Median Household Research Articles

A Cluster Randomized Controlled Trial of a Home-Delivered Food Box on Food Security in Chickasaw Nation

BackgroundThe 2010 Child Nutrition reauthorization called for the independent evaluation of innovative strategies to reduce the risk of childhood hunger or improve the food security status of households with children. ObjectiveThe research question was whether the Packed Promise intervention reduces child food insecurity (FI-C) among low-income households with children. DesignThis study was a cluster randomized controlled trial of 40 school districts and 4,750 eligible, consented households within treatment and control schools. Participants/settingData were collected at baseline (n = 2,859) and 2 follow-ups (n = 2,852; n = 2,790) from households with children eligible for free school meals in participating schools in 12 rural counties within the Chickasaw Nation territory in south central Oklahoma in 2016 to 2018. InterventionEach month of the 25-month intervention, for each eligible child, enrolled households could choose from 5 types of food boxes that contained shelf-stable, nutritious foods ($38 food value) and a $15 check for purchasing fruits and vegetables. Main outcome measuresThe primary outcome was FI-C. Other outcomes included household and adult food security, very low food security among children, and food expenditures. Statistical analyses performedDifferences between the treatment and control groups were estimated by a regression model controlling for baseline characteristics. ResultsThe Packed Promise project did not significantly reduce FI-C at 12 months (29.3% prevalence in the treatment group compared with 30.1% in the control group; P = 0.123) or at 18 months (28.2% vs 28.7%; P = 0.276), but reduced food insecurity for adults by 3 percentage points at 12 months (P = 0.002) but not at 18 months (P = 0.354). The intervention led to a $27 and a $16 decline in median household monthly out-of-pocket food expenditures at 12 and 18 months, respectively. ConclusionsAn innovative intervention successfully delivered nutritious food boxes to low-income households with children in rural Oklahoma, but did not significantly reduce FI-C. Improving economic conditions in the demonstration area and participation in other nutrition assistance programs among treatment and control groups might explain the lack of impact.ClinicalTrials.gov ID: NCT04316819 (http://www.clinicaltrials.gov). Funding/SupportThis article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

Abstract S10-02: Using real-world data (RWD) from an integrated platform for rapid analysis of patients with cancer with and without COVID-19 across distinct health systems

Abstract Introduction: Reports suggest worsened outcomes in patients with cancer (pts) and COVID-19 (Cov), varying by geography and local peak dynamics. We describe characteristics and clinical outcomes of pts with and without Cov. Methods: RWD at 2 Midwestern health systems from the Syapse Learning Health Network were used to identify adults with active cancer (AC) or past history of cancer (PHC). AC pts were identified by encounters with ICD-10 code for malignant neoplasm or receipt of an anticancer agent within 12 months prior to February 15, 2020; PHC pts were identified by encounters with an active cancer code from May 15, 2015 to February 15, 2019 and no receipt of anticancer therapy within the prior 12 months. Cov was defined by diagnostic codes and laboratory results from February 15 to May 13, 2020. Comorbidities were assessed prior to February 15, 2020; hospitalizations (hosp), invasive mechanical ventilation (IMV), and all-cause mortality (M) were assessed from February 15 to May 27, 2020. Results: We identified 800 pts with Cov (0.5%) out of a total of 154,585 pts with AC or PHC. Compared to AC pts without Cov (AC WO, 39,402), AC pts with Cov (AC Cov, 388) were more likely to be non-Hispanic Black (NHB, 39% vs. 9%), have renal failure (RF, 24% vs. 12%), cardiac arrhythmias (33% vs. 19%), congestive heart failure (CHF, 16% vs. 8%), obesity (19% vs. 14%), pulmonary circulation disorder (PCD, 9% vs. 4%), and a zip code with median annual household income (ZMI) <$30k (18% vs. 5%). Comorbidity and income were similarly distributed for PHC pts with Cov (PHC Cov, 412). Compared to PHC pts without Cov (PHC WO, 114,383), coagulopathy (coag) was more common in PHC Cov pts (10% vs. 5%). Hosp for AC Cov pts was higher than for AC WO pts (81% vs. 15%). Hosp for PHC Cov pts was also higher than for PHC WO pts (68% vs. 6%). Hosp was highest for NHB pts in both AC Cov and PHC Cov groups (88% and 72%) and for AC Cov pts in low ZMI (94% in <$30K). Pts <50 years old had hosp rates of 79% (AC Cov) and 49% (PHC Cov). IMV rate for AC Cov pts was higher than for PHC Cov pts (21% vs. 14%). Rates of IMV for AC Cov pts were highest in low ZMI (27%) and in pts with coag (36%). M by group was: AC Cov 16%; AC WO 1%; PHC Cov 11%; PHC WO 1%. Among AC Cov pts, M was higher for men (19% vs. 13%) and pts with PCD (31%), RF (25%), or diabetes (DM, 24%); among PHC Cov pts, M was also higher for men (14% vs. 8%) and pts with coag (30%), valvular disease (27%), or PCD (24%). Increasing age, DM, RF, and PCD were associated with increased risk of M for AC Cov pts in age, race/ethnicity, and comorbidity-adjusted logistic regression; increasing age and coag were associated with M in PHC Cov pts. Conclusion: In this rapid characterization from RWD, pts with Cov have higher rates of pre-existing cardiopulmonary/vascular and renal conditions and increased risk of hospitalization, IMV, and mortality than pts without Cov. Higher Cov risk and worse outcomes in NHB and lower-income pts suggest health care disparities. Whether these outcomes are due to comorbidities or acute sequelae merits further study, as does investigation of alternative definitions for real-world populations and outcomes. Citation Format: Shirish M. Gadgeel, Michael A. Thompson, Monika A. Izano, Clara Hwang, Tom Mikkelsen, James L. Weese, Frank M. Wolf, Andrew Schrag, Sheetal Walters, Harpreet Singh, Jonathan Hirsch, Thomas D. Brown, Paul G. Kluetz. Using real-world data (RWD) from an integrated platform for rapid analysis of patients with cancer with and without COVID-19 across distinct health systems [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr S10-02.

