Nonprivate Insurance Research Articles

(361) National Trends of Male Urethroplasty Procedures: 2016-2019

Abstract Introduction Urethroplasty remains a valuable surgical option in the management of urethral stricture disease. However, current understanding of the patient- and hospital-level factors associated with inpatient versus (vs.) outpatient male urethroplasty is limited on a national scale. Objective We therefore sought to evaluate contemporary national trends of urethroplasty procedures among men. Methods We performed a retrospective review from 2016 to 2019 of urethroplasty procedures in men utilizing both the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample – the largest publicly available all-payer inpatient and ambulatory databases in the United States. Non-endoscopic urethroplasty procedures were identified by Current Procedural Terminology and International Classification of Diseases (10th Revision) Procedure Coding System codes. Utilizing both inpatient and outpatient encounters, we performed stratified cluster sampling to create weighted national estimates. The primary outcome was the rate of urethroplasty performed in inpatient and outpatient encounters over time. Multivariable logistic regression was used to evaluate patient- and hospital-level factors associated with inpatient urethroplasty. Results From 2016 to 2019, there were 28,532 weighted urethroplasty procedures analyzed (37% inpatient vs. 63% outpatient). Over the study period, there was a 27% increase in the total number of annual procedures (n=6270 to n=7980), and the proportion performed outpatient increased from 60% to 68% [Figure]. Mean total charge for inpatient urethroplasty encounters was $84,267 vs. $30,997 outpatient (p<0.0001). Predictors of inpatient urethroplasty included greater Elixhauser Comorbidity Index, use of buccal mucosal graft, non-private insurance status, and Western hospital region (vs. Northeast) (p<0.05) [Table]. Outpatient urethroplasty was associated with higher median income by Zip Code (vs. lowest quartile of median income), Southern hospital region (vs. Northeast), rural or urban non-teaching hospital (vs. urban teaching hospital), and higher urethroplasty case volume hospitals (vs. lowest case volume hospitals) (p<0.05). Conclusions An increasing proportion of urethroplasty procedures nationwide appears to be performed on an outpatient basis. Outpatient procedures have lower hospital charges than inpatient encounters – and are associated with higher volume hospitals, not using buccal mucosal graft, private insurance, and less comorbid patients who reside in areas of higher median income. Further investigation is warranted to assess how these factors may affect surgical outcomes. Disclosure No.

Disparities and Underutilization of Surgery for Early Stage Small Cell Lung Cancer

BackgroundThe National Comprehensive Cancer Network recommends surgical resection for stage I small cell lung cancer (SCLC). Despite these recommendations and the curative potential of such surgery, many continue to underutilize surgery. Our aim is to investigate factors that contribute to underutilization of surgery for stage I SCLC. MethodsThe National Cancer Database was queried to identify patients with SCLC stage I-IV from 2004 to 2018. Staging was defined by the American Joint Committee on Cancer guidelines. Cochran-Armitage analysis was performed to analyze trends in surgical treatment for patients diagnosed with stage I SCLC. Multivariable logistic regression assessed relationships between patient factors and surgical treatment. ResultsA total of 296,583 patients were diagnosed with SCLC. Of the stage I patients (n = 13,003), only 29.4.% (n = 3823) underwent surgery. Trend analysis demonstrated increased frequency of surgical treatment for stage I SCLC over years 2004 to 2017, from 14.9% to 39.6% (P < .0001). Factors that were associated with underutilization of surgery for stage I SCLC include African American race, lower median income, nonprivate insurance or Medicare, community facility, and geographic regions other than the Northeast. ConclusionsSurgical treatment for stage I SCLC remains underutilized and our study identifies notable associated factors. The recognition of these factors may help patients overcome barriers to receiving recommended treatments, improve guideline adherence, and overall quality of care for stage I SCLC patients.

Abstract A116: Assessment of equitable care for women of color with mBC

Abstract MD Anderson Cancer Center at Cooper in collaboration with The Chrysalis Initiative (TCI), sought to characterize the differences between the care that women of color (WOC) receive for metastatic breast cancer (mBC) compared to White women (WW), and understand the social determinants of health (SDOH) and palliative care (PC) needs that WOC with mBC face compared to WW. Twenty-eight WOC and 74 WW with mBC participated in an IRB approved telephone survey. The survey included questions on SDOH, understanding of PC, and the Edmonton System Assessment Scale which assesses symptoms common in cancer patients. WOC with mBC who participated tended to be less often married, more often had non-private insurance, and had lower educational levels and income. The only statistically significant response between the groups was that 50% of the WOC had ever heard of advance directives compared to 86.5% of WW (P&amp;lt;0.001). However, there were concerns for both groups including: 3 in 5 women had issues with lack of transportation to their appointments; 69% reported stress, nervousness, or anxiety; 78% were not following with a palliative care provider; 63% were dealing with pain; 59% were dealing with depression; 58% did not have a living will; 58% had not had an advanced directive discussed with them; 44% never heard of palliative care; and 40% had not had access to a social worker or nurse navigator. Also, TCI led 6 focus groups of women being treated for mBC at Cooper. Three focus groups comprised of 9 WOC with mBC, and 3 consisted of 15 WW with mBC. The goals of the focus groups were to gain insight into the factors influencing patient’s reasoning for their feelings towards the care they receive, and gain insight into the level of knowledge patients have about their breast cancer type, metastatic terminology, and other factors related to their journey. The themes identified suggest that important factors influence patients’ feelings about the care they receive including religion and faith, overall understanding of their treatment plan, willingness to research new treatment options on their own, and lifestyle and support systems that allow them to address and overcome barriers to care. WOC tended to have a poorer appreciation of their breast cancer disease and tumor characteristics and demonstrated lower health literacy or understanding of their mBC characteristics, and the relevance of these in their treatment plans. They had poorer knowledge of available support and palliative care resources and a higher incidence of feeling that they were not being listened to. Focus groups and surveys of women with mBC taught us that poor access to palliative care and social determinants of health disparities are prevalent for persons of color, and that having metastatic breast cancer is a burden for all ethnicities. Efforts need to continue to focus on educating WOC about their disease and its treatment. More importantly, we need to ensure that WOC have access to support services and opportunity to discuss their issues and concerns in a culturally competent manner. Citation Format: Evelyn Robles-Rodriguez, Ashley Weinmann, Generosa Grana, Jamil Rivers. Assessment of equitable care for women of color with mBC [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A116.

