrence risk and is predictive of adjuvant chemotherapy benefit in patients with hormone receptor (HR)-positive, HER2-negative early breast cancer (EBC). Ki67 protein expression is a proliferation marker that is determined by immunohistochemistry (IHC) and is a prognostic biomarker in HR-positive EBC. Black race is associated with poorer prognosis in patients with EBC. RS, Ki67 and race have not been evaluated together and the impact of race on the association between Ki67 and RS is unknown. The goal of this study was to evaluate the association between the 21-gene RS and Ki67 based on race in patients with HR-positive EBC using the NCDB. Methods: Women with HR-positive EBC with 0-3 involved lymph nodes, diagnosed between 2018 and 2019, who had available information on RS, IHC-measured Ki67, and race in the NCDB dataset were identified. Patients were stratified by RS of low (0-10), intermediate (11-25) and high (26-100) and categorized into Ki67 low (/=30%) based on the International Ki67 Working Group prognostic classification (PMID: 33369635). Wilcoxon rank test was used to test for continuous variables and chi-square test was used for categorical variables. Agreement between Ki67 and RS was estimated using Fleiss Kappa statistic and corresponding p-value was reported. Results: 43,898 eligible women were included. 17.43% were lymph node positive. 78% were Non-Hispanic White, 7.98% Non-Hispanic Black, 6.42% Hispanic, and 4.26% Asian American/Pacific Islander (AAPI). The table below describes the distribution of Ki67 and RS in the overall population and racial subgroups. The distribution of Ki67 scores was significantly different between races with a higher proportion of Black patients having high Ki67 scores, p&amp;lt; 0.0001. RS distribution varied as well with a greater percentage of high RS in the Black group, p&amp;lt; 0.0001. There was only slight agreement (Kappa 0.01-0.20) between Ki67 and RS in the overall population (Kappa=0.1929, p&amp;lt; 0.0001), low Ki67 subgroup (Kappa=0.069, p&amp;lt; 0.0001) and intermediate group (Kappa=0.066, p&amp;lt; 0.0001). However, there was fair agreement (Kappa 0.21-0.40) between high Ki67 and RS (Kappa=0.351, p&amp;lt; 0.0001). Based on race as a covariate, in the overall population, agreement between Ki67 and RS remained slight for White, Hispanic, and AAPI groups but was fair for Black patients (Kappa=0.2345, p&amp;lt; 0.0001). In the low Ki67 and intermediate Ki67 groups, agreement remained slight across all races, p&amp;lt; 0.0001. While there was fair agreement between high Ki67 and RS in all racial subgroups, agreement between high Ki67 and RS was highest in the Black subgroup (Kappa=0.392, p&amp;lt; 0.0001) followed by the AAPI (Kappa=0.363, p&amp;lt; 0.0001), White (Kappa=0.342, p&amp;lt; 0.0001) and Hispanic (Kappa=0.339, p&amp;lt; 0.0001) groups. Conclusions: In this large patient population from the NCDB, there was only slight agreement between Ki67 and RS in the overall, low Ki67, and intermediate Ki67 groups but fair agreement in the high Ki67 group. Agreement between high Ki67 and RS was greatest in the Black subgroup compared to other races. This may be attributed to the higher proportion of patients with high Ki67 and RS in the Black subgroup. Future analyses on overall survival will determine the impact of race on the prognostic value of Ki67 and RS. Table 1. Distribution of Ki67 and RS by Racial/Ethnic Subgroup AAPI: Asian American/Pacific Islander AIAN: American Indian and Alaska Native Citation Format: Rima Patel, Deukwoo Kwon, Grace Van Hyfte, Joseph Sparano, Amy Tiersten. Associations between the 21-gene Oncotype DX Recurrence Score (RS), Ki67, and Race in Early Breast Cancer (EBC) Using the National Cancer Database (NCDB) [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD1-09.

Racial Disparities and Pressure Injuries Among Hospitalized Patients.

To describe the demographic factors, hospitalization-related factors, comorbid states, and social determinants of health among racial groups in a sample of patients with a primary or secondary diagnosis of pressure injury (PI) admitted to New Jersey hospitals during the year 2018. Researchers conducted a retrospective analysis of the Health Care Utilization Project's 2018 New Jersey State Inpatient Database. Patients with a primary or secondary diagnosis of PI (sacrum, buttocks, or heels; N = 17,781) were included in the analytic sample. Analysis compared patients who identified as Black (n = 3,515) with all other racial groups combined (n = 14,266). A higher proportion of Black patients were admitted for a PI (P < .001) and had higher proportions of stage 4 PIs (P < .001) but a lower proportion of stage 1 PIs (P < .001). Higher proportions of Black patients were younger, resided in lower income communities, and identified Medicaid as their primary payor source. Results highlight the racial disparities that exist among patients with PIs in this diverse state and may represent a much larger problem. Clinical research examining the impact of skin tone rather than by racial group is needed. The impact of racial disparities on social determinants of health with regard to PIs remains largely unknown, but its importance cannot be underestimated.

Understanding the Role of Urology Practice Organization and Racial Composition in Prostate Cancer Treatment Disparities.