Abstract C100: Perceptions of breast cancer screening guidelines and intentions for screening: Qualitative commonalities of and differences between Black and White women age 50-75

Abstract The purpose of this investigation was to explore perceptions of Black and White women 50-75 years of age about current breast cancer screening guidelines from three national organizations (National Comprehensive Cancer Network, American Cancer Society, and the U.S. Preventive Services Task Force) and in how these guidelines impact their screening intentions. Non-Hispanic Black (n = 29) and White (n = 28) average risk women were recruited from Houston community sites serving those with low-SES to participate in focus groups. Using questionnaires, women reported on: sociodemographic information, knowledge of screening guidelines, personal history of mammograms, and screening intentions. During the focus groups, participants were presented with the three organizations’ screening guidelines and engaged in discussion on the benefits and harms of breast cancer screening mammography. We used a qualitative descriptive approach with inductive and deductive coding to analyze transcripts of video-recorded focus groups. Descriptive statistics were used to summarize questionnaire data. Participant average age was 65.93 years (SD=7.10). Among Black women, 12 had more than a high school degree and $30k was the median annual household income. Among White women, 25 held higher than high school degree and $60k-$70k was the median income. All women reported receiving a mammogram. Most women also reported they “definitely will be tested” in the next year (Black N=22, White N=21). Qualitative analysis revealed both groups of women expressed they enjoyed learning about the three guidelines but questioned the rationale for guideline development; Black women appeared to do so more strongly, whereas some White women expressed satisfaction with multiple guidelines. Although Black and White women expressed concern for younger generations’ access to screening information, White women expressed additional concern for low resource groups. Both groups expressed mistrust with the healthcare system, yet Black women expressed a desire to receive screening information from providers with whom they have deep and lasting relationships with, whereas White women expressed an interest in seeking information from multiple doctors in a less personal manner. Differences also emerged regarding screening intentions; while Black women expressed renewed motivation to continue screening, White women expressed greater openness to screen with less frequency and with discontinuation. These findings help to inform the ways healthcare providers might effectively customize and communicate screening information to racially/ethnically diverse groups of women. Although both groups of women expressed concerns regarding the guidelines, differences emerged in preferences for communicating and receiving screening information, as well as in the impact on their screening intentions. Citation Format: Maggie Britton, Ashley J. Housten, Diana S. Hoover, Lorna H. McNeill, Robert J. Volk. Perceptions of breast cancer screening guidelines and intentions for screening: Qualitative commonalities of and differences between Black and White women age 50-75 [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C100.

Abstract A092: Cancer caregiver burden and mental health outcomes: Differences by race/ethnicity

Abstract Background: Informal caregivers (CGs) play a critical role in caring for cancer patients at end of life, often to the detriment of their own health outcomes. However, much of the literature focuses on white CGs, with little specifically addressing the experiences and health outcomes of African American cancer CGs. Purpose: To compare the outcomes of perceived burden, depression, and distress between white and African American cancer CGs with a focus on the role of social support and CG preparedness to provide care. Methods: Informal caregivers providing end-of-life care to cancer patients were recruited from an academic cancer center. CGs were administered the following scales: CES-D, Zarit Burden, Distress Thermometer, Preparedness for Caregiving, and demographics. One item each assessed health status and social support from church/religious groups. Results: Caregivers (n=90) were mostly female (77%), married/partnered (61%), and reported a median annual household income of $45,500. African American CGs (n=44; 49%) reported significantly lower distress [2(88); p=0.04], depression [2(86); p=0.04], caregiver burden [3.8(76); p=0003], and greater social support [2(88); p=0.02] from church/religious groups compared to white CGs. No univariate differences in perceived preparedness to provide care, health status, or spirituality were found. Multiple regression models for depression [R2=0.4, F(8,77)=6.8; p<.0001], distress [R2=0.17, F(8, 78)=3.2; p=.003], and CG burden [R2=.50, F(8, 78)=11.3; p<.0001], were significant. CGs who were African American reported greater preparation and better health and had lower depression and distress. Lower CG burden was associated with CGs who were African American, older age, and reported greater CG preparation. Conclusions: African American CGs reported lower CG burden and better mental health outcomes compared to white CGs. Some key intervention targets such as perceived CG preparation to provide care have important associations with health outcomes for all CGs. However, there are likely other components such as social support from church/religious groups that vary in level of importance depending on the unique sociocultural perspectives of racial/ethnicity groups. Interventions are needed that support cancer caregivers and protect their own health outcomes. Developers should consider the diversity of experiences and meanings attributed to cancer caregiving when choosing intervention targets. Citation Format: Maria D. Thomson, Abigail Cadua, Robin Matsuyama, Laura A. Siminoff. Cancer caregiver burden and mental health outcomes: Differences by race/ethnicity [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A092.