Chemotherapy Refusal Patterns in Multiple Myeloma Patients: An in-Depth Analysis of the NCDB Data from 2004 to 2020

Background: Chemotherapy is a cornerstone in the treatment of multiple myeloma (MM), contributing to prolonged patient survival. However, despite its proven efficacy, some individuals opt to decline chemotherapy, leading to variations in treatment strategies and outcomes. Understanding the factors associated with the decision to decline chemotherapy in MM patients is crucial for optimizing patient-centered care and ensuring equitable access to appropriate treatments. Our investigation aims to illuminate potential areas for targeted interventions, with the goal of enhancing patient engagement and optimizing treatment strategies to improve overall outcomes in MM management. Methods: N=152,299 patients diagnosed with MM between 2004 and 2020 were identified using the NCDB, all of whom were recommended for chemotherapy. Overall survival (OS) of patients who received chemotherapy compared to those who did not receive it was evaluated and presented using Kaplan-Meier (KM) curves. Multivariate logistic regression analysis with backward elimination was used to identify factors associated with refusal of chemotherapy. SAS version 9.4 was used to analyze the data. Results: Among 152,299 patients who received a recommendation for chemotherapy from their physicians, 3,289 individuals (2.16%) opted to refuse the treatment. Descriptive statistics for patients who refused chemotherapy are presented in Table 1. The median OS for patients who received chemotherapy was 61.37 months, in contrast to 8.8 months for those who declined this treatment (Figure 1). Our multivariate logistic regression analysis revealed several significant factors associated with chemotherapy refusal in MM patients. Age exhibited a statistically significant association, with increasing odds of refusal observed in patients aged 60-69 years (OR=1.29, p=0.045), 70-79 years (OR=2.26, p&amp;lt;0.0001), and 80 years and older (OR=7.29, p&amp;lt;0.0001) compared to those younger than 50 years. Male patients exhibited lower odds for refusal (OR=0.85, p&amp;lt;0.0001) compared to female patients. Black patients had higher odds for refusal (OR=1.26, p&amp;lt;0.0001) compared to White patients. Patients with Medicare, Medicaid/other government insurance, and no insurance had higher likelihood of refusal (OR=1.71, 1.89 and 3.13 respectively, p&amp;lt;0.0001) than patients with private insurance. The Charlson-Deyo score demonstrated a significant association, with higher scores correlating with increased odds of refusal (p&amp;lt;0.0001). Patients treated at non-academic facilities had higher odds of refusal (OR=1.47, p&amp;lt;0.0001) compared to academic facilities. Education was significantly associated with refusal, with patients having lower education levels exhibiting increased odds of refusal. Patients living in areas where more than 21% of the area residents have no high school diploma (HSD) had higher odds of chemotherapy refusal compared to patients living in areas where less than 7% have no HSD (OR=1.28, p=0.0026). The year of diagnosis was also linked to refusal, with patients diagnosed between 2004-2007, 2008-2011, and 2012-2015 having higher odds of refusal compared to those diagnosed between 2016-2020 (OR=1.62, 1.25 and 1.27 respectively, p&amp;lt;0.0001). It is also important to note that geographical location played a role, with patients treated in the East North Central, Mountain, and Pacific regions exhibiting significantly higher odds for refusal compared to the South Atlantic region (OR=1.17, 1.35 and 1.16 respectively, p=0.01, 0.002 and 0.03 respectively). Conclusion: Our comprehensive analysis of MM patients shows that the chemotherapy refusal rate in the real-world setting is low at 2.16%. Despite the low rate of refusal, this study did identify several important factors significantly associated with chemotherapy refusal in this patient population. Older age, female sex, Black race, non-private insurance, higher comorbidities, lower education level, non-academic facility type, earlier year of diagnosis, and East North Central, Mountain, and Pacific facility locations were associated with higher likelihood of declining chemotherapy. Our findings emphasize the importance of considering socioeconomic (level of education, insurance status), as well as racial and regional factors, while developing targeted interventions to address disparities in order to enhance engagement in myeloma care.

