High-volume Facilities Research Articles

Implementation matters: assessing the effectiveness and sustainment of an obstetric triage program at a high-volume facility in Ghana

BackgroundMaternal mortality remains stubbornly high in Ghana. Current national efforts are focused on improving the quality of care offered in health facilities. Obstetric triage is one intervention that has been proposed to improve the timeliness and appropriateness of care, two key elements of quality. In this study, we describe and evaluate a theory-based implementation approach to introduce obstetric triage into Tema General Hospital, a high-volume maternity hospital in Greater Accra, that blends concepts from implementation science and quality improvement. This implementation project was a first attempt to scale this intervention into a new facility, following initial development in the Greater Accra Regional Hospital (formerly Ridge Hospital) in Accra.MethodsThis was a retrospective mixed-methods evaluation of two stages of implementation: active implementation and sustainment. We triangulated monitoring data captured during active implementation with clinical outcome data (timeliness of first assessment, accuracy of diagnosis, and appropriateness of care plan) from direct observation or patient obstetric triage assessment forms at baseline, at the completion of the active implementation stage, and following a 12-month “washout” period with no contact between hospital staff and the purveyor organization. Finally, we assessed embeddedness of the new triage procedures using the NoMad, a quantitative assessment of constructs from normalization process theory (NPT).ResultsPatient waiting time decreased substantially during the study. At baseline, the median arrival-to-assessment waiting time was 70.5 min (IQR: 30.0–443.0 min). Waiting time decreased to 6.0 min (IQR: 3.0–15.0 min) following active implementation and to 5.0 min (IQR: 2.0–10.0 min) during the sustainment period. Accuracy of diagnosis was high at the end of active implementation (75.7% correct) and improved during the sustainment period (to 77.9%). The appropriateness of care plans also improved during the sustainment period (from 66.0 to 78.9%). Per NoMad data, hospital staff generally perceive obstetric triage to be well integrated into the facility.ConclusionsThis theory-based implementation approach proved to be successful in introducing a novel obstetric triage concept to a busy high-volume hospital, despite resource constraints and a short implementation window. Results proved long-lasting, suggesting this approach has high potential for engendering sustainability in other facilities as well. Our approach will be useful to other initiatives that aim to utilize program data to create and test implementation theories.

EPID-23. FACILITY VOLUME STATUS IS PREDICTIVE OF SURVIVAL AND TREATMENT RECOMMENDATIONS IN PATIENTS WITH INTRACRANIAL MENINGIOMA

Abstract INTRODUCTION There is a growing body of evidence demonstrating improved survival outcomes for patients with CNS neoplasms who are treated at high volume facilities (HVFs) as compared to low volume facilities (LVFs). METHODS The National Cancer Database (NCDB) was queried for adult patients who sought treatment for intracranial meningioma between 2004 and 2019 at one of 1,500 Commission on Cancer-accredited facilities. Data reported included patient sociodemographic information, patient comorbidity status, and relevant tumor characteristics. After patients were stratified by facility volume, the Mann-Whitney U and Fisher exact tests were used for bivariate analysis of both continuous and categorical variables. Multivariate Cox proportional hazard model and log-rank test were used to determine whether there was any association between facility volume and overall survival. RESULTS In total, 336,115 patients diagnosed with meningioma were included; 23,207 (6.9%) patients were treated at an HVF and 312,908 (93.1%) patients were treated at an LVF. On bivariate analysis, patients covered by private insurance were more likely to have been treated at an HVF (50.9% vs 36.8%, p=0.0043). Furthermore, with respect to county-based geographic trends, patients treated at HVFs were more likely to reside in an urban area (14.5% vs 11.6%, p=0.027). With respect to clinical characteristics, these patients had relatively larger tumors (4.22±10.47 cm vs. 4.11±11.03 cm, p< 0.001). On multivariate analysis, significant survival benefits were observed for patients treated at HVFs (HR = 0.977, 95% CI 0.973–0.982, p < 0.001). Patients treated at LVFs were significantly less likely to receive radiotherapy (OR = 0.988, 95% CI 0.985-0.992, p < 0.001) as compared to patients treated for intracranial meningioma at HVFs. CONCLUSION Our results indicate that – for patients who underwent treatment for intracranial meningioma during the 15-year study period – treatment recommendations differed and appeared to be associated with a survival disadvantage at LVFs.

