Private Insurance Patients Research Articles

PERT era, race-based healthcare disparities in a large urban safety net hospital.

Pulmonary embolism (PE) is the third leading cause of cardiovascular death in the United States. Black Americans have higher incidence, greater clot severity, and worse outcomes than White Americans. This disparity is not fully understood, especially in the context of the advent of PE response teams (PERT), which aim to standardize PE-relatedcare. This retrospective single-center cohort study compared 294 Black and 131 White patients from our institution's PERT database. Primary objectives included severity and in-hospital management. Secondary outcomes included length of stay, 30-day readmission, 30-day mortality, and outpatient follow-up. Clot (p = 0.42), acute treatment (p = 0.28), 30-day mortality (p = 0.77), 30-day readmission (p = 0.50), and outpatient follow-up (p = 0.98) were similar between races. Black patients had a lower mean household income ($35,383, SD 20,596) than White patients ($63,396, SD 32,987) (p < 0.0001). More Black patients (78.8%) had exclusively government insurance (Medicare/Medicaid) compared to White patients (61.8%) (p = 0.006). Interestingly, government insurance patients had less follow-up (58.3%) than private insurance patients (79.7%) (p = 0.001). Notably, patients with follow-up had fewer 30-day readmissions. Specifically, 12.2% of patients with follow-up were readmitted compared to 22.2% of patients without follow-up (p = 0.008). There were no significant differences in PE severity, in-hospital treatment, mortality, or readmissions between Black and White patients. However, patients with government insurance had less follow-up and more readmissions, indicating a socioeconomic disparity. Access barriers such as health literacy, treatment cost, and transportation may contribute to this inequity. Improving access to follow-up care may reduce the disparity in PE outcomes.

Financial Outcomes of “Bagging” Oncology Drugs Among Privately Insured Patients With Cancer

This cohort study examines the difference in per-patient per-month costs between drugs distributed under “bagging,” a drug delivery model that requires patients to obtain physician-administered medications via pharmacies, and traditional buy-and-bill practice.

Uptake of Biosimilar Among Privately Insured Patients Undergoing Infliximab Treatment.

Recent literature has found rapid uptake of short-acting filgrastim biosimilars but slower uptake of other biosimilars, such as infliximab, in both Medicare and privately insured enrollees. To describe patient, provider, and health plan characteristics associated with a switch to biosimilar among existing infliximab patients. We constructed a retrospective panel dataset of patients undergoing active infliximab treatments and the choice of infliximab drug for each infusion. We used mixed logit regression controlling for patient, provider, and health plan characteristics as well as time-fixed effects. Medicare Advantage and privately insured enrollees with evidence of active infliximab treatments between 2016 and 2020 (n=357,430). Our primary outcome of interest was to switch from infliximab originator to one of the infliximab biosimilars. Exposure variables of interest variables such as out-of-pocket, site of care, and in-network deductible. Our study found nominally low switching among existing infliximab originator users (3.4%). We found that patients who previously received 1 infliximab originator infusion were 63.7% more likely to switch to biosimilar compared with patients who previously received administration of 20 infliximab originators. We found that biosimilar's placement as health's plan preferred drug was attributed to higher likelihood of biosimilar use (odds ratio: 1.666; P -value=0.001). We did not observe any statistically significant effect among out-of-pocket amount or deductible with respect to switch to infliximab biosimilar. To encourage uptake and switch to biosimilar, policymakers should consider targeted policies that include leveraging health plan tools such as placement of biosimilar as preferred drug and aim to educate patients on the clinical equivalence between infliximab biosimilar and originator.

Impact of Medicaid Expansion on Abdominal Surgery Morbidity, Mortality, and Hospital Readmission

