Insurance Status Research Articles

Disparities in Receipt of Adjuvant Immunotherapy among Stage III Melanoma Patients.

Melanoma survival has greatly improved with the advent of immunotherapy, but unequal access to these medications may exist due to nonmedical patient factors such as insurance status, educational background, and geographic proximity to treatment. We used the National Cancer Database to assess patients with nonmetastatic cutaneous melanoma who underwent surgical resection and sentinel lymph node biopsy (SLNB) with tumor involvement from 2015 to 2020. We evaluated rates of adjuvant immunotherapy among this patient population based on patient, tumor, and facility variables, including insurance status, socioeconomic status, pathologic stage (IIIA-IIID), and treatment facility type and volume. Adjuvant immunotherapy was associated with improved survival for stage III melanoma, with a slight increase in 5-year OS for stage IIIA (87.9% vs. 85.9%, P=0.044) and a higher increase in stages IIIB-D disease (70.3% vs. 59.6%, P<0.001). Receipt of adjuvant immunotherapy was less likely for patients who were older, low socioeconomic status, or uninsured. Low-volume and community cancer centers had higher rates of adjuvant immunotherapy overall for all stage III patients, whereas high-volume and academic centers used adjuvant immunotherapy much less often for stage IIIA patients compared with those in stages IIIB-D. Our results demonstrate inconsistent use of adjuvant immunotherapy among patients with stage III melanoma despite a significant association with improved survival. Notably, there was a lower use of adjuvant immunotherapy in patients of lower SES and those treated at high-volume centers. Equity in access to novel standards of care represents an opportunity to improve outcomes for patients with melanoma.

Lipid goal attainment across baseline socioeconomic and clinical factors comparing an "inclisiran first" implementation strategy and usual care: subgroup analysis of VICTORION-INITIATE

Abstract Background Addressing inequities in cardiovascular care has become a public health priority. Recent results from VICTORION-INITIATE, a pragmatically designed, randomised clinical trial showed the benefit of using inclisiran immediately if patients with atherosclerotic cardiovascular disease (ASCVD) fail to achieve low-density lipoprotein cholesterol (LDL-C) &amp;lt;70 mg/dL (1.8 mmol/L) on maximally tolerated statins. Purpose To evaluate effectiveness and safety of an "inclisiran first" implementation strategy (IF) versus usual care (UC) in subgroups that may be associated with healthcare inequities. Methods VICTORION-INITIATE was conducted at 45 representative clinical settings across 20 states in the USA. Patients with ASCVD randomised 1:1 (stratified by insurance status) received open-label inclisiran 284 mg at Days 0, 90 and 270) plus UC or UC alone (lipid management directed by treating physicians). Treating physicians had access to LDL-C measurements and were encouraged to intensify treatment per lipid guidelines. We compared efficacy and safety endpoints for IF and UC in prespecified subgroups (race, ethnicity, sex, renal function and statin intensity) and by income level (post-hoc analysis). Results The study randomised 450 patients. Baseline demographic and clinical parameters were balanced between study arms (≥65 years of age: IF: 63.1%, UC: 61.3%; non-White: IF: 15.6%, UC: 15.1%; Hispanic: IF: 13.8%, UC: 16.9%; female: IF: 29.8%, UC: 32.0%; income ≤$50,000: IF: 58.7%, UC: 58.2%; estimated glomerular filtration rate ≥30 to &amp;lt;60 mL/min/1.73m2: IF: 20.0%, UC: 17.8%; no statins at baseline: IF: 9.8%; UC: 10.2%). Across all subgroups, more patients achieved LDL-C goals at Day 330 with IF vs UC (Figure 1). Within the UC arm, the proportions of patients achieving LDL-C &amp;lt;70 mg/dL and &amp;lt;55 mg/dL, respectively, were numerically lower for non-White (8.8% and 2.9%) and Hispanic (10.5% and 2.6%) than White (24.6% and 10.2%) and non-Hispanic (24.9% and 10.3%) patients. We did not observe differences in LDL-C goal attainment for these subgroups in patients receiving IF. Compared with UC, IF resulted in greater mean percentage change in other lipids and lipoproteins from baseline to Day 330, irrespective of subgroup (Figure 2). Incidence of treatment-emergent adverse events (TEAEs) and serious TEAEs compared similarly between IF and UC for each subgroup (IF: 35.5−69.2%, UC: 34.2−84.2%, and IF: 3.2−16.9%, UC: 0.0−36.8%, respectively). Conclusions VICTORION-INITIATE enrolled a diverse population reflective of "real-world" US clinical practice. The IF strategy consistently resulted in higher rates of LDL-C goal attainment for all subgroups studied and did not lead to differences in lipid outcomes by race or ethnicity as compared to usual care. No additional safety concerns for the IF strategy were identified.

