Median Household Income Quartile Research Articles

Abstract 115: Resuscitation Preferences of Older Patients Hospitalized with Heart Failure: Temporal Trends and Associations with Patient and Hospital Factors

Background: Preferences regarding end-of-life (EOL) care in patients (pts) with HF may be influenced by personal, cultural, and health system factors. We examined characteristics associated with cardiopulmonary resuscitation preferences among pts hospitalized for HF and explored whether rates of Do Not Resuscitate (DNR) status have changed over time. Methods: Using the California State Inpatient Databases from the Healthcare Cost and Utilization Project and the American Hospital Association Annual Survey Databases, we identified 297,156 pts aged ≥ 60 years hospitalized for HF between 2004 and 2011. The first eligible hospitalization for each patient was selected. DNR status documented within the first 24 hours of admission was assessed. Multivariable logistic regression was used to evaluate associations of DNR status with demographic factors, year of admission, median household income quartile, and hospital teaching status. Results: 39,658 (13.4%) pts had a DNR order. Higher proportions with DNR were found among women than men (15.4% vs. 11.0%, p<.0001) and white pts than non-white pts (16.7% vs. 7.3%). Proportions of pts with DNR increased over the study period for both men and women (from 10.0% to 12.3% and 13.7% to 17.2%, respectively, p<.0001 for trend with time) and in both white pts (15.0% to 19.2%) and non-white pts (6.5% to 7.9%), but more rapidly for white pts (p=.02). In multivariable analysis adjusting for age, gender, race, and year of admission, odds ratios (ORs) for DNR were 1.5 per 5-year increase in age, 1.2 for women vs. men, and 2.0 for white vs. non-white pts. After adding income and hospital teaching status to the model, the respective ORs associated with each incremental increase in income quartile and receiving treatment in a teaching hospital were 1.1 and 1.2 (p<.0001 for both). ORs for age, gender, race, income, and hospital teaching status were essentially unchanged after adjustment for comorbidities. Conclusion: DNR status among pts hospitalized with HF is influenced by age, gender, race, and income in addition to hospital teaching status. The proportions of pts with DNR status have increased, but unequally among demographic subgroups. Continued efforts to understand the factors that influence preferences around resuscitation and EOL care are needed to provide truly patient-centered care.

Sociodemographic disparities in advanced ovarian cancer survival and adherence to treatment guidelines.

To estimate whether race or ethnic and socioeconomic strata are independently associated with advanced-stage ovarian cancer-specific survival after adjusting for adherence to National Comprehensive Cancer Network treatment guidelines. The design was a retrospective population-based cohort study of patients with stage IIIC-IV epithelial ovarian cancer identified from the Surveillance, Epidemiology, and End Results-Medicare database (1992-2009). Quartile of census tract median household income was used as the measure of socioeconomic status (quartiles 1-4). A multivariable logistic regression model was used to identify characteristics predictive of adherence to National Comprehensive Cancer Network guidelines for surgery and chemotherapy. Cox proportional hazards models and propensity score matching were used for survival analyses. A total of 10,296 patients were identified, and 30.2% received National Comprehensive Cancer Network guideline-adherent care. Among demographic variables, black race (adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.22-1.92) and low socioeconomic status (quartile 1, adjusted OR 1.32, 95% CI 1.14-1.52) were independently associated with nonguideline care. Stratified multivariate survival analysis using the propensity score-matched sample (n=5,124) revealed that deviation from treatment guidelines was associated with a comparable risk of disease-related death across race-ethnicity: whites (adjusted hazard ratio [HR] 1.59, 95% CI 1.48-1.71), blacks (adjusted HR 1.66, 95% CI 1.19-2.30), Asian or Pacific Islanders (adjusted HR 1.52, 95% CI 0.99-1.92), and Hispanics (adjusted HR 1.91, 95% CI 0.98-3.72). Across socioeconomic status, deviation from treatment guidelines was also associated with a comparable risk of ovarian cancer mortality for quartile 1 (adjusted HR 1.69, 95% CI 1.47-1.95), quartile 2 (adjusted HR 1.63, 95% CI 1.42-1.87), quartile 3 (adjusted HR 1.51, 95% CI 1.32-1.73), and quartile 4 (adjusted HR 1.57, 95% CI 1.38-1.79). Adherence to treatment guidelines for advanced-stage ovarian cancer is associated with equivalent survival benefit across racial or ethnic and socioeconomic strata. Ensuring equal access to standard treatment is a viable strategic approach to reduce survival disparities.

Associations between socioeconomic status and race with complications after tonsillectomy in children.

