Patient Socioeconomic Characteristics Research Articles

Diagnostic process of cancer in a health system without gatekeeping: a single centre survey analysis.

It is essential to increase the rates of early diagnosis in cancer control, and the diagnostic process needs to be improved to achieve this goal. Previous studies showed that in countries where there is a gatekeeping system, there might be a delay in cancer diagnosis. Our aim is to examine the process of cancer diagnosis in a healthcare system without gatekeeping. A quantitative descriptive study has been conducted in various outpatient clinics of Pendik Training and Research Hospital, between 1 February and 31 May 2019, with individuals aged over 18 and diagnosed with cancer in the last six months. The data was collected through a questionnaire filled in by face-to-face interview method. Patient's socio-economic characteristics, their symptoms at the time of the diagnosis and the diagnosis process were questioned. The median diagnostic interval was 30 days (min-max 1-365), and the median patient interval was 60 (1-600) days. Patients pointed out that the diagnostic tests, especially the pathology reporting process, caused the diagnostic interval to be prolonged. Of the patients, 84% (n 135) stated that they did not consider their symptoms as a sign of serious illness. The patient interval was shortest with symptoms of haematuria and haematochezia and longest with dysuria and change in bladder habit. The study examined the diagnosis process in our health system, where patients can apply for health services at any stage. The results showed that there were no superior outcomes to those observed in primary care-led health systems. Patients reported that waiting times for medical tests led to prolongation of the diagnosis time. Cancer awareness of patients should also be increased to shorten patient admission times.

Demographic and socioeconomic characteristics of patients diagnosed with autism through the Rapid Interactive screening Test for Autism in Toddlers.

We evaluated the integration of the Rapid Interactive screening Test for Autism in Toddlers (RITA-T) model in a community, comparing autism spectrum disorder (ASD) toddlers' demographic and socioeconomic characteristics. Of 394 ASD toddlers, 323 were screened with RITA-T. Those screened were from more deprived areas, traveled farther and were diagnosed earlier. The model improved the diagnosis of ASD in underserved areas.

Malignant blue nevus: Epidemiology, socioeconomic factors, and disease presentation.

e21565 Background: Malignant blue nevus (MBN) is a rare and aggressive melanoma that arises in a blue nevus and tends to metastasize to the lymph nodes. Metastasis has been described in up to 55% of cases, and the 10-year survival rate is 51%. Current literature on MBN is limited. Data from the National Cancer Database (NCDB) on the demographic and socioeconomic characteristics of patients with MBN could provide insightful information regarding the epidemiology of this rare disease. Methods: The 2004-2020 NCDB was used to perform a retrospective cohort analysis of patients diagnosed with malignant blue nevus (N = 118) using ICD-O-3 code 8780/3. This study used descriptive statistics to analyze factors such as age, sex, income status, insurance status, Charlson-Deyo score, treatments, and survival rates. Results: A total of 118 patients diagnosed with MBN were recorded in the NCDB with an average age at diagnosis of 56.7 ± 17.2 years with a female preponderance (59%). Nearly all patients were insured (99%), mostly by private insurance (59%) or Medicare (27%). Over half of patients (54%) were enrolled in research programs, and 62% of patients comprised the top two income quartiles based on median household income. The vast majority of patients (81%) had no major comorbidities (Charlson-Deyo = 0). The top primary sites were the skin of the scalp and neck (36%) and the trunk (21%). The average tumor size was 21.2 ± 30.3 mm ranging from 2 mm-120 mm. The most frequent treatment performed was surgery, with 92% of patients undergoing surgical procedures of the primary site. Among these, the most common procedures were wide excision or re-excision (52%), excisional biopsy (14%), and shave biopsy followed by gross excision (10%). After resection, 77% of patients showed no residual tumor. In place of surgery, a smaller number of patients received alternate treatments as their main therapy, such as radiation therapy (11%), chemotherapy (6%), or immunotherapy (12%). The 2-year and 5-year survival rates were 88% and 68% respectively. Conclusions: Based on our literature review, this study is the first NCDB analysis on MBN and presents data from the largest cohort of patients to date. Patients with MBN are more likely to be female, and most lack major comorbidities. The most common sites are the scalp, neck, or trunk, in line with current literature. Review of socioeconomic factors revealed that an overwhelming majority of patients are likely to be insured and in the top two income quartiles. These findings could implicate that those who are more socioeconomically advantaged may have more resources for recognition of disease and proper diagnosis, especially considering the challenges of diagnosing MBN due to poorly defined histological criteria. Further research efforts should investigate the impacts of socioeconomic factors on diagnosis, treatments, and prognosis.

