Nonprivate Insurance Research Articles

Temporal trends, predictors, and outcomes of acute kidney injury and hemodialysis use in acute myocardial infarction-related cardiogenic shock.

BackgroundThere are limited data on acute kidney injury (AKI) complicating acute myocardial infarction with cardiogenic shock (AMI-CS). This study sought to evaluate 15-year national prevalence, temporal trends and outcomes of AKI with no need for hemodialysis (AKI-ND) and requiring hemodialysis (AKI-D) following AMI-CS.MethodsThis was a retrospective cohort study from 2000–2014 from the National Inpatient Sample (20% stratified sample of all community hospitals in the United States). Adult patients (>18 years) admitted with a primary diagnosis of AMI and secondary diagnosis of CS were included. The primary outcome was in-hospital mortality in cohorts with no AKI, AKI-ND, and AKI-D. Secondary outcomes included predictors, resource utilization and disposition.ResultsDuring this 15-year period, 440,257 admissions for AMI-CS were included, with AKI in 155,610 (35.3%) and hemodialysis use in 14,950 (3.4%). Older age, black race, non-private insurance, higher comorbidity, organ failure, and use of cardiac and non-cardiac organ support were associated with the AKI development and hemodialysis use. There was a 2.6-fold higher adjusted risk of developing AKI in 2014 compared to 2000. Presence of AKI-ND and AKI-D was associated with a 1.3 and 1.7-fold higher adjusted risk of mortality. Compared to the cohort without AKI, AKI-ND and AKI-D were associated with longer length of stay (9±10, 12±13, and 18±19 days respectively; p<0.001) and higher hospitalization costs ($101,859±116,204, $159,804±190,766, and $265,875 ± 254,919 respectively; p<0.001).ConclusionAKI-ND and AKI-D are associated with higher in-hospital mortality and resource utilization in AMI-CS.

Acute respiratory failure and mechanical ventilation in cardiogenic shock complicating acute myocardial infarction in the USA, 2000\u20132014

BackgroundThere are limited epidemiological data on acute respiratory failure (ARF) in cardiogenic shock complicating acute myocardial infarction (AMI-CS). This study sought to evaluate the prevalence and outcomes of ARF in AMI-CS.MethodsThis was a retrospective study of AMI-CS admissions during 2000–2014 from the National Inpatient Sample. Administrative codes for ARF and mechanical ventilation (MV) were used to define the cohorts of no ARF, ARF without MV and ARF with MV. Admissions with a secondary diagnosis of AMI and with chronic MV were excluded. Outcomes of interest included in-hospital mortality, temporal trends of ARF prevalence and resource utilization.Measurements and main resultsDuring 2000–2014, 439,436 admissions for AMI-CS met the inclusion criteria. ARF and MV were noted in 57% and 43%, respectively. Admissions with non-ST-elevation AMI-CS, of non-White race and with non-private insurance received MV more frequently. Noninvasive ventilation and invasive MV increased from 0.4% and 39.2% (2000) to 3.6% and 46.4% (2014), respectively (p < 0.001). Coronary angiography and percutaneous coronary intervention were used less frequently in admissions receiving ARF with MV. Compared to admissions with no ARF, ARF without MV (adjusted odds ratio (aOR) 1.56 [95% confidence interval (CI) 1.53–1.59]; p < 0.001) and ARF with MV (aOR 2.50 [95% CI 2.47–2.54]; p < 0.001) were associated with higher in-hospital mortality. Admissions with ARF without MV had greater resource utilization and lesser discharges to home as compared to no ARF.ConclusionsIn this contemporary AMI-CS cohort, the presence of ARF and MV use was noted in 57% and 43%, respectively, and was associated with higher in-hospital mortality.

Hospital Utilization Among Rural Children Served by Pediatric Neurology Telemedicine Clinics