IntroductionMedicaid expansion's (ME) impact on postoperative outcomes after abdominal surgery remains poorly defined. We aimed to evaluate ME's effect on surgical morbidity, mortality, and readmissions in a state that expanded Medicaid (Virginia) compared to a state that did not (Tennessee) over the same time period. MethodsVirginia Surgical Quality Collaborative (VSQC) American College of Surgeons National Surgical Quality Improvement Program data for Medicaid, uninsured, and private insurance patients undergoing abdominal procedures before Virginia's ME (3/22/18-12/31/18) were compared with post-ME (1/1/19-12/31/19), as were corresponding non-ME state Tennessee Surgical Quality Collaborative (TSQC) data for the same 2018 and 2019 time periods. Postexpansion odds ratios for 30-d morbidity, 30-d mortality, and 30-d unplanned readmission were estimated using propensity score-adjusted logistic regression models. ResultsIn Virginia, 4753 abdominal procedures, 2097 pre-ME were compared to 2656 post-ME. In Tennessee, 5956 procedures, 2484 in 2018 were compared to 3472 in 2019. VSQC's proportion of Medicaid population increased following ME (8.9% versus 18.8%, P < 0.001) while uninsured patients decreased (20.4% versus 6.4%, P < 0.001). Post-ME VSQC had fewer 30-d readmissions (12.2% versus 6.0%, P = 0.013). Post-ME VSQC Medicaid patients had significantly lower probability of morbidity (−8.18, 95% confidence interval: −15.52 ∼ −0.84, P = 0.029) and readmission (−6.92, 95% confidence interval: −12.56 ∼ −1.27, P = 0.016) compared to pre-ME. There were no differences in probability of morbidity or readmission in the TSQC Medicaid population between study periods (both P > 0.05); there were no differences in mortality between study periods in VSQC and TSQC patient populations (both P > 0.05). ConclusionsME was associated with decreased 30-d morbidity and unplanned readmissions in the VSQC. Data-driven policies accounting for ME benefits should be considered.

Implication of dental insurance status on patterns of pre-radiation dental extraction and risk of osteoradionecrosis of the jaw in head-and-neck cancer patients

Oral toxicities such as osteoradionecrosis can be minimized by dental screening and prophylactic dental care prior to head and neck (HN) radiation therapy (RT). However, limited information is available about how dental insurance interacts with prophylactic dental care and osteoradionecrosis. To address this gap in knowledge, we conducted a cohort study of 2743 consecutive adult patients treated with curative radiation for HN malignancy who underwent pre-radiation dental assessment and where required, prophylactic dental treatment. Charts were reviewed to determine patient demographics, dental findings, dental treatment and development of osteoradionecrosis following radiation. Three insurance cohorts were identified: private-insured (50.4 %), public-insured (7.3 %), being patients with coverage through government-funded disability and welfare programs, and self-pay (42.4 %).More than half the public-insured patients underwent prophylactic pre-radiation dental extractions, followed by self-pay patients (44 %) and private-insured patients (26.6 %). After a median follow-up time of 4.23 years, 6.5 % of patients developed osteoradionecrosis. The actuarial rate of osteoradionecrosis in the public-insured patients was 14.7 % at 5-years post-RT, compared to 7.5 % in private-insured patients and 6.7 % in self-pay patients. On multivariable analysis, dental insurance status, DMFS160, age at diagnosis, sex, tumor site, nodal involvement, years smoked and gross income were all significant risk factors for tooth removal prior to HN radiation. However, only public-insured status, tumor site and years smoked were significant risk factors for development of osteoradionecrosis. Our findings demonstrate that lack of comprehensive dental coverage (patients who self-pay or who have limited coverage under public-insured programs) associates strongly with having teeth removed prior to HN RT. Nearly 1 in 6 patients covered under public-insurance developed osteoradionecrosis within 5 years of completing their treatment. Well-funded dental insurance programs for HN cancer patients might reduce the number of pre-RT extractions performed in these patients, improving quality of life post-RT.

Receipt of Electroconvulsive Therapy in Outpatient Settings in a National Sample of Privately Insured Patients With Mood Disorders.

Electroconvulsive therapy (ECT), an effective treatment for bipolar and major depressive disorder, is underused. Little information is available on use of ECT in potentially less costly outpatient settings, possibly reducing cost barriers. Insurance claims from the 2008 to 2017 MarketScan Commercial Database for patients diagnosed with mood disorders were used to compare 4 groups of ECT users in each year: those receiving (1) exclusively outpatient ECT, (2) first inpatient and subsequently outpatient, (3) outpatient and subsequently inpatient, and (4) exclusively inpatient ECT. Groups were compared on the proportion receiving ECT in each group over time as well as on the total numbers of treatments received along with group differences in sociodemographic and diagnostic characteristics and health care costs. Among 2.9 million patients diagnosed with mood disorders, the proportion who received ECT (n = 8859) was small (0.30%) and declined over the decade to 0.17%. Among those who received ECT, most did so exclusively as outpatients (52.3%), the group with fewest comorbidities and lowest costs. This proportion increased by 19.7% over the decade, whereas the proportion receiving ECT exclusively in an inpatient setting (12.1%) fell by 30.6%. The total number of treatments per patient averaged 11.7 per year and increased by 28.0% over the decade, with outpatients decreasing to slightly less than average. Health care costs were greatest for those who started ECT as inpatients. Although the proportion of privately insured patients receiving ECT in outpatient settings has increased, reducing cost barriers, the use of ECT continued to be extremely limited and declining.