Abstract A043: Cancer care in people with HIV: Identifying adherence challenges to improve outcomes

Abstract Background: With improved antiretroviral therapy, people living with HIV are aging and non-AIDS-defining cancers have increasing prevalence in this population. Yet, population-based studies demonstrate that people with HIV are less likely to receive cancer treatment, which contributes to lower cancer-specific survival. Past studies have examined cancer disparities at the provider and healthy system levels, but have not explored the drivers of cancer treatment disparities from the patient’s perspective. We aimed to investigate barriers and facilitators of cancer treatment among patients living with HIV, along with perceptions of their cancer diagnosis and treatment, to inform future interventions, reduce disparities, and improve outcomes. Methods: We conducted in-depth interviews with 27 HIV-infected cancer patients to examine perceptions and care engagement in this population. We recruited equal numbers of patients who had (a) past cancer treatment, (b) were currently undergoing cancer treatment, or (c) experienced challenges with receiving or completing cancer treatment. Semi-structured interviews explored multiple topics related to HIV and cancer care, including treatment decision-making, patient-provider interactions, stigma, coping, and barriers to care. Patients were recruited until thematic saturation was reached. Results: Study participants were predominantly male (n=22, 81%) with a median age of 56 years and median annual household income of $24,000. Prevailing themes from the interviews included descriptions of the “devastating” impact of a cancer diagnosis, with a considerable dual burden of pre-existing HIV. Participants noted that having HIV added anxiety about cancer treatment, side effects, and potential treatment interactions. Among those who experienced cancer treatment adherence challenges, barriers included cancer treatment side effects, stigma, transportation difficulties, cost of care, and challenges with coping and mental health. Despite these challenges, participants generally reported having positive healthcare experiences, including compassionate providers, ease of referral, and sound communication. Several participants indicated that their past experiences of coping with HIV had prepared them to accept and address their cancer diagnosis. Conclusions: This is the first qualitative study assessing barriers and facilitators to cancer care among people living with HIV and cancer in the U.S. For many HIV-infected patients, a cancer diagnosis creates substantial added stress to an already challenging social and medical situation. Often, these stressors impact patients’ ability to complete cancer treatment. Resiliency was noted to be a key facilitator, with participants frequently citing family, friends, faith, and the healthcare system as key sources of support. Citation Format: Kelsey L Corrigan, Brandon A Knettel, Noelani Ho, Stuart Carr, Bijal Shah, Joan Cahill, Melissa Watt, Gita Suneja. Cancer care in people with HIV: Identifying adherence challenges to improve outcomes [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A043.

Nickel and dimed: Parking fees at NCI-designated cancer centers.

2029 Background: Nonmedical costs from cancer treatment can be a significant out-of-pocket expense. As treatment may span over months, parking costs can become a significant burden on patients and caregivers. This cross-sectional study aims to report parking fees at National Cancer Institute (NCI)-designated cancer centers and to project parking costs for the treatment duration of certain cancers. Methods: Parking fees from NCI treatment centers were obtained via online search or phone call in Fall of 2019. City cost of living, median city household income, and discount availability were documented. Pearson correlation was used between parking costs and city variables. Parking costs were estimated for treatment of node positive breast cancer (12 daily rates plus 20 1-hr rates), definitive head and neck cancer (35 1-hr rates) and acute myeloid leukemia (AML) (42 daily rates). RStudio Version 1.2.5033 was used for analyses. Results: Parking costs were obtained for 100% of the 63 NCI centers included. Median city cost of living relative to New York City was 75.0 (out of 100); median city household income was $55,295 (range $28,974-$120,573). Twenty-five (40%) of NCI centers did not have detailed parking cost information online. Average parking costs were $3.55/hr (median $2, range 0-$15) and $7.79/day (median $5, range 0-$40). Twenty centers (32%) offered completely free parking for patients. Free parking was available at 43 (68%) centers for radiation appointments and 34 (54%) centers for chemotherapy appointments. Averaged estimated parking costs including discounts for a course of treatment for breast cancer was $122.03 (range 0-$800); head and neck cancer, $85.56 (range 0-$665); and AML hospitalization, $327.33 (range 0-$1470). City cost of living was positively correlated with daily parking costs (R = 0.7, p < 0.01) and negatively correlated with both free daily parking (R = -0.33, p = 0.02) and free parking during radiation (R = -0.34, p = 0.02) or chemotherapy (R = -0.37, p < 0.01). The median city household income was correlated with the daily parking costs (R = 0.30 p = 0.02) but not with free daily parking (R = -0.19, p = 0.16), free parking for patients on radiation (R = -0.23, p = 0.09) or on chemotherapy (R = -0.21, p = 0.14). Conclusions: Patients may face significant nonmedical costs through parking fees, even at centers that reflect the highest standard of care. There was high variability in costs with the potential for patients to pay hundreds of dollars in parking in order to receive their care. Efforts to minimize financial toxicity should focus on this potentially under-reported patient concern.

Financial risk of seeking maternal and neonatal healthcare in southern Ethiopia: a cohort study of rural households

IntroductionEthiopian households’ out-of-pocket healthcare payments constitute one-third of the national healthcare budget and are higher than the global and low-income countries average, and even the global target. Such out-of-pocket payments pose severe financial risks, can be catastrophic, impoverishing, and one of the causal barriers for low utilisation of healthcare services in Ethiopia. This study aimed to assess the financial risk of seeking maternal and neonatal healthcare in southern Ethiopia.MethodsA population-based cohort study was conducted among 794 pregnant women, 784 postpartum women, and their 772 neonates from 794 households in rural kebeles of the Wonago district, southern Ethiopia. The financial risk was estimated using the incidence of catastrophic healthcare expenditure, impoverishment, and depth of poverty. Annual catastrophic healthcare expenditure was determined if out-of-pocket payments exceeding 10% of total household or 40% of non-food expenditure. Impoverishment was analysed based on total household expenditure and the international poverty line of ≈ $1.9 per capita per day.ResultsApproximately 93% (735) of pregnant women, 31% (244) of postpartum women, and 48% (369) of their neonates experienced illness. However, only 56 households utilised healthcare services. The median total household expenditure was $527 per year (IQR = 390: 370,760). The median out-of-pocket healthcare payment was $46 per year (IQR = 46: 46, 92) with two episodes per household, and shared 19% of the household’s budget. The poorer households paid more than did the richer for healthcare, during pregnancy-related and neonatal illness. However, the richer paid more than did the poorer during postpartum illness. Forty-six percent of households faced catastrophic healthcare expenditure at the threshold of 10% of total household expenditure, or 74% at a 40% non-food expenditure, and associated with neonatal illness (aRR: 2.56, 95%CI: 1.02, 6.44). Moreover, 92% of households were pushed further into extreme poverty and the poverty gap among households was 45 Ethiopian Birr per day. The average household size among study households was 4.7 persons per household.ConclusionsThis study demonstrated that health inequity in the household’s budget share of total OOP healthcare payments in southern Ethiopia was high. Besides, utilisation of maternal and neonatal healthcare services is very low and seeking such healthcare poses a substantial financial risk during illness among rural households. Therefore, the issue of health inequity should be considered when setting priorities to address the lack of fairness in maternal and neonatal health.