Telemedicine is increasingly used to provide outpatient pediatric neurology consultations in underserved communities. Although telemedicine clinics have been shown to improve access, little is known about how they alter patients' utilization of hospital services. To evaluate the association between access to telemedicine clinics and hospital utilization among underserved children with neurologic conditions. This retrospective cross-sectional study included 4169 patients who received outpatient care from pediatric neurologists affiliated with an academic children's hospital in California between January 1, 2009, and July 31, 2017, either in person or using telemedicine. Consultation modality (telemedicine or in person) in the outpatient neurology clinics. Demographic and clinical variables were abstracted from the hospital's electronic medical records. The association between the modality of outpatient neurology care and patients' utilization of the emergency department and hospitalizations was evaluated. Both all-cause and neurologic condition-related hospital utilization were analyzed using multivariable negative binomial regression in overall and matched samples. The telemedicine cohort comprised 378 patients (211 [55.8%] male), and the in-person cohort comprised 3791 patients (2090 [55.1%] male). The mean (SD) age at the first encounter was 7.4 (5.4) years for the telemedicine cohort and 7.8 (5.1) years for the in-person cohort. The telemedicine cohort was more likely than the in-person cohort to have nonprivate insurance (public insurance, self-pay, or uninsured), lower education, and lower household income. The rates of all-cause and neurologic hospital encounters were lower among children who received pediatric neurology consultations over telemedicine compared with children who received care in the in-person clinics (5.7 [95% CI, 3.5-8.0] vs 20.1 [95% CI, 18.1-22.1] per 100 patient-years and 3.7 [95% CI, 2.0-5.3] vs 8.9 [95% CI, 7.8-10.0] per 100 patient-years, respectively; P < .001). Even after adjusting for demographic and clinical factors, the telemedicine cohort had a lower risk of hospital encounters (emergency department visits and admissions) with an adjusted incidence rate ratio of 0.57 (95% CI, 0.38-0.88) for all-cause encounters and an adjusted incidence rate ratio of 0.60 (95% CI, 0.36-0.99) for neurologic encounters. After matching on travel time to the neurology clinic, the adjusted incidence rate ratio was 0.19 (95% CI, 0.04-0.83) for all-cause admissions and 0.14 (95% CI, 0.02-0.82) for neurologic admissions. Pediatric neurology care through real-time, audiovisual telemedicine consultations was associated with lower hospital utilization compared with in-person consultations, suggesting that high-cost hospital encounters can be prevented by improving subspecialty access.

Trends and Racial Disparities of Palliative Care Use among Hospitalized Patients with ESKD on Dialysis.

Study findings show that although palliative care decreases symptom burden, it is still underused in patients with ESKD. Little is known about disparity in use of palliative care services in such patients in the inpatient setting. To investigate the use of palliative care consultation in patients with ESKD in the inpatient setting, we conducted a retrospective cohort study using the National Inpatient Sample from 2006 to 2014 to identify admitted patients with ESKD requiring maintenance dialysis. We compared palliative care use among minority groups (black, Hispanic, and Asian) and white patients, adjusting for patient and hospital variables. We identified 5,230,865 hospitalizations of such patients from 2006 through 2014, of which 76,659 (1.5%) involved palliative care. The palliative care referral rate increased significantly, from 0.24% in 2006 to 2.70% in 2014 (P<0.01). Black and Hispanic patients were significantly less likely than white patients to receive palliative care services (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.61 to 0.84, P<0.01 for blacks and aOR, 0.46; 95% CI, 0.30 to 0.68, P<0.01 for Hispanics). These disparities spanned across all hospital subtypes, including those with higher proportions of minorities. Minority patients with lower socioeconomic status (lower level of income and nonprivate health insurance) were also less likely to receive palliative care. Despite a clear increase during the study period in provision of palliative care for inpatients with ESKD, significant racial disparities occurred and persisted across all hospital subtypes. Further investigation into causes of racial and ethnic disparities is necessary to improve access to palliative care services for the vulnerable ESKD population.

Factors Associated with Timeliness of Surgical Repair among Infants with Myelomeningocele: California Perinatal Quality Care Collaborative, 2006 to 2011.

This study aimed to examine factors associated with timely (0-2 days after birth) myelomeningocele surgical repair. We examined 2006 to 2011 births from the California Perinatal Quality Care Collaborative, linking to hospital discharge and vital records. Selected maternal, infant, and delivery hospital characteristics were evaluated to understand disparities in timely repair. Poisson regression was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). Overall, 399 of the 450 (89%) infants had a timely repair and approximately 80% of them were delivered in level III/IV hospitals. Infants with hydrocephalus were significantly less likely to have a delayed myelomeningocele repair compared with those without (aRR = 0.22; 95% CI = 0.13, 0.39); infants whose medical care was paid by Medi-Cal or other nonprivate insurance were 2.2 times more likely to have a delayed repair compared with those covered by a private insurance (aRR = 2.23; 95% CI = 1.17, 4.27). Low birth weight was a significant predictor for delayed repair (aRR = 2.06; 95% CI = 1.10, 3.83). There was a significant disparity in myelomenigocele repair based on medical care payer. Families and hospitals should work together for timely repair in hospitals having specialized multidisciplinary teams. Findings from the study can be used to follow best clinical practices for myelomeningocele repair.

Immediate Breast Reconstruction Allows for the Timely Initiation of Postmastectomy Radiation Therapy.