Financial toxicity risk among patients with gastric banding complications in the United States: analysis of the National Inpatient Sample

BackgroundLaparoscopic adjustable gastric banding (AGB) was historically among the most performed bariatric procedures but has fallen out of favor in recent years due to poor long-term weight loss and high revisional surgery rates. Significant financial hardship of medical care, known as “financial toxicity,” can occur from experiencing unexpected complications of AGB. ObjectiveTo investigate the risk of financial toxicity among patients being admitted for AGB complications. SettingUnited States. MethodsAll uninsured and privately-insured patients who were admitted for AGB complications were identified from the National Inpatient Sample 2015–2019. Publicly available government data (U.S. Census Bureau, Bureau of Labor, The Centers for Medicare and Medicaid Services) were utilized to estimate patient income, food expenditures, and average maximum out-of-pocket expenditures. Financial toxicity was defined as total admission cost from AGB complications ≥40% of postsubsistence income. ResultsAmong 28,005 patients, 66% patients had private insurance and 44% patients were uninsured. Median total admission cost was $12,443 (interquartile range $7959–$19,859) and $15,182 for those who received revisional bariatric surgery. Approximately 55% of the uninsured patients and 1% of insured patients were at risk of financial toxicity after admission for banding-related complications. Patients who had an emergency admission, revisional surgery, or postoperative intensive care unit admission were more likely to experience financial catastrophe following admission (P < .01). ConclusionsAbout 1 in 2 uninsured patients admitted for AGB-related complications were at risk of financial toxicity. In addition to surgical risks, providers should consider the potential financial consequences of AGB when counselling patients on their choice of surgery.

Impact of Private Payer Policies on the Transition to Telemental Health Care Among Privately Insured Patients with Mental Health Disorders.

Introduction: Mental health patients in states without private payer telehealth reimbursement policies before the public health emergency (PHE) may have experienced reduced access to telemental health (TMH). We estimate the association between private payer telehealth policy status in 2019 and the transition to TMH in 2020. Methods: Retrospective cohort study of privately insured individuals 2-64 years old with a mental health disorder and without TMH use in 2019. We examined new telemental use in 2020 by three categories of policy reimbursement status in 2019 (partial parity, full parity vs. no policy), overall (any telemental), and by modality (live video, audio-only, and online assessments) using logistic regression models clustered by state. Results: Among the 34,612 enrollees, 54.7% received TMH for the first time. Relative to no policy states, enrollees in partial or full parity states were equally likely to receive TMH in 2020. However, enrollees in states with a private payer telehealth policy were less likely to receive audio-only (partial parity: odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.39-0.90; full parity: OR: 0.38, 95% CI: 0.26-0.55), but more likely to receive online assessments (full parity: OR: 2.28, 95% CI: 1.4-4.59). Conclusions: Privately insured enrollees similarly transitioned to TMH across states suggesting a broad impact of the PHE policies on access to this care. The differences in audio-only and online assessments suggest that providers were possibly better prepared to implement TMH care via live video or patient portals in states with telehealth policies.

Prescribed Opioid Dosages, Payer Type, and Self-Reported Outcomes After Surgical Procedures in Michigan, 2018-2020