1549. Risk Factors, Risk Perception, and Long-acting PrEP Awareness and Interest among US Women: A National Survey

Abstract Background Cisgender women account for approximately 20% of incident HIV diagnoses in the US. However, only 10% of women who could benefit from HIV pre-exposure prophylaxis (PrEP) have been prescribed PrEP. US women face several challenges that may affect their seeking HIV prevention services, such as lack of PrEP awareness. Understanding these challenges may improve PrEP uptake, especially as innovative PrEP options, such as long-acting (LA) injectable PrEP, become available. This study explored interest in using LA-PrEP by factors that may increase risk of HIV acquisition. Methods Cisgender women were recruited between November 2021 – March 2022 though targeted social media ads on Facebook, Instagram, and Tinder to complete an online, self-administered survey. Eligible participants were cisgender women who were: 18+ years, current US residents, reported penetrative sex in the past six months, and reported an unknown or negative HIV status. The survey included questions on demographics, sexual health and behavior, LA-PrEP awareness, and LA-PrEP interest. Descriptive statistics were calculated using SAS v9.4. Results 1,834 eligible women completed the survey (median age: 28 years (IQR: 25, 33); Geography: South – 65%, West – 21%, Northeast – 7.3%, Midwest – 6.8%; Race: Black, non-Hispanic – 34%, White, non-Hispanic – 25%, Hispanic – 27%, Another race – 14%). Women were more likely to have heard of LA-PrEP if they had reported injection drug use in the past year (71%), had an STI diagnosis (70%) or HIV test (66%) in the past two years, and were currently using contraception (65%). Interest in using LA-PrEP was consistently high; the difference between LA-PrEP awareness and interest was greatest among women with non-private health insurance and those with perceived likelihood of future HIV acquisition. Conclusion Although interest in using LA-PrEP is high among US women, these results demonstrate the large gap between LA-PrEP awareness and interest in using it. Disclosures Tonia Poteat, PhD, MPH, PAC, Viiv Healthcare: Advisor/Consultant Supriya Sarkar, PhD, MPH, GlaxoSmithKline: Stocks/Bonds|Viiv Healthcare: Employee Leigh Ragone, MS, GlaxoSmithKline: Stocks/Bonds|ViiV Healthcare: Employee Danielle Bogan, BSN, MPH,DrPH, ViiV Healthcare: Contract worker Keith Rawlings, MD, GlaxoSmithKline: Stocks/Bonds|ViiV Healthcare: Employee Alex R. Rinehart, PhD, ViiV Healthcare: Employee Vani Vannappagari, MBBS, MPH, PhD, GlaxoSmithKline: Stocks/Bonds|ViiV Healthcare: Employee

Demographic and socioeconomic determinants of access to care: A subgroup disparity analysis using new equity-focused measurements.

Disparities in healthcare access and utilization associated with demographic and socioeconomic status hinder advancement of health equity. Thus, we designed a novel equity-focused approach to quantify variations of healthcare access/utilization from the expectation in national target populations. We additionally applied survey-weighted logistic regression models, to identify factors associated with usage of a particular type of health care. To facilitate generation of analysis datasets, we built an National Health and Nutrition Examination Survey (NHANES) knowledge graph to help automate source-level dynamic analyses across different survey years and subjects' characteristics. We performed a cross-sectional subgroup disparity analysis of 2013-2018 NHANES on U.S. adults for receipt of diabetes treatments and vaccines against Hepatitis A (HAV), Hepatitis B (HBV), and Human Papilloma (HPV). Results show that in populations with hemoglobin A1c level ≥6%, patients with non-private insurance were less likely to receive newer and more beneficial antidiabetic medications; being Asian further exacerbated these disparities. For widely used drugs such as insulin, Asians experienced insignificant disparities in odds of prescription compared to White patients but received highly inadequate treatments with regard to their distribution in U.S. diabetic population. Vaccination rates were associated with some demographic/socioeconomic factors but not the others at different degrees for different diseases. For instance, while equity scores increase with rising education levels for HBV, they decrease with rising wealth levels for HPV. Among women vaccinated against HPV, minorities and poor communities usually received Cervarix while non-Hispanic White and higher-income groups received the more comprehensive Gardasil vaccine. Our study identified and quantified the impact of determinants of healthcare utilization for antidiabetic medications and vaccinations. Our new methods for semantics-aware disparity analysis of NHANES data could be readily generalized to other public health goals to support more rapid identification of disparities and development of policies, thus advancing health equity.

Exploring Autologous Hematopoietic Stem Cell Transplantation (HSCT) Utilization and HSCT Refusal Trends in Multiple Myeloma Patients: A Comprehensive Examination of NCDB Data from 2004 to 2020