Complications from breast reconstruction may delay postmastectomy radiation therapy and impact breast cancer outcomes. The authors hypothesized that immediate breast reconstruction may be associated with delays in the initiation of radiation, but that this delay would not significantly impact overall patient survival. Using the National Cancer Database, the authors identified women with breast cancer who underwent mastectomy and received postmastectomy radiation therapy. Delayed radiation was defined as treatment initiated 6 months or more after surgery in patients who received adjuvant chemotherapy or 12 weeks or more after surgery in patients who received neoadjuvant or no chemotherapy. Women undergoing breast reconstruction had an increased time to postmastectomy radiation therapy, 154 days versus 132 days (p < 0.001), and were more likely to experience a delay in initiating radiation (OR, 1.25; 95 percent CI, 1.188 to 1.314). Other factors associated with delayed radiation included increased Charlson/Deyo scores, neoadjuvant chemotherapy, nonprivate insurance, and black race. Cox proportional hazards models revealed no evidence of a reduced adjusted overall survival in the immediate breast reconstruction group (hazard ratio, 0.836; 95 percent CI, 0.802 to 0.871; p < 0.001). Restricted cubic spline analysis identified the threshold number of days at which the start of radiation began to impact survival at 169 days (95 percent CI, 160 to 190 days), 75 days (95 percent CI, 42 to 90 days), and 71 days (95 percent CI, 41 to 90 days) in patients undergoing adjuvant, neoadjuvant, and no chemotherapy, respectively. Immediate breast reconstruction is associated with a modest delay in initiating postmastectomy radiation therapy but does not impact overall survival. Therapeutic, III.

1355-P: HbA1c Trajectories from Time of Diagnosis in Youth with T1D

Most individuals with type 1 diabetes (T1D) do not achieve glycemic targets, particularly in youth. This analysis examined HbA1c trajectories of youth newly diagnosed with T1D. T1D Exchange registry participants &amp;lt;18 years with at least one HbA1c during the year of diagnosis and ≥3 duration-year aggregated HbA1c values over 10 years of follow-up were included. At diagnosis, the 4183 participants were 48% female, 81% Caucasian, age 6±4 years, and 77% privately insured. Suboptimal control was defined as HbA1c ≥9%. Group-based trajectory modelling was used to identify unique HbA1c trajectories over aggregated duration years. Five trajectories emerged (Figure). The majority of youth had stable trajectories within three distinct categories: those at (1) or above (3) glycemic target and those with suboptimal control (4). Two groups showed deterioration over time, one with suboptimal control from diagnosis (5) while the other had above target glycemia that worsened with time (2). Minority status was higher in groups with upward trend in HbA1c trajectory and suboptimal but stable control. Similar trends were seen for non-private insurance. Several distinct patterns of HbA1c progression exist in youth with T1D, partly dependent on HbA1c at diagnosis. Identifying characteristics of those with progressive deterioration in glycemic control and designing appropriate interventions for these groups is warranted. Disclosure J. Sherr: Advisory Panel; Self; Bigfoot Biomedical, Eli Lilly and Company, Insulet Corporation. Consultant; Self; Lexicon Pharmaceuticals, Inc., Medtronic, Sanofi. Research Support; Self; Dexcom, Inc., Insulet Corporation. N.C. Foster: None. K. Bethin: Research Support; Self; Novo Nordisk Inc., Xeris Pharmaceuticals, Inc. L.A. Fox: None. L.D. Mastrandrea: Advisory Panel; Self; Pediatric Diabetes Consortium. Research Support; Self; AstraZeneca, JDRF, Novo Nordisk Inc., Sanofi-Aventis, T1D Exchange. Other Relationship; Self; Novo Nordisk Inc. B.M. Nathan: None. M.J. Redondo: None. J. Silverstein: None. J. Simmons: None. M.A. Clements: Advisory Panel; Self; Glooko, Inc. Consultant; Self; Eli Lilly and Company. Speaker's Bureau; Self; Medtronic. W.V. Tamborlane: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Medtronic MiniMed, Inc., Novo Nordisk Inc., Sanofi, Takeda Pharmaceutical Company Limited. K.M. Thrailkill: None. J.C. Wong: Advisory Panel; Self; Tidepool Project. Research Support; Self; Dexcom, Inc. J. Wood: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc.

Time to surgery (TTS) in renal cell carcinoma (RCC): Predictors and association with overall survival (OS).

e16107 Background: Guidelines recommend surgical resection of primary tumor in stages 1-3 RCC. TTS refers to the time frame from the initial diagnosis to surgical resection of primary tumor. Shorter TTS has shown OS benefit in breast, head and neck cancers whereas longer TSS was shown to be acceptable in colon cancer. However, no such data exists for RCC. Using National Cancer Data Base (NCDB), we sought to determine the factors associated with TTS and its effect on OS. Methods: Patients with RCC who underwent partial or total nephrectomy were included, excluding those received neoadjuvant therapy. Logistic regression model was utilized to evaluate relative risk of delayed TTS. OS in association with TTS was estimated using the Kaplan-Meier method and Cox multivariate analysis (MVA). Results: A total of 60,198 RCC patients met the inclusion criteria. In contrast to a prior study that showed a median TTS of 41 days our study showed a median TTS of 35 days. We dichotomized the TTS as ≤ 35 days or ≥ 36 days. On MVA, TSS ≥ 36 days had significantly better OS (HR: 0.95 [CI:0.92-0.99], p &lt; 0.01). Factors associated with TSS ≥ 36 days were race, insurance, higher Charlson score, lower grade, and getting managed at academic facilities and Pacific region (p &lt; 0.01) (Table). Conclusions: A longer TTS with RCC is understandably associated with greater comorbidity, and non-private insurance, but questionably so in race, ethnicity, and facility related factors. However, given that TTS ≥ 36 days was not associated with higher risk of death, it may indicate that a reasonable delay could be pursued in certain cases for more accurate preoperative evaluation. [Table: see text]

