Public Insurance Status Research Articles

Social Demographic and Clinical Predictors of Time to Clinic Presentation After a Sport-Related Concussion.

To investigate the associations between clinical risk factors, social demographic and time to concussion clinic presentation after sports-related concussion in young athletes. Retrospective cohort study. Multidisciplinary regional concussion center. Athletes ages 12 to 18 years who sustained a SRC from November 2017 to April 2022. Independent variables included social demographic factors (ie, race, ethnicity, public vs private school, public vs private insurance), patient medical history, family medical history, acute concussion characteristics, and initial presentation elsewhere. Descriptive statistics were employed to assess for group differences. Mann-Whitney U tests, Spearman rank order correlations, and linear regressions were performed to explore associations between each independent variable and the main outcome, days to concussion clinic presentation. A total of 945 athletes we included (age 15.8 ± 1.61, 33.7% female). Hispanic/Latino background, (P = 0.009), public insurance status (U = 47 377.0, P = 0.002), amnesia (U = 57 738.0, P = 0.002) at time of injury, family psychiatric (U = 35 091.0, P < 0.001) or migraine (U = 59 594.5, P < 0.001) histories, and personal psychiatric (U = 30 798.0, P = 0.004) or migraine (U = 34 133.5, P = 0.011) histories were associated with longer time to concussion clinic presentation. A multivariable linear regression found that initial presentation elsewhere (β = 0.37, P < 0.001), family migraine history (β = 0.18, P < 0.001), public insurance status (β = 0.09, P = 0.024), and history of learning disability (β = 0.09, P = 0.032) were the only predictors of longer time to concussion clinic presentation. Variables that predicted longer time to concussion clinic presentation included initial presentation elsewhere, public insurance status, positive family migraine history, and history of learning disability. Further research is needed to elucidate these findings and determine how they impact concussion seeking behavior.

Impact of Insurance Status on Postoperative Recovery After Microsurgical Breast Reconstruction.

Persistent disparities in breast reconstruction access have been widely documented, yet a significant research gap remains in understanding the impact of social determinants of health (SDOH) on postoperative outcomes and complications. A retrospective chart review was performed on all patients who underwent abdominal-based free-flap breast reconstruction between August 2018 and December 2022 at a racially, ethnically, and socioeconomically diverse urban academic institute with a historically underserved patient population. Patients were stratified by the public (Medicare and Medicaid) versus private insurance as a proxy for SDOH. Patient demographics, length of stay (LOS), timing in progression through postoperative recovery milestones, and complications were compared. A total of 162 patients were included, and 57% of patients had public insurance, with this group more likely to be Hispanic (OR2.7; p=0.003) and Spanish-speaking (OR3.4; p=0.003). Privately insured patients were more likely to be non-Hispanic black (OR2.7; p=0.006). Patients with public insurance had a higher rate of unplanned return to the operating room within 90 days and a higher incidence of complications, though not statistically significant. They also experienced a significantly longer LOS than privately insured patients (3.6±1.0 days vs 3.0±0.7 days; p<0.0001). Logistic regression identified a LOS exceeding 3 days as independently associated with public insurance status (OR3.0; p=0.03), bilateral procedure (OR5.6; p=0.0007), preoperative functional-dependent status (OR7.0; p=0.04), and higher BMI (OR1.1; p=0.03). Patients with public insurance were more likely to encounter delays in achieving recovery milestones. Public insurance status, serving as a proxy for a disadvantage in SDOH, is predictive of extended LOS and postoperative recovery delays following microsurgical breast reconstruction. This underscores the need for future quality improvement efforts to address and mitigate these disparities.

National estimates of nonurgent emergency department utilization for sportsrelated injuries in high school-age population.

Athletic trainers (ATs) can manage nonurgent, musculoskeletal emergency department (ED) visits. Little is known about what populations are most likely to use the ED for nonurgent, sports-related musculoskeletal injuries. Our object is to provide national-level evidence on whether high-school age population with public insurance or lower socioeconomic status were more likely to have ED visits for nonurgent injuries. Cross-sectional study. Secondary data analysis of the 2017-2019 Nationwide Emergency Department Sample (NEDS). ED visits for high school-age patients with a sports-related musculoskeletal injury. We used a multi-step process and AT scope of care threshold to classify ED visits for musculoskeletal injuries as urgent and nonurgent. National estimates of the proportions of visit, patient, and hospital characteristics by urgent, nonurgent, and total injury ED visits were reported. Survey weighted logistic regression was used to calculate odds ratios of an ED visit being for a nonurgent injury based on a patient's insurance type and socioeconomic status. For ED visits for musculoskeletal injuries in a high school-age, sports exposed population, 52.93% (95% CI: 51.11, 54.73) were for nonurgent injuries. Patients with public insurance were more likely (OR = 1.39; 95% CI: 1.35, 1.44) to have an ED visit for a nonurgent injury compared to ED visits for patients with private insurance. Patients from the lowest estimated neighborhood income quartiles were more likely (OR = 1.10; 95% CI: 1.02, 1.20) to have an ED visit for a nonurgent injury compared to ED visits for patients in the highest estimated income quartile. Our results suggest opportunities to reduce nonurgent ED use using AT services exist, especially in high school-age athletes from vulnerable populations.