Mitigating health disparities by improving access to catheter-based therapies for vulnerable patients with acute pulmonary embolism

Abstract Introduction This study explores the implementation and outcomes of catheter-based thrombectomy (CBT) in acute pulmonary embolism (PE) within a safety-net hospital (SNH), addressing a critical gap in the literature concerning CBT in underserved and vulnerable populations. Methods This is a retrospective study of patients undergoing CBT between October 2020 and January 2024 at a SNH. The primary outcome was 30-day all-cause mortality. Results A total of 107 patients (47.6% female, mean age 58.4 years) underwent CBT for acute PE, with 23 (21.5%) high-risk and 84 (78.9%) intermediate-risk PE. Demographically, 64% identified as Black, 10% White, 19% Hispanic or Latino, and 5% Asian. In terms of insurance coverage, 50% had private insurance or Medicare, 36% had Medicaid, and 14% were uninsured. Notably, 67% of the patients resided in high poverty rate zip codes and 11% were non-citizen non-residents. Markers of risk severity, such as biomarkers (troponin, BNP), PE risk classification (high versus intermediate-risk), rates of low CI, lactate level, CPES/sPESI score, and rates of RV dysfunction did not vary significantly across race/ethnic groups, insurance status, level of poverty and citizenship status. Over a median follow up period of 30 days, 6 (5.6%) patients expired (all high-risk PE), 3 of which presented with cardiac arrest. No patients who presented with intermediate-risk PE died at 30 days. There was no difference in 30-day mortality based on race, insurance type, poverty level or citizenship status. Conclusion The findings emphasize the feasibility and success of implementing PERT and CBT at a SNH, offering a potential model to address healthcare disparities in acute PE on a broader scale.

Low-density lipoprotein cholesterol goal attainment with "inclisiran first" versus usual care in patients with atherosclerotic cardiovascular disease

Abstract Background Rapid and sustained attainment of guideline-recommended low-density lipoprotein cholesterol (LDL-C) goals is critical for patients with atherosclerotic cardiovascular disease (ASCVD). In VICTORION-INITIATE, inclisiran administered twice-yearly by a healthcare professional earlier in the treatment pathway allowed more patients with ASCVD to achieve and sustain LDL-C goals vs current usual care (UC). Purpose To evaluate cumulative LDL-C exposure in the overall population and LDL-C goal attainment and safety in subgroups of participants (type of ASCVD, timing of ASCVD event, and history of statin intolerance) who received an "inclisiran first" implementation strategy (IF; adding inclisiran immediately on failure to achieve LDL-C &amp;lt;70 mg/dL [1.8 mmol/L] with maximally tolerated statins) compared with UC. Methods VICTORION-INITIATE was a 330-day, prospective, pragmatically designed trial that randomised participants 1:1 (stratified by insurance status) to IF (open-label inclisiran 284 mg at Days 0, 90 and 270 plus UC) or UC alone (lipid management directed by treating physician’s discretion). The study took place at 45 sites across 20 states in the USA. Treating physicians had access to LDL-C measurements and were encouraged to intensify treatment per clinical practice guidelines. This prespecified subgroup analysis evaluated LDL-C goal attainment by timing of the most recent ASCVD event (&amp;lt;1 year/≥1 year prior to consent), ASCVD subtype (coronary heart disease [CHD], peripheral arterial disease [PAD], and cerebrovascular disease [CVD]) and statin intolerance status. Cumulative LDL-C exposure over time in the overall population and safety by subgroup were also evaluated. Results Of 450 patients randomised to IF or UC, 11.1% and 84.2% had an ASCVD event &amp;lt;1 year or ≥1 year prior to consent, respectively; 91.8%, 18.2% and 14.7% had a history of CHD, CVD or PAD, and 25.8% were statin intolerant. Cumulative exposure to LDL-C to Day 330 was lower in patients treated with IF vs UC (mean time-adjusted LDL-C: 42.4 mg/dL vs 90.7 mg/dL, Figure). Significantly more patients who received IF achieved LDL-C goals of &amp;lt;70 mg/dL and &amp;lt;55 mg/dL at Day 330 vs UC, irrespective of subgroup (Table). Across subgroups, the incidence of treatment-emergent adverse events (TEAEs) and serious TEAEs were similar between IF and UC (IF: 52.6−71.2%, UC: 46.2−66.0% and IF: 10.7−28.3%, UC: 11.4−22.2%, respectively). Conclusions Participants with ASCVD and LDL-C &amp;gt;70 mg/dL who received IF had lower cumulative LDL-C exposure over the study period than those treated with UC. IF resulted in rapid and sustained achievement of LDL-C goals regardless of ASCVD subtype, event timing and statin intolerance. The safety profile of IF was consistent across the subgroups analysed.