The Odds of Stage IV Melanoma Diagnoses Based on Socioeconomic Factors

When diagnosed at stage 0-I, melanoma has a 5-year survival rate of 92% to 100% in comparison with stage IV, which has a 5-year survival rate of 15% to 20%. The objective of this article is to identify what socioeconomic and demographic factors were associated with increased odds in receiving a delayed melanoma diagnosis. This study analyzed the odds of 108,628 patients from the National Cancer Database who were diagnosed between 2004 and 2012 with American Joint Committee on Cancer stage 0-I and stage IV based on race, sex, insurance type, income, facility type, and education. We identified significantly (P < .05) increased odds of stage IV primary melanoma diagnosis in those who had nonprivate insurance, including Medicare (odds ratio [OR] = 1.31, 95% confidence interval [CI]: 1.19-1.45), other government insurance (OR = 2.19, 95% CI: 1.61-2.98), Medicaid (OR = 6.97, 95% CI: 5.98-8.13), or no insurance (OR = 5.10, 95% CI: 4.41-5.91). Increased odds of late-stage melanoma were also associated with male sex (OR = 1.46, 95% CI: 1.36-1.57), race and ethnicity other than non-Hispanic white such as Hispanic whites (OR = 1.49, 95% CI: 1.15-1.92) or African Americans (OR=4.81, 95% CI: 3.75-6.18), and who had decreased education (OR = 1.19, 95% CI: 1.09-1.30). There was not a significant increase in odds of late-stage melanoma in patients from areas with the lowest levels of income compared with areas of highest income. Certain socioeconomic and demographic factors are associated with odds of a later-stage melanoma diagnosis.

PMH29 OPIOID USE AMONG INDIVIDUALS WITH DEPRESSION:NHAES STUDY 2005-2014

The recent prevalence of opioid use in the general US population has been reported at 6.8%. Of these, individuals with mental health disorders account for half of all prescription opioids used. Given the relatively high depression morbidity in US adults, we examined the prevalence of opioid use associated with depression in particular. We analyzed data from the National Health and Nutrition Examination Survey (NHANES), nationally representative survey from 2005 to 2014. Depression was identified using the Patient Health Questionnaire (PHQ-9). The PHQ-9 score >=5 were categorized as mild depression, score>=10 as moderate depression, and score >=15 as severe depression. We estimated the prevalence and trend of opioid use among people with depression and constructed a logistic regression model to identify key drivers of opioid use. The model was adjusted for sex, race, income level, education level, alcohol intake (>=12 drinks a year), ever marijuana use, ever heroin use, hospital admission in the last year, seen a mental health provider, antidepressant use, and severity of depression. We identified a total of 6006 adults with depression. The overall prevalence of opioid use in that population was 13% [95% CI:12-15%]. From 2005 to 2014, the prevalence of opioid use among people with depression remained steady with no significant change in trend [OR:1.12, 95% CI:0.74-1.7,p=0.58]. The adjusted model showed opioid use was statistically significantly associated with male sex, White race, low income, non-private health insurance, multiple chronic illnesses, heroin use, antidepressant use, and hospital admission in the last year. The prevalence of opioid use among US adults with depression is close to the reported estimate for overall mental health disorder population, and is associated with demographic and clinical characteristics, as well as higher risk behaviors. This study result could prove useful for prescribers and health care providers to identify mechanisms to prevent potential abuse.

Disparities in colostomy reversal after Hartmann's procedure for diverticulitis.