Abstract 102: Racial, Gender, and Socioeconomic Differences in Sacubitril-valsartan and Ivabradine Utilization for the Management of Heart Failure With Reduced Ejection Fraction in The United States

Background: Current guidelines for heart failure with reduced ejection fraction (HFrEF) recommend transition to an angiotensin receptor-neprilysin inhibitor (ARNI) from an angiotensin-converting enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB), and addition of ivabradine in select patients because of the proven clinical benefit of these therapies. Inequitable care delivery based on race, gender, and socioeconomic status has been demonstrated in other settings. In this study, we assessed the association of race, gender, and socioeconomic status with ARNI and ivabradine utilization among commercially-insured HFrEF patients. Methods: We performed a retrospective cohort analysis of adult patients with diagnosis of HFrEF based on ICD 10 codes between October 2015 and December 2018 using OptumInsight’s Clinformatics Data Mart. HFrEF patients were considered eligible for ARNI analysis or ivabradine analysis if they had a prescription for ACE/ARB or beta-blocker, respectively, within 12 months of the study period. We performed a multivariable logistic regression, adjusting for age, sex, race/ethnicity, region, median zip code-linked household income, and clinical covariates to identify factors associated with the incident use of ARNI and ivabradine. Results: Of 112, 068 patients who met inclusion criteria in the ARNI analysis, 8,747 (7.8%) were prescribed an ARNI during the study period. Only 385 (0.3%) patients of 128,997 who met inclusion criteria were prescribed ivabradine during the study period. In multivariable analyses, black and Latinx patients were more likely to receive an ARNI compared with white patients (OR 1.16; 95% CI, 01.08-1.24; P =<0.0001 for black, OR 1.21; 95% CI 1.11-1.32;P<0.0001 for Latinx). Female gender was independently associated with lower odds of ARNI prescription (OR 0.70; 95% CI 0.67-0.74; p<0.0001). Patients with household income greater than $100,000 or $50,000-99,999 were more likely to be prescribed an ARNI than those with income less than $50,000 (OR 1.35, 95% CI 1.26-1.46; p<0.0001 and OR 1.19; 95% CI 1.13-1.26; p<0.0001 respectively). Race, socioeconomic status, and gender were not independently associated with ivabradine prescription. Conclusion: There have been relatively low rates of ARNI and ivabradine utilization among privately insured HFrEF patients. Female gender and lower socioeconomic status were independently associated with lower rates of ARNI utilization, but racial and ethnic minorities had higher ARNI use rates than whites.

Millennial Generation: Information on the Economic Status of Millennial Households Compared to Previous Generations

Recent research indicates that, across three key measures, economic mobility in the United States is limited. Specifically, the Millennial generation (those born between 1982 and 2000) might not have the same opportunity as previous generations had to fare better economically than their parents. According to studies GAO reviewed, the share of people making more money than their parents at the same age (absolute mobility) has declined over the last 40 years, and the chances of moving up the income distribution (relative mobility) have been flat over time. Using a third measure of economic mobility (intergenerational income elasticity), researchers have found that income in adulthood is linked to how much a person's parents made, and that between one-third and two-thirds of economic status is passed down from parents to children. This is especially true of the lowest and highest income groups. Researchers also identified race and geography as key determinants of an individual's economic mobility. Millennials have different financial circumstances than Generation X (born 1965-1981) and Baby Boomers (born 1946-1964), and in light of flat or declining economic mobility, there is uncertainty about how they will fare financially as they age. A snapshot of data that allowed GAO to compare Millennials aged 25-34 to the previous two generations at similar ages showed that Millennial households were more likely than other generations to be college educated; however, incomes have remained flat across the three generations, implying that Millennials have not yet benefited from the potential additional lifetime income earned by college graduates. Millennial households had significantly lower median and average net worth than Generation X households at similar ages, especially among those with low net worth. Median net worth for the lowest quartile of Baby Boomers and Generation X was around zero, but it was substantially negative for Millennials, indicating that debt was greater than assets for the median low net worth Millennial household. Regarding assets, a significantly lower percentage of Millennials owned homes compared to previous generations at similar ages, but had retirement resources at rates comparable to Generation X and Baby Boomers. Finally, Millennials were more likely to have student loan debt that exceeded their annual income. It remains to be seen how these factors will affect Millennials' financial circumstances in the long run, including retirement.

Abstract P5-07-02: Factors associated with rapid relapse in triple negative breast cancer: A multi-institution study