Leveraging Artificial Intelligence to Uncover Hidden Biases in Survival Disparities of Patients with Multiple Myeloma

In 2000, the Institute of Medicine highlighted significant evidence supporting a positive association between higher surgical oncologic procedure volume and improved clinical outcomes. Over nearly two decades since that report, research on the volume-outcome relationship in hematologic malignancies remains somewhat unclear. Most of the research on the impact of procedural volume in Multiple Myeloma (MM) management has relied on the National Cancer Database (NCDB), which consistently indicated that MM patients treated at higher-volume facilities experienced lower mortality rates compared to those treated at lower-volume facilities. Still, the underlying reasons for this disparity have remained elusive. In our pursuit of understanding the underlying factors contributing to the survival disparities in MM, we delved into the data from the NCDB studies. Notably, we observed a significant separation in the Kaplan-Meier (KM) curve for overall survival (OS) between patients treated in high-volume and low-volume facilities during the first 2-3 years. However, intriguingly, the divergence in survival rates tended to plateau after this initial period, with similar event rates observed between the two cohorts in subsequent years. This observation led us to question whether hidden biases or confounding factors might influence the outcomes beyond the scope of traditional analyses. Artificial Intelligence (AI) and machine learning algorithms offer powerful tools for unraveling complex patterns and identifying subtle biases in large datasets. By leveraging these advanced techniques, we aim to dig deeper into the NCDB data to uncover potential hidden factors influencing the survival disparities among MM patients. Objective: To assess the early separation of KM curves, and potential violation of proportional hazard assumptions, we used image analysis software to extract survival numerical value from the KM graph of major three studies of NCDB. We hypothesized that majority of significance in the survival between high vs low volumes occurs in the first 3 years and after that the difference in death rate remains stable. Methods: We included three main analyses of NCDB with KM curve assessment of high vs. low volume facilities. The Computer Vision 2 module on Python programming was used to convert the KM graph image to a gray-scale version. Then the X and Y coordinates of both lines were extracted. The vertical distance between two Y values for each value on X-axis was calculated as the difference between event rates in two cohorts. Further, we created a cumulative hazard plot to visualize the cumulative hazard function for each group over time. This plot can provide insights into whether the proportional hazard assumption holds. Kernel Density Estimation (KDE) was utilized for estimating probability densities from the underlying distribution. Results: We successfully reproduced the KM curve using the coordinates' numerical value (Figure-1).Kernel Density Estimation (KDE) plot visualizes the density of survival difference values over time. The color intensity indicates the density of points, with darker regions representing higher densities. The plot shows the prominent increase in the difference between survival rates occurring relatively early (roughly 30-36 months). After this initial increase, the plot's color intensity becomes lighter, indicating that the survival rate difference tends to plateau, i.e., it remains relatively constant. A large portion of the difference between the two curves occurs early in the course and, after that, stays stable, illustrating early separation in the KM curve. Conclusion: Our findings illustrate that the main survival difference between high and low-volume facilities for MM treatment occurs early in the disease course, potentially violating the proportional hazard assumption. This divergence from expectation may be attributed to patient migration from lower to higher-volume facilities over time, influencing survival data. In light of this, we recommend using alternative approaches, such as cumulative hazard plots and time-varying coefficient Cox models, to assess the Proportional Hazard assumption for patient volume in future research.

Association of Radiation Facility Volume with Overall Survival in Patients with Very High-Risk Prostate Cancer Treated with Radiation and Androgen Deprivation Therapy.

Studies suggest an association of treatment at high volume facilities with improved survival in cancer patients receiving surgery or radiation therapy. This association has not been studied in patients with very high-risk prostate cancer, who are treated using a multimodality approach that often requires specialized care with advanced diagnostic imaging, complex radiotherapeutic planning, and multidrug antiandrogen regimens. We used the National Cancer Database (NCDB) to study the association of radiation treatment facility volume (FV) with overall survival (OS). We selected for patients with very high risk, localized prostate cancer by NCCN criteria (cT3b-T4, primary Gleason pattern 5, >4 cores with grade group 4-5, and/or 2-3 high risk features). We included patients who received hormone therapy with either external beam radiation to a dose of ≥60 Gy or external beam radiation to a dose of ≥45 Gy combined with brachytherapy. Association of FV with OS was evaluated through a bias-adjusted log-rank test to identify the optimal cut point of FV for dichotomization. Kaplan-Meier curves were used to study the association of binary FV with overall survival (OS) with and without IPTW (inverse probability treatment weighting) balancing the following confounders: age, race, median income, education, insurance, academic treatment facility, Charlson comorbidity score, T stage, PSA, Gleason score, total radiation dose, year of diagnosis, and patient distance from treatment facility. Cox proportional hazards model was built using backward variable selection strategy (α of 0.05 for removal). We identified 25,219 very high-risk prostate cancer patients by NCCN criteria (median follow up 57.36 months; 95% CI 56.67 - 58.09) diagnosed between 2004 and 2015. High FV (n = 6,438) was associated with better OS on univariable analysis (hazard ratio [HR] = 0.81; 95% confidence interval [CI] 0.77 - 0.86; p < 0.001) and multivariable analysis (HR = 0.89; 95% CI 0.84 - 0.95; p < 0.001). Other factors associated with improved OS on multivariable analysis included younger age, non-white/black race, higher income, private insurance, academic/research treatment facility, lower comorbidity, lower T-stage, lower PSA, and lower Gleason score. After IPTW adjustment, high FV remained associated with better OS (HR = 0.90; 95% CI 0.85 - 0.95; p < 0.001). Patients with NCCN very high-risk prostate cancer treated at a radiation facility with high case volume had better OS than patients treated at a facility with low volume, after adjustment for confounders. This may suggest that for very high-risk patients, outcomes may be improved by the expertise and optimal multidisciplinary care that typically accompany high facility treatment volume.