Predictors of follow-up of pediatric stone patients after surgical intervention

We investigated if socioeconomic and demographic factors predict post-surgical follow-up in pediatric stone patients. All patients having kidney stone surgery at a single academic pediatric hospital over a 5 year period (2016-2020) were identified through the use of CPT® codes specific to ureteroscopy, shock wave lithotripsy, and percutaneous nephrolithotomy. Electronic charts were reviewed for patient demographics, stone characteristics, and characteristics of intervention. Unique patients with a scheduled post-operative follow-up office visit following a first time stone surgery were included in the patient cohort (Figure 1). Primary outcome was attendance of a scheduled provider visit within 6 months after surgery. Secondary outcomes included completion of scheduled post-operative imaging and 24-h urine study. Univariable analysis was performed. 195 pediatric patients, a median age of 15.4 years (IQR: 11.34, 17.14) at surgery, were identified. The majority were non-Hispanic white (86.2%) and female (62.1%). Most had undergone ureteroscopy alone (85.6%). Of the 195 patients, 146 (74.9%) attended a post-operative office visit. Indicators of lower socioeconomic status, such as having public insurance and being from a single-parent home, were associated with not attending a scheduled follow-up visit (p<0.01 and p=0.02, respectively). Patients with a pre-operative urology clinic visit were more likely to follow-up with a clinic visit (p=0.02), while those with a larger total stone burden treated were more likely to undergo ordered imaging (p<0.01). We found that indicators of lower socioeconomic status, such as having public insurance status and being in a single-parent household, were associated with lower pediatric follow-up compliance after kidney stone surgery, while patients seen in the urology clinic preoperatively were more likely to attend follow-up. Identifying factors that may predict non-compliance could be used to help at-risk patient populations.

Local practice variations and payer differences underlie state-wide disparities in oncoplastic breast surgery.

Little is known about disparities in oncoplastic breast surgery delivery. The Massachusetts All-Payer Claims Database was queried for patients who received lumpectomy for a diagnosis of breast cancer. Oncoplastic surgery was defined as adjacent tissue transfer, complex trunk repair, reduction mammoplasty, mastopexy, flap-based reconstruction, prosthesis insertion, or unspecified breast reconstruction after lumpectomy. We identified 18 748 patients who underwent lumpectomy between 2016 and 2020. Among those, 3140 patients underwent immediate oncoplastic surgery and 436 patients underwent delayed oncoplastic surgery. Eighty-one percent of patients who underwent oncoplastic surgery did so in the same county as they underwent a lumpectomy. However, the relative frequency of oncoplastic surgery varied significantly among counties. In multivariable regression, public insurance status (odds ratio: 0.87, 95% confidence interval: 0.80-0.95, p = 0.002) was associated with lower odds of undergoing oncoplastic surgery, even after adjusting for macromastia, other comorbidities, and county of lumpectomy. Average payments for lumpectomy with oncoplastic surgery were more than twice as high from private insurers ($840 vs. $1942, p < 0.001). Disparities in the receipt of oncoplastic surgery were related to differences in local practice patterns and the type of insurance patients held. Expanding services across counties and considering billing reform may help reduce these disparities.

Unexpected variation in outcomes following total (procto)colectomies for ulcerative colitis in New South Wales, Australia: a population-based 19-year linked-data study.

Total (procto)colectomy for ulcerative colitis (UC) is associated with significant morbidity, which is increased in the emergency setting. This study aimed to evaluate the outcomes following total (procto)colectomies at a population level within New South Wales (NSW), Australia, and identify case mix and hospital factors associated with these outcomes. A retrospective data linkage study of patients undergoing total (procto)colectomy for UC in NSW over a 19-year period (2001-2020) was performed. The primary outcome was 90-day mortality. The influence of hospital level factors (including annual volume) and patient demographic variables on outcomes was assessed using logistic regression. Temporal trends in annual volume and evidence for centralization were assessed. In all, 1418 patients (mean 47.0 years [SD 18.7], 58.7% male) underwent total (procto)colectomy during the study period. The overall 90-day mortality rate was 3.2% (emergency 8.6% and elective 0.8%). After adjusting for confounding, increasing age at total (procto)colectomy, higher comorbidity burden, public health insurance (Medicare) status, emergency operation and living outside a major city were significantly associated with increased mortality. Hospital volume was significantly associated with mortality at a univariate level, but this did not persist on multivariate modelling. Outcomes of UC patients undergoing total (procto)colectomy in NSW Australia are comparable to international experience. Whilst higher mortality rates are observed in low volume and public hospitals, this appears attributable to case mix and acuity rather than surgical volume alone. However, as inflammatory bowel disease surgery is not centralized in Australia, only one NSW hospital performed >10 UC total (procto)colectomies annually. Variation in mortality according to insurance status and across regional/remote areas may indicate inequality in the availability of specialist inflammatory bowel disease treatment, which warrants further research.