Collaborative quality improvement (CQI) models, often supported by private payers, create hospital networks to improve health care delivery. Recently, these systems have focused on opioid stewardship; however, it is unclear whether reduction in postoperative opioid prescribing occurs uniformly across health insurance payer types. To evaluate the association between insurance payer type, postoperative opioid prescription size, and patient-reported outcomes in a large statewide CQI model. This retrospective cohort study used data from 70 hospitals within the Michigan Surgical Quality Collaborative clinical registry for adult patients (age ≥18 years) undergoing general, colorectal, vascular, or gynecologic surgical procedures between January 1, 2018, and December 31, 2020. Insurance type, classified as private, Medicare, or Medicaid. The primary outcome was postoperative opioid prescription size in milligrams of oral morphine equivalents (OME). Secondary outcomes were patient-reported opioid consumption, refill rate, satisfaction, pain, quality of life, and regret about undergoing surgery. A total of 40 149 patients (22 921 [57.1%] female; mean [SD] age, 53 [17] years) underwent surgery during the study period. Within this cohort, 23 097 patients (57.5%) had private insurance, 10 667 (26.6%) had Medicare, and 6385 (15.9%) had Medicaid. Unadjusted opioid prescription size decreased for all 3 groups during the study period from 115 to 61 OME for private insurance patients, from 96 to 53 OME for Medicare patients, and from 132 to 65 OME for Medicaid patients. A total of 22 665 patients received a postoperative opioid prescription and had follow-up data for opioid consumption and refill. The rate of opioid consumption was highest among Medicaid patients throughout the study period (16.82 OME [95% CI, 12.57-21.07 OME] greater than among patients with private insurance) but increased the least over time. The odds of refill significantly decreased over time for patients with Medicaid compared with patients with private insurance (odds ratio, 0.93; 95% CI, 0.89-0.98). Adjusted refill rates for private insurance remained between 3.0% and 3.1% over the study period; adjusted refill rates among Medicare and Medicaid patients decreased from 4.7% to 3.1% and 6.5% to 3.4%, respectively, by the end of the study period. In this retrospective cohort study of surgical patients in Michigan from 2018 to 2020, postoperative opioid prescription size decreased across all payer types, and differences between groups narrowed over time. Although funded by private payers, the CQI model appeared to have benefitted patients with Medicare and Medicaid as well.

Medicaid Insurance is Associated with Treatment Disparities for Proximal Humerus Fractures in a National Database Analysis.

Proximal humerus fractures (PHFs) are the third most common type of fragility fracture in the elderly and are increasing in incidence. Disparities in treatment type, time to surgery (TTS), and complications based upon insurance type have been identified for other orthopedic conditions. Given the incidence and burden of PHFs, we sought to evaluate if insurance type was associated with treatment received, TTS, and complications in the treatment of PHFs. We used PearlDiver, a national administrative claims database that consists of 122 million patient records. Patients diagnosed with an isolated PHF between 2010-2019 were identified by ICD-9/10 diagnostic codes and stratified by insurance type (Medicaid, private, or Medicare). Outcomes evaluated were rate of surgery within 3 months of diagnosis with open reduction and internal fixation, hemiarthroplasty, or reverse shoulder arthroplasty; average TTS; 90-day readmissions and medical postoperative complications (deep vein thrombosis, urinary tract infection, pneumonia, sepsis, acute respiratory failure, cerebrovascular event, and acute renal failure); and 1-year surgical postoperative complications (stiffness, non-infectious wound complications, dislocation, and infection). Multivariable logistic regressions adjusting for age, sex, and Elixhauser comorbidity index were utilized to determine the association between insurance type and surgery rate/complications. We included 245,396 patients for analysis. 14% of Medicaid patients (1,789/12,498) underwent surgery compared to 17% (25,347/149,830) of privately-insured patients and 16% (13,305/83,068) of Medicare patients (pairwise p < 0.001). TTS (Medicaid: 11.7 days, private: 10.6 days (p < 0.001), Medicare: 10.7 days (p = 0.003)) varied by insurance type. Private or Medicare-insured patients were less likely to be readmitted (adjusted odds ratio [OR]: 0.77 [95% confidence interval (CI): 0.63 - 0.93] for private vs Medicaid, and 0.71 [95% CI: 0.59 - 0.88] for Medicare vs Medicaid) and experienced fewer 90-day postoperative complications (adjusted ORs: 0.73 [95% CI: 0.62 - 0.85] for private vs Medicaid, 0.65 [95% CI: 0.55 - 0.77] for Medicare vs Medicaid), such as acute renal failure. TTS was also associated with differing rates of readmissions and complications. There are differences in rates of surgery, TTS, and complications after PHFs based on insurance type, representing opportunities for quality-improvement initiatives. Potential methods to address these disparities include implementing standardized PHF protocols and/or reimbursement models and quality metrics that reward equitable treatment. Further research and policy adaptations should be incorporated to decrease barriers patients face and minimize healthcare inequities seen in the treatment of PHFs based on insurance type.