Diagnosing Provider, Referral Patterns, Facility Type, and Patient Satisfaction Among Iowa Rectal Cancer Patients.

Rectal cancer treatment at high-volume centers is associated with higher likelihood of guideline-concordant care and improved outcomes. Whether rectal cancer patients are referred for treatment at high-volume hospitals may depend on diagnosing provider specialty. We aimed to determine associations of diagnosing provider specialty with treating provider specialty and characteristics of the treating facility for rectal cancer patients in Iowa. Rectal cancer patients identified using the Iowa Cancer Registry completed a mailed survey on their treatment experience and decision-making process. Provider type was defined by provider specialty and whether the provider referred patients elsewhere for surgery. Multivariable-adjusted logistic regression models were used to examine predictors of being diagnosed by a general surgeon who also performed the subsequent surgery. Of 417 patients contacted, 381 (76%) completed the survey; our final analytical sample size was 267. Half of respondents were diagnosed by a gastroenterologist who referred them elsewhere; 30% were diagnosed by a general surgeon who referred them elsewhere, and 20% were diagnosed by a general surgeon who performed the surgery. Respondents who were ≥ 65years old, had less than a college education, and who made < $50,000 per year were more likely to be diagnosed by a general surgeon who performed surgery. In multivariable-adjusted models, respondents diagnosed and treated by the same general surgeon were more likely to have surgery at hospitals with low annual colorectal cancer surgery volume and less likely to be satisfied with their care. Among rectal cancer patients in Iowa, respondents who were diagnosed and treated by the same provider were less likely to get treatment at a high-volume facility. This study informs the importance of provider referral in centralization of rectal cancer care.

Socioeconomic Disparities in the Pursuit of Care at a High-Volume Institution for Surgical Resection of Vestibular Schwannomas.

Increased institutional surgical resection case volume for vestibular schwannomas (VSs) has been associated with improved patient outcomes, including reduced risk of prolonged hospital stay and readmission. Socioeconomic disparities in the pursuit of care at these high-volume institutions remain unknown. Retrospective cohort epidemiological study. National Cancer Database, a hospital-based registry of over 1,500 facilities in the United States. Adult VS patients (age, >18 years) treated surgically. High- versus low-volume facilities, defined using a facility case volume threshold of 25 cases per year. A risk-adjusted restricted cubic spline model was previously used to identify this risk threshold beyond which the incremental benefit of increasing case volume began to plateau. Sociodemographic factors, including race, ethnicity, income, insurance status, and rurality. Multivariable analyses were adjusted for patient and tumor characteristics, including age, sex, Charlson-Deyo score, and tumor size. A totoal of 10,048 patients were identified (median [interquartile range] age = 51 [41-60] years, 54% female, 87% Caucasian). Patients with Spanish/Hispanic ethnicity (OR = 0.71, 95% confidence interval [CI] = 0.52-0.96), income below median (OR = 0.63, 95% CI = 0.55-0.73]), and Medicare, Medicaid, or other government insurance versus private insurance (OR = 0.63, 95% CI = 0.53-0.74) had reduced odds of treatment at a high-volume facility. Further sensitivity analyses in which facility volume was operationalized continuously reinforced direction and significance of these associations. Socioeconomic disparities exist in the propensity for VS patients to be treated at a high-volume facility. Further work is needed to understand the nature of these associations and whether interventions can be designed to mitigate them.

The Impact of Medicaid Expansion on Early-Stage Pancreatic Adenocarcinoma at High- Versus Low-Volume Facilities.