Abstract Background: Triple-negative breast cancer (TNBC) accounts for a disproportionate amount of poor outcomes among breast cancers. A subset of TNBCs demonstrates an aggressive course with marked chemoresistance, rapid distant metastatic spread, and poor survival. The clinicopathologic and sociodemographic features associated with rapid relapse among TNBCs remain poorly understood. Primary Objective: To evaluate the relationship between clinicopathologic and sociodemographic features with rapid relapse in TNBC (rrTNBC). Methods: This large multi-institutional study analyzed a cohort of breast cancer patients diagnosed with TNBC who received treatment at one of ten academic centers that previously participated in a National Comprehensive Cancer Network (NCCN) outcomes database between 1998 and 2012. We defined rrTNBC as a distant metastatic recurrence event or death from any cause ≤24 months after diagnosis. We included patients with ≥2 years follow-up or had suffered a survival event within that timeframe. We excluded patients with de novo metastatic disease and those who did not receive chemotherapy. We randomly divided the total dataset into 70% training and 30% validation cohorts, balanced by the number of rrTNBC events. Covariates included study site, age at diagnosis, body mass index (BMI), race/ethnicity, education, median annual household income (2000 census tract), insurance type (Managed Care, Medicare, Medicaid, and Other), Charlson comorbidity index, tumor stage and grade at diagnosis, and adjuvant radiation treatment. Logistic regression was performed among the training dataset univariately for associations with rapid relapse vs. not. Features with a p-value <0.10 were included in a multivariable logistic regression model, using backward elimination performed with a p<0.10 criterion. The final multivariable model was applied to the training dataset and to the independent validation cohort. Results: Among 41,839 patients with invasive breast cancer treated in these ten centers, 5256 had TNBC (12.6%), among whom 3016 had adequate follow-up to be included in the analysis. Bivariable analyses in the training cohort (n=2112) identified tumor stage at diagnosis, insurance type, age at diagnosis, BMI, race, and income to be associated with rrTNBC events (p<0.10). The multivariable model identified tumor stage at diagnosis, insurance type, and age at diagnosis as significant contributors. In the final multivariable model, tumor stage was the most significant factor, with patients who presented at stage III having a >15x increased risk of rapid relapse (adjusted OR [95% CI]: 16.5 [10.3, 26.4]; p<0.0001) compared to stage I. Additionally, patients with Medicare (aOR: 2.25 [1.35, 3.73]; p=0.002) versus Managed Care and patients in the youngest age category (aOR: 1.90 [1.27, 2.86]; p=0.002) versus 60-69 years old were significantly more likely to develop rrTNBC. Patients with Medicaid had a non-significant trend towards an increased risk of rrTNBC (aOR: 1.43 [0.98, 2.09]; p=0.06). In the validation cohort (n=904), tumor stage at diagnosis and insurance remained significantly associated with rrTNBC. Conclusion: Advanced tumor stage at diagnosis was the most influential predictor of rapid relapse among patients who had TNBC, while type of insurance remains an independent predictor in training and validation cohorts. Given the known association of sociodemographic disparities with tumor stage, further study of underlying causes and potential interventions to reduce rapid relapse of TNBC is warranted. Citation Format: Sarah Asad, Carlos H. Barcenas, Richard J. Bleicher, Adam L. Cohen, Sara H. Javid, Ellis G. Levine, Nancy U. Lin, Beverly Moy, Joyce Niland, Antonio C. Wolff, Michael J. Hassett, Daniel G. Stover. Factors associated with rapid relapse in triple negative breast cancer: A multi-institution study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-07-02.

Association of Neighborhood Race and Income With Survival After Out‐of‐Hospital Cardiac Arrest

BackgroundFor individuals with an out‐of‐hospital cardiac arrest (OHCA), survival may be influenced by the neighborhood in which the arrest occurs.Methods and ResultsWithin the national CARES (Cardiac Arrest Registry to Enhance Survival) registry, we identified 169 502 patients with OHCA from 2013 to 2017. On the basis of census tract data, OHCAs were categorized as occurring in predominantly white (>80% white), majority black (>50% black), or integrated (neither of these 2) neighborhoods and in low‐income (median household <$40 000), middle‐income ($40 000 to $80 000), or high‐income (>$80 000) neighborhoods. With hierarchical logistic regression, the association of neighborhood race and income on overall survival was assessed. Overall, 37.5%, 16.6%, and 45.9% of people had an OHCA in predominantly white, majority black, and integrated neighborhoods, and 30.1%, 53.4%, and 16.5% in low‐, middle‐, and high‐income neighborhoods, respectively. Compared with OHCAs occurring in predominantly white neighborhoods, those in majority black neighborhoods were 12% less likely (6.9% versus 10.6%; adjusted odds ratio 0.88; 95% CI 0.82‐0.95; P<0.001) to survive to discharge, whereas those in integrated neighborhoods had similar survival (10.3% versus 10.6%; adjusted odds ratio 1.00; 95% CI 0.96‐1.04; P=0.93). Compared with high‐income neighborhoods, those in middle‐income neighborhoods were 11% (10.1% versus 11.3%; adjusted odds ratio 0.89; 95% CI 0.8‐0.94; P<0.001) less likely to survive to discharge, whereas those in low‐income neighborhoods were 12% (8.6% versus 11.3%; adjusted odds ratio 95% CI 0.83‐0.94; P<0.001) less likely to survive. Differential rates of bystander cardiopulmonary resuscitation only modestly attenuated neighborhood differences in survival.ConclusionsOHCAs in majority black and non–high‐income neighborhoods have lower survival rates, and these differences were not explained by differential bystander cardiopulmonary resuscitation rates.

Total Trihalomethane Levels in Major Watersheds across the United States

Trihalomethanes, such as chloroform, bromoform, dibromo(chloro)methane, and bromo(dichloro)methane, are present in the major watersheds across the United States. These chemicals play an important role in the development of cancer, have adverse reproductive outcomes, and were found to be present above the threshold established by the Environmental Protection Agency. To understand the impact of socioeconomic background on the quality of water and possible disparities, we have analyzed the levels of total trihalomethanes in the metropolitan areas in the major watersheds across the United States, in 2018, as they correlated to average household incomes. Our study found that Arkansas, Nevada, and Rhode Island demonstrated higher than federally mandated levels of total trihalomethanes in their watersheds. The median annual household and per capita incomes of the three states (Arkansas, Nevada, and Rhode Island) were lower than the national average. In addition, Delaware, New Hampshire, and Wisconsin, which had higher median income levels, demonstrated the lowest total trihalomethane levels across the United States.