Out of sight, into mind: a socioecological model-informed qualitative study on barriers and facilitators to hepatitis B care among West African immigrants in the Bronx, New York

BackgroundThere is a high burden of hepatitis B virus (HBV) in West Africa. Over the past 20 years, West African immigration to the United States (U.S.) has been increasing. Prevalence of HBV infection in West Africa has been reported to be as high as 5–10%.MethodsWe sought to understand knowledge and attitudes of and barriers and facilitators to HBV screening, vaccination, and treatment in a cohort of West African immigrants in the Bronx living with or at risk for HBV through a series of one-on-one qualitative interviews. We interviewed 23 West African immigrants and analyzed transcripts for recurring themes using Applied Thematic Analysis. We situated our analysis in the socioecological model (SEM) and adhered to the consolidated criteria for reporting qualitative research (COREQ).ResultsMultiple themes emerged, most prominently themes relating to HBV knowledge/awareness, trust in U.S. healthcare providers and the U.S. healthcare system, positive social support improving healthcare access, knowledge sharing, stigma towards those with HBV, issues concerning immigration status, insurance status, and access to healthcare services.ConclusionRaising awareness of HBV, addressing social and structural barriers such as stigma and health insurance, and improving access to culturally sensitive programs among West African communities are needed to increase HBV screening, vaccination, and linkage to care.

Language barrier as social determinant of health: unmasking the disparities in the emergency department evaluation for patients with chest pain at a community hospital

Abstract Background/Introduction Patients with limited English proficiency (LEP) constitute 8.6% of the United States population. They may have lower health literacy related to cardiovascular disease, reluctance to seek care, and communication difficulties in reporting symptoms, posing challenges to care provision. Throughout medical literature, these barriers reportedly lead to increased utilisation of diagnostic testing, hospital admission rate, and length of stay. Purpose Language barrier appears to negatively impact individuals' healthcare experience. The goal of this study is to examine whether disparities exist in the emergency department (ED) evaluation and management of chest pain in LEP patients by comparing their wait time and admission rate to that of English-proficient (EP) counterparts. Methods This retrospective cohort study included adults age 18 or older that presented to our hospital ED with a chief complaint of chest pain from 1/9/2022 to 30/9/2023. We identified all LEP patients during this period and matched a random sample of EP patients in a 1:2 ratio. We treated each encounter as an independent subject and eliminated those that left prior to disposition. Our primary outcomes were time from arrival to provider evaluation, and admission rate. Covariates were sex, age, race, acuity level, arrival mode, and insurance status to adjust for characteristic difference between cohorts. Descriptive comparisons between cohorts and bivariate outcomes were conducted using independent samples t-tests for continuous variables and chi-squared tests for categorical ones. Multivariable linear and logistic regression models were used to compute adjusted mean wait time for provider and adjusted odds of admission, respectively. All analyses were done on SAS 9.4. Results Our study sample included 690 encounters, with 239 LEP and 451 EP patients. The two cohorts were similar in sex, age, and acuity level, but there were significant disparities in insurance status, arrival mode, and race. A higher proportion of EP patients were admitted to the hospital or observational unit than LEP patients (45.0% vs. 28.0%, respectively, P&amp;lt;0.001). After multivariable adjustment, LEP patients were half as likely to be admitted compared to EP patients (adjusted odds ratio, 0.51 [95% CI, 0.35-0.74], P&amp;lt;0.001). LEP patients waited longer for provider evaluation from the point of ED arrival, though this was not statistically significant when adjusting for acuity and arrival mode (19.6 minutes, [95% CI, 5.9-45.1], P=0.132). Conclusions Whilst we did not observe a significant difference in wait time for provider between LEP and EP patients, LEP patients were less likely to be admitted when presenting with chest pain at the ED. One possibility is that language barrier may limit a patient’s ability to convey cardiac versus non-cardiac chest pain, adversely influencing downstream management and outcomes. To address this, further large-scale investigation is needed.