Background: Autologous hematopoietic stem cell transplantation (HSCT) remains standard of care in multiple myeloma (MM) in eligible patients and is proven to improve survival. However, a significant number of patients can decline HSCT as part of their treatment. Understanding the patterns and factors behind HSCT refusal is crucial for optimizing patient care and tailoring effective interventions. Methods: A total of 43,653 patients MM patients recommended for HSCT from 2004 to 2020 were identified via the NCDB, after excluding cases with incomplete values. KM curves compared overall survival (OS) between HSCT and non-HSCT patients, with both groups receiving induction chemotherapy. Factors influencing HSCT refusal were determined using multivariate logistic regression with backward elimination. SAS version 9.4 was used to analyze the data. Results: Among 43,653 patients recommended for HSCT only 1.95% (850 individuals) refused HSCT and 98.05% received HSCT. The patient characteristics are presented in Table 1. As noted in Figure 1, the median OS of MM patients who opted for induction chemotherapy followed by HSCT, had a much higher OS of 124 months, compared to the MM patients who declined HSCT and had chemotherapy alone with a median OS of 95 months. On multivariate logistic regression analysis patients aged 60-69 and those aged 70 and above demonstrated higher odds of refusing HSCT compared to those below 50 years, with OR of 1.50 (p = 0.0120) and 3.26 (p &amp;lt; 0.0001), respectively. Male patients exhibited decreased odds of HSCT refusal compared to females, with an OR of 0.84 (p = 0.0329). Black patients showed a higher likelihood of HSCT refusal than White patients (OR = 1.38, p = 0.0022). Hispanic patients were less likely to refuse HSCT compared to non-Hispanic patients (OR = 0.65, p = 0.0296). Patients without insurance, those covered by Medicaid/other government insurance and Medicare, exhibited increased odds of HSCT refusal compared to private insurance with ORs of 2.23 (p = 0.0066), 1.38 (p = 0.0366) and 1.34 (p = 0.0048), respectively. Moreover, patients with a Charlson-Deyo score of 2 or 3 had a higher likelihood of HSCT refusal compared to those with a score of 0 (OR = 1.48, p = 0.0024). Patients treated at non-academic facilities were more likely to refuse HSCT than those treated at academic facilities (OR = 2.67, p &amp;lt; 0.0001). Furthermore, patients with a median household income less than $38,000 had increased odds of HSCT refusal compared to those earning $63,000 or more (OR = 1.62, p = 0.0002). Patients with incomes in the ranges of $38,000-$47,999 and $48,000-$62,999 also demonstrated higher odds of refusal with ORs of 1.39 (p = 0.0043) and 1.34 (p = 0.0050), respectively. The year of diagnosis exhibited a significant association with the likelihood of HSCT refusal: patients diagnosed in 2004-2007, 2008-2011 and 2012-2015 had lower odds of refusing HSCT compared to those diagnosed in the reference period (2016-2020), with ORs of 0.16 (p &amp;lt; 0.0001), 0.56 (p &amp;lt; 0.0001) and 0.75 (p = 0.0024), respectively. Geographic location significantly influenced HSCT refusal, with the South Atlantic region (SA) as the reference category. Lower odds of refusal were observed in West South Central (OR 0.29, p &amp;lt; 0.0001), Mountain (OR 0.53, p = 0.001), East South Central (OR 0.63, p = 0.025), and East North Central (OR 0.72, p = 0.01) regions. Conclusion: Our analysis of large real-world database shows that the HSCT significantly improves survival in MM and should be recommended for eligible patients. Furthermore, the study shows that the HSCT refusal rate in real-world is low at ~2% but still represents a missed opportunity to provide standard of care with room for improvement. Older patients (age &amp;gt;60), females, Blacks, non-Hispanics, patients with non-private health insurance, higher comorbidities, non-academic facilities, and lower income (&amp;lt;$63,000/yr), were found to be associated with increased odds of declining HSCT. There was also geographic variation across the USA with higher HSCT refusal in the South Atlantic region compared to other regions. In addition, the increasing trend in HSCT refusal from 2004 to 2020 is likely due to advances in MM therapeutics due to the availability of novel agents and anti-CD38-immunotherapy. Our study suggests significant racial, economic, and geographic variation regarding the utilization of HSCT across the US which should be further studied in prospective studies.

Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis

BackgroundThe traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes. MethodsAdults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004–2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan–Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type. ResultsA total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%–4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35–1.60, P < .001), higher Charlson–Deyo score (score ≥3: 1.79, 1.58–2.04, P < .001), stage II cancer (1.22, 1.17–1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts. ConclusionDespite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.

Uncovering Health-Care Disparities Through Patient Decisions in Lung Cancer Surgery

IntroductionDeclining cancer surgery represents a conflict between patients' rights to autonomy and providers’ perspectives of best practice. We hypothesize that, among patients with nonmetastatic lung cancer, patient demographics would be associated with different rates of declination of lung cancer surgery. MethodsPatients with nonmetastatic lung cancer from 2004 to 2018 in the National Cancer Database were identified. Patients were categorized into two groups based on surgical treatment: surgical resection and declined surgery. Patient characteristics were compared using bivariate and multivariate models to identify factors associated with surgical declination. Additionally, we performed subgroup analyses of cT1N0M0 patients with no comorbidities. Survival analysis done using multivariate cox analysis and Kaplan-Meier survival analysis. Results478,757 patients were identified. In a multivariate model, declining surgery was associated with increased age (odds ratio 1.09, 1.09-1.10), non-Hispanic Black race (odds ratio 1.95, 1.73-2.21), nonprivate insurance, and lower Socioeconomic Status. In a subgroup of cT1N0M0 patients with no comorbidities, declining surgery was associated with increasing age, non-Hispanic Black race, nonprivate insurance, and socioeconomic status. Patient's that declined surgery demonstrated lower overall survival when compared to patients that underwent surgical resection (5 y overall survival: declined surgery 40% versus underwent resection 72%, P < 0.001). ConclusionsAlthough early-stage lung cancer is potentially curable, many patients decline guideline-based surgery, and have worse overall survival. There are social and economic factors associated with patients declining lung cancer surgery. Providers have an ethical responsibility to understand the basis of patient's decision to decline recommended surgery and address endemic disparities related to race and access to care.

Impact of Employment and Insurance Status on Hope Among Patients Treated within Radiation Oncology