While Medicaid Expansion (ME) has improved healthcare access, disparities in outcomes after volume-dependent surgical care persist. We sought to characterize the impact of ME on postoperative outcomes among patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) at high-volume (HVF) versus low-volume (LVF) facilities. Patients who underwent resection for PDAC were identified from the National Cancer Database (NCDB; 2011-2018). HVF was defined as ≥20 resections/year. Patients were divided into pre-and post-ME cohorts, and the primary outcome was textbook oncologic outcomes (TOO). Difference-in-difference (DID) analysis was used to assess changes in TOO achievement among patients living in ME versus non-ME states. Among 33,764 patients who underwent resection of PDAC, 19.1% (n=6461) were treated at HVF. Rates of TOO achievement were higher at HVF (HVF: 45.7% vs. LVF: 32.8%; p<0.001). On multivariable analysis, undergoing surgery at HVF was associated with higher odds of achieving TOO (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.49-1.72) and improved overall survival (OS) [hazard ratio (HR) 0.96, 95% CI 0.92-0.99]. Compared with patients living in non-ME states, individuals living in ME states were more likely to achieve TOO on adjusted DID analysis (5.4%, p=0.041). Although rates of TOO achievement did not improve after ME at HVF (3.7%, p=0.574), ME contributed to markedly higher rates of TOO among patients treated at LVF (6.7%, p=0.022). Although outcomes for PDAC remain volume-dependent, ME has contributed to significant improvement in TOO achievement among patients treated at LVF. These data highlight the impact of ME on reducing disparities in surgical outcomes relative to site of care.

Gastric Cancer Surgery in the US: a Contemporary Trend Analysis of Lymphadenectomy and the Impact of Minimally Invasive Approaches

BackgroundThe National Comprehensive Cancer Network guidelines recommend harvesting 16 or more lymph nodes for the adequate staging of gastric adenocarcinoma. This study examines the rate of adequate lymphadenectomy over recent years, its predictors, and its impact on overall survival(OS). Study designThe National Cancer Database was utilized to identify patients who underwent surgical treatment for gastric adenocarcinoma between 2006–2019. Trend analysis was performed for lymphadenectomy rates during the study period. Logistic regression, Kaplan-Meier survival plots, and Cox proportional hazard regression were utilized. ResultsA total of 57,039 patients who underwent surgical treatment for gastric adenocarcinoma were identified. Only 50.5% of the patients underwent a lymphadenectomy of ≥ 16 nodes. Trend analysis showed that this rate significantly improved over the years, from 35.1% in 2006 to 63.3% in 2019 (p < .0001). The main independent predictors of adequate lymphadenectomy included high-volume facility with ≥ 31 gastrectomies/year (OR: 2.71; 95%CI:2.46–2.99), surgery between 2015–2019 (OR: 1.68; 95%CI: 1.60–1.75), and preoperative chemotherapy (OR:1.49; 95%CI:1.41–1.58). Patients with adequate lymphadenectomy had better OS than patients who did not: median survival: 59 versus 43 months (Log-Rank: p < .0001). Adequate lymphadenectomy was independently associated with improved OS (HR:0.79; 95%CI:0.77–0.81). Laparoscopic and robotic gastrectomies were independently associated with adequate lymphadenectomy compared to open, OR: 1.11, 95%CI:1.05–1.18 and OR: 1.24, 95%CI:1.13–1.35, respectively. ConclusionAlthough the rate of adequate lymphadenectomy improved over the study period, a large number of patients still lacked adequate lymph node dissection, negatively impacting their OS despite multimodality therapy. Laparoscopic and robotic surgeries were associated with a significantly higher rate of lymphadenectomy ≥ 16 nodes.

Impact of centralization of initial breast cancer care on time to surgery.

