Patients Of Black Race Research Articles

Predictors of End-of-Life Care in Nonelderly Adults With Severe Traumatic Brain Injury

IntroductionOlder age is a well-established risk factor for withdrawal of life-sustaining therapy (WDLST) and discharge to hospice (DH) in traumatic brain injury (TBI). However, a paucity of data exists in identifying factors associated with end-of-life (EoL) care in younger patients with TBI. We sought to identify hospital and patient factors associated with EoL care and timing of EoL care in younger adults with severe TBI. MethodsThis is a retrospective analysis of the National Trauma Databank (2019). Adults (18-65 y) with severe TBI (GCS<9) were included in the analysis. Inclusion criteria included death, WDLST, or DH during the hospital stay. Exclusion criteria included GCS>8, death in the emergency department, and missing WDLST status. The primary outcome was EoL Care defined as those who either underwent WDLST or DH. The secondary outcome was early EoL care defined as EoL care within 72 h of admission. ResultsA total of 1239 patients were included in the study, the median age was 43 y, and the majority were males (77%) and of white race (68%). A total of 667 (54%) patients underwent EoL Care. On multivariable analysis, increasing age (aOR: 1.02; 95% CI: 1.01-1.03) and chronic alcoholism (OR: 1.78; 95% CI: 1.05-3.03) were independently associated with EoL. Conversely, patients of Black race (aOR: 0.33; 95% CI: 0.22-0.49) and those admitted to university hospitals (OR 0.51 95% CI 0.33-0.74) and level II trauma centers (OR 0.57; 95% CI 0.37-0.88) were less likely to undergo EoL care. A total of 225 (34%) patients underwent early EoL Care. On multivariable analysis, presence of nonreactive pupils and absence of intracranial pressure monitor were independently associated with early EoL care. ConclusionsSignificant variation in EoL care exists in patients presenting with severe TBI. Better understanding of patient and hospital factors that influence these complex decisions may allow for targeted interventions to reduce variability in EoL practice in TBI across institutions.

Abstract 4118804: Use and Clinical Outcomes Associated with Urgent versus Elective Catheter Ablation of Atrial Fibrillation in the United States

Introduction: Catheter ablation of atrial fibrillation (AF) is an increasingly important evidence-based treatment option for select patients. Although typically performed as an outpatient elective procedure, the use and clinical outcomes of AF ablation pursued urgently among inpatients have not been adequately characterized. Hypothesis: Rate of urgent AF ablation, defined as an AF ablation procedure pursued among inpatients hospitalized for a non-procedural indication, has increased over time, and may be associated with worse outcomes. Aims: To describe the use and outcomes of urgent versus elective AF ablation. Methods: Using the NCDR AFib Ablation Registry, patients who underwent AF ablation from 1/1/2016 to 6/30/2023 were stratified according to whether AF ablation was urgent or elective. Logistic regression models were fitted to determine patient and hospital-level factors associated with use of urgent AF ablation. Cochrane-Armitage tests were used to test for trends over time. Unadjusted and adjusted in-hospital event rates were reported. Results: Among 140,051 patients, 2,714 (1.9%) underwent urgent inpatient AF ablation and 137,337 (98.1%) elective ablation. Compared with the elective cohort, those undergoing urgent ablation had higher rates of co-morbid conditions including: diabetes (30.6% vs. 20.4%, P&lt;0.0001), coronary artery disease (30.8% vs. 22.7%, P&lt;0.0001), and heart failure (47.1% vs 20.8%, P&lt;0.0001). Urgent AF ablation was more often used among patients of Black race (OR 1.68; 95% CI: 1.41 – 2.0) and those with AF at the time of the procedure (OR 1.73; 95% CI: 1.36 – 2.20). Higher hospital procedural volume of AF ablations ([per 100 cases] OR 1.22; 95% CI: 1.20 – 1.25) was also associated with higher odds of urgent AF ablation. The use of urgent AF ablation increased from 0.5% in 2016, to 2.0% in 2023 (P&lt;0.0001). Unadjusted event rates for AF-related complications were significantly higher for the urgent cohort (Figure). The adjusted rate of any procedure-related complication was significantly higher in the urgent cohort (urgent 4.9% vs. elective 2.4%, P&lt;0.0001). Conclusions: The rate of urgent inpatient AF ablation has increased over time. Compared with elective AF ablation, after adjustment for patient risk factors, urgent AF ablation is associated with significantly higher rates of procedural complications. Use of urgent, inpatient AF ablation should be carefully considered within clinical contexts and offered to select patients.

Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer

BackgroundWhile utilization of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time for surgical management of early-stage uterine cancer, practice varies significantly in the United States, with disparities among low-volume centers and patients of Black race. A significant number of counties in the US are without a gynecologic oncologist, and almost half of counties with the highest gynecologic cancer rates lack a local gynecologic oncologist. ObjectiveTo evaluate relationships of distance traveled and proximity to gynecologic oncologists with receipt of and racial disparities in the quality of surgical care in patients undergoing hysterectomy for nonmetastatic uterine cancer. Study designPatients who underwent hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in 2012-2018 State Inpatient Database and State Ambulatory Surgery Services Database files. County-to-county distances were used for distances traveled and to nearest gynecologic oncologist. Factors associated with receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models including assessment for interactions of travel for surgery with patient race. ResultsAmong 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; 55.5% overall traveled to another county for surgery, including 88% of those lacking a local gynecologic oncologist. Patients lacking local access to a gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were even more likely. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had similar likelihood of minimally invasive surgery (71%) but greater likelihood of lymph node dissection (64.7% vs 57.2%) compared to non-travelers. Among counties without a gynecologic oncologist, longer distance traveled was associated with receipt of lymph node assessment. Compared to non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models controlling for a diagnosis of fibroids, Black race was an independent risk factor for receipt of open surgery. There was a significant interaction of Black race and travel for surgery, with Black patients who lived in counties without a gynecologic oncologist who did not travel facing incrementally lower likelihood of receiving minimally invasive surgery (OR=0.57 vs non-Black patients who traveled for surgery; OR=0.60 as interaction term; p<0.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county for surgery. ConclusionsPatients, particularly those of Black race, who lack local access to gynecologic oncologist specialty care benefit from traveling to specialty centers to ensure access to high-quality surgery for nonmetastatic uterine cancer. Further work is needed to ensure equitable and universal access to high-quality care through patient travel or specialist outreach.

Comparing Medicare Fee-for-Service Beneficiaries with ESKD who Switched to Medicare Advantage versus Remained in Traditional Medicare.

Patients choosing Medicare Advantage vs. Medicare fee-for-service (FFS) differ with respect to race, socioeconomic status, and burden of disease. However, it is unclear whether these differences also occur among patients with kidney failure, who were newly allowed to switch to Medicare Advantage after the 21st Century Cares Act. We used data from the United States Renal Data System (USRDS) to examine differences in characteristics of dialysis patients and kidney transplant recipients who switched from FFS to Medicare Advantage compared with those who stayed with FFS in 2021, the first year such switching was allowed. We used unadjusted and adjusted logistic regression to compare odds of switching among demographic and geographic subgroups. Among 411,513 patients with FFS coverage in 2020, 10.1% switched to Medicare Advantage in 2021. Switchers constituted 12% of the dialysis population and 5% of the kidney transplant population. In the dialysis population, patients of Black race and Hispanic ethnicity were more likely to switch than patients of White race (adjusted OR 1.69, 95% Confidence Interval [CI] 1.64, 1.73 and OR 1.42, 95% CI 1.40, 1.47, respectively), as were patients with dual eligibility for Medicaid (adjusted OR 1.12, 95% CI 1.09, 1.15). Patients living in the South were also more likely to switch to Medicare Advantage than those living in the West (adjusted OR 1.48, 95% CI 1.43, 1.52). Similar differences were observed among kidney transplant recipients. Patients who switched from FFS to Medicare Advantage were disproportionately from historically marginalized groups, including Black, Hispanic, and low income individuals. They were also more likely to live in the South. These differences may threaten the generalizability of USRDS data that relies on FFS insurance claims and suggest that comparisons of outcomes between FFS and MA beneficiaries with kidney failure should be adjusted for key patient characteristics.

Multiplicative Impact of Adverse Social Determinants of Health on Outcomes in Lupus Nephritis: A Meta-analysis and Systematic Review.