Hope is important in serious illnesses including cancer, as it has been linked to patient well-being and quality of life. We assessed hope among patients seen in radiation oncology and aimed to determine associated socioeconomic and disease factors. We hypothesized that patients who may have less resources to cope with their illness would have lower hope scores. The Adult Dispositional Hope Scale (AHS) is a questionnaire that aims to measures an individual's determination to accomplish goals and planning strategies to accomplish goals. We prospectively collected AHS survey scores from patients with benign or malignant disease seen in 2 radiation oncology clinics at our institution from 10/2022 to 1/2023. The AHS survey contains 12 items to measure hope through two qualities: agency (goal-directed energy) and pathways (plan to meet goals). Each item is answered using an 8-point scale. There are 4 items each for the Agency and Pathway subscales with 4 filler items for total scores ranging from 8 to 64, with higher scores reflecting higher agency and pathways thinking. Kruskal-Wallis H test and Kendall's Tau Rank Correlation were used to determine differences between categorical and continuous variables on AHS scores, respectively. We included 228 patients with a median age of 62 years (range 16.9-92.6). Half were male (51%), 56% were white, and 77% had malignant disease. The primary disease subsite was CNS, GI and other in 76 (34%), 70 (31%), and 81 (36%) patients, respectively. Of patients with known occupation and insurance information, 32 (14%), 67 (29%), and 49 (22%) were not employed, employed, and retired, respectively, and 115 (50%), 85 (37%), and 20 (9%) had private insurance, Medicare, and Medical, respectively. Median agency, pathway, and total hope scores were 27 (interquartile range [IQR] 24-29), 28 (IQR 24-30), and 55 (IQR 48-58), respectively. Higher total hope scores were associated with being employed (p = 0.02), having private insurance (p<0.02), and higher ECOG scores (p<0.01). After excluding those who are not employed because they are retired (n = 99), lack of employment was significantly associated with hope (p<0.01). Characteristics such as race/ethnicity, gender, marital status, pain, symptoms from disease, malignant or benign disease, stage of disease, and treatment modalities were not associated with AHS scores. In our study, patients with non-private insurance and being currently unemployed had lower AHS scores. The lower hope scores suggest that these patients may have fewer resources to cope with their treatments and diagnoses and may benefit from further inquiry about the need to mitigate cancer-related financial burden to improve hope levels. Further studies are needed to evaluate whether financial toxicity, which has been shown to negatively impact patient outcomes, is correlated to coping and hope.

Evaluating the Optimal Time Between Diagnosis and Surgical Intervention for Early-Stage Lung Cancer

IntroductionThere is no consensus on the optimal timing for lung cancer surgery. We aim to evaluate the impact of timing of surgical intervention. We hypothesize delay in intervention is associated with worse overall survival and higher pathologic upstaging in early-stage lung cancer. MethodsWe identified patients with cT1/2N0M0 nonsmall cell lung cancer in the National Cancer Database from 2004 to 2018. Patients were categorized by time to surgery groups: early (<26 d), average (26-60 d), and delayed (61-365 d). Primary outcome was overall survival and secondary outcome was pathologic upstaging. Multivariate models and survival analyses were used to determine factors associated with time from diagnosis to surgery, pathologic upstaging, and overall survival. ResultsIn multivariate model, advanced age, non-Hispanic Black patients, nonprivate insurance, low median income and education, and treatment at low-volume facilities were less likely to undergo early intervention and compared to the average group were more likely to receive delayed intervention. Pathologic upstaging was more likely in the delayed group (odds ratio 1.11, 1.07-1.14) compared to early group (odds ratio 0.96, 0.93-0.99). Early intervention was associated with improved overall survival (hazard ratio 0.93, 0.91-0.95), while delayed intervention was associated with inferior survival (hazard ratio 1.11, 1.09-1.14). ConclusionsExpeditious surgical intervention is associated with lower rates of pathologic upstaging and improved overall survival in early-stage lung cancer. Delays in surgery are associated with social and economic factors, suggesting disparities in access to surgery. Lung cancer surgery should be performed as quickly as possible to maximize oncologic outcomes.

131-LB: Diabetes and Disparities in Continuous Glucose Monitoring in Community Health Care Settings

Federally qualified health centers (FQHCs) serve vulnerable DM patients in primary care in underserved settings. The state of DM (glycemic control, complications) may differ and utilization of technologies (e.g. continuous glucose monitoring [CGM]) may be essential. But the current state of DM and CGM is poorly characterized. Using EHR data from a national FQHC network (2015-2021) we examined baseline demographic characteristics, CGM prescriptions, and their association. We included 47,579 with DM: n=1630 with T1D [3%], n= 45,949 T2D [97%], 38% Hispanic, 34% Black (Table 1). Notably, T1D pts [mean age 43 SD 16], had poor glycemic control (HbA1c 9.4 SD 2.4) with elevated DM complications severity index scores [mean DSCI 2.3 SD 4.7]. Overall CGM prescriptions were extremely low; 9% in T1D and only 1% in T2D. Among T1D, those who were Hispanic [OR 0.39, (CI 0.23, 0.66), p &amp;lt; 0.001] or Black [OR 0.52, (CI 0.33, 0.81), p = 0.003] were less likely to have CGM prescribed than White adults, after adjustment. Among T2D, those who were Hispanic [OR 0.42, CI 0.33, 0.55, p &amp;lt; 0.001] or Black [OR 0.68, CI 0.54, 0.85, p = 0.001] were similarly less likely to have CGM. Non-private insurance was also a significant factor. DM severity (poor control, complications) is notable in FQHCs, yet CGM is exceptionally low. These findings underscore the major translation gap in standard of care for FQHCs and the critical need to understand inequities. Disclosure A. Wallia: Research Support; UnitedHealth Group, Novo Nordisk, Eli Lilly and Company. D. Bright: None. A. Eggleston: None. M. J. O'brien: None. S. Agarwal: Advisory Panel; Medtronic, Consultant; Beta Bionics, Inc., Research Support; Abbott Diabetes, Dexcom, Inc. A. L. Owen: None. E. L. Lam: None. K. Davis: None. S. Bailey: Advisory Panel; Gilead Sciences, Inc., Consultant; Lundbeck, Pfizer Inc., Research Support; Eli Lilly and Company, Merck Sharp &amp; Dohme Corp., Gilead Sciences, Inc., Lundbeck, Pfizer Inc. S. E. Delacey: None. A. Pack: Consultant; Gilead Sciences, Inc., Research Support; Merck &amp; Co., Inc., Pfizer Inc., Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, Eli Lilly and Company, Gilead Sciences, Inc. J. Espinoza: Consultant; Sanofi, Research Support; NIH - National Institutes of Health, FDA, Speaker's Bureau; Glooko, Inc. Funding Centers for Diabetes Translation Research (5P30DK020541, 472P30DK092949-11A); National Pilot and Feasibility Grant for Diabetes Research Centers; Center for Diabetes Translation Research