Disparities in clinical trial participation in ovarian cancer: A real-world analysis

BackgroundSignificant disparities exist in clinical trial participation in non-gynecologic cancers, but little is known about disparities in ovarian cancer trial participation. Our objective was to examine patient, sociodemographic (race/ethnicity, insurance), cancer, and health system factors associated with clinical trial participation in ovarian cancer. MethodsWe conducted a retrospective cohort study of patients with epithelial ovarian cancer diagnosed from 2011 to 2021, using a real-world electronic health record derived database, representing around 800 sites of care in US academic and community practices. We used multivariable Poisson regression modeling to analyze the association of ever participating in an ovarian cancer clinical drug trial with patient, sociodemographic, health system, and cancer factors. ResultsOf the 7540 patients with ovarian cancer, 5.0% (95% CI 4.5–5.5) ever participated in a clinical drug trial. Patients of Hispanic or Latino ethnicity were 71% less likely to participate in clinical trials (RR 0.29, 95% CI 0.13–0.61) than non-Hispanic patients, and patients whose race was unknown or other than Black or White were 40% less likely to participate in clinical trials (RR 0.68, 95% CI 0.52–0.89). Patients who had Medicaid insurance were 51% less likely (RR 0.49, 95% CI 0.28–0.87) and those with Medicare were 32% (RR 0.48–0.97) less likely to participate in clinical trials than privately-insured patients. ConclusionIn this national cohort study, only 5% of patients with ovarian cancer participated in clinical drug trials. Interventions are needed to decrease race, ethnicity, and insurance disparities in clinical trial participation.

EE358 Estimated Costs of Malaria Treatment in the United States Among Privately Insured Patients and Medicaid Enrollees, 2015‒2019

The number of malaria cases in the United States (US) has increased in recent years. Few studies have reported costs associated with malaria treatment in the US. To fill this gap, we estimated mean inpatient and outpatient payments for malaria treatment among patients with private and Medicaid insurance.

Trends in Use of Robotic Surgery for Privately Insured Patients and Medicare Fee-for-Service Beneficiaries

This cohort study evaluates trends in the adoption of robotic surgery among Medicare beneficiaries and privately insured patients for common general surgical procedures.

Patient Utilization of Premium Intraocular Lenses Before and During the COVID-19 Pandemic.

To compare the choice of intraocular lens (IOL) and sociodemographic characteristics between patients who underwent elective cataract surgery before the COVID-19 pandemic and during the pandemic at the Wilmer Eye Institute. A retrospective chart review of patients who underwent cataract surgery before the COVID-19 pandemic (June 1 to November 30, 2019) and during the pandemic (June 1 to November 30, 2020) was conducted. Sociodemographic information, including age, sex, race, and insurance, and choice of IOL (premium or standard) were analyzed. The association between timing of surgery and choice of IOL was analyzed using multivariable logistic regression. The study included 2,877 patients (3,946 eyes) before COVID-19 and 2,564 patients (3,605 eyes) during COVID-19. However, 9.0% (357/3,946) of surgeries before COVID-19 used premium IOLs compared with 11.1% (399/3,605) during COVID-19 ( P =0.004). There was no difference in the racial characteristics of patients between before and during COVID-19. After adjusting for time of surgery and demographics, the odds of choosing premium IOLs for black patients was 0.32 times the odds for white patients ( P <0.001). There was an increase in private-insured patients but a decrease in Medicare-insured patients during COVID-19. After adjusting for time of surgery and demographics, private-insured patients had higher odds of choosing premium IOLs ( P <0.001), whereas Medicaid-insured patients had lower odds ( P =0.007) when compared with Medicare-insured patients. More patients chose premium IOLs during COVID-19 than before COVID-19, concurrent with change in insurance status. White patients were more likely to choose premium IOLs than black patients, as were private-insured patients compared with Medicare-insured patients.