A Review of Socioeconomic Disparities in Submucous Cleft Diagnosis and Outcomes.

Submucous cleft palate (SMCP) is a common congenital anomaly characterized by a diastasis of the levator veli palitini muscle. The subtlety of SMCP on physical examination can contribute to diagnostic delays. This study aims to analyze the factors contributing to delays in care and subsequent postoperative outcomes in patients with SMCP. All patients with surgical indications for SMCP who underwent palatoplasty at an urban academic children's hospital were included. Patient socioeconomic characteristics, medical history, and postoperative outcomes were collected. Patients were compared based on insurance type and government assistance utilization. Statistical analyses including independent t-test, Wilcoxon ranked sum test, χ2 analyses, Fisher's exact test, and stepwise logistic regression were performed. Among the 105 patients with SMCP, 69.5% (n=73) had public insurance and 30.5% (n=32) private. Patients with public insurance were diagnosed later (5.5±4.6 versus 2.6±2.4 years old; p<0.001) and underwent palatoplasty later (7.3±4.1 versus 4.4±3.4 years old; p<0.001) than those with private insurance. Patients receiving government assistance experienced higher rates of post-surgical persistent velopharyngeal insufficiency (74.5% versus 44.8%; p=0.006). The authors' results suggest a disparity in the recognition and treatment of surgical SMCP. Hence, financially vulnerable populations may experience an increased risk of inferior speech outcomes and subsequent therapies and procedures.

Exploring disparities in surgical recommendations for patients with primary intramedullary spinal cord tumors: an analysis of the Surveillance, Epidemiology, and End Results database from 2000 to 2019.

Factors that may drive recommendations for operative intervention for patients with intramedullary spinal cord tumors (ISCTs) have yet to be extensively studied. The authors investigated racial and socioeconomic disparities in the management of patients with primary spinal cord ependymomas and nonependymal gliomas, with the aim of determining the associations between socioeconomic patient characteristics, survival, and recommendations for the resection of primary ISCTs. The Surveillance, Epidemiology, and End Results registry was queried to identify all patients > 18 years of age with ISCTs diagnosed between 2000 and 2019. Univariable and multivariable logistic regression analyses were used to calculate odds ratios for variables associated with receiving a surgical recommendation. Log-rank tests and multivariable Cox proportional hazards models were used to investigate overall survival (OS) and disease-specific survival (DSS). The authors identified 2325 patients (mean age 49 [SD 16] years; 48.8% female; 67.4% non-Hispanic White, 7.8% non-Hispanic Black, 16.2% Hispanic, 6.5% Asian/Pacific Islander, 0.6% Native American; 56.7% married; 64.4% with household income < $75,000; 73.8% with spinal ependymoma; and 26.2% with nonependymal spinal glioma). Eighty-seven percent of patients received a surgical recommendation. In multivariable models, marriage was associated with higher odds of receiving a surgical recommendation for ependymomas (OR 1.80, p = 0.005). In multivariable models for nonependymal spinal gliomas, older age (OR 0.98, p = 0.001) and increased number of tumors (OR 0.62, p = 0.015) were associated with decreased odds of receiving surgical recommendations. Among ependymomas, marriage (HR 0.59, p = 0.001), younger age (HR 0.93, p < 0.001), female sex (HR 0.43, p = 0.006), and decreased number of tumors (HR 0.56, p < 0.001) were associated with improved OS. Among nonependymal spinal gliomas, median household income ≥ $75,000 (HR 0.69, p = 0.020) and younger age (HR 0.98, p < 0.001) were associated with improved DSS, while Black race (HR 4.65, p = 0.027) and older age (HR 1.05, p < 0.001) were associated with worse OS. In patients with spinal ependymomas and nonependymal spinal gliomas, recommendations for surgery appear to be unaffected by patient sex, race, or income. Survival disparities appear to exist among unmarried, male, Black, and lower-income cohorts. Continued initiatives to identify drivers of disparities while improving health equity in this patient population are needed.