Timing of Alveolar Bone Graft and Barriers to Care.

The current standard timing for alveolar bone grafting (ABG) occurs during mixed dentition, typically between the ages of six and twelve. A delay in receiving this operation is associated with an increase in graft loss and an overall thinner maxilla. This study aims to determine whether socioeconomic barriers are associated with a delay in timely ABG. A retrospective analysis of patients who received ABG at our institution since 2012. Patient demographics, cleft classifications, operative details, and surgical dates were examined. A logistic regression model was created using socioeconomic variables to predict patients receiving delayed ABG. Significant variables were then included in a backwards selection logistic regression, followed by a final analysis of maximum likelihood estimates. Single-institution, primary cleft care center. 202 patients with cleft palates who underwent ABG. ABG. Timing in which patients received ABG: standard (6-12 years) and delayed (>12 years). Female sex was a protective factor in the timing of ABG in our initial univariate analysis (OR = 0.44; p = .015). Socioeconomic factors resulting in delayed presentation for ABG include median income (OR = 1.0; p = .018) and public insurance status (OR = 3.75; p < .001). Median income, sex, and driving distance to the cleft clinic were not significant following backward elimination, however, private insurance status remained significant (OR = 3.71; p = .0001). Patients with public insurance are approximately 3.75 times more likely to receive ABG during permanent dentition. Multidisciplinary teams should work closely with patients on public insurance to ensure timely delivery of ABG.Level of Evidence III, Retrospective.

Social determinants of health rather than race impact health-related quality of life in 10-year-old children born extremely preterm.

Reducing healthcare disparities among children is extremely important given the potential impact of these disparities on long-term health-related quality of life (HRQL). Race and parental socioeconomic status (SES) are associated with child HRQL, but these associations have not been studied in infants born extremely preterm (EP), a population at increased risk for physical, cognitive, and psychosocial impairments. Achieving health equity for infants born EP across their life course requires identifying the impact of racism and SES on HRQL. We aimed to evaluate the association between self-reported maternal race, SES factors, and HRQL among 10-year-old children born EP. Participants were identified from an ongoing multicenter prospective longitudinal study of Extremely Low Gestational Age Newborns (ELGAN Study), born between 2002 and 2004, and evaluated at 10 years of age using the Pediatric quality of life (QoL) Inventory completed by their parent or guardian, assessing physical, emotional, social, school, and total (composite) QoL domains. Multivariable regression models were used to evaluate the relationship between QoL scores and self-identified maternal race, adjusting for SES factors (education level, marital status, and public insurance). Of 1,198 study participants who were alive at 10 years of age, 863 (72.0%) were evaluated at 10 years of age. Differences in mean 10-year QoL scores across racial groups were observed and were significant on univariate analysis. However, these associations attenuated when adjusted for the marital status, public insurance status, and education status of mothers. A comparison of children with English as the primary language spoken at home vs. any other language revealed a significant difference only in school QoL, in which non-English language was associated with more favorable school QoL scores. Among 10-year-old children born EP, differences in parent-reported QoL were associated with maternal SES factors but not with race. Our results suggest that interventions designed to improve the SES of mothers may enhance the QoL of children born EP. Furthermore, these results underscore that race is a social construct, rather than a biological variable, as we work toward greater equity in care provision.

Lower Prevalence of Diabetic Ketoacidosis at Diagnosis in Research Participants Monitored for Hyperglycemia.