Hartmann's procedure for diverticulitis is a common procedure, with highly variable rates and timing of colostomy reversal. The aim of this study was to evaluate the impact of race and insurance coverage on reversal within 2years of Hartmann's procedure for diverticulitis. The Healthcare Cost and Utilization Project (HCUP) State Inpatient Database of five states (2007-2010) was queried for patients who had Hartmann's procedure in the setting of diverticulitis. Patients were grouped by race and insurance status, and multivariable adjustment was performed to evaluate rate and timing of colostomy takedown at 2years. Among 11,019 patients who had Hartmann's procedure for diverticulitis, 6900 (69%) patients had colostomy reversal by 2years, with a median time to reversal of 19weeks. Compared to white patients with private insurance, combinations of black race and non-private insurance significantly reduced likelihood of colostomy reversal at 2years across all combinations. Black patients without insurance had the lowest likelihood of reversal at 2years (OR 0.27, 95% CI 0.14-0.51, p < 0.001). For patients who had colostomy reversal within 2years, black patients without insurance had a significant delay in time to reversal (11weeks, 95% CI 6-16, p < 0.001) compared to white patients with private insurance, and delays persisted across all other groups. Black patients and those without private insurance experienced significantly lower rates of, and delayed time to, colostomy reversal compared to white patients with private insurance. These disparities must be considered for allocation of resources in marginalized communities.

Appointment completion in pediatric neurology telemedicine clinics serving underserved patients.

To determine whether telemedicine improves access to outpatient neurology care for underserved patients, we compared appointment completion between urban, in-person clinics and telemedicine clinics held in rural and underserved communities where neurology consultations are provided remotely. In this retrospective study, we identified patients scheduled for outpatient care from UCDH pediatric neurologists between January 1, 2009, and July 31, 2017, in person and by telemedicine. Demographic and clinical variables were abstracted from electronic medical records. We evaluated the association between consultation modality and visit completion in overall and matched samples using hierarchical multivariable logistic regression. We analyzed 13,311 in-person appointments by 3,831 patients and 1,158 telemedicine appointments by 381 patients. The average travel time to the site of care was 45.8 ± 52.1 minutes for the in-person cohort and 22.3 ± 22.7 minutes for the telemedicine cohort. Telemedicine sites were located at an average travel time of 217.1 ± 114.8 minutes from UCDH. Telemedicine patients were more likely to have nonprivate insurance, lower education, and lower household income. They had different diagnoses and fewer complex chronic conditions. Telemedicine visits were more likely to be completed than either "cancelled" or missed ("no show") compared with in-person visits (OR 1.57, 95% CI: 1.34-1.83; OR 1.66, 95% CI: 1.31-2.10 matched on travel time to the site of care; OR 2.22, 95% CI: 1.66-2.98 matched on travel time to UCDH). The use of telemedicine for outpatient pediatric neurology visits has high odds of completion and can serve as an equal adjunct to in-person clinic visits.

282 Eczema is associated with increased hospitalization rates in United States children

Childhood atopic dermatitis (AD) is associated with severe and unpredictable flares, and multiple comorbidities, e.g. atopic, mental health, and infectious disorders, all of which may lead to hospitalization. However, the impact of childhood AD on hospitalizations in the US has not been well described. Data were analyzed from the 1997-2017 National Health Interview Survey, a US population-based household survey (n=251,555 children). In multivariable logistic regression models adjusting for multiple socio-demographics, atopic and mental health comorbidities, children with caregiver-reported eczema compared to those without eczema had significantly higher odds of having 1-2 overnight hospitalizations (logistic regression; adjusted odds ratio [95% confidence interval]: 1.17 [1.05-1.30]) and ≥3 hospitalizations (1.64 [1.19-2.25]) in the past year. In logistic regression models of ≥1 overnight hospitalization with stepwise selection, female sex (1.16 [0.94–1.43]), black race (black: 1.52[1.18–1.96]), Hispanic ethnicity (1.12 [0.88–3.81]), having Medicaid (1.06 [0.97–1.17]), outpatient physician interaction (1.85 [0.90–3.81]), asthma attack (2.11 [1.65–2.70]), feeling depressed (1.41 [1.12-1.78]), attention deficit (hyper)activity disorder (1.33 [0.98-1.82]), hay fever and/or respiratory allergy (2.23 [1.60–3.12]), and digestive allergy (3.19 [2.43–4.19]) were all associated with higher odds of hospitalization in children with eczema. Whereas, Asian race (0.87 [0.45-1.67]), multiracial/other race (0.88 [0.53-1.45]) and non-private insurance (Medicaid: 0.98 [0.77-1.21]; other/none: 0.91 [0.69-1.21]) were associated with lower odds of hospitalization. In conclusion, childhood eczema is associated with higher odds of overnight hospitalization in the US. Future studies are needed to determine optimal strategies to prevent hospitalization in children with eczema.