Social determinants of health (SDoH) likely contribute to outcome disparities in lupus nephritis (LN). Understanding the overall burden and contribution of each domain could guide future health equity-focused interventions to improve outcomes and reduce disparities in LN. Objectives of this meta-analysis were to 1) determine the association of overall SDoH and specific SDoH domains on LN outcomes and 2) develop a framework for the multidimensional impact of SDoH on LN outcomes. We performed a comprehensive search of studies measuring associations between SDoH and LN outcomes. We examined pooled odds of poor LN outcomes including death, end-stage kidney disease, or cardiovascular disease in patients with and without adverse SDoH. Additionally, we calculated the pooled odds ratios of outcomes by four SDoH domains: individual (eg, insurance), health care (eg, fragmented care), community (eg, neighborhood socioeconomic status), and health behaviors (eg, smoking). Among 531 screened studies, 31 meeting inclusion criteria and 13 with raw data were included in meta-analysis. Pooled odds of poor outcomes were 1.47-fold higher in patients with any adverse SDoH. Patients with adverse SDoH in individual and health care domains had 1.64-fold and 1.77-fold higher odds of poor outcomes. We found a multiplicative impact of having two or more adverse SDoH on LN outcomes. Black patients with public insurance and fragmented care had 12-fold higher odds of poor LN outcomes. Adverse SDoH is associated with poor LN outcomes. Having two or more adverse SDoH, specifically in different SDoH domains, had a multiplicative impact leading to worse LN outcomes, widening disparities.

Nurses’ moral distress and leadership communication in hospitals serving Black patients during COVID-19

BackgroundPoorer leadership communication during COVID-19 may have contributed to the moral distress of nurses in hospitals where Black patients predominantly access their care (BSH). PurposeTo compare nurse moral distress and leadership communication during the COVID-19 pandemic in hospitals that serve disproportionately many or few patients of Black race. MethodsIn a national hospital sample (n=90), nurse survey data were collected (March 2021). Nurse moral distress was analyzed in linear regression models. The key covariates were BSH category (Medicare Black patient percentage) and leadership communication. FindingsNurses in high-BSH had significantly greater moral distress and more difficulty accessing personal protective equipment than nurses in low-BSH. The percentage of nurses in high-BSHs with high moral distress was double that of nurses in low-BSHs. Poorer leadership communication in BSHs accounted for the nurses’ greater moral distress. DiscussionPolicies should improve leadership communication, mitigate distress, and support nurses in under resourced settings.

Outcomes of Antineoplastic Immunotherapy at a Large Healthcare Organization: Impact of Provider, Race and Socioeconomic Status.

Disparities in cancer care delivery remain a pressing health-care crisis within the United States (US). The use of immune checkpoint inhibitors (ICIs) and their management may be a disparity generator that impacts survival. This retrospective study assessed disparities in a cohort of patients with a variety of solid tumors treated with ICIs within a single health-care organization focusing on the impact of race, socioeconomic status (SES) and site of care delivery on survival and the development of severe immune-related adverse events (irAEs). Manual chart review was performed on all patients with solid tumors treated with ICIs within a health-care organization from 2012 to 2018. Care delivery was dichotomized as DOP (disease-oriented provider at academic center) and COP (community oncology provider). Primary and secondary outcomes were overall survival (OS) and rates of grade 3-4 irAEs, respectively. Relationships with covariates of interest, including race, socioeconomic status and type of care delivery, were assessed among both outcomes. A total of 1070 eligible patients were identified. Of those, 11.4% were of Black race, 59.7% had either non-small cell lung cancer (NSCLC) or melanoma and 82.8% had stage IV disease. Patients of Black race and lower SES were more likely to be treated by DOPs (p<0.0001). A superior OS was associated with care delivered by DOPs when compared to COPs (HR 0.68; 95% CI 0.56-0.84; p=0.0002), which was durable after accounting for race, SES, histopathologic diagnosis and disease stage. Melanoma patients experienced higher rates of severe irAEs (HR 2.37; 95% CI 1.42-3.97; p=0.001). Race, SES and site of care delivery were not related to rates of severe irAEs. In a large health-care organization, patients treated with checkpoint inhibitors by DOPs benefited from a significant OS advantage that was durable after controlling for racial and socioeconomic factors, providing evidence that disease-oriented care has the potential to mitigate racial and socioeconomic disparities.

MDRD is the eGFR equation most strongly associated with 4-year mortality among patients with diabetes in Colombia

IntroductionWe compared the association of glomerular filtration rate (GFR) estimated with the Cockcroft-Gault, Modification of Diet in Renal Disease study (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), or the new...

