Lower Median Household Income Research Articles

Factors Associated With Quality Care Among Adults With Rheumatoid Arthritis

Although quality care markers exist for patients with rheumatoid arthritis (RA), the predictors of meeting these markers are unclear. To explore factors associated with quality care among patients with RA. A retrospective cohort study using insurance claims from 2009 to 2017 was conducted, and 6 sequential logistic regression models were built to evaluate quality care markers. Quality care markers were measured at 1 year post-RA diagnosis for each patient. The MarketScan Research Database, which contains commercial and Medicare Advantage administrative claims data from more than 100 million individuals in the US, was used to identify patients aged 18 to 64 years with a diagnosis claim for RA. Patients with conditions presenting similar to RA and missing demographic characteristics were excluded. Data analysis occurred between February 18 and May 5, 2022. Success or failure to meet selected RA quality care markers within 1 year after RA diagnosis. Prevalence of meeting successive quality care markers for RA. Among 581 770 patients, 430 843 (74.1%) were women and the mean (SD) age was 48.9 (11.3) years. Most patients (236 285 [40.6%]) resided in the South and had an income less than or equal to $45 200 (490 366 [84.3%]). Of the total study population, 399 862 individuals (68.7%) met at least 1 quality care marker and 181 908 (31.3%) met 0 markers. Most commonly, patients met annual laboratory testing (299 323 [51.5%]) and referral to a rheumatologist (256 765 [44.1%]) markers. The least met marker was receiving hepatitis B screening prior to initiation of disease-modifying antirheumatic drug (DMARD) therapy (18 548 [3.2%]). Women were most likely to meet all quality care markers except receiving DMARDs with hepatitis B screening (odds ratio, 1.14; 95% CI, 1.12-1.16). Individuals with lower median household income had lower odds of receiving a rheumatologist referral, an annual physical examination, or annual laboratory testing, but greater odds of receiving the other quality care markers. Patients with Medicare and those with comorbidities were generally less likely to meet quality care markers. In this cohort study of patients with RA, findings indicated downstream associations with rheumatologist referral and receiving DMARDs and varied associations between meeting quality care markers and patient characteristics. These findings suggest that prioritizing early care, especially for vulnerable patients, will ensure that quality care continues.

Increases in Ambulance Call Volume Are an Early Warning Sign of Major COVID-19 Surges in Children.

Background: Infectious diseases, including COVID-19, have a severe impact on child health globally. We investigated whether emergency medical service (EMS) calls are a bellwether for future COVID-19 caseloads. We elaborated on geographical hotspots and socioeconomic risk factors. Methods: All EMS calls for suspected infectious disease in the pediatric population (under 18 years of age) in Rhode Island between 1 March 2018 and 28 February 2022 were included in this quasi-experimental ecological study. The first of March 2020 was the beginning of the COVID-19 pandemic. We used the 2020 census tract and the most recent COVID-19 data. We investigated associations between pediatric EMS calls and positive COVID-19 tests with time series analysis and identified geographical clusters using local indicators of spatial association. Economic risk factors were examined using Poisson regression. Results: We included 980 pediatric ambulance calls. Calls during the omicron wave were significantly associated with increases in positive COVID-19 tests one week later (p < 0.001). Lower median household income (IRR 0.99, 95% CI [0.99, 0.99]; p < 0.001) and a higher child poverty rate (IRR 1.02, 95% CI [1.02, 1.02]; p < 0.001) were associated with increased EMS calls. Neighborhood hotspots changed over time. Conclusion: Ambulance calls might be a predictor for major surges of COVID-19 in children.

Evaluating the Effect of Socioeconomic Status on Complex Abdominal Wall Reconstruction Outcomes.

In complex abdominal wall reconstruction, maintenance and follow-up are vital to effective long-term patient care. This can present a challenge for individuals from a low-income household who may have less ability to afford time away from work or caring for dependents as well as challenges with transportation to and from follow-up appointments. Given the expenses and high complication rate in abdominal wall reconstruction, we elected to determine whether socioeconomic status had an impact on patient outcomes. After obtaining institutional review board approval, all patients who underwent complex abdominal wall reconstruction between 2002 and 2021 by the senior author were reviewed in a retrospective cohort analysis of a prospectively maintained database. Complications were classified into overall, major, infection, and delayed wound healing. Outcomes were classified into recurrence and reoperation. The cohort was divided by median household income (MHI) level and race. A total of 478 patients received complex abdominal wall repair over a 19-year interval. A total of 324 patients identified MHI as <$75,000 (low MHI), and 154 patients identified MHI as > $75,000 (high MHI). Mean patient age was 53.9 (SD, 12.3) years. Mean patient body mass index (BMI) was 32.1 (SD, 7.8) kg/m 2 . There was no significant difference in age between the 2 MHI cohorts. There was a significant difference in BMI between MHI cohorts, with higher BMI among patients with low MHI ( P = 0.0001). The majority of risk factors and surgical techniques were comparable. There was a statistically significant difference in hernia etiology, with higher rates of recurrent hernia repair among patients with low MHI ( P = 0.007). The risk of overall complications ( P = 0.0307) and delayed wound healing ( P = 0.0263) was higher among patients with low MHI. Median household income was found to be an independent risk factor for complications after controlling for BMI, diabetes mellitus, and hernia etiology. There was no significant difference in follow-up time between cohorts. Patients with low MHI who undergo complex abdominal wall reconstruction are at an increased risk for complications and poor outcomes, including delayed wound healing and hernia recurrence. This indicates the need to provide resources to address barriers to follow-up and maintenance following complex abdominal wall reconstruction in this patient cohort.