e13511 Background: Evidence suggests that centralization of care in high(er) volume facilities is an effective strategy to improve patient outcomes. However, particularly in the case of breast cancer, concerns about the potential impact on timely access to care have limited its promotion. Leveraging a natural experiment afforded by New York’s statewide implementation of a policy in 2009 restricting Medicaid reimbursement for breast cancer surgery provided at low-volume hospitals (&lt;30 breast cancer surgeries annually), we examined the effect of centralization of care on days from breast cancer diagnosis to initial treatment. Methods: From a linked dataset merging NY state tumor registry with hospital discharge data, we identified 71,135 women diagnosed with Stage 1-3 incident breast cancer who underwent surgery as first course of treatment during the pre-policy (2004-08) and post-policy (2010-13) periods. Multivariable difference-in-difference models were used to estimate the policy effect on the probability of experiencing delayed care (&gt;60 days) between diagnosis and initial surgical treatment by Medicaid beneficiaries before and after policy implementation relative to the experience of commercially or otherwise insured women unaffected by the policy change. Results: The cohort consisted of 8435 Medicaid beneficiaries (4070 pre-/4365 post-policy) and 62,700 non-Medicaid women (34,909 pre-/28,610 post-policy). The mean time to surgery pre- and post-policy was 34 (SD=37.2) and 45.5 (SD=41.3) days for Medicaid beneficiaries and 27.5 (SD=27.7) and 36 (SD=28.4) days for non-Medicaid patients. Multivariate estimates indicate that, regardless of insurance status, the more recently treated patients were more likely to wait &gt;60 days to initial treatment (OR=1.5, 95% CI=1.43-1.59, p&lt;0.001) suggesting a temporal trend of longer time to treatment unrelated to the centralization policy. Regardless of the policy period, Medicaid beneficiaries were more likely to experience delayed care than commercially insured women (OR=1.75; 95% CI=-1.59 to 1.92, p&lt;0.001). Difference-in-difference estimates, however, indicate that the adjusted probability of delayed care among Medicaid patients (from 14.3% to 20.5%) was not significantly larger than that of patients not affected by the policy (from 8.8% to 12.6%). Controlling for time trends and policy effects, age, race, ethnicity, comorbidities, urbanicity, tumor size, nodal status and hormone receptor status, Black women (OR=1.74, 95%CI=1.63-1.85), those of other races (OR=1.15; 95%CI=1.01-1.24), and Hispanic women (OR=1.34; 95%CI=1.24-1.44) were more likely to experience delayed care than their white or non-Hispanic counterparts. Conclusions: Given these findings and growing evidence of better survival among breast cancer patients treated at high(er) volume hospitals, centralization of breast cancer care may be one effective approach to improving breast cancer outcomes.

Uptake and effectiveness of a mobile application for real-time reporting and quality assurance of decentralized SARS-CoV-2 testing in Uganda.

Effective management of the COVID-19 pandemic required rapid expansion of diagnosis. The introduction of antigen tests presented an opportunity to decentralize testing, but raised challenges with ensuring accurate and timely reporting of testing data, which is essential to guide the response. Digital solutions can help address this challenge and provide more efficient means of monitoring and quality assurance. Uganda's existing laboratory investigation form was digitized in the form of an Android-based application, eLIF, which was developed by the Central Public Health Laboratory and implemented in 11 high-volume facilities between December 2021 and May 2022. The app enabled healthcare workers to report testing data via mobile phone or tablet. Uptake of the tool was monitored through a dashboard that enabled real-time visibility into data being transmitted from sites, as well as qualitative insights from site visits and online questionnaires. A total of 15,351 tests were conducted at the 11 health facilities during the study period. Of these, 65% were reported through eLIF, while 12% were reported through preexisting Excel-based tools. However, 23% of tests were only captured in paper registers and not transmitted to the national database, illustrating the need for increased uptake of digital tools to ensure real-time data reporting. While data captured through eLIF were transmitted to the national database within 0-3 days (min, max), data transmitted through Excel were transmitted in within 0-37 days (min, max), and data for paper-based reporting took up to 3 months. The majority of healthcare workers interviewed in an endpoint questionnaire responded that eLIF improved timeliness of patient management, and reduced reporting time. However, some functions of the app were not successfully implemented, such as providing random selections of samples for external quality assurance and enabling seamless linkage of these data. Challenges arose from broader operational complexities, such as staff workload, frequent task-shifting and unexpected changes to facility workflows, which limited adherence to the envisioned study procedures. Ongoing improvements are needed to adjust to these realities, to strengthen the technology and support to healthcare workers using it, to optimize the impact of this digital intervention.

Association of sociodemographic characteristics with utilization of sentinel lymph node biopsy for American Joint Committee on Cancer 8th edition T1b cutaneous melanoma.

Sentinel lymph node biopsy (SLNB) is an important staging and prognostic tool for cutaneous melanoma (CM). However, there exists a knowledge gap regarding whether sociodemographic characteristics are associated with receipt of SLNB for T1b CMs, for which there are no definitive recommendations for SLNB per current National Comprehensive Cancer Network guidelines. We performed a retrospective analysis of the 2012-2018 National Cancer Database, identifying patients with American Joint Committee on Cancer staging manual 8th edition stage T1b CM, and used multivariable logistic regression to analyze associations between sociodemographic characteristics and receipt of SLNB. Among 40,458 patients with T1b CM, 23,813 (58.9%) received SLNB. Median age was 62years, and most patients were male (57%) and non-Hispanic White (95%). In multivariable analyses, patients of Hispanic (aOR 0.67, 95%CI 0.48-0.94) and other (aOR 0.78, 95%CI 0.63-0.97) race/ethnicity, and patients aged > 75 (aOR 0.33, 95%CI 0.29-0.38), were less likely to receive SLNB. Conversely, patients in the highest of seven socioeconomic status levels (aOR 1.37, 95%CI 1.13-1.65) and those treated at higher-volume facilities (aOR 1.29, 95%CI 1.14-1.46) were more likely to receive SLNB. Understanding the underlying drivers of these associations may yield important insights for the management of patients with melanoma.