The Variation of Withdrawal of Life Sustaining Therapy in Older Adults With Traumatic Brain Injury

IntroductionThe decision to withdraw life sustaining treatment (WDLST) in older adults with traumatic brain injury is subject to wide variability leading to nonbeneficial interventions and unnecessary use of hospital resources. We hypothesized that patient and hospital factors are associated with WDLST and WDLST timing. MethodsAll traumatic brain injury patients ≥65 with Glasgow coma scores (GCS) of 4-11 from 2018 to 2019 at level I and II centers were selected from the National Trauma Data Bank. Patients with head abbreviated injury scores 5-6 or death within 24 h were excluded. Bayesian additive regression tree analysis was performed to identify the cumulative incidence function (CIF) and the relative risks (RR) over time for withdrawal of care, discharge to hospice (DH), and death. Death alone (no WDLST or DH) served as the comparator group for all analyses. A subanalysis of the composite outcome WDLST/DH (defined as end-of-life-care), with death (no WDLST or DH) as a comparator cohort was performed. ResultsWe included 2126 patients, of whom 1957 (57%) underwent WDLST, 402 (19%) died, and 469 (22%) were DH. 60% of patients were male, and the mean age was 80 y. The majority of patients were injured by fall (76%, n = 1644). Patients who were DH were more often female (51% DH versus 39% WDLST), had a past medical history of dementia (45% DH versus 18% WDLST), and had lower admission injury severity score (14 DH versus 18.6 WDLST) (P < 0.001). Compared to those who DH, those who underwent WDLST had a lower GCS (9.8 versus 8.4, P < 0.001). CIF of WDSLT and DH increased with age, stabilizing by day 3. At day 3, patients ≥90 y had an increased RR of DH compared to WDLST (RR 2.5 versus 1.4). As GCS increased, CIF and RR of WDLST decreased, while CIF and RR of DH increased (RR on day 3 for GCS 12: WDLST 0.42 versus DH 1.31).Patients at nonprofit institutions were more likely to undergo WDLST (RR 1.15) compared to DH (0.68). Compared to patients of White race, patients of Black race had a lower RR of WDLST at all timepoints. ConclusionsPatient and hospital factors influence the practice of end-of-life-care (WDLST, DH, and death), highlighting the need to better understand variability to target palliative care interventions and standardize care across populations and trauma centers.

The Impact of the COVID-19 Pandemic on Hepatocellular Carcinoma Time to Treatment Initiation: A National Cancer Database Study.

The COVID-19 pandemic strained oncologic care access and delivery, yet little is known about how it impacted hepatocellular carcinoma (HCC) management. Our study sought to evaluate the annual effect of the COVID-19 pandemic on time to treatment initiation (TTI) for HCC. The National Cancer Database was queried for patients diagnosed with clinical stages I-IV HCC (2017-2020). Patients were categorized based on their year of diagnosis as "Pre-COVID" (2017-2019) and "COVID" (2020). TTI based on stage and type of treatment first received was compared by the Mann-Whitney U test. A logistic regression model was used to evaluate factors of increased TTI and treatment delay (> 90 days). In total, 18,673 patients were diagnosed during Pre-COVID, whereas 5249 were diagnosed during COVID. Median TTI for any first-line treatment modality was slightly shorter during the COVID year compared with Pre-COVID (49 vs. 51 days; p < 0.0001), notably in time to ablation (52 vs. 55 days; p = 0.0238), systemic therapy (42 vs. 47 days; p < 0.0001), and radiation (60 vs. 62 days; p = 0.0177), but not surgery (41 vs. 41 days; p = 0.6887). In a multivariate analysis, patients of Black race, Hispanic ethnicity, and uninsured/Medicaid/Other Government insurance status were associated with increased TTI by factors of 1.057 (95% CI: 1.022-1.093; p = 0.0013), 1.045 (95% CI: 1.010-1.081; p = 0.0104), and 1.088 (95% CI: 1.053-1.123; p < 0.0001), respectively. Similarly, these patient populations were associated with delayed treatment times. For patients diagnosed during COVID, TTI for HCC, while statistically significant, had no clinically significant differences. However, vulnerable patients were more likely to have increased TTI.

Achieving Equity in Hospital Performance Assessments Using Composite Race-Specific Measures of Risk-Standardized Readmission and Mortality Rates for Heart Failure.