Factors Influencing Health Literacy among South Korean Adults: A Nationwide Study

Abstract Background Health literacy is crucial for health knowledge, behaviors, and outcomes, but research on health literacy has been limited to specific populations and settings in South Korea. This study aimed to identify factors influencing health literacy in a nationally representative sample of South Korean adults to inform public policies. Methods This cross-sectional study utilized data from the 2020 Korea Health Panel survey (10,262 adults aged 18-84 years). Sociodemographic factors (age, gender, education level, monthly household income, employment status, marital status, household characteristics, and region) and health (subjective health status, presence of chronic diseases, depression, and health insurance status) factors were examined. Health literacy was assessed using the 16-item European Health Literacy Survey Questionnaire (HLS-EU-Q16). Linear regression analysis was performed to identify factors associated with health literacy. Results The mean health literacy score was 9.1 (SD 1.60), with significant differences across age groups (p &amp;lt; 0.001). Linear regression analysis (adjusted R2=0.287, F = 322.83, P &amp;lt; 0.001) revealed that higher age, female gender, lower education, lower household income, being single, living outside a metropolitan area, having chronic diseases, lower subjective health, depression, and being uninsured or receiving medical aid were significantly associated with lower health literacy (all p &amp;lt; 0.001). Conclusions This study identified several socio-economic and health-related factors significantly associated with health literacy among South Korean adults. The findings suggest that older individuals, who may require more time to understand and use health information, are particularly vulnerable to low health literacy. These results provide valuable insights for developing targeted interventions and public health policies aimed at promoting health literacy and successful aging in the context of a rapidly aging society. Key messages • Various socio-economic and health-related factors significantly influence health literacy among South Korean adults. • Older individuals are particularly vulnerable to low health literacy, which has implications for successful aging in a rapidly aging society.

Factors Associated with Inequities in Donor Milk Bank Access Among Different Hospitals.

Objective: Donor human milk (DHM) can provide many benefits to neonates. This study examines access to DHM and how structural barriers may exacerbate inequities. Study Design: The median test and analysis of variance test were used to compare the distribution of maternal race/ethnicity and insurance status variables with DHM access for California neonatal intensive care units (NICUs) in 2021. Results: Across 124 NICUs, those serving a higher percentage of white families were more likely to have access to DHM (p = 0.04). NICUs with a higher percentage of Hispanic families were less likely to have access to DHM (p = 0.03). Hospitals that had higher proportions of uninsured patients were also less likely to have access to DHM (p = 0.015). Conclusion: Inequities in DHM access and use among NICU infants begin at the structural level. Policies that reduce barriers to DHM access may reduce health inequities for Hispanic and uninsured families.

Determinants of health-seeking behaviour in rural district of Jasikan, Ghana: a cross-sectional study

BackgroundThe Ghana Health Service aims to ensure the health of all Ghanaians. Understanding the factors that influence people’s health-seeking behaviour will help the Ghana Health Service evaluate and enact policies that will enable it to achieve set targets. This research aimed to determine the factors that influence the health-seeking behaviour of the residents of Jasikan District and ascertain the importance of the well-being clinic in this context.MethodsThe study design was a community-based cross-sectional study using a mixed method of data collection. A stratified sample of 295 respondents from the five [5] sub-districts of the target population was obtained. Cramer’s V statistic was used to assess the effect size and significance of the association between categorical variables. Further, multiple binary logistic regression was used to determine significant predictors of health-seeking behaviour. Health seeking behaviour was categorised as appropriate or inappropriate. The health seeking behaviour of participants was considered appropriate if they sought health care at public health facilities, private health facilities, and licensed Pharmacies/OTCMS and inappropriate when participants sough care at traditional/faith healers, engaging in self-medication, and not taking action during an illness episode.ResultsThe mean age of participants in the study was 37.49 ± 15.74 years. Females comprised the majority of study respondents (160; 56.3%). When they fell ill, 61% of respondents chose formal public health institutions as the first port of call. A significant proportion of respondents (245; 83%) preferred appropriate health-seeking behaviour, with age (p = 0.045) and health insurance status (p < 0.01) significantly influencing where respondents sought care. More than half of respondents indicated that affordable service (59.9%), readily available drugs (54.5%), and good services (52.0%) are key characteristics of respondents’ preference for service in healthcare. The educational level significantly correlated with service characteristics when people seek health care (p = 0.035). The severity of illness (9; 28.1%), perception of a facility as the best place (7; 21.9%), well-trained staff (4; 12.5%), and professionalism (3; 9.4%) influenced respondents’ choice of health care. More than half (78%) of respondents agreed with the need for a well-being clinic in a hospital. The binary logistic regression indicates that religion is a significant predictor the appropriateness of participants’ health seeking behaviour, but the overall model could not improve the overall prediction rate of the constant model.ConclusionThe health-seeking behaviour of the people of Jasikan is good. The participants’ sex, good service, affordability, and availability of medicines are critical service characteristics that influence the choice of healthcare providers. Managers of health facilities should consider these characteristics to remain competitive and drive positive health-seeking behaviour in the community. Facilities are encouraged to set up a functional well-being clinic and open it to the public.

Insurance remains a major source of disparity for patients with testicular cancer: call for advocacy.