In Colorado children, the prevalence of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) has been increasing over time. Evaluate the prevalence of and factors involved in DKA at T1D diagnosis among participants followed in monitoring research studies before diagnosis compared to patients from the community. Patients<18 years diagnosed with T1D between 2005 and 2021 at the Barbara Davis Center for Diabetes. Prevalence of and factors associated with DKA at diagnosis among participants in preclinical monitoring studies compared to those diagnosed in the community. Of 5049 subjects, 164 were active study participants, 42 inactive study participants, and 4843 were community patients. Active study participants, compared to community patients, had lower HbA1c (7.3% vs 11.9%]; P<0.001) and less frequently experienced DKA (4.9% vs 48.5%; P<0.001), including severe DKA (1.2% vs 16.2%; P<0.001). Inactive study participants had intermediate levels for both prevalence and severity of DKA. DKA prevalence increased in community patients, from 44.0% to 55%, with less evidence for a temporal trend in study participants. DKA prevalence was highest in children <2 years (13% in active study participants vs 83% in community patients). In community patients, younger age (P=0.0038), public insurance (P<0.0001), rural residence (P<0.0076), higher HbA1c (P<0.0001), and ethnicity minority status (P<0.0001) were associated with DKA at diagnosis. While DKA prevalence increases in community patients over time, it stayed <5% in active research participants, who have a 10 times lower prevalence of DKA at diagnosis, including in minorities.

Clinical Features and Outcomes of Myxedema Coma in Patients Hospitalized for Hypothyroidism: Analysis of the United States National Inpatient Sample.

Background: Hypothyroidism is a common endocrine condition and chronic thyroid hormone deficiency is associated with adverse effects across multiple organ systems. In compensated hypothyroidism, however, patients remain clinically stable due to gradual physiological adaptation. In contrast, the clinical syndrome of decompensated hypothyroidism referred to as myxedema coma (MC) is an endocrine emergency with high risk of mortality. Because of its rarity, there are currently limited data regarding MC. This study analyzes the clinical features and hospital outcomes of MC compared with hypothyroid patients without MC (nonMChypo) in national United States hospital data. Methods: A retrospective analysis of the National Inpatient Sample, a public database of inpatient admissions to nonfederal hospitals in the United States, 2016-2018, including adult patients with primary diagnosis of MC (International Classification of Diseases 10th Revision [ICD-10]: E03.5) or nonMChypo (E03.0-E03.9, E89.0). Patient demographics, relevant clinical features, mortality, length of stay (LOS), and hospital costs were compared. Results: Of 18,635 patients hospitalized for hypothyroidism, 2495 (13.4%) had a diagnosis of MC. Sex distribution and race/ethnicity were similar between patients with MC and nonMChypo, whereas MC was associated with older patient age (p = 0.02), public insurance (p = 0.01), and unhoused status (p = 0.04). More admissions with MC occurred in winter compared with other seasons (p = 0.01). The overall mortality rate for MC was 6.8% versus 0.7% for nonMChypo (p < 0.001), and MC was independently associated with in-hospital mortality after adjusted regression analysis (adjusted odds ratio = 9.92 [CI 5.69-17.28], p < 0.001). Mean LOS ± standard error was 9.64 ± 0.73 days for MC versus 4.62 ± 0.12 days for nonMChypo (p < 0.001), and total hospital cost for MC was $21,768 ± $1759 versus $8941 ± $276 for nonMChypo (p = 0.07). In linear regression analyses, MC was an independent predictor of both increased LOS and total hospital cost. Conclusions: In summary, MC remains a clinically significant diagnosis in the modern era, independently associated with high mortality and health care costs. This continued burden demonstrates a need for further efforts to prevent, identify, and optimize treatment for patients with MC.

Differential Utilization of Parental Presence and Premedication for Induction of Anesthesia in Pediatric Patients

PurposeKnown disparities exist in pain treatment between African American, Latino, and White children, and a recent study described ‘adultification’ of Black children, with Black children being less likely to have a parent present at induction of anesthesia and less likely to receive an anxiolytic premedication before proceeding to the operating room. The aim of this study is to identify differences based on race and socioeconomic status when treating children and their families for anesthetic induction. We hypothesize that differences exist such that certain populations are less likely to receive sedative premedication and less likely to have parents present at induction of anesthesia. DesignThis retrospective cohort study utilized demographic data along with types of surgical procedure, type of anesthesia induction, use of premedication, and involvement of child life services (including the plan for parental presence at induction) were obtained for all pediatric patients presenting for anesthetics from February 2019-March 2020. MethodsStatistical analysis consisted of fitting logistic mixed effects models for caregiver presence or for midazolam use during induction, with fixed effects for sex, race, ethnicity, language, public/private insurance, and anesthetic risk, and with provider as a random effect. FindingsA total of 7753 patients were included in our statistical analyses, Parental presence focused on 4102 patients with documentation from child life specialists (Figure 2). Females were less likely than males to have parents present at induction (OR 0.77, CI [0.67, 0.89]). When looking at race, American Indian/Alaskan Native patients (OR 0.23 [CI 0.093, 0.47]) and Black/African American patients OR 0.64 [CI 0.47, 0.89]) were less likely to have a parent present induction than White patients. Patients with private insurance were more likely to have parents present than patients with public insurance (OR 0.63 CI [0.5, 0.78]). These findings held true in age separated sensitivity analysis. For midazolam usage, Asian patients were less likely to receive this premedication (OR 0.65 CI [0.49, 0.86]). ConclusionsThis study supports previous work showing differential use of parental presence at induction based on race. Additionally, it also shows different treatment based on sex and public insurance status, a surrogate for socioeconomic status.