The contemporary measures of hospital performance for heart failure hospitalization and 30-day risk-standardized readmission rate (RSRR) and risk-standardized mortality rate (RSMR) are estimated using the same risk adjustment model and overall event rate for all patients. Thus, these measures are mainly driven by the care quality and outcomes for the majority racial and ethnic group, and may not adequately represent the hospital performance for patients of Black and other races. Fee-for-service Medicare beneficiaries from January 2014 to December 2019 hospitalized with heart failure were identified. Hospital-level 30-day RSRR and RSMR were estimated using the traditional race-agnostic models and the race-specific approach. The composite race-specific performance metric was calculated as the average of the RSRR/RMSR measures derived separately for each race and ethnicity group. Correlation and concordance in hospital performance for all patients and patients of Black and other races were assessed using the composite race-specific and race-agnostic metrics. The study included 1 903 232 patients (75.7% White [n=1 439 958]; 14.5% Black [n=276 684]; and 9.8% other races [n=186 590]) with heart failure from 1860 hospitals. There was a modest correlation between hospital-level 30-day performance metrics for patients of White versus Black race (Pearson correlation coefficient: RSRR=0.42; RSMR=0.26). Compared with the race-agnostic RSRR and RSMR, composite race-specific metrics for all patients demonstrated stronger correlation with RSRR (correlation coefficient: 0.60 versus 0.74) and RSMR (correlation coefficient: 0.44 versus 0.51) for Black patients. Concordance in hospital performance for all patients and patients of Black race was also higher with race-specific (versus race-agnostic) metrics (RSRR=64% versus 53% concordantly high-performing; 61% versus 51% concordantly low-performing). Race-specific RSRR and RSMR metrics (versus race-agnostic) led to reclassification in performance ranking of 35.8% and 39.2% of hospitals, respectively, with better 30-day and 1-year outcomes for patients of all race groups at hospitals reclassified as high-performing. Among patients hospitalized with heart failure, race-specific 30-day RSMR and RSRR are more equitable in representing hospital performance for patients of Black and other races.

County Rurality is Associated with Increased Tumor Size and Decreased Survival in Patients with Ewing Sarcoma.

Ewing Sarcoma (ES) is an aggressive tumor affecting adolescents and young adults. Prior studies investigated the association between rurality and outcomes, although there is a paucity of literature focusing on ES. This study aims to determine whether ES patients in rural areas are subject to adverse outcomes. This study utilized the Surveillance, Epidemiology, and End Results (SEER) database. A Poisson regression model was used with controls for race, sex, median county income, and age to determine the association between rurality and tumor size. A multivariate Cox Proportional Hazard Model was utilized, controlling for age, race, gender, income, and tumor size. There were 868 patients eligible for analysis, with a mean age of 14.14 years. Of these patients, 97 lived in rural counties (11.18%). Metropolitan areas had a 9.50% smaller tumor size (p<0.0001), compared to non-metropolitan counties. Patients of Black race had a 14.32% larger tumor size (p<0.0001), and male sex was associated with a 15.34% larger tumor size (p<0.0001). The Cox Proportional Hazard model estimated that metropolitan areas had a 36% lower risk of death over time, compared to non-metropolitan areas (HR: 0.64, p ≤ 0.04). Patients in metropolitan areas had a smaller tumor size at time of diagnosis and had a more favorable survival rate for cancer-specific mortality compared to patients residing in rural areas. Further work is needed to examine interventions to reduce this discrepancy and investigate the effect of extremely rural and urban settings and why racial disparities occur.

Telehealth as a Tool to Improve Access and Reduce No-Show Rates in a Large Safety-Net Population in the USA.

Low-income populations are at higher risk of missing appointments, resulting in fragmented care and worsening disparities. Compared to face-to-face encounters, telehealth visits are more convenient and could improve access for low-income populations. All outpatient encounters at the Parkland Health between March 2020 and June 2022 were included. No-show rates were compared across encounter types (face-to-face vs telehealth). Generalized estimating equations were used to evaluate the association of encounter type and no-show encounters, clustering by individual patient and adjusting for demographics, comorbidities, and social vulnerability. Interaction analyses were performed. There were 355,976 unique patients with 2,639,284 scheduled outpatient encounters included in this dataset. 59.9% of patients were of Hispanic ethnicity, while 27.0% were of Black race. In a fully adjusted model, telehealth visits were associated with a 29% reduction in odds of no-show (aOR 0.71, 95% CI: 0.70-0.72). Telehealth visits were associated with significantly greater reductions in probability of no-show among patients of Black race and among those who resided in the most socially vulnerable areas. Telehealth encounters were more effective in reducing no-shows in primary care and internal medicine subspecialties than surgical specialties or other non-surgical specialties. These data suggest that telehealth may serve as a tool to improve access to care in socially complex patient populations.