To evaluate the effects of socioeconomic factors, including insurance status, on treatment and survival for patients with testicular cancer. We extracted a retrospective cohort from the National Cancer Database that included patients diagnosed with testicular cancer 2004-2020. Competing-risks and Cox regression multivariate models including demographic, pathological, and socioeconomic covariates were constructed to evaluate receipt of treatment and death, respectively. A total of 95 955 patients with testicular cancer were identified. Compared with private insurance, Medicaid (sub-distribution hazard ratio [SHR] 0.70, P < 0.001), Medicare (SHR 0.73, P < 0.001), and uninsured (SHR 0.72, P < 0.001) patients were associated with decreased likelihood of receiving chemotherapy. Compared with private insurance, Medicaid (SHR 0.55, P < 0.001), Medicare (SHR 0.76, P-value <0.001), uninsured (SHR 0.63, P-value < 0.001), and other government insurance (SHR 0.71, P = 0.010) was associated with decreased likelihood of receiving radiation. Medicaid insurance status (reference private, HR 2.60, P < 0.001) conferred the second largest hazard of death, behind having Stage III disease (reference Stage 0). Compared with private insurance, Medicare (HR 2.20, P < 0.001), no insurance (HR 2.32, P < 0.001), and other government insurance (HR 1.53, P = 0.027) statuses had higher risk of death. Patients diagnosed in Medicaid-expansion states had lower all-cause mortality (11.4% vs 13.6%, P < 0.001). Testicular cancer care relies on early diagnosis and treatment. It is critically important to have a healthcare system where individuals have access to insurance and are served equitably.

Association of borderline fetal growth with progression to fetal growth restriction.

To evaluate if an estimated fetal weight (EFW) between the 10-15th percentiles at time of anatomy ultrasound, referred to as borderline fetal growth, is associated with progression to fetal growth restriction (FGR) on subsequent ultrasound, delivery of a SGA neonate or neonatal intensive care (NICU) admission. We performed a secondary analysis using the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be data (NuMom2b). The exposures were normotensive pregnancies with non-anomalous singleton gestations with normal growth, defined as EFW >15th percentile at the anatomy scan compared to borderline fetal growth fetuses defined as those with an EFW in the 10-15th percentile. The primary outcome was FGR at subsequent ultrasound, defined as EFW or AC <10%. The secondary outcomes were NICU admission and small for gestational age (SGA) neonate. Univariable analyses were performed comparing maternal baseline demographic and clinical characteristics. Multivariable analysis was performed for the primary outcome with variables adjusted a priori for body mass index, smoking status, race/ethnicity, insurance status, and drug use. 4883 patients met inclusion criteria with 114 in the borderline fetal growth group and 4769 in the normal growth group. There were no significant differences in maternal demographic or medical characteristics (Table 1). In adjusted multivariable analysis, patients with borderline growth had significantly higher odds of being diagnosed with FGR at their subsequent scan (aOR 6.68, CI 3.98-11.20) compared to those with normal growth. For secondary outcomes, patients with borderline fetal growth were significantly more likely to have SGA neonates (6.14% vs. 2.67%, p= 0.025). There was no difference in admissions to the NICU between groups. Diagnosis of borderline fetal growth at time of anatomy scan was associated with a significantly increased odds of progression to FGR at subsequent scan and delivery of a SGA neonate.

Changes in BMI prior to and during the COVID-19 pandemic among children: a retrospective cohort study in San Francisco, CA

BackgroundThe COVID-19 pandemic led to dramatic changes in the lives of children that impact cardiometabolic health. Cities and counties had varying policies with respect to school closure, recreational programs, and efforts to mitigate food insecurity and economic distress. Our objective was to evaluate changes in BMI-z score and prevalence of overweight/obesity prior to and during the pandemic among children in San Francisco, CA, where public schools were closed for 18-months.MethodsThis was an electronic medical record-based retrospective cohort study. We included 15,401 children, 4–17 years of age at study onset. Our exposure was time into each of three time periods: (1) March 2018-February 2019; (2) March 2019-February 2020; (3) March 2020-August 2021 (the pandemic period of school closure). Generalized estimating equations (GEE) were used to assess changes in BMI-z score and overweight/obesity across the three time periods. We assessed for effect modification by age-category, insurance status, and race/ethnicity.ResultsMean BMI-z score increased by 0.06 per year in time period 2, the year prior to the pandemic (p < 0.001, 95% CI: 0.04, 0.09), and by 0.12 per year during time period 3, the first 18 months of the pandemic (p < 0.001, 95% CI 0.10, 0.13). The proportion of children with overweight/obesity increased by 1.4% points per year during time period 2 (p = 0.012, 95% CI: 0.03, 2.46) and by 4.9% points per year during the first 18 months of the pandemic (p < 0.001, 95% CI: 4.11, 5.67). The effect modification analysis demonstrated that the youngest age group, publicly insured children (versus privately insured), and Black, Latino, and Asian children (versus White children) experienced greater increases in BMI-z score during the pandemic (p < 0.01 for all comparisons). The youngest age group (p = 0.022) and publicly insured children (versus privately insured children) (p < 0.001) also experienced greater increases in the proportion of children with overweight/obesity during the pandemic.ConclusionsAmong children in San Francisco, increases in BMI-z score and overweight/obesity were greater during the pandemic compared to prior changes, with the most pronounced increases among younger and publicly insured children. These findings support the need for more targeted and effective policies for addressing childhood overweight/obesity, especially among these high-risk populations.