Demographic Characteristics and Outcomes in Patients with ALL and Previous Diagnosis of CML or MDS

Introduction: Acute Lymphocytic Leukemia (ALL) is a malignancy of lymphocytes characterized by uncontrolled proliferation of immature cells which ultimately leads to the replacement of bone marrow and other lymphoid organs. Typically, ALL develops in a previously healthy person however, it can rarely progress from an existing Myelodysplastic syndrome (MDS) or Chronic Myeloid Leukaemia (CML). In this study, we highlight the baseline characteristics and outcomes in patients with ALL and previous diagnoses of MDS or CML. Methodology: Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) was queried to identify all ALL admissions between 2016-2019 in adult patients with a secondary diagnosis of MDS or CML using International Classification of Disease 10th Revision (ICD-10) codes. We evaluated baseline characteristics including Age, Sex, Race, Insurance type, Median household income, Region of hospital, Hospital Bed size, and Location/teaching status of hospital, in addition to mortality as the primary outcome and length of the hospital stay (LOS) and total hospital charges (THC) as secondary outcomes. Results: A total of 27385 patients with ALL were hospitalized and among them, 195 (0.7%) had a secondary diagnosis of CML. The mean age of the CML group was non-significantly higher (51.3 vs. 48.5) compared to those without CML. In patients with ALL and previous CML, there was a higher proportion of female sex, black race, Medicaid insurance, hospitalizations in south and west region, small sized hospitals in comparison to those with ALL without previous CML. though not statistically significant as reflected in Table (1). There was no difference in, Charlson comorbidity index, and household income. CML group had non-significantly lower odds of mortality in comparison to patients without CML (5.1% vs 5.8 % P=0.84) with adjusted odds ratio (AOR) of 0.79 (p=0.75 CI 0.18-3.34). Patients with a higher Charlson comorbidity index had significantly higher odds of mortality (1.68 with P=0.022). Among secondary outcomes, the CML group had a higher mean length of stay (20.3 vs 18) and lower THC ($240161 vs $279386) although this did not reach statistical significance. Out of all patients admitted with ALL, 180 (0.6%) had a secondary diagnosis of MDS, and the mean age of the MDS group was higher (62.6 vs. 48.4) compared to the other group. In ALL patients with previous MDS group, there was a significantly higher proportion of people with Medicare insurance, and hospitalization in the south and west region. There was a trend towards an increased proportion of Female sex, white Race, lower median household income, small sized hospitals in comparison to ALL without previous MDS group though it was not statistically significant (Table1). Patients with ALL and a previous Diagnosis of MDS had non-significantly higher odds of mortality (11% vs 6 %) in comparison to patients without MDS (AOR 1.7 p=0.32 CI 0.60-6.65). Among the secondary outcomes, the MDS group had a non-significantly lower mean LOS (12 vs 18) and lower THC ($243389 vs $ 279112). Conclusion: In this analysis, we found that sex, race, insurance type, median household income, and region of the hospitalization impacts the risk of developing ALL after MDS or CML. Prospective studies are required to look into the cause of these differences as it can be related to the socioeconomic disparities or specific gene mutations more prevalent in certain races of regions. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 13858: The Epidemiological Characteristics &amp; Outcome Trend of Cannabis Abuse Among Stroke Hospitalizations in the United States - A Nationwide Study