394. Impact of Day of Admission and Time to Diagnostic Arthrocentesis on Mortality and Other Outcomes in Solid-Organ Transplant Recipients with Septic Arthritis: A Nationwide Analysis

BackgroundMultiple cases have been reported assessing the outcomes for solid-organ transplant recipients (SOTR) admitted to the hospital with septic arthritis of a native joint (SANJ); however, there are no data evaluating the outcome of these patients when they are admitted on the weekend compared with the rest of the week.MethodsThe NIS database of the year 2016 was utilized to identify all SOTR with SANJ using ICD-10 codes. SOTR status was defined as those adults with a history of a transplanted organ including heart, lungs, a combined heart and lung, liver, kidney, intestine or pancreas. Admissions between midnight Friday and midnight Sunday were classified as weekend admissions. Early arthrocentesis was defined as percutaneous arthrocentesis performed within 24 hours of admission. Odds ratios (OR) were calculated for primary and secondary outcomes including in-hospital mortality rate, rates of diagnostic arthrocentesis and early arthrocentesis, length o¬f stay and total hospital charges. These results were compared after univariable and multivariable logistic regression adjusted for age, gender, race, day of admission, Charlson comorbidity index and median household yearly income in the patient’s zip code. We used STATA-15 for statistical analysis.ResultsWe identified 319 SOTR with SANJ. Compared with SOTR admitted with SANJ on weekdays, those admitted on weekends had increased in-hospital mortality rates (odds ratio[OR] 11; 95% [CI] 1.2–97.9, P < 0.05), but similar, length of stay (P > 0.05) and hospital charges (P > 0.05). However, regardless of the day of admission those who received an early arthrocentesis had a lower length of stay (P < 0.05), and lower total hospital charges (P < 0.05).ConclusionOur study showed that compared with SOTR admitted with SANJ on weekdays, those admitted on weekends had increased mortality rates but similar length of stays and total hospital charges. However, patients who received an early arthrocentesis had a significantly lower length of stay and hospital charges regardless of the day of admission. These results add weight to the hypothesis of negative outcomes in weekend admissions. Moreover, we believe that our findings require further investigation to establish the role of early arthrocentesis in the management of septic arthritis.Disclosures All authors: No reported disclosures.

Predictors of financial toxicity among head and neck cancer patients: A prospective cohort study.

e18361 Background: Treatment of Head and Neck Cancer (HNC) is associated with significant costs and treatment morbidity. The impact of treatment on financial well-being has not been investigated. Methods: Patients with HNC treated at Princess Margaret Cancer Centre, Canada between 2014 and 2018 were enrolled in a longitudinal study from treatment up to 24 months of follow up. Participants completed questionnaires for demographics, out-of-pocket cost during treatment and at 3, 6, 12, 24 months, and the Financial Toxicity Index (FTI) at 12 and 24 months. The FTI is a 14 item, Likert response scale, with summary score out of 14, and higher scores indicating greater toxicity. Preliminary reliability, validity, and responsiveness for the FTI are very good and ongoing. Uni- and multi-variable analyses (UVA, MVA) were performed to identify predictors for FTI score. Results: Among 363 patients enrolled, average age was 61, 76% male, 81% Caucasian, 72% married, 84% living with others, 53% at least college educated, 57% currently unemployed and 59% had stage IV disease. Median pre-treatment household income was $85K, median lost household income was $15K over 12 months following treatment. At least some difficulty paying for food (14%), housing (17%), or medications (11%) was experienced; 13% had to borrow money and 5% had to relocate housing due to financial pressures. Predictors of greater FTI scores on MVA were younger age (p &lt; 0.001), living alone (p = 0.009), and lower baseline household income (p &lt; 0.001). In subgroup analysis of patients with available information, lost household income (p &lt; 0.001) but not out of pocket costs (p = 0.58) was associated with higher FTI score. Conclusions: Financial toxicity is not uncommon in patients with HNC. Younger age, lower baseline income, living alone, and loss of household income are associated with financial toxicity. This should be a priority population for research into improved supportive care and return to work strategies.

The Interest Rate Exposure of Euro Area Households

We estimate the unhedged interest rate (URE) of euro area households. The URE is a welfare metric that captures the extent to which households are exposed to changes in real interest rates, and reflects the direct gains and losses in interest income flows incurred by households after such a change. It is defined as the difference between maturing assets and maturing liabilities at a given point in time (Auclert 2019). We examine the distribution of the UREs along the net wealth, income, age and housing status distributions for the euro area as a whole and for individual countries, and document substantial heterogeneity across these dimensions. The median household in the euro area has a positive interest rate exposure, indicating that it would gain, in the first instance, from an increase in the interest rate, all other things remaining constant. Households in the lower end of the net wealth and income distribution, younger households and mortgagors, have negative interest rate exposure and would lose from an increase in interest rates. The heterogeneity across countries is largely attributed to the differences in the prevalence of adjustable rate mortgages (ARMs). Countries with a high prevalence of ARMs have interest rate exposure distributions skewed to the left, with negative mean interest rate exposure. Interest gains/losses after a monetary policy shock can be substantial for households with negative interest rate exposure, particularly for mortgagors, and of a similar (absolute) magnitude to capital gains/losses from associated changes in house prices. Besides the direct distributional consequences and the implications for monetary policy, the distribution of the interest rate exposures may help explain the general public's views with the respect to the prevailing monetary policy regime or the central bank.

Neighborhood Differences in Alternative Tobacco Product Availability and Advertising in New York City: Implications for Health Disparities.