Systematic Review and Meta-analysis of the Association Between Radiation Therapy Treatment Volume and Patient Outcomes

Evidence of a volume-outcome association in cancer surgery has shaped the centralization of cancer services; however, it is unknown whether a similar association exists for radiation therapy.The objective of this study was to determine the association between radiation therapy treatment volume and patient outcomes. This systematic review and meta-analysis included studies that compared outcomes of patients who underwent definitive radiation therapy at high-volume radiation therapy facilities (HVRFs) versus low-volume facilities (LVRFs). The systematic review used Ovid MEDLINE and Embase. For the meta-analysis, a random effects model was used. Absolute effects and hazard ratios (HRs) were used to compare patient outcomes. The search identified 20 studies assessing the association between radiation therapy volume and patient outcomes. Seven of the studies looked at head and neck cancers (HNCs). The remaining studies covered cervical (4), prostate (4), bladder (3), lung (2), anal (2), esophageal (1), brain (2), liver (1), and pancreatic cancer (1). The meta-analysis demonstrated that HVRFs were associated with a lower chance of death compared with LVRFs (pooled HR, 0.90; 95% CI, 0.87- 0.94). HNCs had the strongest evidence of a volume-outcome association for both nasopharyngeal cancer (pooled HR, 0.74; 95% CI, 0.62-0.89) and nonnasopharyngeal HNC subsites (pooled HR, 0.80; 95% CI, 0.75-0.84), followed by prostate cancer (pooled HR, 0.92; 95% CI, 0.86-0.98). The remaining cancer types showed weak evidence of an association. The results also demonstrate that some centers defined as HVRFs are undertaking very few procedures per annum (<5 radiation therapy cases per year). An association between radiation therapy treatment volume and patient outcomes exists for most cancer types. Centralization of radiation therapy services should be considered for cancer types with the strongest volume-outcome association, but the effect on equitable access to services needs to be explicitly considered.

High acceptability and viral suppression rate for first-Line patients on a dolutegravir-based regimen: An early adopter study in Nigeria.

Nigeria adopted dolutegravir (DTG) as part of first line (1L) antiretroviral therapy (ART) in 2017. However, there is limited documented experience using DTG in sub-Saharan Africa. Our study assessed DTG acceptability from the patient's perspective as well as treatment outcomes at 3 high-volume facilities in Nigeria. This is a mixed method prospective cohort study with 12 months of follow-up between July 2017 and January 2019. Patients who had intolerance or contraindications to non-nucleoside reverse-transcriptase inhibitors were included. Patient acceptability was assessed through one-on-one interviews at 2, 6, and 12 months following DTG initiation. ART-experienced participants were asked about side effects and regimen preference compared to their previous regimen. Viral load (VL) and CD4+ cell count tests were assessed according to the national schedule. Data were analysed in MS Excel and SAS 9.4. A total of 271 participants were enrolled on the study, the median age of participants was 45 years, 62% were female. 229 (206 ART-experienced, 23 ART-naive) of enrolled participants were interviewed at 12 months. 99.5% of ART-experienced study participants preferred DTG to their previous regimen. 32% of particpants reported at least one side effect. "Increase in appetite" was most frequently reported (15%), followed by insomnia (10%) and bad dreams (10%). Average adherence as measured by drug pick-up was 99% and 3% reported a missed dose in the 3 days preceding their interview. Among participants with VL results (n = 199), 99% were virally suppressed (<1000 copies/ml), and 94% had VL <50 copies/ml at 12 months. This study is among the first to document self-reported patient experiences with DTG in sub-Saharan Africa and demonstrated high acceptability of DTG-based regimens among patients. The viral suppression rate was higher than the national average of 82%. Our findings support the recommendation of DTG-based regimen as the preferred 1L ART.

The Impact of Medicaid Expansion on Early-Stage Hepatocellular Carcinoma Care.