Strong Negative Association of non-HDL Cholesterol Goal Achievement With Incident CKD Among Adults With Diabetes.

The relative importance of the control of different metabolic risk factors for the prevention of chronic kidney disease among patients with diabetes in real life conditions is insufficiently understood. We evaluated the effect of the achievement of glycated hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDLc) or non-high-density lipoprotein cholesterol (non-HDLc) goals (ABC goals) on the development of incident chronic kidney disease (iCKD) among patients with diabetes. In a nationwide registry of all individuals diagnosed with diabetes assisted by the health system in Colombia, we analyzed the association between baseline or sustained goal achievement and development of iCKD over a 4-year follow-up. iCKD was defined as a new occurrence of an estimated glomerular filtration rate less than 60 mL/min/1.73 m2, hemodialysis, peritoneal dialysis, or kidney transplant. The study included 998 790 adults with diabetes (56% female, mean age 59). There were 125 626 cases of iCKD. After adjustment for multiple confounders, a baseline SBP less than 130 mm Hg (odds ratio [OR] 0.79 [0.78-0.80]) and a baseline HbA1c less than 7.0% (OR 0.86 [0.85-0.87]) were negatively associated with iCKD. Sustained achievement showed stronger negative associations with iCKD than just baseline achievement. Considering each goal separately, sustained non-HDLc less than 130 mg/dL had the strongest negative association with iCKD (OR 0.67 [0.65-0.69]). Patients who maintained the triple ABC goal over the entire follow-up had 32% (29-34) lower odds of developing CKD, 38% (34-42) if they additionally kept a normal body mass index (BMI). Sustained ABC control including a normal BMI was more strongly associated with a lower incidence of CKD in patients of Black race (OR 0.72 vs 0.89; P for interaction = .002). At the country level, sustained achievement of ABC goals and most especially non-HDLc were associated with substantial reductions in iCKD.

Worsened outcomes of newly diagnosed cancer in patients with recent emergency care visits: A retrospective cohort study of 3699 adults in a safety net health system.

Many patients receive a suspected diagnosis of cancer through an emergency department (ED) visit. Time to treatment for a new diagnosis of cancer is directly associated with improved outcomes with little no describing the ED utilization prior to the diagnosis of cancer. We hypothesize that patients that have an ED visit in proximity to a diagnosis of cancer will have worse outcomes, including mortality. This study is a retrospective cohort study of all patients with cancer diagnosed at Eskenazi Health (Indiana) between 2016 and 2019. Individual health characteristics, ED utilization, cancer types, and mortality were studied. We compared those patients seen in the ED within 6months prior to their diagnosis (cases) to patients not seen in the ED (controls). A total of 3699 patients with cancer were included, with 1239 cases (33.50%). Patients of black race had higher frequencies in the cases vs. controls (46.57% vs. 40.68%). Lung cancer was the most frequently observed cancer among cases vs. controls (11.70% vs. 5.57%). For the cases, 232 patients were deceased (18.72%) compared with 247 patients among the controls (10.04%, p< 0.0001, OR 2.06 95% confidence interval [CI] 1.70-2.51). An ED visit in past 6months (OR=1.73, 95% CI 1.38-2.18) and Medicaid insurance type (versus commercial, OR=4.16, 95% CI 2.45-7.07) were associated with of mortality. Female gender (OR=0.76, 95% CI 0.67-0.88), tobacco use (OR=1.62, 95% CI 138-1.90), and Medicaid insurance type (versus commercial, OR=2.56, 95% CI 2.07-3.47) were associated with prior ED use. Over one third of patients with cancer were seen in the ED within 6months prior to their cancer diagnosis. Higher mortality rates were observed for those seen in the ED. Future studies are needed to investigate the association and impact that the ED has on eventual cancer diagnoses and outcomes.