Adherence to Pediatric Screening.

Preventive screenings in children encourage maintenance of optimal cardiovascular health, but gaps may exist between recommendations and clinical practice. We evaluated adherence to pediatric guidelines for universal age-based and risk-based screening for body mass index, blood pressure, lipids, and blood glucose. We used 2010 to 2018 ambulatory visit data from children aged 2 to 12 years within CAPRICORN (Chicago Area Patient-Centered Outcomes Research Network), an electronic health record network in Chicago. This study included 87 549 children who attended 197 559 well-child encounters. Across all encounters, children were 51.5% male and mean (SD) age 6.4 (3.3) years. For each child who attended a well-child visit and met age and/or risk-based criteria, receipt of body mass index, blood pressure, lipids, and/or hemoglobin A1c or fasting blood glucose measurements were assessed. We used generalized estimating equations to calculate proportion adherence for each metric overall and stratified by age, sex, race and ethnicity, and insurance status. Universal age-based screening prevalence (95% CI) per 100 eligible visits was 77.1 (76.8-77.3) for body mass index, 33.4 (33.1-33.7) for blood pressure, and 9.6 (9.3-9.9) for lipids. Risk-based screening prevalence (95% CI) per 100 eligible visits was 13.9 (12.2-15.9) for blood pressure, 6.9 (6.4-7.5) for lipids, and 13.3 (12.6-14.1) for blood glucose. Early screening of cardiovascular health risk factors could lead to earlier interventions, which could alter cardiovascular health trajectories across the lifetime. Low-to-moderate levels of adherence to universal age-based and risk-based cardiovascular health screening highlight the gap between recommendations and clinical practice, emphasizing the need to understand and address barriers to screening in pediatric populations.

Association Between Insurance Status and Nonelderly Penile Squamous Cell Carcinoma Survivorship: A National Retrospective Analysis

Background: Penile squamous cell carcinoma is an aggressive malignancy with significant physical and psychological impacts. Socioeconomic factors influence prognosis in genitourinary cancers, making the investigation of insurance status critical for reducing cancer burden and promoting health equity. Materials and Methods: Men diagnosed with primary penile squamous cell carcinoma from 2007 to 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) national database. Participants were categorized based on insurance status: privately insured, Medicaid, and uninsured. Pearson’s chi-squared test assessed the distribution of observed frequencies between the patient demographics, socioeconomic status, tumor characteristics, and surgical variables across the insurance groups. Overall and cancer-specific survival was estimated using a multivariate Cox hazards proportional model analysis. Results: The multivariate Cox hazards proportional model showed that, compared to privately insured patients, Medicaid patients had an increased risk for overall death (hazard ratio [HR] = HR 1.54; 95% CI, 1.12–2.07). For cancer-specific mortality, Medicaid patients had an increased risk of death compared to privately insured patients (HR 1.58; 95% CI, 1.11–2.25). Conclusions: Medicaid does not mitigate the differences caused by health insurance status due to health insurance disparities for overall or cancer-specific mortality. Lower Medicaid reimbursements and out-of-pocket costs lead to a narrow network of physicians, hospitals, and treatment modalities that compromise health equity. Increasing awareness of health insurance disparities and improving access to care via a clinician–community–governmental partnership can potentially lead to improved predictive outcomes.