The impact of Medicaid expansion (ME) on hepatocellular carcinoma (HCC) remains controversial, and heterogeneous effects on care processes may relate to sociodemographic factors. We sought to evaluate the association between ME and receipt of surgery in early-stage HCC. Patients diagnosed with early-stage HCC between 40 and 64 years of age were identified from the National Cancer Database and divided into pre- (2004-2012)and post- (2015-2017) expansion cohorts. Logistic regressionwas used to identify predictors of surgical treatment. Difference-in-difference (DID) analysis assessed changes in surgical treatment between patients living in ME and non-ME states. Among 19,745 patients, 12,220 (61.9%) were diagnosed before MEand 7525 (38.1%) after. Although overall utilization of surgery decreased after expansion (ME, pre-expansion: 62.2% versus post-expansion: 51.6%; non-ME, pre-expansion: 62.1% versus post-expansion: 50.8%, p < 0.001), this trend varied relative to insurance status. Notably, receipt of surgery increased among uninsured/Medicaid patients living in ME states after expansion (pre-expansion: 48.1%, post-expansion: 52.3%, p < 0.001). Moreover, treatment at academic or high-volume facilities increased the likelihood of undergoing surgery before expansion. After expansion, treatment at anacademic facility and living in anME state (OR 1.28, 95% CI 1.07-1.54, p < 0.01) were predictors of surgical treatment. DID analysis demonstrated increased utilization of surgery for uninsured/Medicaid patients living in ME states relative to non-ME states (uninsured/Medicaid: 6.4%, p < 0.05), although no differences were noted among patients withother insurance statuses (overall: 0.7%, private: -2.0%, other: 0.3%, all p > 0.05). Implementation of ME heterogeneously impacted utilization of care in early-stage HCC. Notably, uninsured/Medicaid patients residing in ME states demonstrated increased utilization of surgical treatment after expansion.

Recurrence of Protruding Calcified Nodule Visualized Using Optical Coherence Tomography Following Stent Implantation

Disparities in access to percutaneous coronary intervention (PCI) for patients with acute myocardial infarction may result from openings and closures of PCI-providing hospitals, potentially leading to low hospital PCI volume, which is associated with poor outcomes.The authors sought to determine whether openings and closures of PCI hospitals have differentially impacted patient health outcomes in high- vs average-capacity PCI markets.In this retrospective cohort study, the authors identified PCI hospital availability within a 15-minute driving time of zip code communities. The authors categorized communities by baseline PCI capacity and identified changes in outcomes associated with PCI-providing hospital openings and closures using community fixed-effects regression models.From 2006 to 2017, 20% and 16% of patients in average- and high-capacity markets, respectively, experienced a PCI hospital opening within a 15-minute drive. In average-capacity markets, openings were associated with a 2.6 percentage point decrease in admission to a high-volume PCI facility; high-capacity markets saw an 11.6 percentage point decrease. After an opening, patients in average-capacity markets experienced a 6.5% and 8.6% relative increase in likelihood of same-day and in-hospital revascularization, respectively, as well as a 2.5% decrease in mortality. PCI hospital closures were associated with a 10.4% relative increase in admission to high-volume PCI hospitals and a 1.4 percentage point decrease in receipt of same-day PCI. There was no change observed in high-capacity PCI markets.After openings, patients in average-capacity markets derived significant benefits, whereas those in high-capacity markets did not. This suggests that past a certain threshold, facility opening does not improve access and health outcomes.

The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures.

The aim of this study was to characterize the case volume dependence of both facilities and surgeons on morbidity and mortality after femoral shaft fracture (FSF) fixation. Adults who had an open or closed FSF between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database. Claims were identified by International Classification of Disease-9, Clinical Modification diagnostic codes for a closed or open FSF and International Classification of Disease-9, Clinical Modification procedure codes for FSF fixation. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20% to represent low-volume and high-volume surgeons/facilities. Of 4,613 FSF patients identified, 2,824 patients were treated at a high or low-volume facility or by a high or low-volume surgeon. Most of the examined complications including readmission and in-hospital mortality showed no statistically significant differences. Low-volume facilities had a higher 1-month rate of pneumonia. Low-volume surgeons had a lower 3-month rate of pulmonary embolism. There is minimal difference in outcomes in relation to facility or surgeon case volume for FSF fixation. As a staple of orthopaedic trauma care, FSF fixation is a procedure that may not require specialized orthopaedic traumatologists at high-volume facilities.

Do PCI Facility Openings and Closures Affect AMI Outcomes Differently in High- vs Average-Capacity Markets?