Preoperative Treatment of Severe Diabetes Mellitus and Hypertension Mitigates Healthcare Disparities and Prevents Adverse Postoperative Discharge to a Nursing Home.

To evaluate whether patients of Black race are at higher risk of adverse postoperative discharge to a nursing home, and if a higher prevalence of severe diabetes mellitus and hypertension are contributing. It is unclear whether a patient's race predicts adverse discharge to a nursing home after surgery, and if preexisting diseases are contributing. A total of 368,360 adults undergoing surgery between 2007 and 2020 across 2 academic healthcare networks in New England were included. Patients of self-identified Black or White race were compared. The primary outcome was postoperative discharge to a nursing facility. Mediation analysis was used to examine the impact of preexisting severe diabetes mellitus and hypertension on the primary association. In all, 10.3% (38,010/368,360) of patients were Black and 26,434 (7.2%) patients were discharged to a nursing home. Black patients were at increased risk of postoperative discharge to a nursing facility (adjusted absolute risk difference: 1.9%; 95% confidence interval: 1.6%-2.2%; P <0.001). A higher prevalence of preexisting severe diabetes mellitus and hypertension in Black patients mediated 30.2% and 15.6% of this association. Preoperative medication-based treatment adherent to guidelines in patients with severe diabetes mellitus or hypertension mitigated the primary association ( P -for-interaction <0.001). The same pattern of effect mitigation by pharmacotherapy was observed for the endpoint 30-day readmission. Black race was associated with postoperative discharge to a nursing facility compared to White race. Optimized preoperative assessment and treatment of diabetes mellitus and hypertension improves surgical outcomes and provides an opportunity to the surgeon to help eliminate healthcare disparities.

Disparities in Biomarker Testing and Clinical Trial Enrollment Among Patients With Lung, Breast, or Colorectal Cancers in the United States.

Comprehensive tumor biomarker testing is a fundamental step in the selection of highly effective molecularly driven therapies for a variety of solid tumors. The primary objective of this study was to examine racial differences in biomarker testing and clinical trial participation in the United States using a real-world database. Patients in a real-world deidentified database diagnosed with advanced/metastatic non-small-cell lung cancer (NSCLC), metastatic colorectal cancer (CRC), or metastatic breast cancer were eligible. Biomarker testing and clinical trial participation was compared between Black and White racial groups using chi-squared test and stepwise logistic regression controlling for baseline covariates. A total of 23,488 patients met eligibility criteria. Next-generation sequencing (NGS) testing rates differed significantly between White versus Black race before first-line therapy (36.6% v 29.7%, P < .0001) and at any given time (54.7% v 43.8%, P < .0001) in the nonsquamous NSCLC cohort. Similar disparities in NGS testing rates at any time during the study were observed among patients with CRC (White 51.6%; Black 41.8%, P < .0001). No differences were observed in the breast cancer cohort. Patients of Black race were less likely to be treated in a clinical trial in the overall NSCLC cohort when compared with White counterparts (3.9% v 2.1%, P = .0002). A statistically significant relationship between biomarker/NGS testing and clinical trial enrollment was observed in all cohorts (P < .003) after adjusting for covariates. In a real-world database, significant disparities in NGS-based testing rates were observed between Black and White races in NSCLC and CRC. NGS and any biomarker testing were both associated with trial enrollment in all cohorts. There is a need for interventions to promote access to comprehensive testing for patients with advanced/metastatic tumors.

Achievement of treatment goals among adults with diabetes in Colombia, 2015–2019: Results from a national registry

AimsTo assess the achievement of essential treatment goals among patients with diabetes in Colombia. MethodsWe analyzed data from a nationwide registry of all individuals with diagnosed diabetes, hypertension or CKD assisted by the health system. We explored the prevalence of treatment goals (HbA1c < 7% [<53 mmol/mol], systolic blood pressure (SBP) < 130 mmHg and LDLc < 100 mg/dL), and their variations by race and type of health insurance, between July 1, 2015, and June 30, 2019. ResultsWe studied 1 352 846 patients with diagnosed diabetes. The prevalence of HbA1c < 7% (<53 mmol/mol) remained steady at 52%, systolic blood pressure (SBP) < 130 mmHg was also stable at 80–82%. Meanwhile, the prevalence of both LDLc < 100 mg/dL and non-HDLc < 130 mg/dL increased by 6 percentage points. Achievement of the triple HbA1c + SBP + LDLc goal was only 21.4% in 2015, increasing to 24.4% by 2019. Goal achievement was consistently lower among patients of black race, especially for HbA1c (5% lower than other races), but also for the SBP, LDLc and joint goals. Patients under third-party insurance reached better HbA1c, SBP, and LDLc control. ConclusionsAchievement of treatment goals of patients with diabetes in Colombia remains substantially low, despite improvements in LDLc control.