172 Health Inequities in Access to Treatment for Unruptured Intracranial Aneurysms in the United States over 20 Years

INTRODUCTION: Literature suggests that minority racial and ethnic groups have lower treatment rates for unruptured intracranial aneurysms (UIA). It is uncertain how these disparities have changed across time. METHODS: The National Inpatient Sample (NIS) database was queried using diagnostic and procedural codes for adult patients who underwent open surgical or endovascular treatment for UIA. Aneurysmal SAH patients were used as a substitute control for patients with intracranial aneurysms that progressed to hemorrhage before intervention. A multivariable logistic regression model was constructed using patient factors and hospital factors to identify predictors of treatment. RESULTS: A total of 213,350 UIA patients and 173,375 aSAH patients from 2000-2019 were included in the final analysis. After adjusting for covariates, Black patients (0.715, 95% CI 0.699-0.730), Hispanic patients (0.734, 95% CI 0.717-0.751) and other racial/ethnic minority patients (0.633, 95% CI 0.617-0.651) had lower odds of intervention for UIA compared to White patients with UIA. Medicare patients had higher odds of treatment than private insurance patients while Medicaid and the uninsured patients had lower odds. Non-White/Hispanic females (0.697, 95% CI 0.646-0.752) and males (0.602, 95%CI 0.556-0.651) had lower treatment odds than their white counterparts, irrespective of insurance status. Multivariable regression analysis revealed that the treatment odds of Black patients improved over time, while other minority group patients had variable treatment odds over time. CONCLUSIONS: This analysis of NIS data from 2000 to 2019 demonstrates disparities in treatment for UIA across race, sex, insurance status, and hospital factors. The persistence of inequalities over time requires attention in order to target improvement.

Risk factors for inpatient hospital admission following isolated orbital floor fractures

Orbital floor fractures are common injuries seen in the emergency department (ED). In this study, the National Trauma Data Bank (NTDB, 2016–2017) was used to identify patients presenting with isolated orbital floor trauma. Patient-specific factors were analyzed to determine associations with management. The sample comprised 912 patients; 285 (31.3%) of these patients were discharged from the ED, 541 (59.3%) were admitted to the hospital but did not undergo an operation, and 86 (9.4%) underwent operative treatment. Pediatric patients and older patients (<18 years and>55 years) were more likely to be admitted than those aged 18–55 years, and pediatric patients were more likely to undergo an urgent operative intervention than those in the other age groups (all P < 0.001). Patients with alcohol use disorder (P = 0.002) and hypertension (P = 0.004) had increased odds of admission. Private and Medicare insurance patients were more likely to be admitted, and self-pay patients less likely (P < 0.001). Older age and Medicaid payor status showed increased odds of a greater hospital length of stay. Biological sex, race/ethnicity, functionally dependent health status, myocardial infarction, steroid use, and substance use disorder were not associated with discharge disposition. There are non-injury related, patient-specific factors that may influence the management of orbital floor fractures.

Abstract PD16-01: Racial Disparities in the Use of Preoperative Breast MRI after Breast Cancer Diagnosis

Abstract Introduction: The use of magnetic resonance imaging (MRI) prior to surgical treatment for breast cancer has greatly increased over the past decade. As MRI more accurately defines disease extent vs mammography and sonography, it is frequently utilized for staging women at elevated risk of occult disease due to young age, dense breast tissue, and/or lobular histology. However, it is not known whether women from different racial backgrounds and socioeconomic statuses have equal access to preoperative breast MRI. The goal of this study was to assess whether the use of preoperative breast MRI varies by race and insurance type. Methods: We identified adult women who were diagnosed with Stage 0-III breast cancer within our mixed academic/community health system between 2016-2019 and were subsequently treated with surgical resection. We limited our analysis to non-Hispanic Black and non-Hispanic White women, as they comprised 93% of the eligible cohort. Patients who underwent breast MRI between their date of diagnosis and date of surgery were considered to have had a “preoperative MRI.” We used multivariable logistic regression to quantify the association between patient factors and receipt of preoperative MRI. Covariates included patient race, insurance type, age, year of diagnosis, clinical stage, histology, breast density, receptor subtype, and receipt of neoadjuvant systemic therapy. Results: 1,268 women met inclusion criteria and had complete clinical information available for analysis. 362 (29%) were Black, and 906 (71%) were White. 718 (57%) had private insurance, 460 (36%) had Medicare, and 72 (6%) had Medicaid. Compared to White patients, a larger proportion of Black patients had Medicaid (15% vs. 2.0%), fatty or scattered density (i.e., level 1 or 2) breasts (69% vs 48%), and regional disease (26% vs 19%) (Table). Patients with Medicare had the highest proportion of fatty or scattered density breasts (67% vs private=46% vs Medicaid=56%), while patients with Medicaid had the highest proportion of regional disease (35% vs private=23% vs Medicare=15%). The proportion of patients who received preoperative MRI was higher for White (49%) vs Black women (37%, p&amp;lt; 0.001). After adjustment, Black patients were 52% less likely to undergo preoperative MRI compared to White patients (OR 0.48, 95% CI 0.35-0.66, p&amp;lt; 0.001). Compared to privately-insured patients, patients with Medicare had a similar likelihood of undergoing preoperative MRI (OR 0.81, 95% CI 0.54-1.22, p=0.309), while patients with Medicaid may have had a lower likelihood of undergoing preoperative MRI (OR 0.55, 95% CI 0.30-1.00, p=0.053). Conclusions: Black patients with newly diagnosed breast cancer were less likely than White patients to undergo preoperative breast MRI, a disparity that persisted after controlling for insurance and clinical factors. Algorithmic use of preoperative MRI may mitigate provider- and system-level biases and promote more equitable resource utilization. Table 1: Characteristics of patients with non-metastatic breast cancer, diagnosed and treated at our institution (2016-2019) *Biomarker data for 2019 cohort is pending Citation Format: Sara P. Ginzberg, Connor B. Grady, Oluwadamilola (Lola) Fayanju, Christine E. Edmonds. Racial Disparities in the Use of Preoperative Breast MRI after Breast Cancer Diagnosis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD16-01.