Background: With the legalization of cannabis in many states for medical or recreational purposes, cannabis utilization has been increased to treat various health concerns. However, little is known about the prevalence of cannabis abuse and outcome trend among acute ischemic stroke (AIS) patients. This study examines the epidemiological characteristics and outcome trend of cannabis abuse among adults with AIS hospitalizations in the USA. Methods: We performed a population-based retrospective analysis of the Nationwide Inpatient Sample over year from 2003 to 2017 in adult hospitalizations for AIS to compare the outcomes [death, risk mortality &amp; discharge disposition (short-term hospital / skilled nursing home/home health care)] in cannabis abusers using ICD 9 &amp; 10 codes. We performed weighted analyses using chi-square, t-test, and Cochran-Armitage trend test. Results: Amongst the total of 5,690,773 AIS hospitalizations, 50,895 (0.89%) cannabis users were identified from 2003 to 2017. The prevalence trend of cannabis abuse has increased among stroke hospitalizations (2003: 0.22% to 2017:1.64%; p-trend &lt; 0.0001). The cannabis abuse was higher among the younger to middle age compared to older aged stroke hospitalization (&lt;50 year: 3.89% vs 50-75 year: 1.09% vs &gt;75 year: 0.02%; p &lt;0.0001). Cannabis abuse was more prevalent among the male (1.32% vs female: 0.50%), Black (2.29% vs White: 0.61%; p&lt;0.0001). The cannabis abusers had lower median household income (1.39% vs higher income:0.44%), medicaid insurance (3.61% vs medicare: 0.31%), highly prevalent in midwest (1.05% vs northeast: 0.57%; p&lt;0.0001). There was also increased trend in mortality (2003: 0.38% to 2017: 0.97%), extreme/major likelihood of dying (2003: 0.21% to 2017: 1.22%), extreme/major loss of function (2003: 0.19% to 2017: 1.52%), discharge to non-home (2003: 0.14% to 2017: 1.25%; p-trend&lt;0.0001) among cannabis abusers following stroke hospitalizations. Conclusion: This study identified a higher prevalence of abuse, abuse-related poor outcomes, and higher stroke-related mortality among stroke survivors. Cannabis use in patients with neurovascular insults has raised safety concerns, and more long-term research is needed to determine its risks and benefits in stroke patients.

Abstract 14034: 30-day Readmission Rates of Cardiogenic Shock: A Nationwide Analysis of Inpatient Demographics and Clinical Outcomes

Introduction Cardiogenic shock (CS) is a common medical emergency that causes significant morbidity and mortality. Our aim was to characterize patient demographics and analyze the factors that increase the likelihood for CS readmissions. Methods This was a retrospective cohort study using the 2019 Nationwide Readmissions Database (NRD) database to identify admissions in adults with principal diagnosis of CS. Results The index CS admission cohort was 62.2% males, mean age 66.9 years. Of 146,254 index admissions with CS, 19,238 (20.4%) were readmitted. 30-day mortality rate (MR) of index admission was 35.4%, with a MR of 9.7% in those readmitted. The most common cause for readmissions was acute heart failure (26.7%). Patients with the lowest median household income, Medicare, and Medicaid insurance were more likely to be readmitted (1.10 OR 95% CI 1.04 -1.16, p &lt;0.01, 1.17 OR 95% CI 1.11-1.24, p &lt;0.001 and 1.27 OR 95% CI 1.12-1.86, p &lt;0.001 respectively). Meanwhile, being in the highest median household income quartile (&gt;75 th ) or having private insurance were protective against readmission. Acute MI patients were less likely to be readmitted (0.83 OR 95% CI 0.79 -0.87, p &lt;0.001). Diastolic HF and CHF were associated with increased odds of readmission when adjusted for other comorbidities, age, and gender (2.52 OR 95% CI 1.09-5.83, p&lt;0.031 and 2.15 OR 95% CI 1.01-4.57, p&lt;0.046 respectively). Conclusion Readmission after CS is common, with high mortality. Risk factors for readmission include lower household income and Medicare/Medicaid insurance, and those that leave AMA after index cardiogenic shock admission have increased odds of readmission. Conversely, those with the highest median household income and with private insurance had a significantly lower rate of readmission. Additional research is needed to elucidate the contributing factors for this stark difference.

Abstract 322: Impact Of Safety Net Hospital Burden On Outcomes Of In-hospital Cardiac Arrest In The United States.

Background: Safety net hospitals treat a large burden of uninsured, or Medicaid insured patients, and have been linked to worse outcomes across several medical and surgical conditions. Currently, there is limited data on the effect of safety net burden on outcomes of inpatient cardiopulmonary resuscitation (CPR) for patients that suffered in-hospital cardiac arrest (IHCA) in the US. Hypothesis: Patients that experience IHCA in high burden safety net hospitals (HBH) will have worse outcomes compared to low burden safety net hospitals (LBH). Methods: Using the National Inpatient Sample database, from 2008 – 2018, we identified patients aged ≥ 18 years who experienced IHCA, using International Classification of Diseases (ICD) codes. Hospitals’ safety net burden was calculated from the proportions of Medicaid and uninsured patients using previously published methodology and categorized into LBH and HBH. Multivariate regression models were used to estimate the odds of key clinical outcomes Result: From 2008 to 2018, an estimated 555,016 unweighted adult hospitalizations underwent CPR for IHCA, out of which 19.2 % occurred at LBH and 55.2 % occurred at HBH. Compared with LBH, patients at HBH on average were younger 62 years ± 20 vs 67 years ± 17), less likely to be of White race, and more likely to be in the lowest median household income. On multivariate regression analysis, HBH was associated with lower chances of survival to hospital discharge (aOR 0.88; 95% CI 0.85 – 0.96) and lower odds of routine discharge (aOR 0.6; 95% CI 0.47 – 0.75)), compared to LBH. Patients who suffered IHCA in safety net hospitals with medium and large hospital bed size (aOR 0.96; 95% CI 0.94 – 0.98) and those publicly owned (aOR 0.95; 95% CI 0.92 – 0.98) were less likely to survive to hospital discharge. Median household income of patients in the 26 th – 100 th quartile and hospital location in the Midwest and Southern region were associated with better odds of hospital survival. Conclusion: Our study suggests that patients who experience IHCA at HBH had lower rates and odds of in-hospital survival and also less likely to be routinely discharged home. Patients’ income level and hospital-level characteristics appear to contribute to survival.