To determine if disparities exist for revisits and complications after pediatric tonsillectomy. Cross-sectional analysis of multistate databases. Ambulatory surgery. Cases of pediatric tonsillectomy with or without adenoidectomy were extracted from state ambulatory surgery databases and linked to state emergency department databases and inpatient databases for California, Iowa, Florida, and New York for 2010 and 2011. Revisit rates and diagnoses within 14 days were analyzed for potential associations of these complications with sex, race, and median household income quartile. There were 79,520 cases of pediatric tonsillectomy that were extracted (50.3% male; mean age, 7.5 years). Overall, 6419 patients (8.1%) incurred a revisit after the procedure. Revisit rates for posttonsillectomy bleeding, acute pain, and fever/dehydration were 2.1%, 1.5%, and 2.2%, respectively. On multivariate analysis, increasing household income quartile was significantly associated with a decreasing rate of all complications: revisits (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.84-0.89), posttonsillectomy bleeding (OR, 0.91; 95% CI, 0.86-0.96), acute pain (OR, 0.79; 95% CI, 0.74-0.84), and fever/dehydration (OR, 0.93; 95% CI, 0.89-0.98). Female sex was associated with a decreased rate of posttonsillectomy hemorrhaging (OR, 0.81; 95% CI, 0.73-0.91). Black and Hispanic children had an increased risk for a revisit after tonsillectomy (OR, 1.11; 95% CI, 1.01-1.22; and OR, 1.17; 95% CI, 1.09-1.26, respectively) and increased odds for acute pain at the revisit (OR, 1.36; 95% CI, 1.10-1.67; and OR, 1.34; 95% CI, 1.14-1.57, respectively) relative to white children. Race was not associated with the rate of hemorrhage posttonsillectomy. Significant disparities, particularly with respect to household income, exist in the incidence of revisits and complications after pediatric tonsillectomy. The disparate burden of increased revisits and acute pain diagnoses after tonsillectomy deserve further attention.

Kidney transplantation and the intensity of poverty in the contiguous United States.

Geographic variation in kidney transplantation rates in the United States has been described previously but remains unexplained by age, race, sex, or socioeconomic status differences. Geographic variations in the concentration of poverty appear to impact end-stage renal disease care and potentially access to transplantation. We studied the impact of how spatial topography of poverty across geographical regions in the contiguous United States is associated with kidney transplantation in the 48 contiguous U.S. states. We found considerable geographic variation in transplantation rates across the country that persisted across quartiles of county-level median household income and percentage minority population. Higher transplant rates were seen with increasing median household income and decreasing minority populations but were not influenced by education level. Transplantation rates in counties with poverty rates above the national average had low transplant rates, but these rates were influenced by the poverty level in the surrounding counties. Similarly, wealthy counties had higher transplant rates but were lowered in counties of relative wealth that were surrounded by less wealthy counties. Our results underline the geographical heterogeneity of kidney transplantation in the United States and identify regions of the country most likely to benefit from interventions that may reduce disparities in transplantation.

Clinical and socioeconomic factors influence treatment decisions in Graves' disease.

Definitive treatment of Graves' disease includes radioactive iodine (RAI) and thyroidectomy, but utilization varies. We hypothesize that, in addition to clinical reasons, there are socioeconomic factors that influence whether a patient undergoes thyroidectomy or RAI. Patients treated for Graves' disease between August 2007 and September 2013 at our university hospital were included. A comparative analysis of clinical and socioeconomic factors was completed. Of 427 patients, 300 (70 %) underwent RAI, whereas 127 (30 %) underwent surgery. Multiple factors were associated with surgery: younger age (mean 36 vs. 41 years, p < 0.01), female gender (33 vs. 19 % males, p = 0.01), black race (56 vs. 28 % nonblack, p < 0.01), Medicaid or uninsured (43 vs. 27 % private insurance or Medicare, p < 0.01), ophthalmopathy (38 vs. 26 %, p < 0.01), goiter (35 vs. 23 %, p < 0.01), and lowest quartile of median household income (38 vs. 27 % upper three quartiles, p = 0.03). Thyroidectomy increased annually, with 52 % undergoing surgery during the final year (p < 0.01). Adjusting for confounding, younger age (odds ratio [OR] 1.04; 95 % confidence interval [CI] 1.02, 1.05), female gender (OR 2.06; 95 % CI 1.06, 4.01), ophthalmopathy (OR 2.35; 95 % CI 1.40, 3.96), and later year of treatment (OR 1.66; 95 % CI 1.41, 1.95) remained significantly associated with surgery. Surgery has now become the primary treatment modality of choice for Graves' disease at our institution. Clinical factors are the main drivers behind treatment choice, but patients with lower SES are more likely to have clinical features best treated with surgery, underlying the importance of improving access to quality surgical care for all patients.

The cost and inpatient burden of treating mandible fractures: a nationwide inpatient sample database analysis.

