North Carolina Health Research Articles

Mapping pharmacy deserts in North Carolina: a geospatial analysis and its implications for University of North Carolina Health’s catchment population

BackgroundPharmacy deserts represent areas where residents face notable challenges to accessing pharmacies. North Carolina (NC) presents an intriguing case study due to its diverse geographic landscape yet lacks extensive research regarding its pharmacy deserts. ObjectivesThis study aims to map pharmacy deserts in NC using pharmacy location and social determinants of health (SDOH) data measured using the social vulnerability index (SVI) and descriptively characterize health care utilization statistics for University of North Carolina (UNC) Health’s catchment population. MethodsPharmacy location data was compiled from the NC Board of Pharmacy. Pharmacy deserts were defined based on SVI > 0.75 and distance thresholds aligned to United States Department of Agriculture standards. Residential characteristics were retrieved from PolicyMap and Social Explorer databases. UNC Health patient utilization data were collected by UNC Pharmacy Data Analytics group for 3 NC counties. ResultsTwo thousand and two NC pharmacies met inclusion criteria. 17.2% urban tracts (1.3M residents) and 4.25% rural tracts (0.14M residents) were identified as pharmacy deserts (adj. P < 0.001). Those residing in deserts had significantly less internet access, annual medical cost per capita, and access to homeless relief services as well as significantly higher food insecurity rates and Medicare cost per capita (adj. P < 0.001). UNC-specific health care utilization statistics for the 3 assessed counties were all poorer in deserts compared to nondeserts within the same counties (P > 0.05). ConclusionA geospatial map with the location of pharmacy deserts in NC was created to highlight differences in patient health care utilization, affecting rural and urban areas. By incorporating SDOH predictors, this study provides a more nuanced map of NC pharmacy deserts compared to reviewing distance to pharmacies alone. Higher rates of emergency department and inpatient visits in counties with more residents in pharmacy deserts suggests potential health outcomes associated with limited pharmacy access.

Neurological manifestations of ehrlichiosis among a cohort of patients: prevalence and clinical symptoms

BackgroundEhrlichiosis is a potentially fatal tick-borne disease that can progress to involve the central nervous system (CNS) (i.e., neuro-ehrlichiosis), particularly in cases where diagnosis and treatment are delayed. Despite a six-fold national increase in the incidence of ehrlichiosis over the past 20 years, recent data on the prevalence and manifestations of neuro-ehrlichiosis are lacking.MethodsWe conducted a retrospective chart review of all patients tested for ehrlichiosis at University of North Carolina Health facilities between 2018 and 2021 and identified patients who met epidemiological criteria for ehrlichiosis as established by the Council of State and Territorial Epidemiologists and employed by the Centers for Disease Control and Prevention. We estimated the prevalence of neurological symptoms and described the spectrum of neurological manifestations in acute ehrlichiosis, documenting select patient cases in more detail in a case series.ResultsOut of 55 patients with confirmed or probable ehrlichiosis, five patients (9.1%) had neurologic symptoms, which is notably lower than previous estimates. Neurological presentations were highly variable and included confusion, amnesia, seizures, focal neurological deficits mimicking ischemic vascular events, and an isolated cranial nerve palsy, though all patients had unremarkable neuroimaging at time of presentation. All but one patient had risk factors for severe ehrlichiosis (i.e., older age, immunosuppression).ConclusionsNeuro-ehrlichiosis may lack unifying patterns in clinical presentation that would otherwise aid in diagnosis. Clinicians should maintain a high index of suspicion for neuro-ehrlichiosis in patients with acute febrile illness, diverse neurological symptoms, and negative neuroimaging in lone star tick endemic regions.

A Compass for North Carolina Health Care Workers Navigating the Adoption of Artificial Intelligence.

This article underscores the economic benefits of AI, the importance of collaborative innovation, and the need for workforce development to prepare health care professionals for an AI-enhanced future. We include guidance for strategic and ethical AI adoption while advocating for a unified approach to leveraging technology to improve patient outcomes.

Multifaceted role of inosine in complex diseases and human health.