Longitudinal analysis of tobacco and vape retail density in California.

INTRODUCTIONTobacco retailer density may be associated with greater youth initiation and reduced success during quit attempts; however, the extent to which tobacco retailer density has changed overtime across multiple categories of retailers has not been reported.METHODSData on licensed tobacco retailers within California from 2015–2019 were obtained from the California Department of Tax and Fee Administration. Store type was categorized by automated cross-referencing with Yelp. Geolocations were aggregated at county level for analyzing longitudinal trends in changes in tobacco retail density including demographic characteristics.RESULTSThe number of active CA tobacco retailer licenses increased from 19825 in 2015 to 25635 in 2019. The highest percent increase in tobacco retailer licenses (9.1%) was observed in 2017. The number of specialized tobacco stores was highest in Los Angeles, San Diego, and Riverside counties. We observed a significant increase in the number of active licenses for non-specialized and specialized tobacco stores, both overall and after controlling for the size of populations within each region. Time was a statistically significant predictor for the number of active licenses for only non-specialized stores, after adjusting for covariates. Regional volume of retailers was positively associated with higher proportion of women, lower median household income, and higher proportion of Hispanic residents.CONCLUSIONSMonitoring the changes in tobacco retail density and associated sociodemographic factors over time can help to identify communities at higher risk for tobacco and nicotine product exposure and access, and its associated health disparities.

Geospatial analysis of blindness within rural and urban counties.

PurposeTo determine the associations of blindness within rural and urban counties using a registry of blind persons and geospatial analytics.MethodsWe used the Oregon Commission for the Blind registry to determine the number of persons who are legally blind, as well as licensure data to determine the density of eye care providers (optometrists and ophthalmologists) within each county of the State of Oregon. We used geospatial statistics, analysis of variance, and logistic regression to determine the explanatory variables associated with blindness within counties.ResultsWe included 8350 individuals who are legally blind within the state of Oregon in the calendar year 2015. The mean observed prevalence of registered blindness was 0.21% and ranged almost 9-fold from 0.04% to 0.58% among counties (p < .001). In univariate models, higher blindness was associated with increasing median age (p = .027), minority race (p < .001), decreased median household income (p < .001), increased poverty within a county (p < .001), and higher density of ophthalmologists (p = .003). Density of optometrists was not associated with prevalence of blindness (p = .89). The final multivariable model showed higher blindness to be associated with lower median household income, higher proportion of black race, and lower proportion of Hispanic race (p < .001 for all).ConclusionGeospatial analytics identified counties with higher and lower than expected proportions of blindness even when adjusted for sociodemographic factors. Clinicians and researchers may use the methods and results of this study to better understand the distribution of individuals with blindness and the associated factors to help design public health interventions.

Access, socioeconomic environment, and death from COVID-19 in Nebraska.

Our study assesses whether factors related to healthcare access in the first year of the pandemic affect mortality and length of stay (LOS). Our cohort study examined hospitalized patients at Nebraska Medicine between April and October 2020 who were tested for SARS-CoV-2 and had a charted sepsis related diagnostic code. Multivariate logistic was used to analyze the odds of mortality and linear regression was used to calculate the parameter estimates of LOS associated with COVID-19 status, age, gender, race/ethnicity, median household income, admission month, and residential distance from definitive care. Among 475 admissions, the odds of mortality is greater among those with older age (OR: 1.04, 95% CI: 1.02–1.07) and residence in an area with low median household income (OR: 2.11, 95% CI: 0.52–8.57), however, the relationship between mortality and wealth was not statistically significant. Those with non-COVID-19 sepsis had longer LOS (Parameter Estimate: −5.11, adjusted 95% CI: −7.92 to −2.30). Distance from definitive care had trends toward worse outcomes (Parameter Estimate: 0.164, adjusted 95% CI: −1.39 to 1.97). Physical and social aspects of access to care are linked to poorer COVID-19 outcomes. Non-COVID-19 healthcare outcomes may be negatively impacted in the pandemic. Strategies to advance patient-centered outcomes in vulnerable populations should account for varied aspects (socioeconomic, residential setting, rural populations, racial, and ethnic factors). Indirect impacts of the pandemic on non-COVID-19 health outcomes require further study.