Measuring food insecurity among a national sample of children with recurrent acute otitis media

IntroductionAcute otitis media is one of the most common reasons for pediatric medical visits in the United States. Additionally, past studies have linked food insecurity and malnutrition with increased infections and worse health outcomes. However, there is a lack of information on the risk factors for food insecurity in specific patient populations, including the pediatric recurrent acute otitis media (RAOM) population. MethodsThe 2011 to 2018 National Health Interview Survey (NHIS) datasets were used to obtain a national estimate of the presentation of food insecurity within pediatric patients with RAOM. Relevant sociodemographic information and prevalence were identified. A multivariable logistic regression model was used to determine sociodemographic risk factors. Calculations were conducted using R with the “survey” package to account for the clustering and sampling of the NHIS. ResultsOf 3844 children with RAOM who responded to the food insecurity module, 20.8 % (19.0–22.6 %) were food insecure. Age, race/ethnicity, percentage of federal poverty level status, insurance status, and self-reported health status were significant and were not independent of food insecurity status. Using multivariable regression, this study found the following sociodemographic risk factors: age 6–10 and age > 10 (reference: age 0–2); Black (reference: Non-Hispanic White); 100 % to 200 % and <100 % federal poverty level (reference: >200 % federal poverty level); public insurance or uninsured status (reference: private insurance); and poor to fair self-reported health status (reference: good to excellent). DiscussionChildren with RAOM who were older, Black, less insured, living in lower-income households, and of poorer health had a greater association with being food insecure. Due to the frequency of RAOM pediatric visits, identifying at-risk groups as well as incorporating food insecurity screening and food referral programs within clinical practice can enable otolaryngologists to reduce disparities and improve outcomes in a targeted approach.

Prevalence and patterns of executive function, adaptive function, and behavioral outcomes in preschool and school age children with congenital diaphragmatic hernia

BackgroundExecutive function, adaptive function, and behavioral outcomes in congenital diaphragmatic hernia (CDH) survivors have not been well studied. AimTo evaluate executive and neurobehavioral dysfunction in preschool and early school-aged children with CDH. Study designRetrospective cohort study. SubjectsAll eligible CDH survivors ages 3 to 7 years enrolled in our follow-up program between February 2020 and February 2021. Outcome measuresThe Behavior Rating Inventory of Executive Function (BRIEF), the Adaptive Behavior Assessment System, 2nd Edition (ABAS-II), and the Child Behavior Checklist (CBCL) were used to assess functional and behavioral outcomes. Summary scores were compared to standard population norms. ResultsA total of 100 patients were enrolled during the study period. Of those, 73 parents completed at least one of the questionnaires, resulting in completion of the BRIEF, ABAS-II, and CBCL for 63, 68, and 63 patients, respectively. Preschool children had normal executive function (BRIEF-P) while global executive composite (P = 0.012) and the emotional regulation index (P = 0.010) for school age patients (BRIEF-2) were worse. CDH survivors had favorable adaptive functioning (ABAS-II). Mean CBCL scores for preschool attention problems (P = 0.018), school age attention problems (P = 0.001), and attention deficits hyperactivity problems (P = 0.027) were significantly worse. Prematurity, surrogate markers of disease severity, non-white race, and public insurance status were associated with worse neurobehavioral dysfunction in bivariable analysis. ConclusionsThe majority of preschool and school age CDH survivors have age-appropriate executive, adaptive and behavioral functioning. CDH survivors, however, have lower executive function and attention scores compared with the general population.

Acceptance of Routine Vaccines in Pregnancy during the COVID-19 Pandemic.