Purines are chemical compounds integral to health and are crucial for the synthesis of nucleic acids. They are part of DNA and RNA and participate in various metabolic and signaling processes. They also function as neurotransmitters and serve as co-substrates for activating many metabolites. Inosine, a purine nucleoside, is a breakdown product of adenosine with similar properties and a much longer half-life (15 h vs ∼5 s) than adenosine. The purpose of this narrative review is to discuss the metabolic effects of inosine and highlight its beneficial properties and implication in complex diseases such as obesity, type 2 diabetes, cancers, cardiovascular diseases, and neurodegenerative diseases. A search was performed for purine- and inosine-related articles on the University of North Carolina (UNC) Health Sciences Library, PubMed, and Google Scholar sites. Inosine is involved in the regulation of RNA editing, metabolic enzyme activity, and signaling pathways. Animal and cell culture studies have shown inosine to be anti-inflammatory, immunomodulatory, and neuroprotective, and serving as a critical regulator of immune checkpoint inhibition therapeutic response in various tumor types. Recent studies have also implicated inosine in increasing energy expenditure, browning of adipose tissue, and improving leptin sensitivity. Human studies, however, have been limited to urate-elevating properties of inosine. These findings make inosine relevant to many complex diseases, and need to be translated to humans. Future studies should be conducted to investigate the mechanisms underlying the role of inosine in adiposity, inflammation, oxidative stress, and neuronal function.

Incorporating social determinants of health into patient care workflows within a health-system specialty pharmacy

BackgroundThe influence of adverse factors on social determinants of health (SDOH) and their impact on patient outcomes is widely recognized. Pharmacists, as accessible healthcare professionals, can play a pivotal role in identifying and addressing SDOH concerns. Health-system specialty pharmacies have consistently assisted patients in accessing expensive specialty medications and ensuring adherence to therapy. As such, they are uniquely positioned to address SDOH concerns of patients. ObjectiveTo assess the effectiveness of incorporating standardized SDOH screening and referral methods into the patient care workflows of a health-system specialty pharmacy. Practice descriptionThe University of North Carolina Health Care (UNC Health) Specialty and Home Delivery Pharmacy is a health-system owned specialty pharmacy serving patients in North Carolina, South Carolina, and Virginia. It holds accreditations from the Utilization Review Accreditation Commission and Accreditation Commission for Health Care. Practice innovationA standardized SDOH screening and referral method were integrated into patient care workflows of a health-system specialty pharmacy. If SDOH concerns were identified upon screening by a specialty pharmacist, patients were referred to an entity within the health-system responsible for connecting patients to local community resources to address their SDOH concerns. Evaluation methodsThe types of SDOH concerns, frequency of SDOH referrals, referral turnaround time, outcomes of the referrals, and patient demographics were evaluated to determine the impact of this project. Descriptive statistics were used to analyze results. ResultsSixty-nine patients were included (female: n = 38, 55.1%; age (mean±SD: 48.9 ± 16.3). Eighty-seven SDOH concerns were reported, 54 patients (78.3%) were connected to local resources upon referral, and the average turnaround time of referrals was 2.2 business days. ConclusionThe findings of this pilot study highlight the effectiveness of incorporating SDOH screening and referral methods into specialty pharmacy workflows. Specialty pharmacies can successfully identify and address nonmedical factors impacting patients.

Validation of an international classification of disease, tenth revision, clinical modification (ICD-10-CM) algorithm in identifying severe hypoglycaemia events for real-world studies.

The transition to the ICD-10-CM coding system has reduced the utility of hypoglycaemia algorithms based on ICD-9-CM diagnosis codes in real-world studies of antidiabetic drugs. We mapped a validated ICD-9-CM hypoglycaemia algorithm to ICD-10-CM codes to create an ICD-10-CM hypoglycaemia algorithm and assessed its performance in identifying severe hypoglycaemia. We assembled a cohort of Medicare patients with DM and linked electronic health record (EHR) data to the University of North Carolina Health System and identified candidate severe hypoglycaemia events from their Medicare claims using the ICD-10-CM hypoglycaemia algorithm. We confirmed severe hypoglycaemia by EHR review and computed a positive predictive value (PPV) of the algorithm to assess its performance. We refined the algorithm by removing poor performing codes (PPV ≤0.5) and computed a Cohen's statistic to evaluate the agreement of the EHR reviews. The algorithm identified 642 candidate severe hypoglycaemia events, and we confirmed 455 as true severe hypoglycaemia events, PPV of 0.709 (95% confidence interval: 0.672, 0.744). When we refined the algorithm, the PPV increased to 0.893 (0.862, 0.918) and missed <2.42% (<11) true severe hypoglycaemia events. Agreement between reviewers was high, = 0.93 (0.89, 0.97). We translated an ICD-9-CM hypoglycaemia algorithm to an ICD-10-CM version and found its performance was modest. The performance of the algorithm improved by removing poor performing codes at the trade-off of missing very few severe hypoglycaemia events. The algorithm has the potential to be used to identify severe hypoglycaemia in real-world studies of antidiabetic drugs.