Race and Socioeconomic Status Are Associated With Inferior Patient-Reported Outcome Measures Following Rotator Cuff Repair

To investigate the impact social determinants of health (SDOH) have on National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive test scores and postoperative health care use in patients who undergo rotator cuff repair (RCR). All patients who underwent RCR surgery by 3 shoulder and/or sports medicine fellowship-trained orthopaedic surgeons between July 2017 and January 2020 were included. The electronic medical record (EMR) was used to identify SDOH for each patient. PROMIS computer adaptive test measures of Upper Extremity function, Pain Interference, and Depression were completed preoperatively and postoperatively (6 months and 1 year). Postoperative health care use (clinical visits, virtual encounters, imaging encounters, and physical therapy visits) were recorded as well. Univariate associations, multiple linear regressions, and Wilcoxon rank-sum tests were used to analyze mean differences between patient groups based on SDOH. Three hundred thirty-eight patients who underwent RCR were included. Patients who were Black, in lower median household income quartiles, had public insurance, and female reported lower PROMIS scores compared with their counterparts. Smokers and White patients attended fewer postoperative office visits whereas Black patients had more physical therapy and nonvisit encounters compared with their respective counterparts. Black race and lower socioeconomic status are associated with worse function and pain outcomes post-RCR compared with White race. Similarly, Black race and positive smoking status are associated with differential use of health care following RCR. Further attention may be required for these patients to address health care disparities. III, retrospective cohort study.

Incorporating field-based research into remote learning: An assessment of soil lead pollution in different land-use types in Los Angeles

A research-based course was developed to investigate the legacy of soil lead (Pb) pollution in Los Angeles, California. During the course, undergraduate and graduate students collected a total of 270 soil samples for analyses of metal (loid) concentrations in different land-use types (residential, park, and school). Residential soils had significantly higher Pb concentrations than other land uses (p < 0.01) exceeding the California recommended safety level for soil Pb (80 mg/kg) at the highest frequency (64% of samples), followed by schools (42%) and parks (6.0%). Soil Pb from all 87 census block groups was correlated with battery recycling plant and railroad proximity as geospatial indicators of childhood Pb exposure risk. Meanwhile, census block groups with higher Pb levels were correlated with higher percentages of the following population: those without health insurance, without college degrees, with a lower median household income and income below the poverty line, and ethnic and racial minorities (r = −0.46 to 0.59, p < 0.05). Principal component regression models significantly improved soil Pb estimation over correlation analysis by incorporating sociodemographic, economic, and geospatial risk factors for Pb exposure (R2 = 0.58, p < 0.05). This work provides new insights into how topsoil Pb prevails in various land-use types and their co-occurring sociodemographic, economic, and geospatial risk factors, indicating the need for multi-scalar assessment across urban land uses.

Impact of transfer status on coronary artery bypass graft surgery outcomes

Abstract Background There is limited research on how patients fare when they are transferred from one acute care center to another acute care facility for further management. Purpose In this study, we explore the short-term, in-hospital outcomes of patients undergoing coronary artery bypass graft (CABG) surgery who were transferred to acute care hospitals from other acute care centers. Methods This was a retrospective cohort study comparing adult patients who were transferred to the hospital from other acute centers with non-transferred hospital admissions between 2016 to 2018. We queried the National Inpatient Sample database to identify patients admitted with a principal procedural diagnosis of CABG. We analyzed the categorical and continuous variables by Pearson's chi-squared and Student t-test respectively. Multivariable logistic regression, adjusted for age, gender, hospital bed size, hospital location and comorbidities, was used to compare mortality. The comorbidities adjusted for included atrial fibrillation, chronic kidney disease, heart failure, hypertension, obesity and type 2 diabetes mellitus. Results 379,195 patients met our inclusion criteria. CABG patients transferred from acute care centers had 1.34 times higher odds of suffering in-hospital mortality compared to regular hospital admissions (aOR 1.34, 95% CI: 1.17–1.52; p&amp;lt;0.001). When separated by race, acute care transfers had higher mortality rates amongst White patients (2.2% vs 1.4%, p&amp;lt;0.001, Figure 1) as well as longer hospital stays (10.9 vs 8.8 days, p&amp;lt;0.001, Table 1). Acute care transfers consisted of more female patients, had higher average APR-DRG mortality scores and lower median household income (Table 1). These patients also had higher rates of comorbidities such as congestive heart failure and chronic kidney disease, but decreased rates of atrial fibrillation, hypertension, obesity, prior myocardial infarction and type 2 diabetes mellitus (Table 1). In terms of operative complications, acute care transfers were more likely to have intraoperative cardiac arrest (0.2% vs 0.1%, p&amp;lt;0.001) and postoperative cardiac insufficiency (0.2% vs 0.1%, p&amp;lt;0.001, Table 1). There was no significant difference between our two cohorts in postoperative complications such as cardiac arrest, intracerebral infarction or heart failure. Conclusion Patients who were transferred to acute care hospitals from other acute care centers to undergo CABG had higher odds of suffering in-hospital mortality compared to regular hospital admissions. These patients were also at increased risk of intraoperative cardiac arrest and postoperative cardiac insufficiency. Our findings illustrate that acute care transfers undergoing CABG require additional medical support in the operative and postoperative setting. While additional studies are required to better understand this relationship, this study highlights the need for innovative clinical change to address these differences moving forward. Funding Acknowledgement Type of funding sources: None.