Characteristics of Patients Restrained in the Emergency Department and Evaluation for Disparities in Care

BackgroundPhysical restraints are used in the emergency department (ED) for agitated patients to prevent self-harm and protect staff. Prior studies identified associations between sociodemographic factors and ED physical restraints use. ObjectivesThe primary objective was to compare characteristics of ED patients receiving physical restraints for violent and nonviolent indications vs. patients who were not restrained. The secondary objective was to compare rates of restraint use among ED providers. MethodsThis was a single-center cross-sectional study of adult ED patients from March 2019 to February 2021. Factors compared across groups were age over 50 years, gender, race, ethnicity, insurance, housing, primary language, Emergency Severity Index, time of arrival, mode of arrival, chief complaint, and medical admission. Odds ratios were reported. Rates of emergency physician restraint orders were compared using the chi-square test. ResultsRestraints were used in 1228 (0.9%) visits. Younger age, male gender, “unknown” ethnicity, self-pay or “other” nonprivate insurance, homelessness, arrival by first responders, and medical hospitalization were associated with increased odds of restraint. Black patients had lower odds of any restraint than White patients (odds ratio 0.93; 95% confidence interval 0.79–1.09) and higher odds of violent restraint than White patients, although not significant (odds ratio 1.55; 95% confidence interval 0.95–2.54). ED providers had significant differences in total and violent restraint use (p-values < 0.0001 and 0.0003, respectively). ConclusionAt this institution, certain sociodemographic characteristics were associated with receiving both types of physical restraint. Emergency physicians also differed in restraint-ordering practice. Further investigation is needed to understand the influence of implicit bias on ED restraint use.

Demographic and socioeconomic determinants to the access to hematopoietic stem cell transplantation (HSCT) in multiple myeloma (MM): A National Cancer Database (NCDB) analysis of years 2004-2017.

e20013 Background: Despite the advent of novel chemo-immunotherapies in multiple myeloma (MM), hematopoietic stem cell transplantation (HSCT) remains a crucial aspect of therapy in eligible patients. However, disparities in access to HSCT have been well documented. In this IRB approved retrospective analysis, the NCDB was used to evaluate the determinants of access to HSCT among MM patients who were treated in Commission on Cancer (CoC) accredited facilities across the USA. Methods: Using the NCDB, we identified N = 171,261 patients diagnosed and treated for MM from 2004 to 2017. Multivariable logistic regression analysis was conducted to identify the predictors for receiving HSCT, using significance level of p &lt; 0.05. SAS version 9.4 was used to analyze the data. Results: Multivariable logistic regression analysis showed that there were 12 significant factors associated with HSCT: age, sex, race, ethnicity, facility, insurance, median income, education level, year of diagnosis, distance to facility, Charlson score, and type of treatment regimen. Patients of age 65-75 (OR = 0.65, p &lt; 0.0001) and age ≥ 75 (OR = 0.04, p &lt; 0.0001) were less likely to receive HSCT compared to patients of age &lt; 55. Male patients were more likely to be treated with HSCT compared to female patients (OR = 1.08, p = 0.005). Black patients were predicted to have less access to HSCT compared to White patients (OR = 0.69, p &lt; 0.0001). Patients of non-Hispanic ethnicity were predicted to have better access to HSCT compared to Hispanic patients (OR = 1.25, p = 0.0007). Furthermore, subjects who were treated in non-academic facilities were less likely to receive HSCT compared to the ones who received care in academic or research centers (OR = 0.51, p &lt; 0.0001). Patients with Medicare (OR = 0.79, p &lt; 0.0001), Medicaid (OR = 0.77, p &lt; 0.0001), and no insurance (OR = 0.38, p &lt; 0.0001) were less likely to receive HSCT compared to patients with private insurance. Interestingly, the lower median income &lt; $38,000 was associated with increased frequency of HSCT in comparison with higher median income ≥ $63,000 (OR = 1.17, p &lt; 0.0001). This may be due to reduced access to novel agents by lower income patients who typically cannot afford high co-payment associated with novel agents. In contrast, subjects with a lower level of education (no high school diploma in 21% or more) were predicted to have less access to HSCT in comparison with subjects who had a higher level of education (no high school diploma in less than 7%) (OR = 0.57, p &lt; 0.0001). Detailed analysis will be presented. Conclusions: Our study shows that Black and Hispanic patients as well as those with non-private insurance were less likely to receive HSCT in this large cohort of real world data set from across the USA. These results further corroborate the need to improve equitable access to care to all myeloma patients to ameliorate outcomes.

“You matter”: Patient reported outcomes on cancer disparities related to the COVID-19 pandemic.