Black men have a higher risk of prostate cancer diagnosis and mortality but are less likely to receive definitive treatment. The impact of structural aspects on treatment is unknown but may lead to actionable insights to mitigate disparities. We sought to examine the associations between urology practice organization and racial composition and treatment patterns for Medicare beneficiaries with incident prostate cancer. Using a 20% sample of national Medicare data, we identified beneficiaries diagnosed with prostate cancer between January 2010 and December 2015 and followed them through 2016. We linked urologists to their practices with tax identification numbers. We then linked patients to practices on the basis of their primary urologist. We grouped practices into quartiles on the basis of their proportion of Black patients. We used multilevel mixed-effects models to identify treatment associations. We identified 54,443 patients with incident prostate cancer associated with 4,194 practices. Most patients were White (87%), and 9% were Black. We found wide variation in racial practice composition and practice segregation. Patients in practices with the highest proportion of Black patients had the lowest socioeconomic status (43.1%), highest comorbidity (9.9% with comorbidity score ≥ 3), and earlier age at prostate cancer diagnosis (33.5% age 66-69 years; P < .01). Black patients had lower odds of definitive therapy (adjusted odds ratio, 0.87; 95% CI, 0.81 to 0.93) and underwent less treatment than White patients in every practice context. Black patients in practices with higher proportions of Black patients had higher treatment rates than Black patients in practices with lower proportions. Black patients had lower predicted probability of treatment (66%) than White patients (69%; P < .05). Despite Medicare coverage, we found less definitive treatment among Black beneficiaries consistent with ongoing prostate cancer treatment disparities. Our findings are reflective of the adverse effects of practice segregation and structural racism, highlighting the need for multilevel interventions.

Health systems and telemedicine adoption for diabetes and hypertension care.

The COVID-19 pandemic accelerated telemedicine use nationally, but differences across health systems are understudied. We examine telemedicine use for adults with diabetes and/or hypertension across 10 health systems and analyze practice and patient characteristics associated with greater use. Encounter-level data from the AMGA Optum Data Warehouse for March 13, 2020, to December 31, 2020, were analyzed, which included 3,016,761 clinical encounters from 764,521 adults with diabetes and/or hypertension attributed to 1 of 1207 practice sites with at least 50 system-attributed patients. Linear spline regression estimated whether practice size and ownership were associated with telemedicine during the adoption (weeks 0-4), de-adoption (weeks 5-12), and maintenance (weeks 13-42) periods, controlling for patient socioeconomic and clinical characteristics. Telemedicine use peaked at 11% to 42% of weekly encounters after 4 weeks. In adjusted analyses, small practices had lower telemedicine use for adults with diabetes during the maintenance period compared with larger practices. Practice ownership was not associated with telemedicine use. Practices with higher proportions of Black patients continued to expand telemedicine use during the de-adoption and maintenance periods. Practice ownership was not associated with telemedicine use during first months of the pandemic. Small practices de-adopted telemedicine to a greater degree than medium and large practices. Technical support for small practices, irrespective of their ownership, could enable telemedicine use for adults with diabetes and/or hypertension.

Do Not Attempt Resuscitation Order Rates in Hospitalized Patients With Heart Failure, Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Pneumonia.

Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site-level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end-of-life care.

Abstract 14535: Association Between Lower Extremity Revascularization Reinterventions and Treating Facility on Limb Preservation

Introduction: Lower extremity revascularization (LER) improves quality of life and limb preservation rates. However, LER is complicated by the frequent need for short-term reintervention (re-LER). It is unclear if re-LER at a facility that did not perform the initial revascularization is associated with subsequent amputation. Hypothesis: Re-LER at a non-index procedural site is associated with 90-day major amputation. Methods: This was a national cohort study of older adults who underwent endovascular LER for PAD with subsequent re-LER (January 1, 2010 - December 31, 2018) in the Vascular Quality Initiative dataset linked to CMS claims and American Hospital Association facility-level data. We excluded acute limb ischemia and aneurysm procedural indications. The primary outcome was 90-day amputation. The primary exposure was site of first re-LER (same or different than index site). Multivariable logistic regression was used to determine the association between patient and facility characteristics and the likelihood of 90-day amputation. Results: Among 4,473 patients, 60.6% were male and 82.5% were White. One-fifth of patients had their re-LER at a non-index procedural site. Chronic limb threatening ischemia (CLTI) was the operative indication in 52.9%, 44.2% were on the femoropopliteal segment, and 64.8% of index LER procedures were completed in the outpatient setting. Comparing those who had re-LER at a non-index versus index procedural site, there were no differences in age or sex. However, a higher proportion of Black patients had their first re-LER at a non-index site (16.0% vs 13.7%, p=0.01). After adjusting for patient characteristics, re-LER at a non-index facility was associated with a 34% increase in the odds of amputation (odds ratio [OR] 1.34 [95% CI 1.02-1.75]). Additionally, non-White race was also associated with increased odds of amputation (OR 1.40 [95% CI 1.06-1.84]). After adjusting for facility characteristics, these differences were no longer significant. Conclusions: Disease-specific factors appear to be associated with the likelihood of amputation after re-LER while sociodemographic and facility-level factors do not. Quality improvement efforts should focus on early identification and management of patients with PAD.