Psychosocial and socioeconomic factors are most predictive of health status in patients with claudication

BackgroundAs a key treatment goal for patients with symptomatic peripheral artery disease (PAD), improving health status has also become an important end point for clinical trials and performance-based care. An understanding of patient factors associated with 1-year PAD health status is lacking in patients with PAD. MethodsThe health status of 1073 consecutive patients with symptomatic PAD in the international multicenter PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry was measured at baseline and 1 year with the Peripheral Artery Questionnaire (PAQ). The association of 47 patient characteristics with 1-year PAQ scores was assessed using a random forest algorithm. Variables of clinical significance were retained and included in a hierarchical multivariable linear regression model predicting 1-year PAQ summary scores. ResultsThe mean age of patients was 67.7 ± 9.3 years, and 37% were female. Variables with the highest importance ranking in predicting 1-year PAQ summary score were baseline PAQ summary score, Patient Health Questionnaire-8 depression score, Generalized Anxiety Disorder-2 anxiety score, new onset symptom presentation, insurance status, current or prior diagnosis of depression, low social support, initial invasive treatment, duration of symptoms, and race. The addition of 19 clinical variables in an extended model marginally improved the explained variance in 1-year health status (from R2 0.312 to 0.335). ConclusionsPatients’ 1-year PAD-specific health status, as measured by the PAQ, can be predicted from 10 mostly psychosocial and socioeconomic patient characteristics including depression, anxiety, insurance status, social support, and symptoms. These characteristics should be validated and tested in other PAD cohorts so that this model can inform risk adjustment and prediction of PAD health status in comparative effectiveness research and performance-based care.

Survival and treatment in older patients with ewing sarcoma: an analysis of the national cancer database

BackgroundEwing sarcoma (EWS) is a malignancy which primarily arises in adolescence and has been studied extensively in this population. Much less is known about the rare patient cohort over the age of 40 at diagnosis. In this study, we describe the survival outcomes and clinical characteristics of this population.MethodsThis retrospective cohort study utilized the National Cancer Database (NCDB) to identify 4600 patients diagnosed between 2004 through 2019. Of these patients, 4058 were under the age of 40 and 542 were over 40. Propensity score 1:1 matching was performed according to sex and race. Univariate and multivariate logistic regression was performed to generate odds ratios (OR) and a Multivariate Cox regression model was used to generate a hazard ratio (HR) for patients over 40. Kaplan–Meier curves were used to estimate survival from diagnosis to death between age groups. Chi-square tests were used to compare demographic and socioeconomic patient characteristics. IBM statistics version 27.0 was used. p < 0.05 was used to indicate statistical significance.ResultsEWS patients older than 40 experienced worse survival outcomes compared to patients under the age of 40. 5-year survival was 44.6% for older patients vs. 61.8% for younger patients (p < 0.05). A multivariate Cox proportional hazards model showed that age was independently associated with inferior survival. (HR 1.96; p < 0.05). EWS patients over the age of 40 were more likely to have tumors originating from the vertebral column (16.1% vs 8.9%; p < 0.05) and cranium (5.3% vs. 2.9%; p < 0.05) and had a higher rate of axial tumors (31.6% vs. 18.5%; p < 0.05) compared to patients under 40. Additionally, patients older than 40 experienced a significantly longer delay between the date of diagnosis and initiation of systemic treatment (36.7 days vs. 24.8 days; p < 0.05) and were less likely to receive adjuvant chemotherapy (93.4% vs. 97.9%; p < 0.05).ConclusionAn age over 40 is associated with decreased survival for patients with EWS. Due to the rarity of EWS in this cohort, the optimal role of systemic treatment remains unknown and has yet to be clearly elucidated. Consequently, our findings suggest that older patients receive disparities in treatment which may be contributing to decreased survival rates.

Abstract A128: A novel approach to understanding disparities in cancer clinical trial enrollment