Alternative tobacco products (ATPs), such as cigars, smokeless tobacco, and electronic nicotine delivery systems (ENDS), have a strong presence in the US retail environment amid declining cigarette consumption. This study documented the promotion of ATPs in tobacco retailers in New York City and examined associations with neighborhood demographics. Data on product availability and advertising were collected from a stratified, random sample of tobacco retailers in 2017 (n = 796). Multilevel models estimated adjusted prevalence ratios (aPRs) for each outcome by neighborhood racial/ethnic composition and median household income. Nearly half (49.8%) of retailers carried 99-cent cigarillos, but availability was significantly greater in neighborhoods in the highest (vs. lowest) quartile for the percentage of Black residents [68.2%, aPR: 1.59 (1.19, 2.11)] and in the lowest (vs. highest) income quartile [67.3%, aPR: 1.56 (1.04, 2.35)]. Conversely, retailers in neighborhoods with the highest percentage of White residents were significantly more likely to carry ENDS [66.4%, aPR: 1.71 (1.11, 2.62)]. Advertisements for ENDS were less common in neighborhoods in the highest (vs. lowest) quartiles for the percentage of Black and Hispanic residents [20.3%, aPR: 0.64 (0.41, 0.99); 22.9%, aPR: 0.62 (0.40, 0.98)]. The marketing of inexpensive, combusted tobacco products disproportionately saturates low-income, minority communities, while potentially lower risk, noncombusted products are more accessible in largely White and higher income neighborhoods. This pattern may exacerbate tobacco-related inequities. Public health policies should prioritize reducing the appeal and affordability of the most harmful tobacco products to help reduce health disparities. Although cigarette promotion at the point-of-sale is well documented in the literature, questions remain about the ways in which alternative tobacco products (ATPs) are marketed in communities. Importantly, these products fall on a continuum of harm, with combusted tobacco overwhelmingly responsible for tobacco-related death and disease. We found that retailers in minority and low-income communities were more likely to carry and advertise inexpensive ATPs such as cigarillos, while potentially less risky, noncombusted products such as smokeless tobacco and e-cigarettes were more accessible in higher income and predominantly White neighborhoods. Policies aligned with product risk may help reduce health disparities.

Factors Associated With Cancer Disparities Among Low-, Medium-, and High-Income US Counties

There are concerns about the degree to which county income level might underlie the stark disparities in cancer death rates among US counties; at the same time, there is uncertainty about the factors that may mediate the disparities. To assess county-level cancer death rates and to identify possible mediators of the association between county-level median incomes and cancer death rates. Cross-sectional study using death records from the National Center for Health Statistics in 2014, with data collected and analyzed between October 1, 2016, and July 31, 2017. All US counties and county equivalents were included. County-level median household income. County-level age-standardized cancer death rate. In 3135 counties, median incomes ranged from $22 126 to $121 250 per year. Low-income counties (median income, $33 445) vs high-income counties (median income, $55 780) had higher proportions of residents who were non-Hispanic black, lived in rural areas, or reported poor or fair health. The mean (SD) cancer death rate was 185.9 (24.4) per 100 000 person-years in high-income counties, compared with 204.9 (26.3) and 229.7 (32.9) per 100 000 person-years in medium- and low-income counties, respectively. In mediation models, health risk behaviors (smoking, obesity, and physical inactivity); clinical care factors (unaffordable care and low-quality care); health environments (food insecurity); and health policies (state smoke-free laws and Medicaid payment rates) in aggregate accounted for more than 80% of the income-related disparity. The strongest possible mediators were food insecurity (explaining 19.1% [95% CI, 12.5%-26.5%] of the association between county incomes and cancer deaths), low-quality care (17.9%; 95% CI, 14.0%-21.8%), smoking (12.7%; 95% CI, 9.4%-15.6%), and physical inactivity (12.2%; 95% CI, 9.4%-15.6%). There are wide gaps in cancer death rates between low-, medium-, and high-income counties. Future studies are needed to assess whether targeting the possible mediators might ameliorate the substantial socioeconomic cancer disparities.

Healthy diets ASAP \u2013 Australian Standardised Affordability and Pricing methods protocol

BackgroundThis paper describes the rationale, development and final protocol of the Healthy Diets Australian Standardised Affordability and Pricing (ASAP) method which aims to assess, compare and monitor the price, price differential and affordability of healthy (recommended) and current (unhealthy) diets in Australia. The protocol is consistent with the International Network for Food and Obesity / non-communicable Diseases Research, Monitoring and Action Support’s (INFORMAS) optimal approach to monitor food price and affordability globally.MethodsThe Healthy Diets ASAP protocol was developed based on literature review, drafting, piloting and revising, with key stakeholder consultation at all stages, including at a national forum.DiscussionThe protocol was developed in five parts. Firstly, for the healthy (recommended) and current (unhealthy) diet pricing tools; secondly for calculation of median and low-income household incomes; thirdly for store location and sampling; fourthly for price data collection, and; finally for analysis and reporting. The Healthy Diets ASAP protocol constitutes a standardised approach to assess diet price and affordability to inform development of nutrition policy actions to reduce rates of diet-related chronic disease in Australia. It demonstrates application of the INFORMAS optimum food price and affordability methods at country level. Its wide application would enhance monitoring and utility of dietary price and affordability data from a health perspective in Australia. The protocol could be adapted in other countries to monitor the price, price differential and affordability of current and healthy diets.