The Insurance Landscape for Implant- and Autologous-based Breast Reconstruction in the United States.

A retrospective analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database from 2014 to 2017 was performed. International Classification of Diseases Clinical Modification and Procedure Coding System codes were used to identify patients for inclusion. De-identified sociodemographic and insurance data were analyzed using χ 2, least absolute shrinkage and selection operator regression analysis, and classification trees. In total, 31,468 patients were identified for analysis and stratified by reconstructive modality, sociodemographics, insurance, and hospital characteristics. Most patients underwent nonautologous reconstruction (63.2%). Deep inferior epigastric perforator flaps were the most common autologous modality (46.7%). Least absolute shrinkage and selection operator regression identified Black race, urban-teaching hospitals, nonsmoking status, and obesity to be associated with autologous reconstruction. Publicly-insured patients were less likely to undergo autologous reconstruction than privately-insured patients. Within autologous reconstruction, publicly-insured patients were 1.97 (P < 0.001) times as likely to obtain pedicled flaps than free flaps. Black patients were 33% (P < 0.001) less likely to obtain free flaps than White patients. Breast reconstruction is influenced by insurance, hospital demographics, and sociodemographic factors. Action to mitigate this health disparity should be undertaken so that surgical decision-making is solely dependent upon medical and anatomic factors.

Catastrophic Health Care Expenditure Following Brachial Plexus Injury

Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery. Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis. Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE. Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery. Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs.

Increased risk of diabetic ketoacidosis in an Urban, United States, safety-net emergency department in the COVID-19 era

&lt;abstract&gt;&lt;sec&gt; &lt;title&gt;Aims&lt;/title&gt; &lt;p&gt;The incidence of diabetic ketoacidosis (DKA) increased during the COVID-19 pandemic but estimates from low-resource settings are limited. We examined the odds of DKA among emergency department (ED) visits in the Los Angeles County Department of Health Services (DHS) (1) during the COVID-19 pandemic compared to the pre-COVID era, (2) without active COVID infections, and (3) stratified by effect modifiers to identify impacted sub-groups.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Methods&lt;/title&gt; &lt;p&gt;We estimated the odds of DKA from 400,187 ED visits pre-COVID era (March 2019–Feb 2020) and 320,920 ED visits during the COVID era (March 2020–Feb 2021). Our base model estimated the odds of DKA based on the COVID era. Additional specifications stratified by effect modifiers, controlled for confounders, and limited to visits without confirmed COVID-19 disease.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Results&lt;/title&gt; &lt;p&gt;After adjusting for triage acuity and interaction terms for upper respiratory infections and payor, the odds of DKA during the COVID era were 27% higher compared to the pre-COVID era (95%CI 14–41%, p &amp;lt; 0.001). In stratified analyses, visits with private payors had a 112% increased odds and visits with Medicaid had a 20% increased odds of DKA during the COVID era (95%CI 7–36%, p = 0.003).&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Conclusions&lt;/title&gt; &lt;p&gt;We identified increased odds of DKA during the COVID pandemic, robust to a variety of specifications. We found differential effects by the payor; with increased odds during COVID for privately-insured patients.&lt;/p&gt; &lt;/sec&gt;&lt;/abstract&gt;