Abstract Background: Cancer patients who participate in clinical trials have access to novel therapies, increased monitoring, and potentially improved survival. However, this access is not universal. Striking disparities in clinical trial enrollment have been linked to race, sex, and geography. However, studies on this topic are limited due to a lack of patient-specific socioeconomic data. Methods: This analysis used a novel linkage of administrative patient data from University Hospitals Seidman Cancer Center (Cleveland, Ohio) linked to the LexisNexis Socioeconomic Health Attributes, a robust dataset containing 442 patient-specific attributes gathered from public records regarding income, education, housing stability, property ownership and value, social support, and many others. We included cancer patients aged 18-75 years at the time of the latest cancer diagnosis (before trial enrollment if patient was enrolled) during 2007-2022. Because of the substantial differences in the demographic and clinical characteristics between the trial and non-trial patients, we applied the propensity score matching technique to one-to-one match all trial patients to non-trial patients by age, sex, race/ethnicity, cancer type, and year of the latest cancer diagnosis. Next, we applied the classification and regression tree (CART) machine learning algorithm to identify “phenotypes”, or combinations of patient socioeconomic characteristics that predict their trial enrollment status. We additionally performed the random forest algorithm to determine whether our CART model captured the most important variables in predicting trial enrollment. Results: We identified 28,671 cancer patients with a mean and median age of 60 and 62 years. Of those, 2,479 patients were enrolled in trials, and a corresponding 2,479 non-trial patients were matched. We identified 9 phenotypes of trial enrollment from the results of CART. The percentage of patients enrolled in trials ranges from 30% to 80%. Patients belonging to the highest-enrollment phenotype were identified by their estimated annual income exceeding $50,000, higher fraud-risk level, and age under 61 years. Patients falling into the lowest-enrollment phenotype were characterized by an estimated annual income below $30,000, an estimated home value below $243,000, and no college attendance. Variables identified by CART were also among the top-ranked variables in the random forest regarding their variable. Other important variables identified by random forest include, whether the patient ever registered to vote, risk of not being motivated to manage one's own health, and business records. Conclusion: Compared to community-level data, the use of patient-specific socioeconomic data provides a more granular understanding of clinical trial disparities. The use of machine learning methods of CART and random forest offers a promising avenue for future disparities research. This novel approach will deepen our understanding of cancer disparities and improve our ability to intervene and improve care for our most vulnerable patients. Citation Format: Weichuan Dong, Jamie Shoag, Tamila Kindwall-Keller, Ali Kara, John Shanahan, Debora Bruno, Johnie Rose, Siran Koroukian, Richard Hoehn. A novel approach to understanding disparities in cancer clinical trial enrollment [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A128.

Socio-economic disparities influence likelihood of post-operative radiation to resection cavities of metastatic brain tumors.

Irradiating the surgical bed of resected brain metastases improves local and distant disease control. Over time, stereotactic radiosurgery (SRS) has replaced whole brain radiotherapy (WBRT) as the treatment standard of care because it minimizes long-term damage to neuro-cognition. Despite this data and growing adoption, socio-economic disparities in clinical access can result in sub-standard care for some patient populations. We aimed to analyze the clinical and socio-economic characteristics of patients who did not receive radiation after surgical resection of brain metastasis. Our sample was obtained from Clinformatics® Data Mart Database and included all patients from 2004 to 2021 who did or did not receive radiation treatment within sixty days after resection of tumors metastatic to the brain. Regression analysis was done to identify factors responsible for loss to adjuvant radiation treatment. Of 8362 patients identified who had undergone craniotomy for resection of metastatic brain tumors, 3430 (41%) patients did not receive any radiation treatment. Compared to patients who did receive some form of radiation treatment (SRS or WBRT), patients who did not get any form of radiation were more likely to be older (p = 0.0189) and non-white (p = 0.008). Patients with Elixhauser Comorbidity Index ≥3 were less likely to receive radiation treatment (p < 0.01). Fewer patients with household income ≥ $75,000 did not receive radiation treatment (p < 0.01). Age, race, household income, and comorbidity status were associated with differential likelihood to receive post-operative radiation treatment.

Social portrait and features of the medical behavior of consumers of medical services in the Moscow region health system: A medico-sociological study

BACKGROUND: The healthcare system is the most important social institution affecting the life of each member of Russian society. To improve the organization of the provision of medical care to citizens in the context of long-term program-oriented strategic planning for health development in the region, it is necessary to take into account the interests, expectations, and requests of patients (as consumers of medical services) regarding the quality of medical care, staffing, and the material, technical, and technological equipment of medical organizations.&#x0D; AIM: Construction of a social portrait of consumers of medical services of the healthcare system of the Moscow region, taking into account the socio-demographic and socioeconomic characteristics of patients and the salient characteristics of their medical behavior.&#x0D; MATERIALS AND METHODS: The study (a questionnaire survey of 531 patients) was conducted in FebruaryMay 2022 based on the Moscow Regional Research Clinical Institute named after M.F. Vladimirsky. The subject of the study was consumers of medical services at the institute at the age of 18 years, permanently residing in the Moscow region. The survey participants were recruited based on the calculated selective population, with quotas by sex and age. The thematic sections of the questionnaire focused on the study of the level of satisfaction of respondents with the medical services received, the characteristics of their medical behavior and attitudes to their health, and the analysis of the main socio-demographic characteristics of patients (gender, age, social and family status, education, and financial situation).&#x0D; RESULTS: The study, conducted among residents of the Moscow region, made it possible to determine their attitude to their health, the level of satisfaction with the medical service received, features of medical behavior, and experience of interaction with medical workers (primarily doctors), including conflict situations. It has been established that among patients, a positive assessment of the quality of the medical services they receive prevails, most of them prefer to receive information about diseases, methods of treatment, and drugs from medical professionals, and they tend to trust doctors and comply with their prescriptions. When patients experience conflict situations, this most often happens with registry workers and is mainly due to the difficulty of getting an appointment with a doctor.&#x0D; CONCLUSION: The study identified the most characteristic features of medical behavior and described a social portrait of a typical consumer of medical services in the Moscow region.