Abstract 12786: Predictors of Intermediate to Long-Term Ventricular Pacing Requirement Following Transcatheter Aortic Valve Replacement

Objectives: To identify factors associated with persistent atrioventricular (AV) block in patients with permanent pacemaker (PPM) in the peri-transcatheter aortic valve replacement (TAVR) setting. Background: Patients undergoing TAVR may develop AV block requiring pacing. However, whether there are patients who recover AV conduction over time is unknown. Methods: Patients who underwent TAVR and either had pre-existing PPM implanted for sinus node dysfunction or required PPM implantation during the peri-procedural TAVR period were identified from two hospitals in the University of North Carolina Health system. Demographic, electrocardiographic, echocardiographic, and procedural characteristics were abstracted. PPM data was abstracted from remote and in-person PPM interrogations at intermediate (1-12 mo) and long-term (&gt;12 mo) checks. Patients were separated into cohorts with negligible (&lt;1%) or significant (&gt;1%) ventricular pacing burdens. Bivariable and multivariable analyses were performed to identify factors associated with a significant ventricular pacing requirement. Results: The cohort consisted of 159 patients with PPM implanted prior to (n=38) or in the peri-procedural (n=121) TAVR period. Bivariate analyses identified pre-procedural RBBB (17.1% vs 42.9%, p=0.007) and post-procedural RBBB (15.2% and 39.3%, p=0.015) with significant ventricular pacing requirement in the intermediate or long-term period after TAVR. In multivariate analyses, atrial fibrillation (AF) (OR 5, 95% CI 1.78-16.6, p=0.003) and RBBB (OR 11, 95% CI 2.2-100.0, p=.008) in the post-TAVR period were associated with significant ventricular pacing requirements. Patients without AF or RBBB less often required significant ventricular pacing in the intermediate (19.3% vs 80.7%) or long-term periods (19.8% vs 80.2%) after TAVR. Conclusions: Post-procedure RBBB or a history of AF predict long-term persistence of AV block post-TAVR. However, patients without RBBB or AF less often require long-term ventricular pacing and may be candidates for temporary or more basic pacing options (e.g. leadless ventricular devices) as necessary in the peri-op period.

Doing Your Part for National Security: Providing Quality Care to Our Military and Veterans.

Civilian health professionals can play a significant role in our national security as it relates to medical readiness of the military. Members of the Reserve Component and many Veterans receive their health care in the civilian sector, thus all North Carolina health professionals need to understand the unique issues affecting this population. This issue high-lights current challenges facing our military, their families, and our Veterans, and authors offer suggestions for provid-ing quality care to this population.

Dementia and Parkinson’s disease diagnoses in electronic health records vs. Medicare claims data: a study of 101,980 linked patients

BackgroundMedicare claims and electronic health record data are both commonly used for research and clinical practice improvement; however, it is not known how concordant diagnoses of neurodegenerative diseases (NDD, comprising dementia and Parkinson’s disease) are in these data types. Therefore, our objective was to determine the sensitivity and specificity of neurodegenerative disease (NDD) diagnoses contained in structured electronic health record (EHR) data compared to Medicare claims data.MethodsThis was a retrospective cohort study of 101,980 unique patients seen at a large North Carolina health system between 2013–2017, which were linked to 100% North and South Carolina Medicare claims data, to evaluate the accuracy of diagnoses of neurodegenerative diseases in EHRs compared to Medicare claims data. Patients age > 50 who were enrolled in fee-for-service Medicare were included in the study. Patients were classified as having or not having NDD based on the presence of validated ICD-CM-9 or ICD-CM-10 codes associated with NDD or claims for prescription drugs used to treat NDD. EHR diagnoses were compared to Medicare claims diagnoses.ResultsThe specificity of any EHR diagnosis of NDD was 99.0%; sensitivity was 61.3%. Positive predictive value and negative predictive value were 90.8% and 94.1% respectively. Specificity of an EHR diagnosis of dementia was 99.0%, and sensitivity was 56.1%. Specificity of an EHR diagnosis of PD was 99.7%, while sensitivity was 76.1%.ConclusionsMore research is needed to investigate under-documentation of NDD in electronic health records relative to Medicare claims data, which has major implications for clinical practice (particularly patient safety) and research using real-world data.