This study aimed to evaluate the rates of vaccination against infectious diseases (Tetanus, Diphtheria, and Pertussis [Tdap] and influenza) in pregnancy during the coronavirus disease 2019 (COVID-19) pandemic compared to contemporary historical controls. This was a retrospective cohort study comparing rates of Tdap and influenza vaccination in pregnant people who received care at NYU Langone Health and delivered from September 1, 2020, to January 31, 2021 ("COVID cohort") to the same period the prior year ("2019 cohort"). Demographic information, trimester of initiation of prenatal care, insurance status, and medical comorbidities were evaluated. Outcomes were analyzed using chi-square, Fisher's exact test, and multivariable logistic regression, with significance of p < 0.05. In total, 1,713 pregnant people were included. Compared to historical controls, the COVID cohort differed in age, race, timing of initiation of prenatal care, insurance status, and medical comorbidities. After adjusting for these covariates, pregnant people were significantly more likely to accept influenza vaccine in the COVID cohort (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.27-2.29) and had similar Tdap acceptance (aOR 1.5, 95% CI 0.99-2.17). However, this trend was not observed for the entire obstetric population; public insurance status and medical comorbidities were associated with lower vaccine rates during the pandemic. For those who had public insurance, rates of influenza vaccination decreased from 83% in 2019 to 40% during COVID (aOR 0.16, 95% CI 0.10-0.24) and for Tdap rates decreased from 93 to 54% (aOR 0.13, 95% CI 0.08-0.21). During the COVID-19 pandemic era, pregnant people at large were more likely to accept the influenza vaccine. However, this trend did not apply to Tdap, and high-risk groups with public insurance and medical comorbidities. This study highlights potential disparities in vaccination rates, which need to be accounted for when evaluating national vaccine trends. These data support increased efforts in vaccine counseling for high-risk populations. · Antenatal flu vaccination increased during the pandemic.. · Antenatal Tdap vaccination was unchanged during the pandemic.. · High-risk pregnant patients had decreased vaccine uptake.. · High-risk subgroups were not included in overarching vaccination trends..

Insurance status impacts survival of hepatocellular carcinoma patients after liver resection.

This study intends to examine the effect of public insurance status on survival outcomes of HCC patients after liver resection in China. We divided 2911 HCC patients after liver resection included in our study into the Urban Employed-based Medical Insurance group (UEBMI group, n = 1462) and the non-Urban Employed-based Medical Insurance group (non-UEBMI group, n = 1449). A propensity score matching (PSM) analysis was used to control confounding factors. Overall survival (OS) was estimated by Kaplan-Meier curves and Cox proportional hazard models based on variables screened by Lasso regression. Competing risk analysis was used to analyze cancer-specific survival (CSS). UEBMI group had more male patients (p = 0.031), patients in the UEBMI group were older (p < 0.001) and had lower Charlson Comorbidity Index scores (CCI score, p < 0.001). Meanwhile, patients in the UEBMI group had better liver function (albumin-bilirubin grade I [ALBI I], p < 0.001) and lower tumor burden (α-fetoprotein [AFP], p = 0.009; Barcelona Clinic Liver Cancer stage [BCLC], p = 0.026; Milan criteria, p < 0.001; tumor size, p < 0.001; microvascular invasion [MVI], p = 0.030; portal vein tumor thrombosis [PVTT], p = 0.002). More patients in the UEBMI group received laparoscopic surgery (p = 0.024) and adjuvant transarterial chemoembolization (TACE, p < 0.001). After PSM, patients in the two matched groups had similar characteristics. Patients with recurrent HCC in the UEBMI were more likely to receive curative therapy (p < 0.001) and less likely to receive supportive care (p < 0.001). HCC patients after liver resection in the non-UEBMI group had a worse OS before (p < 0.0001) and after PSM (p = 0.0031). In our Lasso-Cox risk regression model, public health insurance status was an independent factor linked with OS (non-UEBMI vs. UEBMI, hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 1.12-1.46; p < 0.001). In the competing risk analysis, patients in the UEBMI group had a lower cumulative incidence of CSS before (p < 0.001) and after PSM (p = 0.001), and public insurance status of HCC patients after liver resection remained independently associated with CSS (non-UEBMI vs. UEBMI; HR:1.36; 95% CI: 1.18-1.58; p < 0.001). Underinsured HCC patients after liver resection had worse survival outcomes. Less access to care for underinsured patients may explain the difference in survival, but the corresponding conclusions need to be further explored.

Expanding the use of patient-reported outcomes (PROs): Screening youth with type 1 diabetes from underrepresented populations

AimYouth from lower socioeconomic status (SES) have suboptimal type 1 diabetes (T1D) outcomes. Patient reported outcomes (PROs) measure psychosocial states and are associated with T1D outcomes, however are understudied in low SES youth. We aimed to evaluate associations between PROs and public insurance status, a proxy for low SES. MethodsWe analyzed survey data from 129 youth with T1D (age 15.7 ± 2.3 years, 33 % publicly insured) screened with PROMIS Global Health (PGH, measuring global health) and Patient Health Questionnaire (PHQ-9, measuring depressive symptoms) during diabetes appointments. Correlation and regression analyses evaluated differences in PGH and PHQ-9 by insurance status. ResultsFor youth with public insurance, lower global health correlated with lower self-monitoring blood glucose (SMBG; r = 0.38,p = 0.033) and older age (r = −0.45,p = 0.005). In youth with private insurance, lower global health correlated with lower SMBG (r = 0.27,p = 0.018) and female sex (rho = 0.26,p = 0.015). For youth with private insurance, higher depressive symptoms correlated with higher body mass index (r = 0.22,p = 0.03) and fewer SMBG (r = −0.35,p = 0.04). In multivariate regression analyses, public insurance was inversely associated with global health (p = 0.027). ConclusionPGH is a particularly salient PRO in youth with public insurance. Global health may be an important psychosocial factor to assess in youth with T1D from low SES backgrounds.