SAT-138 Predictors and Health Care Expenditures Associated with Recurrent Diabetic Ketoacidosis Admissions in Adults with Type 1 Diabetes

Introduction: Diabetic ketoacidosis (DKA) is a serious complication in patients with type 1 diabetes (T1D). Recurrent DKA admissions have been associated with increased mortality and substantial healthcare costs. In contrast to pediatrics, significantly less attention has been devoted to exploring and addressing recurrent DKA admissions in adults with T1D. We aimed to characterize the adult population of T1D admitted with DKA in Maryland, identify predictors of recurrent DKA admissions, and quantify their associated healthcare costs. Methods: We conducted a cross-sectional study using the Maryland Health Services Cost Review Commission's database, which collects data from all acute care hospitals in the state. We defined DKA using ICD diagnostic codes for ketoacidosis and hyperosmolality in T1D. We selected adult patients (age 20 or above) with T1D who lived in or bordering Maryland and had at least one admission with a primary diagnosis of DKA between January 1, 2012 and December 31, 2017. The predictors analyzed in this study represent patient characteristics from the first DKA admission. The primary outcome was readmission for DKA in the study period. The summation of admission charges was used to calculate DKA healthcare expenditures. Results: There were 6,147 DKA admissions by 3,368 T1D adults admitted in Maryland in the study period. Readmissions occurred in 915 (27%) patients, with 1-3 and >4 readmissions occurring in 700 (76%) and 487 (24%) of these patients, respectively. Overall, the patients admitted with DKA were predominately non-Hispanic (96%) white (45%) or black (45%) men (53%) between the ages 20-39 years old (48%) from areas of low to moderate socioeconomic status (SES). The majority of patients were insured by private (37%) and Medicaid (27%) insurance. The strongest predictors for DKA readmissions were female sex (OR 1.3; 95%CI 1.1-1.6), residing in an area of low SES (OR 1.5; 95% 1.1-2.0), being insured by Medicare (OR 1.7; 95%CI 1.3-2.2), Medicaid (OR 1.5 95%CI 1.2-1.8) or Self-pay/charity (OR 1.5; 95%CI 1.1-1.9), and discharge against medical advice (OR 1.6; 95%CI 1.2-2.3). Older and non-white patients had a reduced odds of readmission. The expenditure of all adult DKA admissions totaled 5.4 billion dollars. While patients who had DKA readmissions consisted of only 27% of those admitted with DKA, their total costs were 59% of these DKA charges at 3.2 billion dollars. Conclusion: There is a high prevalence of recurrent DKA admissions in adults with T1D. Younger patients, women, having non-private insurance and those living in areas of low SES have the highest odds for readmission. Although these patients are a minority, they account for a majority of DKA health expenditures. Further studies are needed to understand drivers of these admissions in order to intervene in this population at high risk for poor outcomes. Supported by a NIH T32 Grant T32 and Saudek Fellowship Award.

Contemporary Analysis of Calculous Nephrectomy Utilization and Outcomes in the United States.

Introduction: Calculous nephrectomy was a mainstay of treatment of complex upper tract stone disease up until the 1970s, but data on its contemporary utilization in the current era of rising rates of stone disease are lacking. We characterized the nationwide utilization and outcomes for calculous nephrectomy in the United States. Patients and Methods: The National/Nationwide Inpatient Sample databases for 2001 to 2014 were queried for adults with a principal diagnosis of upper urinary tract calculi (UUTCs), who underwent nephrectomy as well as other inpatient surgeries for UUTCs. Per-population trend in utilization of calculous nephrectomy was analyzed using negative binomial regression. The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTCs was analyzed using the Cochran-Armitage test. Patient demographics, hospital characteristics, perioperative outcomes, and complications were analyzed using appropriate statistical tests. Results: Of almost 1.42 million inpatient UUTC procedures performed over the study period, 9232 (0.65%) were calculous nephrectomies. Per-population utilization rate for calculous nephrectomy decreased significantly over time (incidence rate ratio = 0.82; 95% confidence interval = 0.73-0.91, p < 0.001). The proportion of calculous nephrectomy as a fraction of all inpatient surgical procedures for UUTC also decreased significantly over time (p < 0.0001). Majority of the procedures were performed in females, in urban teaching hospitals, and in the Southern United States. The overall complication rate was 38.3%, most commonly hemorrhage requiring transfusion (15.6%). Older age, female gender, and nonprivate insurance or lack of insurance were significant predictors of increased risk of complications, whereas hospitalization in urban hospitals was a predictor of lower risk. Conclusions: Despite increasing prevalence of stone disease in the United States in the contemporary era, utilization of calculous nephrectomy is low and is declining. Inpatient complication rates are moderately high and influenced by patient sociodemographic and hospital characteristics.