Access and Financial Burden for Patients Seeking Essential Surgical Care in Pakistan.

Pakistan is a lower middle-income country in South Asia with a population of over 220 million. With the recent development of national health programs focusing on surgical care, two areas of high priority for research and policy are access and financial risk protection related to surgery. This is the first study in Pakistan to nationally assess geographic access and expenditures for patients undergoing surgery. This is a cross-sectional study of patients undergoing laparotomy, cesarean section, and surgical management of a fracture at public tertiary care hospitals across the country. A validated financial risk protection tool was adapted for our study to collect data on the socio-economic characteristics of patients, geographic access, and out-of-pocket expenditure. A total of 526 patients were surveyed at 13 public hospitals. 73.8% of patients had 2-hour access to the facility where they underwent their respective surgical procedures. A majority (53%) of patients were poor at baseline, and 79.5% and 70.3% of patients experienced catastrophic health expenditure and impoverishing health expenditure, respectively. A substantial number of patients face long travel times to access essential surgical care and face a high percentage of impoverishing health expenditure and catastrophic health expenditure during this process. This study provides valuable baseline data to health policymakers for reform efforts that are underway. Strengthening surgical infrastructure and services in the existing network of public sector first-level facilities has the potential to dramatically improve emergency and essential surgical care across the country.

Differences in Surgery Classification and Indications for Peripartum Hysterectomy at a Major Academic Institution.

Peripartum hysterectomy is associated with increased morbidity and mortality relative to elective gynecologic hysterectomy and its incidence has grown with the rising cesarean delivery rate. We sought to understand indications and perioperative outcomes for peripartum hysterectomy at our academic institution and to evaluate differences among racial/ethnic groups. We performed a retrospective chart review of women at a tertiary care center who underwent delivery of a newborn and had a peripartum hysterectomy during the same admission between 2008 and 2018. Demographic, clinical, and socioeconomic characteristics of patients were compared with respect to patient's race/ethnic group. A total of 112 hysterectomies were included in our study. White women undergoing peripartum hysterectomy were more likely to have had an elective/anticipated peripartum hysterectomy (vs. a nonelective/emergent peripartum hysterectomy) than Black women. There were racial differences detected in the indication for peripartum hysterectomy; White women were more likely to have abnormal placentation (75 vs. 54% in Black women, p = 0.036), whereas Black women were more likely to present with postpartum hemorrhage (27 vs. 2%, p = 0.002). Black women were also more likely to undergo reoperation after peripartum hysterectomy (15 vs. 2% in White women, p = 0.048). There were no differences in any other perioperative outcomes including blood transfusion, accidental laceration, and 30-day readmission. Differences exist among elective versus nonelective peripartum hysterectomy by race/ethnicity and in indications for peripartum hysterectomy by race/ethnicity. Further investigation should be performed to determine whether the differences identified are due to disparate management of atony/postpartum hemorrhage or inequitable referral patterns for suspected abnormal placentation by race/ethnicity. · White patients were more likely to have an elective hysterectomy when compared with Black women.. · Abnormal placentation was the indication more often for White patients; hemorrhage for Black ones.. · Black patients were likely to be nulliparous or at greater gestational age at the time of hysterectomy..

Establishment of a qualified integrated care system after total knee arthroplasty as a role of regional rheumatoid and degenerative arthritis centers

BackgroundThe geriatric population and advanced knee osteoarthritis are rapidly increasing in Korea, and the socioeconomic burden of total knee arthroplasty (TKA) is increasing. This study aimed to analyze the demographic, clinical and socioeconomic characteristics of patients who underwent TKA and to differentiate the factors affecting participation in inpatient-intensive rehabilitation programs after TKA in the Jeju regional rheumatoid and degenerative arthritis center established by the government.MethodsThis retrospective cohort study included 845 patients (735 females; 72.0 ± 5.8 years) diagnosed with primary osteoarthritis (OA) of the knee who underwent elective unilateral primary TKA between January 2013 and June 2016. Demographic, clinical, and socioeconomic characteristics, including age, body mass index, obesity, length of stay, OA severity, underlying disease, education level, occupation, and location of residence were reviewed. Patients were allocated to the TKA-only group (home discharge) and to the TKA + rehab group (participation in post-TKA rehabilitation). The variables were analyzed and compared before and after the establishment of the center and according to participation in intensive rehabilitation.ResultsPatients who underwent TKA were mostly female, in the 60 s, and had a high prevalence of comorbidities and obesity. After the rehabilitation center's establishment, the intensive post-TKA participation increased profoundly from 3% to 59.2%. Participants after the center establishment had lower mean BMI and a higher proportion of K-L grade 4 compared to those before the center establishment. The location of residence was the only factor differentiating the participation in the intensive rehabilitation.ConclusionThe regional rheumatoid and degenerative arthritis center was appropriate to satisfy the high unmet need for participating in the intensive rehabilitation after TKA and to execute the qualified integrated post-TKA care system. Policy support should ensure the early rehabilitation and a qualified integrated care system and prepare for the increased burden of revision. Future longitudinal studies should be conducted to assess the long-term effect of the integrated post-TKA rehabilitation program on functional outcomes and patient survivorship free from revision.