Environmental Health and Justice Impacts of Steam Cracker Facilities

Background/Aim: Steam crackers (SCs) convert gas feedstocks into ethylene and propylene (the building blocks of plastics) at high temperatures and release toxic/carcinogenic chemicals and greenhouse gases (GHGs). The recent shale boom in the United States (US) has incentivized the expansion of SCs, but analyses of their potential environmental health and justice impacts are limited. We described SC operations, constructed a US SC emissions inventory, and evaluated socioeconomic characteristics of populations residing in proximity to SCs. Methods: We searched peer-reviewed and gray literature to describe SC operations. We constructed an inventory using publicly available datasets from industry, government, and non-governmental sources. We used descriptive statistics and data visualization to sumarize emissions from the US Environmental Protection Agency’s (EPA’s) Toxic Release Inventory (TRI) and EPA’s GHG Reporting Program. We compared population characteristics from US Census block groups (BGs) less than versus greater than 5km of an SC, within counties with a SC. Results: SC operations include: (1) pyrolysis, (2) quenching, (3) compression, cooling, and drying, and (4) fractionation. Major toxic emission sources include furnaces, fugitive emissions, and flaring. We identified 32 SC facilities across five states, with most in the Gulf Coast of Texas and Louisiana. TRI chemicals with the highest self-reported cumulative air-emission volumes from 1987-2019 were: ethylene, propylene, hydrochloric acid, benzene, n-hexane, 1,3-butadiene, ammonia, toluene, vinyl acetate, and methanol. SC facilities emitted &amp;#x3e;650 million metric tons (carbon dioxide equivalents) of GHGs in total from 2010-2019. We found that 752,465 people live in census BGs within 5km of an SC. BGs closer to SCs had higher proportions of residents who were Black, had non-professional occupations, lower educational attainment, and lower median household income. Conclusion: SC operations have the potential for adverse human health impacts and environmental inequities, underscoring the need for additional research on hazards of petrochemical infrastructure. Keywords: plastics, petroleum

Quantifying sociodemographic inequities in exposure to point source carcinogenic industrial pollution emissions across the United States

Background/Aim: Few studies have investigated how carcinogenic environmental exposures are distributed among the general population. We described recent cross-sectional relationships between carcinogenic industrial emissions and sociodemographic characteristics across the United States (US). Methods: We linked US Environmental Protection Agency’s 2018 Toxics Release Inventory to sociodemographic characteristics in 2010 Census tracts. Using chemical abstract service registry numbers, we identified onsite emissions (e.g., air, landfill, surface) of known and probable carcinogens as classified by the International Agency for Research on Cancer. Tract characteristics included total population, median household income, Yost neighborhood deprivation index, poverty, and percentages of Black, Hispanic, and white populations. We used linear regression to investigate the relation between quintiles of emissions in each census tract and distributions of these characteristics. Results: 5,209 (7%) tracts with an estimated 23.2 million population contained 7,028 facilities emitting known (n=22) or probable (n=33) carcinogens, including 1 billion pounds of these emissions in total (median: 226; IQR 7-5970 pounds/tract). Compared to tracts without emissions (all p-values &amp;#x3c;0.01), those with the highest quintile of emissions had higher proportions of rural (44% vs. 19%) and white (71% vs. 62%) populations, lower median household income ($45,000 vs. $55,000), and a higher deprivation score (62 vs. 49). Tracts with the highest emissions had a higher proportion of population with a high school education or less (53% vs. 44%). Overall, the proportions of families below the poverty level did not differ; however, greater numbers of black and white families below poverty lived in the tracts with the highest emissions. We observed similar demographic patterns in analyses restricted to air emissions. Conclusions: Our novel assessment demonstrates that carcinogenic emissions are not homogeneously distributed among the US population. It may be important to consider joint distributions of sociodemographic characteristics when describing environmental exposures and associated health disparities. Keywords: carcinogens, health disparities

Cannabis Use in Patients with Gastroparesis.