Early mortality of stage IV non-small cell lung cancer in the United States

Background: Early mortality is a major deterrent to oncologic management, often preventing delivery of therapy or leading to administration of treatment that offers limited benefit from aggressive interventions. Due to more recent progress in therapeutic options for stage IV non-small cell lung cancer (NSCLC) patients, identifying those at high risk of early mortality (within 30 days) could have implications for treatment selection. Because early mortality following diagnosis of metastatic non-small cell lung cancer (NSCLC) is not well-characterized, this investigation evaluated national trends and predictors thereof.Material and methods: The National Cancer Database was queried for cases of pathologically confirmed metastatic NSCLC with complete vital status and clinical information, diagnosed between 2006 and 2014. Multivariable logistic regression ascertained factors associated with 30-day mortality.Results: Of 346,681 patients, 45,861 (13%) experienced early mortality over the past decade, which remained relatively constant over time. Predictors of early mortality included advancing age (>65 years), male gender, Caucasian race, non-private insurance, lower income, greater comorbidities, residence in metropolitan and/or lesser-educated areas, treatment at community centers, patients with no prior history of cancer and regional differences (p < .01 for all). Early mortality was highest in patients older than 80 years with multiple comorbidities (29%). The majority of patients (71%) who died within 30 days did not receive any therapy.Conclusions: A fair proportion of NSCLC patients experience early mortality, which has not decreased over time. The majority of patients with early mortality do not receive treatment. Prognostic factors for early mortality should be considered during initial evaluation and subsequent follow-up of these patients. Doing so may impact systemic treatment selection by medical oncologists, management of (oligo)metastatic disease by radiation and surgical oncologists and cost-effective administration of these therapies in the stage IV NSCLC population.

Positive surgical margins after radical nephrectomy for localized kidney cancer: Impact on survival.

676 Background: Impact of positive surgical margins (PSM) in patients undergoing radical nephrectomy (RN) in localized renal cell carcinoma (RCC) is poorly understood. We sought to understand the impact of PSM for on overall survival (OS) after RN in clinically localized RCC. Methods: Retrospective analysis of patients from the US National Cancer Database who RN for clinically localized (cT1a-cT2b cN0M0) RCC between 2003-13, were stratified into their pathological stage group [pT1a, pT1b, pT2a, pT2b, and pT3a ( = Upstaged)] and analyzed by final margin status. Cox Regression Multivariable analysis (MVA) was performed to investigate associations of PSM and covariates on OS. Kaplan-Meier analysis (KMA) of OS was performed for PSM verses NSM for the overall cohort and by stage. Results: 37,656 RN events [14312 (38%) pT1a, 13598 (36.1%) pT1b, 6551 (17.4%) pT2a, 2937 (7.8%) pT2b, and 4286 (11.3%) with pT3a upstaging]. PSM rate was 0.9% overall (0.4% pT1a, 0.4% pT1b, 0.4% pT2a, 0.4% pT2b, and 4.7% pT3a upstaged). On MVA for all-cause mortality, PSM was independently predictive for decreased OS (HR 1.51, p &lt; 0.001), along with increasing age (HR 1.04, p &lt; 0.001), non-Caucasian race (HR 1.199, p &lt; 0.001), increasing charlson score (HR 2.23, p &lt; 0.001), non-private insurance (HR 1.61, p = 0.001), high grade histology (HR 1.21, p = 0.001), and sarcomatoid histology (HR 3.61, p &lt; 0.001). Pathologic T-stage was also predictive of decreased OS (Referent pT1a, HR 1.17, 1.47, 1.74, and 1.93, for pT1b, pT2a, pT2b, pT3a, respectively; all p &lt; 0.001). KMA revealed worsened 5-year OS for PSM vs. NSM for the overall cohort (62.4% vs. 81%, p &lt; 0.001), pT2a (61% vs. 79.4%, p = 0.013), and pT3a (50% vs. 68.3%, p &lt; 0.001) groups. Conclusions: PSM is a rare event after RN, but is associated with worsened OS, particularly in pT2 and pT3a upstaged patients. Mechanism of decreased OS cannot be clarified given limitations of the NCDB, these suggest that PSM may pose increased oncologic risks in higher pathological stage. Consideration of further definitive strategies (ex: preemptive wide field resection) may be warranted in select circumstances. Furthermore, our findings call for re-consideration of exclusion of PSM patients from adjuvant therapy trials.

Utilization and outcomes of surgical castration in comparison to medical castration in metastatic prostate cancer.

288 Background: Androgen deprivation therapy (ADT) is the gold standard for metastatic prostate cancer (mPC) which can be achieved either by surgical or medical castration (SC, MC). In this study we evaluate the trends of utilization of SC and also assess survival difference compared to MC. Methods: National Cancer Database was used to identify patients with mPC from 2004 to 2014. Logistic and Cox regression models were utilized to estimate the odds of utilization of SC and effect of treatment on overall survival (OS). Results: A total of 33712 pts with mPC were identified; 31722 (94.1%) had MC and 1990 (5.9%) underwent SC. There was significant decline in the trend of utilization of SC from 8.5% in 2004 to 3.1% in 2014. On multivariable analysis, being a non-caucasian race, lower household income levels, having non-private insurance and earlier years of Dx were found to be associated with increased odds of choosing SC over MC. Notably, the odds of SC were lower at academic centers. On univariate analysis, a survival difference between ADTs was evidenced (p&lt;0.01); 5-yr OS for MC and SC was 24.8% and 18.2%. However, on multivariate analysis there was no OS difference between SC and MC (p=0.14). Conclusions: In this large contemporary analysis, the utilization of SC has declined overtime with no OS difference when compared to MC. With rising health care costs, changing the practice by utilizing SC can help reduce healthcare expenditure. [Table: see text]