Diagnostic Delays and Psychosocial Outcomes of Childhood-Onset Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that manifests in affected individuals with a variety of clinical features and involves multiple organs. Despite recent advances over the past decades, higher morbidity and mortality have been reported by studies in patients with childhood-onset systemic lupus erythematosus (cSLE) compared to patients with adult-onset. The interplay of several factors can cause diagnostic delays resulting in worse disease activity, multiple organ damage, increased risk of hospitalization, and management with aggressive treatment. Significant factors include demographic, clinical, and socioeconomic characteristics of patients with cSLE. Moreover, despite recent advances in lupus treatment, prolonged disease duration in these young patients can result in debilitating psychosocial outcomes and can significantly impact their health-related and general quality of life (QOL). Important domains affected include patient self-esteem, education, employment, healthcare utilization, and mental health. In this review, we examined the barriers that lead to a delay in diagnosing lupus in the pediatric population and addressed cSLE morbimortality and its long-term impact on patient health-related and general QOL.

The Association of Socioeconomic Factors With Percutaneous Coronary Intervention Outcomes.

Numerous studies have identified the association of socioeconomic factors with outcomes of cardiac surgical procedures. Most have focused on easily measured demographic factors or on socioeconomic characteristics of patients' 5-digit zip codes. The impact of socioeconomic information that is derived from smaller geographic regions has rarely been studied. The association of the Area Deprivation Index (ADI) with short-term mortality and readmissions was tested for patients undergoing percutaneous coronary intervention (PCI) in New York whileadjusting for numerous patient risk factors, including race, ethnicity, and payer. Changes in hospitals' risk-adjusted outcomes and outlier status with the addition of socioeconomic factors were examined. After adjustment, patients in the 2 most deprived ADI quintiles were more likely to experience in-hospital and 30-day mortality after PCI (adjusted odds ratios [95% confidence intervals] 1.39 [1.18-1.65] and 1.24 [1.03-1.49], respectively), than patients in the first quintile (least deprived). Also, patients in the second and fifth ADI quintiles had higher 30-day readmissions rates than patients in the first quintile (1.12 [1.01-1.25] and 1.17 [1.04-1.32], respectively). Medicare patients had higher mortality and readmission rates, Hispanics had lower mortality, and Medicaid patients had higher readmission rates. Patients with the most deprived ADIs are more likely to experience short-term mortality and readmissions after PCI. Ethnicity and payer are significantly associated with adverse outcomes even after adjusting for ADI. This information should be considered when identifying patients who are at the highest risk for adverse events after PCI and when risk-adjusting hospital outcomes and assessing quality of care.

The Association of Socioeconomic Factors With Outcomes for Coronary Artery Bypass Surgery

BackgroundNumerous studies have identified the associations of socioeconomic factors with outcomes of cardiac procedures. The majority have focused on easily measured factors like sex, race, and insurance status, or on socioeconomic characteristics of patients’ 5-digit zip codes. The impact of more granular census-derived socioeconomic information on outcomes has rarely been studied. MethodsThe independent impact of the Area Deprivation Index (ADI) on short-term mortality and readmissions was tested on patients undergoing isolated coronary artery bypass grafting (CABG) surgery in New York by using it in logistic regression models in conjunction with patient risk factors and typical disparities measures (race, ethnicity, payer). Changes in hospitals’ risk-adjusted outcomes and outlier status with the addition of socioeconomic measures were also tested. ResultsAfter adjusting for numerous patient characteristics, patients in the fourth and fifth highest ADI quintiles (most deprived) were more likely to experience in-hospital/30-day mortality after CABG surgery (adjusted odds ratio [AOR] 1.54, 95% confidence interval [CI] 1.08, 2.20; and AOR 1.50, 95% CI 1.02, 2.21), respectively. ADI was not associated with readmissions, but African Americans (AOR 1.49, 95% CI 1.18, 1.87), Hispanics (AOR 1.33, 95% CI 1.06, 1.65) and Medicaid patients (AOR 1.34, 95% CI 1.09, 1.64) were more likely to be readmitted. ConclusionsPatients with high ADIs are more likely to experience short-term mortality after CABG surgery. African Americans, Hispanics, and Medicaid patients are more likely to experience 30-day readmissions. This information should be taken into account when monitoring patients to reduce adverse events following surgery, and more studies related to ADI are needed to fully understand its implications.