To discuss patient demographics, hospitalization characteristics, and costs associated with the treatment of mandible fractures. Cross-sectional study. The 2009 Nationwide Inpatient Sample (NIS) database. Patient demographics, hospital characteristics, fracture locations, and common comorbidities for patients with isolated mandible fractures were analyzed, and variables associated with increased cost and length of hospitalization stay were ascertained. A total of 1481 patients were identified with isolated mandible fractures. The average age was 32, 85.4% were male, 39% were Caucasian, and 25% African American. Forty percent were from the lowest median household income quartile, and 77% were uninsured or government funded. The average length of stay (LOS) was 2.65 days, and average hospitalization cost was $35,804. A statistically significant increased LOS was associated with alcohol abuse, drug abuse, mental illness, diabetes mellitus type 2, cardiovascular disease, HIV, and age over 40. There was a statistically significant increased total cost associated with drug abuse, alcohol abuse, mental illness, cardiovascular disease, and age over 40. The average cost for treatment of mandible fractures was $35,804 per person with increased expenditures for older patients and those with a history of mental illness, cardiovascular disease, or substance abuse. To improve outcomes and reduce hospital charges, outpatient resources and inpatient protocols should be implemented to address the factors we identified as contributing to higher costs and increased hospital stay.

Socioeconomic disparity in inpatient mortality after traumatic injury in adults

Prior studies have demonstrated that race and insurance status predict inpatient trauma mortality, but have been limited by their inability to adjust for direct measures of socioeconomic status (SES) and comorbidities. Our study aimed to identify whether a relationship exists between SES and inpatient trauma mortality after adjusting for known confounders. Trauma patients aged 18-65years with an Injury Severity Scores (ISS) of ≥9 were identified using the 2003-2009 Nationwide Inpatient Sample. Median household income (MHI) by zip code, available by quartiles, was used to measure SES. Multiple logistic regression analyses were performed to determine odds of inpatient mortality by MHI quartile, adjusting for ISS, type of injury, comorbidities, and patient demographics. In all, 267,621 patients met inclusion criteria. Patients in lower wealth quartiles had significantly greater unadjusted inpatient mortality compared with the wealthiest quartile. Adjusted odds of death were also higher compared with the wealthiest quartile for Q1 (odds ratio [OR], 1.13;95% confidence interval [CI], 1.06-1.20), Q2 (OR, 1.09; 95% CI, 1.02-1.17), and Q3(OR,1.11; 95% CI, 1.04-1.19). MHI predicts inpatient mortality after adult trauma, even after adjusting for race, insurance status, and comorbidities. Efforts to mitigate trauma disparities should address SES as anindependent predictor of outcomes.

The Cost and Inpatient Burden of Treating Mandible Fractures: A Nationwide Inpatient Sample Database Analysis

Objectives: At the conclusion of this presentation, the participants should be able to discuss the patient demographics, hospitalization characteristics, and costs associated with the treatment of mandible fractures. Study design: Cross-sectional study. Methods: A cross-sectional analysis using the 2009 Nationwide Inpatient Sample Database to identify patients hospitalized for isolated mandible fractures. Results: 1481 patients were identified with isolated mandible fractures. The average age of patients was 31, and 93.5% were male. Forty-six percent were White, 30% African-American, 14% Hispanic, 9% other, and 1% Asian. Twelve percent of patients presented with a history of alcohol abuse, 7.2% drug abuse, and 7.7% mental illness. Forty percent were from the lowest median household income quartile, and 75% were uninsured or had Medicaid. Thirty-nine percent of patients underwent surgery within 24 hours of admission, the average length of stay (LOS) was 2.95 days, and average cost of hospitalization was $35,804. Increased LOS was associated with alcohol abuse (3.7 vs. 2.9 days, p&lt;0.001), drug use (4.7 vs. 2.8 days, p&lt;0.001), mental illness (3.9 vs. 2.9 days, p=0.001), and age greater than 40 years (3.8 vs. 2.7 days, p&lt;0.001). Increased total cost was associated with drug use ($56,600 vs. $34,391, p&lt;0.001) and alcohol abuse ($42,343 vs. $34,943, p=0.011). Conclusions: Males, persons of low socioeconomic status, and African-Americans comprise a disproportionately high percentage of mandible fracture patients treated nationally. Healthcare expenditures associated with the treatment of mandible fractures are higher for older patients, those with mental illness, and those with a history of substance abuse.