Prediction of tissue banking participation by patients with pancreatic ductal adenocarcinoma

Background: Translational oncologic research relies heavily on the availability of banked human tissue to discover genetic alterations, identify prognostic factors, and explore new targeted treatments. Despite the minimal requirements for participation by surgical patients, agreement to tissue banking among our population remains low. Here, we explore factors that may help predict participation in tissue banking among patients who have undergone pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC). Methods: All sociodemographic and clinicopathological information was collected for patients who underwent PD or DP for PDAC at a single center between 2011 and 2018. Statistical analysis including logistical regression, chi-square, and Mann-Whitney were performed with SPSS (SPSS Inc., version 23, Chicago, IL). The primary endpoint of the analysis was participation in tissue banking research. Results: 483 (431 white, 52 nonwhite) surgical patients with PDAC who underwent surgical resection were reviewed. Among these patients, race was independently associated with the likelihood of tissue banking, with self-identified non-white patients less likely to participate than self-identified Caucasian patients (white 49.2%, nonwhite 34.6%, p = 0.01). Lack of private insurance was also negatively associated with participation compared with those with private insurance (private insurance 55.8%, non-private 46.2% p = 0.01). Patients who had previously undergone neoadjuvant chemotherapy were statistically more likely to participate (neoadjuvant 61.7%, de novo surgery 41.8%, p = 0.04). Additionally, on secondary analysis of our sample population, we found that nonwhite patients were more likely to have come from urban areas (90.4% v 79.9%), and travelled significantly shorter distance to reach an academic center for treatment (median miles traveled 15 v. 112). Conclusion: Nonwhite race, non-private insurance, and lack of neoadjuvant chemotherapy was negatively associated with participation in tissue banking. Even as nonwhites were more likely to live in urban areas with less distance to a treatment center, they represented a small portion of the sample, inconsistent with known rates of PDAC, indicating unaddressed barriers to accessing care. The difference in patient agreement to tissue banking is likely the result of healthcare inequities, with previous research indicating nonwhites are less likely to be offered participation in clinical trials. Further steps are needed to address these inequalities to increase treatment of nonwhite patients with PDAC. Promoting diversity in the recruitment of patients agreeing to tissue banking will improve the application of translational oncologic research findings to a broader population.

Delivery-associated sepsis: trends in prevalence and mortality

Sepsis is a leading cause of pregnancy-related mortality. Previous studies have reported an increased prevalence of sepsis during pregnancy. Despite national campaigns to increase sepsis awareness, there is a lack of pregnancy-specific guidelines. We aimed to provide updated national estimates of the prevalence and trends of sepsis, sepsis-related in-hospital mortality, and factors associated with in-hospital mortality among women with sepsis at delivery. We conducted a serial, cross-sectional analysis using data from the 2002-2015 National Inpatient Sample, the largest publicly available all-payer inpatient database in the United States. We used International Classification of Diseases, ninth edition, Clinical Modification diagnosis and procedure codes to identify the study sample of delivery-associated hospitalizations and to capture diagnoses of sepsis (defined as infection with associated end-organ dysfunction). The primary outcome was in-hospital mortality. Obstetric comorbidities and pregnancy-related outcomes were also analyzed. Logistic regression was used to explore factors associated with sepsis during pregnancy and, among those with sepsis, to identify predictors of in-hospital mortality. Joinpoint regression was used to estimate the temporal trends in both sepsis and in-hospital mortality. Of the more than 55 million delivery-associated hospitalizations, 13,129 women met criteria for sepsis, corresponding to a rate of 2.4 per 10,000 deliveries. This rate increased from 1.2 to 3.7 per 10,000 over the study period, representing an annual increase of 6.6% (95% confidence interval, 4.2-9.1). The highest crude rates of sepsis (per 10,000) were among deliveries paid for by Medicare (14.8), deliveries to women aged 40 years or older (8.0), and deliveries to non-Hispanic black women (4.6). Compared with women without sepsis, women with sepsis had a greater than 10-fold increased prevalence of most selected obstetric comorbidities. One in 11 women with sepsis died prior to discharge, compared with 1 death in every 15,411 deliveries without sepsis. The sepsis-related mortality rate decreased 21.8% each year from 2010 through 2015. Maternal age greater than 40 years and nonprivate insurance demonstrated the highest odds of sepsis-related in-hospital mortality. While rates of delivery-associated sepsis have increased, case fatality has decreased.