Abstract #1408299: National Trends in Incidence, Mortality, and Costs of Hypothyroidism in Patients Hospitalized with and Without Myxedema Coma in the United States

Myxedema coma (MC) is a syndrome of decompensated hypothyroidism with high mortality risk. But, because of its rarity, data regarding the demographics and outcomes of patients with MC are very limited. To address this gap, we perform an analysis of national data to determine the characteristics, mortality, and costs associated with MC or hypothyroidism without MC in hospitalization patients. A retrospective analysis using National Inpatient Sample database, a large public database of inpatient admissions to non-federal hospitals in the United States from 2016-2018, including patients ≥18 years of age with primary diagnosis of MC (ICD-10 E03.5) or hypothyroidism (E03.0-E03.9, E98.0) evaluating patient demographics, mortality, length of stay (LOS), and costs. Of 18,635 hospitalized patients with hypothyroidism, 2,495 (13.4%) had diagnosis of MC. Diagnosis with MC was associated with older patient age (p=0.02), public insurance (p=0.01), and unhoused status (p=0.04) vs patients without MC, while distribution of sex and ethnicity/race were similar between groups. More admissions with MC occurred in Winter compared to other seasons (p=0.01). Potential precipitating diagnoses associated with MC included septicemia, acute myocardial infarction, and adrenal insufficiency (p<0.001 for all), while medication nonadherence was not. During the years of 2016-2018, mean LOS ranged from 8.28-10.4 days for MC vs 4.36-4.86 days for patients without MC. Annual mortality rate for MC was 5.1-9.3% vs only 0.5%-0.9% for patients with hypothyroidism without MC. Finally, mean hospitalization costs during 2016-2018 varied from $86,511-$92,415 vs %34,025-%42,730 per admission for hypothyroid patients with and without MC, respectively. Myxedema coma diagnosis was significantly associated with cardiogenic shock, vasopressor use, acute heart failure, and acute respiratory failure (p<0.001 for all). National hospitalization data show that while only 13.5% of discharges with hypothyroidism had diagnosis of MC, patients hospitalized with diagnosis of myxedema coma have substantially higher mortality, LOS and costs. The diagnoses associated with myxedema coma may help clinicians identify patients with hypothyroidism at risk for MC and/or poor hospitalization outcomes.

Hospital Admissions in Pediatric Patients With Tracheostomies Based on Rurality and Insurance Status.

Determine whether rurality or public insurance status is associated with greater 30-day readmission after tracheostomy in pediatric patients. Retrospective cohort. Pediatric Health Information System (PHIS) Database. Patients within PHIS who underwent tracheostomy from 2013 to 2017 were included. Rural status was defined by rural-urban commuting area codes. Insurance status was based on the primary payer. All-cause 30-day readmissions and tracheostomy-related readmissions were recorded. Multivariate logistic regression was performed to test for differences in readmissions between cohorts. Among patients, 1092 were rural, and 4329 were publicly insured, with no significant association between rurality and insurance. Compared to nonrural patients, rural patients were more frequently white, less frequently ventilator dependent, and more likely discharged home rather than to a care facility. Publicly insured patients were more frequently non-white. Twenty-eight percent of patients were readmitted within 30 days of discharge. Odds of 30-day readmission were lower in rural patients (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.68-0.95, p = .01) but higher in publicly insured (OR: 1.24, 95% CI: 1.09-1.42, p = .001) controlling for age at tracheostomy, sex, race, and ventilator dependence. The odds of tracheostomy-related admission did not differ by rurality but were higher in publicly insured children (1.39, 95% CI: 1.03-1.88, p = .03). Readmission within 30 days following tracheostomy was more likely in publicly insured patients and less likely in rural patients. These findings help identify at-risk patients when considering discharge planning and follow-up. More work is needed to understand long-term tracheostomy outcomes in these groups.