BackgroundDisparities in access to percutaneous coronary intervention (PCI) for patients with acute myocardial infarction may result from openings and closures of PCI-providing hospitals, potentially leading to low hospital PCI volume, which is associated with poor outcomes. ObjectivesThe authors sought to determine whether openings and closures of PCI hospitals have differentially impacted patient health outcomes in high- vs average-capacity PCI markets. MethodsIn this retrospective cohort study, the authors identified PCI hospital availability within a 15-minute driving time of zip code communities. The authors categorized communities by baseline PCI capacity and identified changes in outcomes associated with PCI-providing hospital openings and closures using community fixed-effects regression models. ResultsFrom 2006 to 2017, 20% and 16% of patients in average- and high-capacity markets, respectively, experienced a PCI hospital opening within a 15-minute drive. In average-capacity markets, openings were associated with a 2.6 percentage point decrease in admission to a high-volume PCI facility; high-capacity markets saw an 11.6 percentage point decrease. After an opening, patients in average-capacity markets experienced a 6.5% and 8.6% relative increase in likelihood of same-day and in-hospital revascularization, respectively, as well as a 2.5% decrease in mortality. PCI hospital closures were associated with a 10.4% relative increase in admission to high-volume PCI hospitals and a 1.4 percentage point decrease in receipt of same-day PCI. There was no change observed in high-capacity PCI markets. ConclusionsAfter openings, patients in average-capacity markets derived significant benefits, whereas those in high-capacity markets did not. This suggests that past a certain threshold, facility opening does not improve access and health outcomes.

Characteristics of Facilities With Early and Rapid Ustekinumab Adoption for Patients With Inflammatory Bowel Disease.

To examine which facility characteristics, including teamwork, are associated with early or rapid inflammatory bowel disease-related ustekinumab adoption. We examined the association between ustekinumab adoption and the characteristics of 130 Veterans Affairs facilities. Mean ustekinumab adoption increased by 3.9% from 2016 to 2018 and was higher in urban compared with rural facilities (β = 0.03, P = 0.033) and among facilities with more teamwork (β = 0.11, P = 0.041). Compared with nonearly adopters, early adopters were more likely be high-volume facilities (46% vs 19%, P = 0.001). Facility variation in medication adoption provides an opportunity for improving inflammatory bowel disease care through targeted dissemination strategies to improve medication uptake.

Hospital facility characteristics and socioeconomic factors on outcomes and treatment in patients with multiple myeloma: National Cancer Database analysis.

Previous studies have shown that socioeconomic factors play an important role in multiple myeloma (MM) health outcomes. We postulated that the type of treatment facilities and their volume of cases also affect overall survival, utilization of various therapies including palliative care services in newly diagnosed MM. Using the National Cancer Database (NCDB), we analyzed 174,551 newly diagnosed MM participants from across the country. We found that at high volume facility centers (over 90th percentile of new patient volume from 2004 to 2016), the median overall survival (OS) was 62.3 months versus 35.3 months at lower volume facilities (p <0.001). Similarly, high volume academic cancer centers had an improved median OS of 66.4 months (65.3-67.4 CI) versus 39.2 months (37.9-40.4 months CI) in lower volume academic centers (p <0.001). The odds of utilizing chemotherapy, immunotherapy, and autologous transplants were higher in academic cancer centers compared to community cancer centers, after adjusting for demographic and socioeconomic factors (OR 1.10, 1.23, and 2.06 respectively, all with p<0.001). There was significantly decreased odds of receiving palliative care (OR 0.89, 95% CI 0.85-0.93) in high volume facilities compared to low volume. Palliative care services were more frequently utilized at integrated network cancers and comprehensive community cancer centers compared to community cancer centers, with similar odds of receiving palliative care between community and academic facility types. Our results likely reflect increased provider experience and resources in higher volume and academic facilities. This highlights the need to integrate resources and improve access to community programs.

Facility type is associated with improved perioperative and oncologic outcomes after minimally invasive surgery for pancreatic cancer

BackgroundThis study sought to evaluate outcome differences by facility type in patients who underwent minimally invasive surgery (MIS) for pancreatic ductal adenocarcinoma (PDAC). MethodsThe National Cancer Database was used to identify patients with clinical stage I-III PDAC who underwent MIS from 2010 to 2019 in academic or community facilities. ResultsOf 6806 patients who fulfilled inclusion criteria; 1788 (26.3%) were treated at community facilities and 5018 (74.7%) at academic facilities. Patients treated at academic facilities were more likely to receive care at a high-volume facility (62% vs. 32%, p < 0.001), undergo a Whipple (64% vs. 61%, p < 0.001), and be clinical stage II (42% vs. 38%) and III (5.6% vs. 4.9%, p = 0.001). Treatment at academic facilities was predictive of receiving neoadjuvant therapy (OR 2.08, p < 0.001), negative margin resection (OR 0.80, p = 0.004), lower 90-day mortality (OR 0.72, p = 0.02), decreased length of stay (IRR 0.96, p < 0.001), and longer OS (HR 0.88, p = 0.002). ConclusionPatients who underwent MIS for PDAC at academic facilities experienced an association with improved perioperative and oncologic outcomes than those treated in community facilities.