Barriers and facilitators of healthcare access for long COVID-19 patients in a universal healthcare system: qualitative evidence from Austria

BackgroundLong COVID-19 challenges health and social systems globally. International research finds major inequalities in prevalence and healthcare utilization as patients describe difficulties with accessing health care. In order to improve long-term outcomes it is vital to understand any underlying access barriers, for which relevant evidence on long COVID-19 is thus far lacking in a universal healthcare system like Austria. This study aims to comprehensively identify access barriers and facilitators faced by long COVID-19 patients in Austria and explore potential socioeconomic and demographic drivers in health and social care access.MethodsApplying an exploratory qualitative approach, we conducted semi-structured interviews with 15 experts including medical professionals and senior health officials as well as focus groups with 18 patients with confirmed long COVID-19 diagnosis reflecting varying participant characteristics (age, gender, urbanicity, occupation, education, insurance status) (July-Nov 2023). Data were analysed following a thematic framework approach, drawing on a comprehensive ‘access to health care’ model.ResultsBased on expert and patient experiences, several access barriers and facilitators emerged along all dimensions of the model. Main themes included scepticism and stigma by medical professionals, difficulties in finding knowledgeable doctors, limited specialist capacities in the ambulatory care sector, long waiting times for specialist care, and limited statutory health insurance coverage of treatments resulting in high out-of-pocket payments. Patients experienced constant self-organization of their patient pathway as stressful, emphasizing the need for multidisciplinary care and centralized coordination. Facilitators included supportive social environments, telemedicine, and informal information provided by a nationwide patient-led support group. Differences in patient experiences emerged, among others, as women and younger patients faced gender- and age-based stigmatization. Complementary health insurance reduced the financial strain, however, did not ease capacity constraints, which were particularly challenging for those living in rural areas.ConclusionsThe findings of this study indicate a call for action to improve the long COVID-19 situation in Austria by empowering both providers and patients via increased information offerings, strengthened interdisciplinary treatment structures and telemedicine offerings as well as research funding. Our insights on potentially relevant socioeconomic and demographic drivers in access barriers lay the necessary foundation for future quantitative inequality research.

Socioeconomic Determinants of Health and Reflux Management: Insights from a Tertiary Medical Center.

To assess the correlation of social determinants of health (SDOH) with the general care patterns related to gastroesophageal reflux disease and laryngopharyngeal reflux. Determine correlation of SDOH on utilization rates for medication, reflux testing and surgical intervention for patients diagnosed with reflux. Describe overall care patterns for gastroesophageal reflux disease care at a tertiary academic facility. Retrospective chart review. Patient demographics (age, sex, race, ethnicity, and insurance status) were extracted for adults diagnosed with reflux between 2009 and 2019. Odds ratios (ORs) for the associations between sociodemographic factors and reflux treatment pathways were determined by chi-square analyses. A total of 143,786 patients were evaluated during the study period with a diagnosis code of reflux. A subgroup of 40,754 patients had objective reflux testing including Bravo, dual pH-impedance, manometry, esophagogastroduodenoscopy (EGD) and esophagram, but no significant difference in utilization rates was found. A total of 239 patients who failed medical management underwent fundoplication. White (OR 2.43, 95% confidence interval [CI] 1.56-3.70) and female (OR 1.37, 95% CI 1.05-1.79) patients were more likely to undergo fundoplication than Black (OR 0.42, 95% CI 0.25-0.70) and male (OR 0.72, 95% CI 0.55-0.95) patients. Patients with private insurance (OR 1.58, 95% CI 1.23-2.04) were more likely to undergo fundoplication than those with public insurance (OR 0.65, 95% CI 0.50-0.84). Male patients were less likely to undergo fundoplication (OR 0.69, 95% CI 0.49-0.98) among patients evaluated for reflux with EGD. SDOH correlate with patterns of reflux evaluation and management at our tertiary care center. IV Laryngoscope, 2024.

A Demographic Description of Children and Adolescents With Concomitant Autism and Anxiety Along With a Comparison of Receipt of Psychological Services

Objective: (1) Evaluate differences in demographic distributions between those with autism alone and those with autism concomitant with anxiety and (2) assess demographic factors associated with receipt of psychological therapy in patients with autism. Methods: Using deidentified health care claims data, we extracted all encounters among children with the International Classification of Diseases-10-CM for Autism Spectrum Disorder (F84) and flagged those with concomitant anxiety (F41.9). Extracted data included age, sex, race, ethnicity, insurance status, and Rural-Urban Continuum Codes. Current procedural terminology codes for psychological services were extracted. Data were analyzed using Mann–Whitney U tests, χ2 tests of association, and logistic regression. Results: Demographic differences between children/adolescents with autism alone versus autism concomitant with anxiety were noted for age, sex, and race/ethnicity, with a greater prevalence of autism/anxiety identified in older-aged children and children identifying as female and non-Hispanic White residing in an urban area. While 21% of those included in this study had received psychotherapy, the percentages within the autism only and autism/anxiety groups were 12% and 50%, respectively (p &lt; 0.001). Children/adolescents who were older age quartile, resided in an urban residence, and with a concomitant diagnosis of anxiety were more likely to receive psychological services, while non-Hispanic Other were less likely to, compared with the reference of non-Hispanic White. Conclusion: We identified demographic disparities in the diagnosis of autism versus autism with concomitant anxiety, including age, sex, race/ethnicity, and residence location. Age quartile, urban location, and concomitant anxiety were associated with increased likelihood of receipt of psychological services.