Aim: The primary aim was to determine the prevalence of cannabis use among patients hospitalized for gastroparesis. The secondary aim was to identify independent variables associated with cannabis use compared with noncannabis-related gastroparesis hospitalization. Methods: We use the nationwide inpatient sample database from January 2012 to December 2014. The patients included in this study were the ones with primary diagnosis of gastroparesis and cannabis use. The analysis was performed using the Statistical Package for the Social Sciences 27 (SPSS) and a multivariable regression was conducted to identify independent variables. Results: We found 50,170 patients with a primary diagnosis of gastroparesis. The prevalence of cannabis use among patients hospitalized for gastroparesis was 4.2%. Multivariate regression analysis was performed, adjusting for confounders. The variables found to increase the odds of cannabis use in gastroparesis populations independently were age interval of 18-35 and 36-50 years, male, Black and Asian, median household income 1-25th percentile, Medicaid insurance, no charge hospitalization, and smoking. Cannabis use was associated with lower odds of vomiting. Conclusion: Patients who used cannabis were younger and of African American, Asian, or Pacific Islander descent. They had Medicaid insurance and a lower median household income.

Refusal of gynecologic cancer surgery is a surgical and oncologic disparity, not an issue of noncompliance (055)

<b>Objectives:</b> To characterize socioeconomic and clinical factors associated with refusal of gynecologic cancer surgery. Secondary objectives were to estimate the effect of the refusal of surgery on overall survival and determine trends in refusal over time. <b>Methods:</b> The National Cancer Database (NCDB) was surveyed for patients with uterine, cervical, or ovarian cancers treated at participating Commission on Cancer sites between 2004 and 2017. Demographic and clinical data were abstracted. Descriptive statistics and Pearson's Chi-square tests were performed. Univariate and multivariate logistic regression analyses were performed to examine the association between variables and refusal of surgery, with the threshold for two-sided significance set at p <0.05. Overall survival (OS) was estimated using the Kaplan-Meier method and compared using the log-rank test. To evaluate changes in refusal over time, we performed joinpoint regression analysis using Joinpoint version 4.9.0. <b>Results:</b> Of the 788,164 women with gynecologic cancer included in our analysis, 5875 (0.75%) patients refused surgery recommended by their treating oncologist. In univariate analysis, age, race, Hispanic ethnicity, metropolitan residence, lower median household income, regional high school graduation rate, insurance status, treatment center type, distance to treating hospital, disease site, stage, and increasing Charlson comorbidity index were all associated with refusal of surgery (p<0.05). On multivariate analysis, patients who refused surgery were older at diagnosis (72.4 ± 16.1 vs 60.3 ± 13.1 years, p<0.001) and more likely Black (OR: 1.77, 95% CI: 1.62-1.92). Refusal of surgery was associated with uninsured status (OR: 2.94, 95% CI: 2.49 - 3.46), primary insurance by Medicare (OR: 1.78, 95% CI: 1.62-1.96), or Medicaid (OR: 2.79, 95% CI: 2.46-3.18) and residence in an area in the lowest national tertile of high school graduation (OR: 1.18, 95% CI: 1.05-1.33). Patients who refused surgery had inferior overall survival (1.0 vs 14.0 years, p<0.01), and this difference persisted when stratified by primary disease site. There were significant differences in survival between patients who refused only surgery but not chemotherapy or radiation therapy and those who refused all treatment modalities (5-year OS: 29.4%, 95% CI: 27.5 - 31.2 vs 9.2%, 95% CI: 7.9-10.6). The rate of refusal of surgery decreased from 2004 to 2008 (-4.4% annual percent change, p<0.05) but increased between 2008 and 2017 (+1.4% annual percent change, p<0.05).Fig. 1 <b>Conclusions:</b> Multiple non-clinical social determinants of health are independently associated with refusal of surgery for gynecologic cancer. Given that patients who refuse surgery are more likely to be underserved, marginalized members of society and have lower survival compared to those who do not, refusal of surgery should be considered an example of oncologic and surgical disparity and tackled as such.

Survival comparison of chemotherapy vs. chemotherapy plus surgery for women with ovarian cancer with distant metastatic disease (387)