Disparities in the prevalence of self-reported dysphagia and treatment among U.S. adults

ObjectiveTo assess sociodemographic differences in the prevalence of self-reported dysphagia and treatment and to identify barriers in access to care. Study designCross-sectional analysis. SettingNational healthcare survey database. MethodsThe 2012 National Health Interview Survey was used to analyze adults who reported a swallowing problem in the prior 12 months. Associations of sociodemographic variables with dysphagia prevalence and treatment as well as access to care were determined by multivariate logistic regression. ResultsAmong 235 million adults in the United States, 9.4 ± 0.3 million (4.0 % ± 0.1 %) adults (mean age 52.1 ± 0.6 years; 60.2 % female) reported swallowing problems, only 19.2 % ± 2.0 % of whom reported receiving treatment or therapy for their swallowing problem. In a multivariate model controlling for sociodemographic factors, female gender, older age, lower income level, public insurance status and unemployment were independently associated with increased odds of reporting dysphagia, while also associated with decreased odds of receiving treatment. Conversely, Black, Hispanic and other racial/ethnic minorities were less likely to report swallowing problems, but among those who did report dysphagia, non-white adults were more likely to receive treatment. Barriers leading to delayed care for women, low-income adults and adults with public or no health insurance included cost, not being able to get an appointment soon enough, limited office hours, inability to get through to an office by phone, lack of transportation, and long office wait times. ConclusionSociodemographic groups at higher risk for dysphagia are less likely to receive treatment. Targeted interventions are needed to address barriers to care. Level of evidenceIV.

A Clinical and Sociodemographic Risk Prediction Model Evaluating Adherence to Long-Term Care in Survivors of Childhood Leukemia

Background: Regular long-term follow-up care is important for surveillance and timely treatment of late effects after childhood leukemia therapy; however, structural barriers may disproportionately affect at-risk populations. Our objective was to evaluate factors associated with failure to utilize Long-Term Survivor (LTS) services following childhood leukemia treatment. Methods: We electronically extracted and manually curated electronic health records to identify childhood leukemia cases diagnosed between 2011 and 2014 at Texas Children's Cancer and Hematology Center. Individuals treated with a stem cell transplant, or those that transferred to an outside hospital, relapsed, or died within two years of end of treatment (EOT) were excluded. Address at the EOT was geocoded using ArcGIS to estimate travel time to the clinic and Area Deprivation Index, a composite measure of 17 neighborhood-level social determinants of health (SDOH). Multivariable logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between clinical factors and attending LTS Clinic. LTS Clinic attendance was defined as at least one visit with an LTS provider at any time following EOT. Predictive performance of the model was evaluated using area under the receiver operating characteristic curve (AUC-ROC). Results: We identified 249 survivors of childhood leukemia that were eligible for LTS care in the designated time frame. Most were male (55%), non-Latino white (27%), Latino (57%), or non-Latino Black (10%) and were diagnosed at a median age of 5.7 years (range: 0.6-20). Overall, 41 survivors (16.5%) never attended LTS clinic. These included 15 survivors (6.0%) that were seen for initial disease follow-up after EOT but had no further contact with the hospital system beginning 2 years after EOT. In adjusted models, older age at EOT was associated with a higher likelihood of never attending LTS clinic (p<0.001). For example, survivors age 15 years and older at EOT were 7.4-times more likely to never attend LTS clinic (95% CI: 1.95-28.24). Additionally, compared with privately insured survivors, those with public insurance (OR=4.09, 95% CI: 1.67-9.99) and those that were uninsured (OR=4.68, 95% CI: 0.69-31.52) were more likely to never attend LTS clinic. LTS clinic attendance was largely comparable regardless of diagnosis, treatment exposures, sex, primary household language, and race/ethnicity, although Latinos were less likely to never attend an LTS visit compared with non-Latino whites (OR=0.36, 95% CI: 0.14-0.94). These observed associations were also independent of estimated travel time and neighborhood-level SDOH. Clinical and demographic factors provided reasonable predictive performance (AUC-ROC: 0.733, 95% CI: 0.655-0.821), e.g., categorizing survivors on their predicted probability of never attending LTS clinic based on observed clinical and demographic factors correctly identified 63.4% of survivors who never attend LTS clinic in the upper tertile of the risk prediction distribution. Conclusions: Texas has the highest rates of uninsured children in the United States, comprising 12.7% of all children and 17.5% of Latino children living in the state (2019 American Community Survey data). Moreover, Medicaid eligibility in Texas is significantly limited for adults between the ages of 18 and 65 years. In this study, both older age at EOT and public insurance or uninsured status at EOT were strongly predictive of no documented LTS care among survivors of childhood leukemia, suggesting health insurance is major limiting factor to accessing survivorship services in Texas. Limiting predictive factors to race/ethnicity, age at EOT and payer status at EOT provides reasonable prediction of leukemia survivor that do not engage in LTS care (AUC-ROC: 0.711). Validation of a simple risk prediction model using information readily available in the electronic medical record at EOT may inform targeted interventions to augment access to survivorship services in this vulnerable population.