Impact of the COVID-19 pandemic on delays in diagnosis and treatment of tick-borne diseases endemic to southeastern USA

BackgroundThe Coronavirus disease 2019 (COVID-19) pandemic was marked by an increase in diagnosis and treatment delays for a range of medical conditions. Yet the impact of the pandemic on the management of tick-borne diseases, which frequently manifest as an acute febrile illness similar to COVID-19, has not been well described.MethodsIn this retrospective cohort study of patients with suspected tick-borne disease attending the University of North Carolina Health facilities, we compared the timeliness of diagnosis and treatment in a “pre-COVID” period (March 2019 to February 2020) and a “post-COVID” period (March 2020 to February 2021). Participants included patients with an ICD-10 diagnosis code of spotted fever group rickettsiosis or ehrlichiosis and a positive Rickettsiarickettsii or Ehrlichia indirect immunofluorescence assay immunoglobulin G antibody test result. Of the 897 patients who had an eligible diagnosis, 240 (26.8%) met the inclusion criteria. The main outcome was time from initial presentation to definitive diagnosis and treatment.ResultsDuring the 2-year study period, 126 (52.5%) patients were grouped in the pre-COVID period and 114 (47.5%) were grouped in the post-COVID period; 120 (50.0%) were female; and 139 (57.9%) were aged > 50 years. Comparing the post-COVID to the pre-COVID period, the adjusted odds ratio (aOR) for delay in treatment > 0 days was 1.81 (95% confidence interval [CI] 1.07–3.07, P = 0.03), and for a treatment delay > 7 days, 1.65 (95% CI 0.94–2.90, P = 0.08). The odds of a delay in diagnosis were similar for patients in the post- and pre-COVID periods, with an aOR of 1.61 (95% CI 0.96–2.72, P = 0.07) for delays > 0 days, and aOR of 1.72 (95% CI 0.99–3.00, P = 0.05) for delays > 7 days.ConclusionsThe odds of a delay in treatment > 0 days were significantly higher in the post-COVID period than in the pre-COVID period. However, the odds of a delay in treatment > 7 days, or a delay in diagnosis, were similar between these two periods. Shifts in care-seeking, alternative care delivery models and prioritization of COVID-19 may contribute to diminished timeliness of treatment for patients with tick-borne diseases.Graphical

Equitable and timely access to outpatient COVID-19 treatment: A review of centralized workflow implementation at an integrated health system

BackgroundDuring the evolution of the COVID-19 pandemic, health care entities had to adapt to rapidly changing research and best practices in disease prevention and treatment to maintain the delivery of high-quality patient care. Prompt interdisciplinary efforts amongst physician, pharmacist, nursing, and information technology teammates are needed to develop robust centralized strategies to allocate and administer COVID-19 therapies in the ambulatory setting. ObjectiveThe objective of this analysis is to demonstrate the impact of a system-wide, centralized workflow on referral times and treatment outcomes for COVID-19 infected patients in the ambulatory setting. MethodsUpon release of monoclonal antibodies for the treatment of COVID-19, a centralized approach for patient treatment referrals to the University of North Carolina Health Virtual Practice team was developed due to the limited supply. Collaboration with infectious disease colleagues played a pivotal role in the rapid application of therapeutic guidance and creation of treatment prioritization levels. ResultsFrom November 2020 through February 2022, the centralized workflow team facilitated the administration of over 17,000 COVID-19 treatment infusions. The median time from treatment referral to infusion was 2 days from a positive COVID-19 test result.From January through February 2022, 514 oral COVID-19 treatment courses were dispensed from the health system’s outpatient pharmacies. The median time from referral to treatment was 1 day from diagnosis. ConclusionGiven the ongoing strain and demand of COVID-19 on the health care system, a centralized, multidisciplinary team of experts allowed for efficient delivery of COVID-19 therapies through one provider touchpoint. The collaboration between outpatient pharmacies, infusion sites, and Virtual Practice culminated in a sustainable, centralized treatment approach that supported widespread reach, and equitable dose distribution, to the most vulnerable patient populations.