Disparities in Access to Preemptive Repeat Kidney Transplant: Still Missing the Mark?

The need for repeat transplant due to failing kidney allografts is increasing over time. The benefit of preemptive kidney retransplant (PKre-T) is controversial. Marginalized populations are less likely to undergo their first transplant preemptively; however, whether inequities exist for those undergoing PKre-T is unknown. We performed a cohort study of adult patients undergoing live and deceased kidney transplant in the United States from 2000 to 2018 identified using the Scientific Registry of Transplant Recipients, and we identified patients with first preemptive kidney transplant (PKT) and PKre-T. In the primary analysis, a multivariable logistic regression was used to identify independent predictors of PKre-T. In secondary analyses, multivariable Cox models were used to determine the association of PKre-T with death-censored and all-cause graft loss. In total, 4910 (15.5%) patients underwent PKre-T, and 43,293 (19.1%) underwent first PKT. Inequities in access to PKre-T persisted (OR, 0.49; 95% CI, 0.44 to 0.55 for unemployed versus full time; OR, 1.61; 95% CI, 1.14 to 2.25 for graduate school versus not completing high school; OR, 0.61; 95% CI, 0.52 to 0.70 for Black versus White race); 7.1% of all transplanted Black patients received PKre-T versus 17.4% of White patients. Women were more likely to undergo PKre-T than men (OR, 1.42; 95% CI, 1.29 to 1.57). PKre-T was associated with superior graft survival relative to retransplant after a period of dialysis (HR, 0.73; 95% CI, 0.67 to 0.80 for all-cause graft failure; HR, 0.72; 95% CI, 0.65 to 0.81 for death-censored graft loss). Despite improved patient and graft survival, inequities in access to PKre-T persist. Patients with lower education, patients with reduced employment status, patients of Black race, and men are less likely to receive PKre-T.

Sociodemographic Factors Are Associated with Patient-Reported Outcome Measure Completion in Orthopaedic Surgery

Background:Patient-reported outcome measures (PROMs) and, specifically, the Patient-Reported Outcomes Measurement Information System (PROMIS), are increasingly utilized for clinical research, clinical care, and health-care policy. However, completion of these outcome measures can be inconsistent and challenging. We hypothesized that sociodemographic variables are associated with the completion of PROM questionnaires. The purposes of the present study were to calculate the completion rate of assigned PROM forms and to identify sociodemographic and other variables associated with completion to help guide improved collection efforts.Methods:All new orthopaedic patients at a single academic medical center were identified from 2016 to 2020. On the basis of subspecialty and presenting condition, patients were assigned certain PROMIS forms and legacy PROMs. Demographic and clinical information was abstracted from the electronic medical record. Bivariate analyses were performed to compare characteristics among those who completed assigned PROMs and those who did not. A multivariable logistic regression model was created to determine which variables were associated with successful completion of assigned PROMs.Results:Of the 219,891 new patients, 88,052 (40%) completed all assigned PROMs. Patients who did not activate their internet-based patient portal had a 62% increased likelihood of not completing assigned PROMs (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.58 to 1.66; p < 0.001). Non-English-speaking patients had a 90% (OR, 1.90; 95% CI, 1.82 to 2.00; p < 0.001) increased likelihood of not completing assigned PROMs at presentation. Older patients (≥65 years of age) and patients of Black race had a 23% (OR, 1.23; 95% CI, 1.19 to 1.27; p < 0.001) and 24% (OR, 1.24; 95% CI, 1.19 to 1.30; p < 0.001) increased likelihood of not completing assigned PROMs, respectively.Conclusions:The rate of completion of PROMs varies according to sociodemographic variables. This variability could bias clinical outcomes research in orthopaedic surgery. The present study highlights the need to uniformly increase completion rates so that outcomes research incorporates truly representative cohorts of patients treated. Furthermore, the use of these PROMs to guide health-care policy decisions necessitates a representative patient distribution to avoid bias in the health-care system.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.