<b>Objectives:</b> Standard treatment of advanced epithelial ovarian cancer (EOC) is a combination of surgical cytoreduction and chemotherapy. However, the impact of cytoreductive surgery for patients with unresectable metastatic disease, in whom optimal cytoreduction is not feasible, is not well described. <b>Methods:</b> The National Cancer Database (NCDB) was used to identify patients with Stage IV EOC with distant organ metastasis at the time of diagnosis, treated from 2005 to 2016. Distant organ metastasis was defined as metastasis to the brain, lung, liver, bone, or distant lymph node. To represent unresectable distant metastasis, a restricted population with only metastasis to the brain, lung, or bone was also analyzed. All patients received chemotherapy with or without surgery. Overall survival was analyzed using the Kaplan-Meier method, Cox proportional hazards models, and propensity score-weighted analyses. In these analyses, the variables included were surgery, age, year of diagnosis, race, Charlson/Deyo Comorbidity Condition (CDCC) Score, facility type, primary insurance, histology, site of metastasis, urban versus rural residence, education, and median household income. <b>Results:</b> We identified 9025 patients with EOC with distant organ metastasis in the NCDB. Among these patients, 2074 received chemotherapy alone, and 6951 received chemotherapy plus surgery (C+S). Those who received chemotherapy alone were older with higher CDCC scores, lived in areas of lower median household incomes, and had lower high school graduation rates. These individuals had a higher proportion of metastatic disease to the liver, bone, or brain. Race was significantly different between groups, with a higher proportion of those receiving chemotherapy alone being Black (12.7% vs 8.2%). Survival was significantly improved for patients who received C+S (HR: 0.46, p<0.0001). Propensity score-weighted analysis similarly showed improved survival for patients undergoing C+S (HR: 0.49, p<0.0001). Individuals who received single-agent chemotherapy had worse overall survival (HR: 1.35, p<0.0001). When accounting for the impact of single-agent chemotherapy on the survival comparison, the benefit of surgery remained significant (HR: 0.47, p<0.0001). In the group defined as unresectable distant metastasis, we identified 1424 patients, of which 396 received chemotherapy alone and 1028 received C+S. A survival benefit was again shown for patients who received C+S, by Cox model (HR: 0.42, p<0.0001) and propensity score-weighted analysis (HR: 0.44, p<0.0001). <b>Conclusions:</b> Despite the poor prognosis associated with Stage IV EOC, obtaining local control with surgery in addition to chemotherapy may provide an added oncologic benefit. Because of the retrospective nature of this analysis, the absolute benefit of surgery for patients with Stage IVB EOC cannot be established. However, this study may provide added value to patient-centered counseling on the role of surgical resection in the setting of ovarian cancer with distant metastatic disease.

Advanced age is not the decisive factor in chemotherapy of small cell lung cancer: a population-based study.

Objective: There is limited research on the impact of chemotherapy on the prognosis of different age group patients with small cell lung cancer (SCLC). The aim of this study was to explore the impact of chemotherapy on survival prognosis of elderly patients with SCLC.Methods: Based on the Surveillance, Epidemiology and End Results (SEER) database, 57,460 SCLC patients between 2004 and 2015 were identified and divided into a ≤ 80 years group (n = 50,941) and a >80 years group (n = 6,519). Confounding factors were controlled by propensity score matching (PSM) analysis. Kaplan Meier (KM) analysis was performed to determine the impact of chemotherapy on overall survival (OS) and lung-cancer specific survival (LCSS) of the patients. Other variables that could affect survival of SCLC patients were also examined by COX analysis.Results: KM analysis showed that both OS and LCSS were improved in chemotherapy group compared to those in non-chemotherapy group (log rank P < 0.001) in both age groups after PSM. Cox analysis demonstrated the survival benefit of chemotherapy in both ≤ 80 years group (OS: HR 0.435; 95% CI 0.424–0.447; LCSS: HR 0.436; 95% CI 0.424–0.448) and >80 years group (OS: HR 0.424; 95% CI 0.397–0.451; LCSS: HR 0.415; 95% CI 0.389–0.444). Additionally, the following parameters had a negative impact on survival of elderly patients: male sex, tumor location in main bronchus, increased stage, bilateral tumor, no surgery or radiation, and lower median household income.Conclusions: Elderly patients with SCLC should be encouraged to receive chemotherapy provided their general conditions permit.

Associations between Florida counties' COVID-19 case and death rates and meaningful use among Medicaid providers: Cross-sectional ecologic study.

Although the Health Information Technology for Economic and Clinical Health (HITECH) Act has accelerated adoption of Electronic Health Records (EHRs) among Medicaid providers, only half achieved Meaningful Use. Furthermore, Meaningful Use' impact on reporting and/or clinical outcomes remains unknown. To address this deficit, we assessed the difference between Medicaid providers who did and did not achieve Meaningful Use regarding Florida county-level cumulative COVID-19 death, case and case fatality rates (CFR), accounting for county-level demographics, socioeconomic and clinical markers, and healthcare environment. We found that cumulative incidence rates of COVID-19 deaths and CFRs were significantly different between the 5025 Medicaid providers not achieving Meaningful Use and the 3723 achieving Meaningful Use (mean 0.8334/1000 population; SD = 0.3489 vs. mean = 0.8216/1000; SD = 0.3227, respectively) (P = .01). CFRs were .01797 and .01781, respectively, P = .04. County-level characteristics independently associated with increased COVID-19 death rates and CFRs include greater concentrations of persons of African American or Black race, lower median household income, higher unemployment, and higher concentrations of those living in poverty and without health insurance (all P < .001). In accordance with other studies, social determinants of health were independently associated with clinical outcomes. Our findings also suggest that the association between Florida counties' public health outcomes and Meaningful Use achievement may have had less to do with using EHRs for reporting of clinical outcomes and more to do with using EHRs for coordination of care-a key measure of quality. The Florida Medicaid Promoting Interoperability Program which incentivized Medicaid providers towards achieving Meaningful Use, has demonstrated success regarding both rates of adoption and clinical outcomes. Because the Program ends in 2021, we support programs such as HealthyPeople 2030 Health IT which address the remaining half of Florida Medicaid providers who have not yet achieved Meaningful Use.