Impact of Race, Ethnicity, Insurance, and Procedural Timing on Sterilization Method.

Objective: This study aims to determine if race, ethnicity, insurance status, or procedural timing is associated with type of sterilization procedure. Methods: A retrospective cohort study was performed. The study population included women who underwent elective sterilization at one institution from January 2010 to December 2020. The medical record was reviewed to obtain age, race, ethnicity, procedure type and timing, and insurance status. Race and ethnicity groups included were Asian, non-Hispanic Black, Hispanic, or non-Hispanic White. Timing was divided into peripartum (at the time of cesarean section or before discharge after vaginal delivery) and interval procedures. Multivariate logistic regression was performed to assess the association of procedure type with race, ethnicity, insurance status, and timing. In addition, a sensitivity analysis was performed for procedures after January 1, 2016, to determine if the associations with the above categories differed. Results: A sample of 2,041 individuals received sterilization procedures, and 1,115 were included in the analysis: 70% (782) of sterilizations were performed during the peripartum period, and 60% (670) of women had public insurance. On multivariate analysis, both non-Hispanic Black (odds ratio [OR] 0.54 95% confidence interval [CI] 0.32-0.89) and Asian (OR 0.23 95% CI 0.06-0.72) individuals were less likely to have salpingectomy (SL) when compared with non-Hispanic White individuals. On sensitivity analysis for procedures after January 1, 2016, non-Hispanic Black (OR 0.31 95% CI 0.17-0.56), Hispanic (OR 0.31 95% CI 0.14-0.66), and Asian (OR 95% CI 0.04-0.54) individuals were less likely to have when compared with non-Hispanic White individuals. Conclusion: Tubal ligation is more frequently performed in our health system, and we identified critical disparities in performance of SL for sterilization.

30-Day Readmissions and the Need for Emergency Surgery Following Non-Operative Management of Perforated Diverticulitis.

Background: Limited data are available on the evaluation and outcomes of patients with perforated diverticulitis who were treated without surgery. Aims: This retrospective review was aimed at investigating the 30-day non-elective re-admission rates for patients hospitalized with perforated diverticular disease who were treated without surgery, rates of patients requiring surgery on re-admission, and the independent predictors of re-admission. Methods: A total of 143,546 patients from the National Readmission Database, between 2016 and 2020, who were admitted with perforated diverticulitis and treated non-operatively were reviewed. Re-admitted patients were compared with those not re-admitted. Comparisons for continuous and categoric variables were made using the student t-test and chi-squared test, respectively. A logistic regression model was used to determine independent factors associated with re-admission. All analyses were done with SAS 9.4; p values <0.05 identified significance. Results: Among patients with perforated diverticulitis who were treated non-operatively, 17,868 (12.4%) were re-admitted within 30 days and 4,924 (27.6%) of patients re-admitted required surgical intervention. The greatest independent predictors of re-admission include patient insurance status, index length of stay, undergoing a drainage procedure, and patient disposition. Comorbidities predicting re-admission include renal failure, chronic pulmonary disease, diabetes mellitus, fluid and electrolyte disorders, and hypertension. Hospital total charges were greater at the index admission for patients requiring re-admission. Conclusion: Non-operative management of perforated diverticulitis is safe for many patients, but the risks for re-admission and subsequent need for emergency surgery require special consideration.

PROVA DA CONDIÇÃO DE SEGURADO ESPECIAL PARA ACESSO À APOSENTADORIA RURAL: DESAFIOS E PERSPECTIVAS NO CONTEXTO JURÍDICO BRASILEIRO

The present study aims to analyze the challenges and perspectives related to proving the condition of special insured status for access to rural retirement in Brazil. The study investigates the obstacles faced by rural workers in producing such proof, identifying the main associated judicial demands. Specifically, it seeks to understand the requirements for the granting of rural retirement in Brazilian law, identify the main challenges for proving rural worker status in both administrative and judicial contexts, and analyze judicial decisions and official documents to observe how the courts have addressed the issue. It was found that the absence of formal records, such as workbooks or contracts, is a factor that contributes to legal uncertainty and the denial of rights to these workers. Judicial decisions have played a fundamental role by adopting a more flexible stance in accepting testimonial evidence and alternative documents, aiming to ensure that rural workers are not penalized for the lack of formal documentation. However, there are still significant gaps between legislation and the reality faced by these workers, highlighting the need for more inclusive public policies to ensure full access to social security rights.