Association of Race, Ethnicity, Age and Socioeconomic Status with Access to Virtual Visits within the Brigham & Women's Hospital Division of Hematology during the COVID-19 Pandemic

Background: The COVID-19 pandemic prompted an expedited shift towards expanding telemedicine services. Historically, telemedicine has been shown to increase healthcare access for those in rural communities but widen care gaps for other vulnerable populations by exacerbating existing digital divides and clinician biases in offering telemedicine services. The purpose of this study is to understand the demographic and socioeconomic characteristics of patients completing telephone, video, and in-person visits at the Brigham and Women's Hospital Division of Hematology (BWH DOH) during the COVID-19 pandemic.Methods: This was a retrospective chart review of patients who completed clinical encounters within the BWH DOH between March 19, 2020, when the division switched to virtual visits, and December 31 st, 2020 (pandemic). Patients who completed visits between January 1, 2019 and March 18, 2020 (pre-pandemic) served as a comparator group. Differences in socio-demographic composition of patients completing telephone only (TO), video only (VO), or a mix of in-person and telemedicine visits (IPTM) were tested for significance using Kruskal-Wallis and Chi-square tests.Results: A total of 8307 pre-pandemic visits and 5910 pandemic visits were included in analysis. Almost all visits (99.8%) were in-person pre-pandemic compared to 32.4% in-person, 42.6% by telephone, and 25% by video during pandemic. Median age was significantly different between patients who had only pre-pandemic visits, only pandemic visits, and both (55 vs 52 vs 58 years; p=0.003). Otherwise, there was no significant difference in racial and median income distributions pre-pandemic to pandemic. Table 1 shows the socio-demographic characteristics of patients who completed TO (1536), VO (1065), or IPTM (1518) visits during the pandemic. VO patients were significantly younger than TO and IPTM patients (p<0.001). The majority of patients identified as White (61.3%) with Black and Hispanic patients accounting for 13.8% and 11.4% of the pandemic population, respectively. A higher proportion of White patients had VO visits (29.9%) compared to Black (15.2%) and Hispanic patients (13%) who both had a higher proportion of TO visits (34.7% vs 40.4% vs 50.9%, p<0.001). More patients with a college (29.9%) or post-graduate (34.3%) degree had VO visits than patients with a high school (16.3%) or other levels of education (21.5%) who were more likely to have TO visits (p<0.001). Median household incomes approximated from patient zip codes were significantly higher in patients with VO visits than those with TO or IPTM visits (p<0.001).Discussion: This study shows that during the COVID-19 pandemic, there were significant differences in the socio-demographic composition of patients completing VO versus TO versus IPTM visits within the BWH DOH. Overall, individuals from groups that historically experience health inequities in the United States including the elderly, African Americans, Hispanics, and those with lower educational levels and socioeconomic status had fewer VO visits and more TO visits compared to patients who were younger, White, and had higher levels of education and socioeconomic status. These differences have important implications as VO visits may offer better clinical interaction when compared to TO visits. The younger age of patients seen during the pandemic compared to pre-pandemic suggests that some older adults lost access to hematology care altogether during the pandemic. This disparity pre-pandemic to pandemic was not observed in other demographic subsets. Our work reveals a need to focus on digital inclusion efforts centered around device access, internet access, and digital literacy. Additionally, while TO and VO visits are temporarily equally reimbursed as in person visits under the U.S government's COVID emergency declaration, there has already been a return to markedly lower reimbursement for TO visits. Many practices and hospital system have lost significant revenue due to the pandemic and this differential reimbursement may disincentivize providing care through TO, even if that is the patient's only means of access. This could pose as a further barrier to telemedicine access for individuals from vulnerable populations and exacerbate structural racism, ageism, and other inequities. Care must be taken moving forward that actions to cope with the pandemic or modernize health care serve all patients. [Display omitted] DisclosuresNeuberg: Pharmacyclics: Research Funding; Madrigal Pharmaceuticals: Other: Stock ownership. Achebe: Fulcrum Therapeutics: Consultancy; Pharmacosmos: Membership on an entity's Board of Directors or advisory committees; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees.