Geographic and Sociodemographic Disparities in PET Use by Medicare Beneficiaries With Cancer

PET use for cancer care has increased unevenly, possibly because of regional health care market characteristics or underlying population characteristics. The aim of this study was to examine variation in advanced imaging use among individuals with cancer in relation to population and hospital service area (HSA) characteristics. A retrospective national study of fee-for-service Medicare beneficiaries with diagnoses of 1 of 5 cancers covered by Medicare for PET (2004-2008) was conducted. Crude and adjusted rates of PET, CT, and MRI were estimated for HSAs and sociodemographic subgroups. Generalized linear mixed models were used to assess the effects of race/ethnicity, area-level income, and HSA-level physician supply and spending on imaging utilization. On the basis of an annual average of 116,452 beneficiaries with cancer, adjusted PET rates (imaging days per person-year) showed significantly higher use for whites compared with blacks in both 2004 (whites, 0.35 [95% confidence interval, 0.34-0.36]; blacks, 0.31 [95% confidence interval, 0.30-0.33]) and 2008 (whites, 0.64 [95% confidence interval, 0.63-0.65]; blacks, 0.57 [95% confidence interval, 0.55-0.59]). This trend was similar for the highest quartile of group-level median household income but was opposite for CT use, with blacks having higher rates than whites. The highest Medicare-spending HSAs had significantly higher adjusted PET rates compared with lower spending areas (0.57 [95% confidence interval, 0.55-0.60] vs 0.69 [95% confidence interval, 0.67-0.71] imaging days/person-year). The use of PET among Medicare beneficiaries with cancer increased from 2004 to 2008, with higher rates observed among whites, among higher socioeconomic groups, and in higher Medicare spending areas. Sociodemographic differences in advanced imaging use are modality specific.

Survival disparities in newborns with congenital diaphragmatic hernia: a national perspective

Purpose The aim of the study was to examine national outcomes for congenital diaphragmatic hernia (CDH). Methods We analyzed the Kids' Inpatient Database for patients admitted at less than 8 days of age. Results Overall, 2774 hospitalizations were identified. Most patients were white and had private insurance. Most patients were treated at urban (96%), teaching (75%), and not identified as children's hospital (NIACH) (50%). Birth was the most common admission source at NIACH (91%) and children's unit in general hospital (CUGH) (59%), compared to hospital transfer at children's general hospital (CGH) (81%). Most CDH were repaired through the abdomen (81%), and 25% required extracorporeal membrane oxygenation (ECMO). Most NIACH patients were transferred to another hospital, whereas most at CGH and CUGH were discharged home. Survival to discharge was 66% after excluding hospital transfers. Univariate analysis revealed higher survival for males, birth weight (BW) of 3 kg or more, whites, patients with private insurance, and those in the highest median household income quartile. Survival was 86% after CDH repair but 46% for ECMO. Multivariate analysis identified black race (hazard ratio [HR], 1.536; P = .03) and other race (HR, 1.515; P = .03) as independent predictors of mortality. Conclusions Hospital survival for CDH is related to sex, BW, race, and socioeconomic status. Blacks and other non-Hispanic minorities have higher mortality rates.

Solvent abuse.

OBJECTIVE:To identify health insurance disparities in the population undergoing continuous EEG monitoring for epilepsy. DESIGN/METHODS:We reviewed the healthcare Cost and Utilization Project9s Nationwide Inpatient Sample (NIS) database from 2000 to 2011 for hospitalizations encoding epilepsy or convulsions as a primary diagnosis (ICD 9-CM codes 345.xx or 780.39).Continuous EEG (cEEG) monitoring was identified by procedure code 89.19. Multivariate regression model were generated after adjusting with confounders to evaluate association between payment type and cEEG utilization. RESULTS:Out of 2795525 hospitalizations for epilepsy or convulsions, 275814 (8.8[percnt]) had continuous EEG monitoring coded. In multivariate analysis, the odds of utilizing cEEG monitoring were lower in Medicare/Medicaid (Adjusted Odds Ratio [OR] 0.65; 95[percnt] Confidence Interval [CI] 0.60-0.71; Beta value [b]: -0.4293; p&lt;0.001) and self/no/other (OR 0.49; 95[percnt] CI 0.42-0.58; b: -0.6508; p&lt;0.001) as compared to private insurance. This effect does not vary over the year (p: 0.10 and P: 0.92 respectively for Medicare/Medicaid and self/no/other), between teaching or non teaching hospitals (p: 0.16 and P: 0.07) and between urban or rural hospitals (p: 0.99 and P: 0.97). Additionally, male gender, black and Hispanic ethnicity as compare to white and lowest quartile of median household income as compare to highest were each independently associated with lower utilization. CONCLUSION: In patients who were admitted with primary diagnosis of epilepsy or convulsions, rates of cEEG monitoring is associated with payment disparity. Further studies are needed to identify the factors leading to these disparities. <b>Disclosure:</b> Dr. dave has nothing to disclose. Dr. Patel has nothing to disclose. Dr. Savani has nothing to disclose. Dr. Bhatia has nothing to disclose. Dr. Eccher has nothing to disclose.