Abstract C22: Cancer-related financial burden, employment, and health among rural cancer survivors

Abstract Purpose: A growing body of literature has begun to document rural-urban disparities among cancer survivors. Rural survivors report worse mental health, health behaviors (e.g., smoking, physical activity), and self-rated health relative to urban counterparts. There is a need to determine modifiable determinants of these disparities, including work. Only one study of which we are aware has explored financial determinants of health: Weaver and colleagues found rural survivors were more likely to report not being able to work because of health-related reasons than urban counterparts. Little, however, is known about cancer-related financial burden during (e.g., filing for bankruptcy) and after treatment (e.g., not returning to work). Objective: This study seeks to: 1) characterize cancer-related financial burden and employment among rural survivors and 2) examine how these factors pertain to their self-rated health. Methods: We drew from an ongoing larger study that is characterizing the health needs of 600 rural cancer survivors and caregivers of cancer patients throughout Illinois State. Participants were recruited via non-probability based sampling methods, including physical flyers placed in rural community organizations (e.g., churches, hair salons, support groups), public health departments, clinics, hospitals, and cancer centers as well as at cancer-related events (e.g., Relay for Life); word of mouth; and electronic flyers distributed via websites, listservs, and social media. Interested participants contacted staff via the study website or phone number. To be eligible for the study, individuals self-reported: 1) being 18 years or older, 2) identifying as a survivor and/or caregiver, and 3) living in a rural part of Illinois State. After screening and providing informed consent, participants completed surveys by mail, phone, or website. Participants received $15 for their time and effort. Results: Since February, we have recruited 72 current survivors, 84% of whom completed the survey online and 27% of whom also self-reported having been caregivers of cancer patients during their lifetime. Our sample was largely female, married, and non-Latino White (NLW). Survivors in the sample are well-educated overall, with 52% holding a bachelor's degree or above. The median annual household income (AHI) was $50,001 to $75,000, with 40% reporting an AHI of more than $75,000. Approximately 26% of respondents indicated cancer-related financial burden. With regard to work, 52% indicated cancer-related work stoppage, 18% indicated they did not return to work, and 40% indicated a reduced workload during treatment. Cancer-related financial burden was associated with family income, in that work stoppage was associated with lower annual household income (B = -0.32, 95% CI [-0.14, -1.35], p = .02). Finally, we examined how cancer-related financial burdens and employment factors were associated with rural residents' self-rated health. Cancer-related employment factors were associated with self-rated health, in that returning to work at a different job (as opposed to the same job) was associated with lower self-rated health (B = -.49, 95% CI [-.34, -.06], p = .008). Discussion: Our study suggests that work may be an important determinant of rural-urban disparities among cancer survivors. Specifically, financial burden and work difficulties were fairly prevalent among our sample. Returning to work at a different job was significantly associated with lower self-rated health. Limitations include small sample size, generalizability, and an inability to make causal inferences. Our next steps will be to further explore how these work-related factors pertain to specific health behaviors, mental health, and physical health outcomes among survivors and caregivers. Citation Format: Emily Hallgren, Leslie R. Carnahan, Kristine Zimmermann, Yamile Molina. Cancer-related financial burden, employment, and health among rural cancer survivors [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C22.

Abstract B25: Empowering Latinas to obtain breast cancer screenings: Comparing intervention effects, part 1

Abstract Purpose: Latinas suffer disproportionately from breast cancer relative to non-Latina Whites (NLWs), partially due to lower guideline-concordant screening. In response, a significant body of work first sought to characterize disparities and associated determinants. Second, multiple approaches were developed to address this disparity, including community health worker (CHW)-driven education to the target population and empowerment interventions, wherein CHWs train a subset of the population to disseminate education to other members of the target population and mobilize in the context of health. The next logical step is to compare the relative effectiveness of interventions for future large-scaled implementation. Objective: We report emerging evidence from an ongoing, quasi-experimental trial that compares the effects of education and empowerment approaches on Latinas who are nonadherent to US Preventive Services Task Force breast cancer screening guidelines. Methods: The setting for this trial is in two Latino, lower-income communities in Chicago (Pilsen/Little Village, East Side/Chicago). Women are recruited via two community-based organizations (The Resurrection Project, Centro Comunitario Juan Diego) and snowball sampling. Eligibility criteria include: 1) age of 50-74; 2) lack of screening within past 2 years; 3) no previous breast cancer diagnosis; and 4) no prior health volunteerism experience. After screening and providing informed consent, women are assigned to a cohort (6-10 sessions) and participate in a three-week intervention (three 2-hour sessions). The education intervention is administered in East Side/Chicago and the empowerment intervention is administered in Pilsen/South Chicago to avoid contamination effects. The education intervention consists of a session focused on breast cancer and methods of early detection, a session focused on diet as a method of prevention, and a session focused on physical activity as a method of prevention. The empowerment intervention consists of a session focused on breast cancer and methods of early detection, a session focused on one-on-one conversations with family and friends about breast cancer, and a session focused on health-related volunteerism. For women who wish to obtain mammography (from either arm), study team provides navigation to free/low-cost services and tracks participants throughout the continuum of care. Three questionnaires are given: baseline (before Session #1), postintervention (after Session #3), and a follow-up (6 months after Session #3). Receipt of screening is confirmed by study and medical records for women who have completed HIPAA forms. Participants are compensated $80 for their participation. As well, during and after the intervention, participants may refer other nonadherent Latinas to the study for a small incentive ($15). Results: Our current sample is 37 women (20 education; 17 empowerment). The average age was 61.62 years old (SD = 6.02). Approximately 89% of participants were born in Mexico and approximately 81% had less than a high school education. The median annual household income was &amp;lt;$15,000. A greater proportion of empowerment participants have scheduled a mammogram relative to education participants (20% vs. 76%; p=.001). Relative to education participants, a greater proportion of empowerment participants have discussed breast cancer with other nonadherent Latinas and referred them to the study (5% vs 33%; p = .05). Discussion: Preliminary findings suggest the empowerment approach may be more effective in promoting breast cancer screening among nonadherent Latinas and disseminating information to their peers. Limitations concern generalizability due to a non-probability based sample and limited ability for causal inferences due to a lack of randomization. Next steps include comparing receipt of screening and characterizing diffusion of information throughout participants' social networks. Citation Format: Yamile Molina, Liliana G. San Miguel, Lizeth Tamayo, Sylvia Gonzalez, Rosa de la Torre, Kryztal Peña, Araceli Lucio, Oliva Hernandez, Juanita Arroyo, Maria C. Medina, Nora Coronado. Empowering Latinas to obtain breast cancer screenings: Comparing intervention effects, part 1 [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B25.