Pregnant Prisoners in Shackles

Pregnant Prisoners in Shackles

Biden’s pick for CDC wins praise

Former North Carolina health chief Mandy Cohen is also a Washington, D.C., veteran

Abstract B028: Vigorous physical activity associated changes in immune cell infiltrate are linked with reduced prostate tumour aggressiveness

Abstract Vigorous physical activity has been associated with lower risk of fatal prostate cancer and improved cancer-specific outcomes. However, the mechanisms contributing to this relationship are not understood. The current study characterized inflammation in prostate cancer tissue and evaluated features of the immune microenvironment related to physical activity and prostate cancer aggressiveness. We studied 119 men with prostate cancer participating in the University of North Carolina Health Registry/Cancer Survivorship Cohort who underwent radical prostatectomy. Structured questionnaires were administered at patients' study entry to assess physical activity. Digital image analysis of H&amp;E-stained tissue sections using QuPath was applied to quantify Tumour Infiltrating Lymphocytes (TILs) in glands and stroma of tumor and adjacent normal regions. Nanostring gene expression profiling was performed on tumour tissue and a 50-gene signature utilized to predict immune cell types. ERG gene expression was used as a surrogate of TMPRSS2:ERG fusion status. Logistic regression was used to test associations of inflammation features with tumour aggressiveness and recreational physical activity measures. Cox proportional hazards analysis was applied to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between immune cell types and risk of prostate cancer progression, with validation in a separate study of 101 radiation-treated prostate cancer patients. Our study comprised 77% white and 23% black men, and 25% of men had Gleason grade ≥4+3, 29% men reported recreational vigorous activity prior to diagnosis of prostate cancer. Acute tumour inflammation affected 30% of men, while 53% showed acute inflammation of adjacent tissue. TILs were more abundant in glands than stroma; two-fold more in tumour and five-fold more in adjacent tissue. Frequency of inflammation was similar between ERG-positive and ERG-negative tumours. An inverse relationship was observed between recreational vigorous activity and TILs abundance. Expression of the immune gene signature was also significantly lower in men reporting any recreational vigorous activity compared to those reporting none (P=0.044), driven by reduced gene expression-predicted abundance of Th cells, exhausted CD8 T cells, macrophages and neutrophils. Moreover, T cells, Tfh, Treg, exhausted CD8 T cells and macrophages were significantly increased in men with Gleason grade ≥4+3 or clinical stage ≥III. Treg abundance was positively associated with prostate cancer progression (HR, 1.35; 95%CI 1.03-1.78) after adjusting for age and race, which was further strengthened in ERG-positive patients (HR, 1.60; 95%CI 1.03-2.47). We show that the immune landscape in prostate cancer is altered in men reporting vigorous physical activity. Immune cell types associated with an immunosuppressive microenvironment, including exhausted CD8 T cells, Tregs, and macrophages, may be potential candidate mechanisms linking recreational vigorous activity with reduced prostate tumour aggressiveness and improved outcomes. Citation Format: Lanshan Huang, Sophia Halliday, Linnea Olsson, Alina Hamilton, Erin Kirk, Laura Farnan, Adrian Gerstel, Stephanie Craig, Stephen Finn, Melissa Wilson, Melissa Troester, Eboneé Butler, Jeannette Bensen, Sara Wobker, Emma Allott. Vigorous physical activity associated changes in immune cell infiltrate are linked with reduced prostate tumour aggressiveness [abstract]. In: Proceedings of the AACR Special Conference: Advances in Prostate Cancer Research; 2023 Mar 15-18; Denver, Colorado. Philadelphia (PA): AACR; Cancer Res 2023;83(11 Suppl):Abstract nr B028.

A Conversation with Rose Hoban, Executive Editor of North Carolina Health News.

The recent pandemic highlighted a critical lack of trust in health information and the need for better ways to communicate health and safety news and recommendations to the general public. Rose Hoban, executive editor of the nonprofit online publication North Carolina Health News, discusses her experience and recommendations.