e13674 Background: Disparities in cancer care have been exacerbated by the COVID-19 pandemic. Understanding the challenges encountered by patients can help alleviate the burden of cancer and improve access to care. Methods: We recruited consecutive patients with cancer at a comprehensive academic cancer center and analyzed patient reported socioeconomic and mental health challenges, and their perception of access to care since the start of the pandemic using a modified version of the You Matter: COVID-19 Mental Health Impact Survey. The survey instrument was self-administered once from November 11, 2022 to January 12, 2023 and consisted of 21 items with questions focused on demographics, social health, telehealth attitudes, and mental health. Established patients diagnosed at the cancer center prior to the start of the COVID-19 pandemic and who are continuing care were included in the study. Results: A total of 136 participants were included in this analysis. Participants characteristics were as follows: 70% had age&gt;65, 75% white, 70% female, 43 % had bachelor's degree or higher, 62.5% with non-private insurance, 95% maintained same insurance throughout the pandemic, and 80% had household of &gt; 1 person. Since April 2020, 49.3% reported increased level of stress and 60.6% reported increased anxiety, stress or experience of distress as a direct result of COVID-19. Among the patients that reported they had participated in telehealth, 84.4% described it as easy and effective, and 70.6% found it either comfortable or neutral. Black participants were more likely to have less contact with providers compared to white participants (OR=5.54, p=0.0180); participants age ≥65 were more likely to report worse overall health compared to younger participants (OR=2.67, p=0.0359); male participants were more likely to experience challenges because of COVID-19 (OR=2.12, p=0.0496), were less uncomfortable with telehealth (OR=0.034, p=0.0350), had increased anxiety and stress, and experienced less distress due to COVID19 (OR=0.47, p=0.0490) compared to female participants. Conclusions: Challenges reported during the COVID-19 pandemic varied across sociodemographic groups, with elderly, male and black reporting the worst impact related to the pandemic. The vast majority of the survey participants reported increased stress, anxiety, or distress affecting quality of life and hindering access to care. The results of the study, however, suggest the important role of telehealth in addressing challenges and narrowing disparities in access to cancer care across the majority of participants.

Determinants of overall survival of young adults with multiple myeloma: A National Cancer Database (NCDB) analysis of years 2004-2017.

8052 Background: There is paucity of real-world data on the outcomes of younger patients with multiple myeloma (MM). In this IRB approved retrospective analysis, the NCDB was used to evaluate the determinants of overall survival (OS) of young adults ≤ 50 years with MM who were treated at commission on cancer (CoC) accredited facilities across the USA. Methods: Using the NCDB, we identified N = 16,792 patients ≤ 50 years old diagnosed and treated for MM from 2004 to 2017. Multivariable cox regression analysis with backward elimination was utilized to identify the independent survival factors, using significance level of p &lt; 0.05. Kaplan-Meier survival curves were generated and SAS version 9.4 was used to analyze the data. Results: Overall median survival time was 119 months; while survival rates of 1, 3, and 5-year were 90.6%, 78.0%, and 67.8%, respectively. Multivariable cox regression analysis with backward elimination method revealed that there were 13 significant independent survival factors: age, sex, race, ethnicity, Charlson-Deyo score, insurance status, facility type, median income, education level, distance to facility, year of diagnosis, hematopoietic stem-cell transplantation (HSCT), and treatment-regimen. Male patients were more likely to die compared to female patients (HR = 1.22, p &lt; 0.0001). Black patients were predicted to have less death events compared to White patients (HR = 0.91, p = 0.004). In addition to that, Hispanic patients were more likely to die compared to non-Hispanics (HR = 1.2, p = 0.0006). Subjects who were treated in non-academic facilities were more likely to die compared to the ones who received care in academic centers (HR = 1.2, p &lt; 0.0001). Moreover, patients with Medicare (HR = 1.65, p &lt; 0.0001), Medicaid (HR = 1.49, p &lt; 0.0001), and no insurance (HR = 1.63, p &lt; 0.0001) had higher chance of death compared to those with private insurance. Patients with lower income &lt; $38,000 were more likely to die compared to income ≥ $63,000 (HR = 1.19, p = 0.0007). Only 6.8% of patients underwent HSCT and 93.2% did not. Patients undergoing HSCT had worse OS compared to those treated without HSCT (HR = 0.36, p &lt; 0.0001). Detailed analysis will be presented. Conclusions: In this large cohort of real-world data analysis of very young MM patients, we found that White and Hispanic patients age ≤ 50 years had significantly inferior survival compared to Black and non-Hispanic patients. Patients with lower income, lower education level, non-private insurance, and those without access to academic centers for MM care had worse survival outcomes. The findings can be useful for designing prospective studies addressing disparity and equitable access to MM care. Despite being a pivotal part of MM therapy, HSCT utilization in the real-world setting is minimal. The barriers to HSCT utilization and the reason why it is inferior to no-HSCT in real-world setting need to be identified and addressed.

Delayed Esophagectomy is Associated With Inferior Survival: A National Cancer Database Study

Background: Locoregionally advanced esophageal cancer is typically treated with neoadjuvant chemoradiation followed by surgery 4 to 8 weeks later. Occasionally surgery is delayed &gt;12 weeks; outcomes of this approach are not well studied. We hypothesized that delayed esophagectomy after chemoradiation would have inferior long-term overall survival relative to planned trimodality esophagectomy. Methods: Adult patients with locally advanced esophageal cancer (T2−4aN0M0, T0−4aN+M0) who received multi-agent chemotherapy, radiation, and esophagectomy were identified in the 2018 National Cancer Database. Esophagectomy performed within 90 days from end of chemoradiation were categorized as “trimodality” and those ≥90 days were categorized as “delayed.” Primary outcome was overall survival measured using Kaplan-Meier estimates and Cox proportional hazard models. Secondary outcomes included surgical margin status, hospital length of stay, and readmission. Results: Included were 19 698 patients, 3905 (19.8%) “delayed.” Median time to surgery for trimodality patients was 51 days (IQR 41-63) versus 110 days (IQR 98-131) for delayed patients. Delayed patients tended to be older, non-white, have non-private insurance, and have more comorbidities. Overall survival was shorter for delayed patients (34.8 months) versus trimodality patients (43.1 months, P ≤ .001). In multivariable analysis, delay was associated with inferior overall survival (HR 1.15, 95% CI 1.08-1.23). Length of stay and readmission rate were similar between cohorts, but delay was associated with a higher rate of positive surgical margins (6.7% vs 4.6%, P ≤ .001). Conclusions: In the National Cancer Database, delayed esophagectomy is associated with inferior long-term survival. Nonetheless, delayed esophagectomy may be appropriate for select patients; further research is needed to identify the optimal approach.