Socioeconomic and Geographic Characteristics of Hospitals Establishing Transcatheter Aortic Valve Replacement Programs, 2012-2018.

Despite the benefits of novel therapeutics, inequitable diffusion of new technologies may generate disparities. We examined the growth of transcatheter aortic valve replacement (TAVR) in the United States to understand the characteristics of hospitals that developed TAVR programs and the socioeconomic status of patients these hospitals served. We identified fee-for-service Medicare beneficiaries aged 66 years or older who underwent TAVR between January 1, 2012, and December 31, 2018, and hospitals that developed TAVR programs (defined as performing ≥10 TAVRs over the study period). We used linear regression models to compare socioeconomic characteristics of patients treated at hospitals that did and did not establish TAVR programs and described the association between core-based statistical area level markers of socioeconomic status and TAVR rates. Between 2012 and 2018, 583 hospitals developed new TAVR programs, including 572 (98.1%) in metropolitan areas, and 293 (50.3%) in metropolitan areas with preexisting TAVR programs. Compared with hospitals that did not start TAVR programs, hospitals that did start TAVR programs treated fewer patients with dual eligibility for Medicaid (difference of -2.83% [95% CI, -3.78% to -1.89%], P≤0.01), higher median household incomes (difference $2447 [95% CI, $1348-$3547], P=0.03), and from areas with lower distressed communities index scores (difference -4.02 units [95% CI, -5.43 to -2.61], P≤0.01). After adjusting for the age, clinical comorbidities, race and ethnicity and socioeconomic status, areas with TAVR programs had higher rates of TAVR and TAVR rates per 100 000 Medicare beneficiaries were higher in core-based statistical areas with fewer dual eligible patients, higher median income, and lower distressed communities index scores. During the initial growth phase of TAVR programs in the United States, hospitals serving wealthier patients were more likely to start programs. This pattern of growth has led to inequities in the dispersion of TAVR, with lower rates in poorer communities.

30 Characteristics of Patients Restrained in the Emergency Department and Evaluation for Disparities in Care

Physical restraints are occasionally used in the emergency department (ED) to manage acute agitation to prevent self-harm and to protect staff, with a reported frequency of 0.5-1.4%. There is limited information comparing the demographic factors associated with the use of restraints for behavioral versus medical indications. Prior studies have also identified an association between socioeconomic and demographic factors and the use physical restraints, raising concern for the presence of implicit bias. The objective of this study was to identify the socioeconomic and demographic characteristics of patients placed in physical restraints for behavioral versus medical indications and to assess the variables that may increase the risk of patients being placed in restraints specifically for behavior indications. A cross sectional study of adult ED patients at a Level 1 Trauma tertiary academic medical center during March 2019 through February 2021 was performed to identify patients placed in physical restraints for medical or behavioral indications. Comparisons between behavioral and medical restraint groups were assessed using the t- test (for age) and the Fisher exact test (for sex, race, ethnicity, emergency severity index (ESI), insurance status, time of arrival, age over 50, psychiatric admission, and medical admission). Factors associated with behavioral restraint use compared to medical restraint use were assessed by a multivariable logistic regression analysis. Odds ratio (OR) and their 95% confidence intervals were reported. A two-sided 0.05 significance level was used throughout. SAS versions 9.4 (SAS Institute, Cary, North Carolina) software was utilized for statistical analysis. Among the 172, 708 ED visits during the study period, 1, 165 (0.67%) involved the use of restraints. Behavioral restraints were applied in 612 patients (53.5%) and medical restraints in 553 (47.5%). Overall physical restraint use was similar between white and non-white patients (0.74% and 0.71% respectively, Fisher Exact OR 1.04, p=0.55). However, significant differences were found among age, sex, race, ESI, insurance status, psychiatric and medically hospitalized patients in further analysis between the behavioral and medical restraint groups (p<0.0001). Factors that were identified as significantly increasing the risk of receiving behavioral restraints in particular included male sex, insurance and race; the c-statistics for the logistic model was 0.864. The demographic and socioeconomic characteristics of patients placed in restraints for medical indications are different than those placed in restraints for behavioral indications. Although race was identified as a factor increasing the risk for behavioral restraints use in the ED, the overall use of physical restraints was similar in white versus non-white patients suggesting against the presence of implicit bias against non-white patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Ambulatory Care Sensitive Conditions in Pediatrics: Time for a Reassessment.

Ambulatory Care Sensitive Conditions in Pediatrics: Time for a Reassessment.