Single-visit insertion of long-acting reversible contraception in a single health system

ObjectiveTo identify patient and practice characteristics associated with single-visit placement of long-acting reversible contraception (LARC) across the University of North Carolina Health system. Study designWe conducted a retrospective observational study using existing electronic health records. We abstracted data from charts of individuals ages 15–50 years who received a LARC device between March 15, 2019, and March 14, 2021. Our primary outcome was whether a patient received LARC at one, or after multiple, outpatient visits. We used descriptive statistics to examine patient, clinician, and practice characteristics. We used bivariate analysis and generalized estimating equation to examine relationships between characteristics and single-visit LARC receipt. ResultsMost of the 4599 individuals received care at obstetrics and gynecology clinics (3411/4599; 74%), and received their LARC device in a single visit (3163/4599; 69%). More intrauterine devices (3151) were placed than implants (1448). The adjusted odds of receiving a LARC in a single visit was highest for those who self-paid (aOR (adjusted odds ratio) 1.83, 1.19–2.82) and those who received an implant (aOR 1.25, 1.07–1.46). Patients seen by advanced practice practitioners (aOR 0.67, 0.56–0.80) or by an internal medicine specialty clinician (aOR 0.13, 0.00–0.35) had lower odds of receiving a single-visit LARC compared to those seen by a specialist obstetrician-gynecologist physician. ConclusionMost single-visit LARC placements were performed by clinicians in obstetrician-gynecologist specialty practices. ImplicationsAmong individuals seeking long-acting reversible contraceptives from clinics in a single health system in North Carolina, most received a device at a single visit and most single-visit insertions were done by an obstetrician-gynecologist.

Impact of a Community-Based Weight Management Program in a North Carolina Health Care System.

Current strategies for obesity management in primary care leave many patients inadequately treated or unable to access treatment entirely. We aimed to evaluate a comprehensive, primary care clinic-based weight management program's clinical effectiveness in a community practice setting. Methods: This was an18-month pre/postintervention study. We collected demographic and anthropometric data on patients enrolled in a primary care-based weight management program.The primary outcomes were percent weight loss postintervention and the proportion of patients who achieved a clinically significant total body weight loss (TBWL) of 5% or greater. Results: Our program served 550 patients over 1,952 visits from March 2019 through October 2020.A total of 209 patients had adequate program exposure, defined as four or more completed visits. Among these, all received targeted lifestyle counseling and 78% received antiobesitymedication.Patients who attended at least four visits had an average TBWL of 5.7% compared to an average gain of 1.5% total body weight for those with only one visit. Fifty-three percent of patients (n=111)achieved greater than 5% TBWL, and 20%(n=43)achieved greater than 10% TBWL. We demonstrated that a community-based weight management program delivered by obesity medicine-trained primary care providers effectively produces clinically significant weight loss. Future work will include wider implementation of this model to increase patient access to evidence-based obesity treatments in their communities.

Differences in severe maternal morbidity and comorbidity indices in two North Carolina health systems

Differences in severe maternal morbidity and comorbidity indices in two North Carolina health systems

Keeping North Carolina's Health Care Workforce Well.

Supporting the wellness needs of North Carolina's health care workforce is crucial for maintaining a robust health care delivery system for all North Carolinians. Organizations and policymakers can provide needed supports to ensure the well-being of health care workers.

Patient- And Provider-Level Predictors of Survival Among Patients With Metastatic Renal Cell Carcinoma Initiating Oral Anticancer Agents.

In an era of rapid expansion of FDA approvals for oral anticancer agents (OAAs), it is important to understand the factors associated with survival among real-world populations, which include groups not well-represented in pivotal clinical trials of OAAs, such as the elderly, racial minorities, and medically complex patients. Our objective was to evaluate patient- and provider-level characteristics' associations with mortality among a multi-payer cohort of metastatic renal cell carcinoma (mRCC) patients who initiated OAAs. This retrospective cohort study was conducted using data from the North Carolina state cancer registry linked to multi-payer claims data for the years 2004 to 2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. Included patients were individuals with mRCC who initiated an OAA and survived ≥90 days after beginning treatment. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox hazard models for associations between patient demographics, patient clinical characteristics, provider-level factors, and 2-year all-cause mortality. The cohort included 207 patients with mRCC who received OAAs. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, patients solely on Medicare had higher adjusted all-cause mortality compared with patients with any private insurance (HR: 2.35, 95% CL: 1.32-4.18). No provider-level covariates investigated were associated with all-cause mortality. Within a real-world population of mRCC patients taking OAAs, survival differed based on patient characteristics. In an era of rapid expansion of FDA approvals for OAAs, these real-world data underscore the continued importance of access to high-quality care, particularly for medically complex patients with limited resources.