Evaluating Disparities in Pathways to Breast Reconstruction.

Rates of postmastectomy breast reconstruction have been shown to vary by racial, ethnic, and socioeconomic factors. In this study, we evaluated disparities across pathways toward breast reconstruction. All women who underwent mastectomy for breast cancer at a single institution from 2017 to 2018 were reviewed. Rates of discussions about reconstruction with breast surgeons, plastic surgery referrals, plastic surgery consultations, and ultimate decisions to pursue reconstruction were compared by race/ethnicity. A total of 218 patients were included, with the racial/ethnic demographic of 56% white, 28% Black, 1% American Indian/Native Alaskan, 4% Asian, and 4% Hispanic/Latina. The overall incidence of postmastectomy breast reconstruction was 48%, which varied by race (white: 58% vs. Black: 34%; p < 0.001). Plastic surgery was discussed by the breast surgeon with 68% of patients, and referrals were made in 62% of patients. While older age (p < 0.001) and nonprivate insurance (p < 0.05) were associated with lower rates of plastic surgery discussion and referral, it did not vary by race/ethnicity. The need for an interpreter was associated with lower rates of discussion (p < 0.05). After multivariate adjustment, a lower reconstruction rate was associated with the Black race (odds ratio [OR] = 0.33; p = 0.014) and body mass index (BMI) ≥ 35 (OR = 0.14; p < 0.001). Elevated BMI did not disproportionately lower breast reconstruction rates in Black versus white women (p = 0.27). Despite statistically equivalent rates of plastic surgery discussions and referrals, black women had lower breast reconstruction rates versus white women. Lower rates of breast reconstruction in Black women likely represent an amalgamation of barriers to care; further exploration within our community is warranted to better understand the racial disparity observed.

117 Social Determinants of Health and Spine Tumor Surgery Outcomes: A Nationwide Analysis of Disparities from 2002-2019

INTRODUCTION: Earlier research has demonstrated that social determinants of health (SDoH) impact neurosurgical access and outcomes, influencing patient disparities. METHODS: We identified all admissions with a spine tumor diagnosis in the National Inpatient Sample from 2002-2019. Four SDoH were analyzed: race and ethnicity, insurance, household income, and safety-net hospital (SNH) treatment. Hospitals in the top quartile of safety-net burden (percentage of patients receiving Medicaid or uninsured) were categorized as SNHs. Multivariable regression queried the association between 22 variables and six perioperative outcomes: mortality, discharge disposition, complications, length of stay (LOS), and hospitalization costs. Relative importance of predictors for disposition were assessed using random forest models. RESULTS: Of 6,593,391 total admissions with spine tumors, 219,380 (3.3%) underwent surgery. Non-white race (odds ratio [OR] = 0.80–0.91, P = 0.001) and non-private insurance (OR = 0.76–0.83, p = 0.001) were associated with lower odds of surgery. Among surgical admissions, presenting severity, including myelopathy and plegia, was elevated among nonwhite, non-private insurance, and low-income admissions (all P = 0.001). Black race (OR = 0.70, P = 0.001), Medicare (OR = 0.70, P = 0.001), Medicaid (OR = 0.90, P = 0.001), and lower income (OR = 0.88–0.93, all P = 0.001) were associated with decreased odds of favorable discharge disposition. Elevated LOS and costs were observed among non-white (LOS: +6-10%, costs: +5-9%, both P = 0.001) and Medicaid (LOS: +16%, costs: +6%, both P = 0.001) admissions. SNH treatment was also associated with higher mortality (OR = 1.49, P = 0.001) and complications (OR = 1.20, P = 0.001). From 2002-2019, disposition improved annually for Medicaid patients (OR = 1.03 per year, P = 0.022) but worsened for Black patients (OR = 0.98 per year, P = 0.046). Random forest models identified household income as the most important disposition predictor. CONCLUSIONS: For spine tumor admissions, SDoH predicted surgical intervention, presenting severity, and perioperative outcomes. Over two decades, disparities improved for Medicaid patients but worsened for Black patients.

Elective and non-elective endomyocardial biopsy in heart transplant patients and procedural outcomes: An IMPACT registry analysis.

Endomyocardial biopsies are standard of care for transplant surveillance, however the procedural risks are not well established, especially in children. The purpose of the study was therefore to assess procedural risks and outcomes associated with elective (surveillance) biopsies and non-elective (clinically indicated) biopsies. We used the NCDR IMPACT registry database for this retrospective analysis. Patients undergoing an endomyocardial biopsy were identified using the procedural code, with a diagnosis of heart transplantation required. Data regarding indication, hemodynamics, adverse events and outcomes was gathered and analyzed. A total of 32 547 endomyocardial biopsies were performed between 2012-2020; 31 298 (96.5%) elective and 1133 (3.5%) were non-elective biopsies. Non-elective biopsy was more commonly performed in infants and in those above 18 years of age, in female and in Black race patients and in those with non-private insurance (all p< .05) and showed hemodynamic derangements. Overall rate of complications was low. Combined major adverse events were more common in non-elective patients, with sicker patient profile, use of general anesthesia and femoral access with overall decline in these events over time. This large-scale analysis shows safety of surveillance biopsies and that non-elective biopsies carry a small but significant risk of major adverse event. Patient profile impacts the safety of the procedure. These data may serve as important comparison point for newer non-invasive tests and for bench marking, especially in children.