United States Census Region Research Articles

Industry Payments to Adult Reconstruction-Trained Orthopedic Surgeons: An Analysis of the Open Payments Database From 2014 to 2019.

In recent time, there has been an increased push toward transparency in industry funding toward physicians. The Physician Payments Sunshine Act called for the creation of the Open Payments Database managed by the Centers for Medicare & Medicaid Services. To our knowledge, there have been no studies evaluating the trends in payments among adult reconstruction fellowship-trained orthopedic surgeons. The purpose of this study is to investigate trends in all payments to adult reconstruction-trained orthopedic surgeons from 2014 to 2019. Secondary outcomes included evaluating trends in yearly subpayment categories, regional variations, as well as characterizing the top 5 industry companies. A review of the Centers for Medicare & Medicaid Services Open Payments Database was performed to identify all payments to adult reconstruction-trained orthopedic surgeons. A total of 94,265 payments were made to 4911 surgeons accounting for a total of $258,865,231.20 during the study period. Our primary outcome was to assess the trend in median payment per year to individual surgeons. Secondary outcomes included evaluating payment trends with respect to subtype, location as defined by United States Census regions, as well as specifics concerning the top 5 companies. Over the study period, there was a nonsignificant increasing trend in median payment per surgeon (r= 0.49, P= .096). However, there was also a significantly increasing trend in the number of payments per year (r= 0.83, P= .014), as well as the number of surgeons receiving payments (r= 0.88, P= .019). With respect to subcategory payments, there were significantly increasing trends in the median payment per surgeon for education (1054%, r= 0.942, P < .001) and entertainment/food and beverage expenses (20.2%, r= 0.49, P= .020), as well as a significantly decreasing trend for median honoraria payments per surgeon (20.2%, r=-0.04, P= .005). No significant regional trends were identified. Of the top 5 companies, one demonstrated a significantly decreasing trend in median payment per surgeon (21.6%, r=-0.109, P < .001), whereas the others remained unchanged. In this study, we found a nonsignificant increasing trend in payments to adult reconstruction-trained surgeons as well as an increasing number of surgeons receiving payments. There were increasing trends in median payment per surgeon for education and entertainment expenses, but a decreasing trend for honoraria payments. No significant regional trends were identified. The majority of the top 5 companies had nonsignificant trends in their payments. Further studies are needed to characterize the disclosure of payments and the impact of industry payments on clinical outcomes. IV.

HPV-Associated Anal Cancer Knowledge, Attitudes, and Health Communication Behaviors Among Non-clinical Providers at HIV/AIDS Service Organizations in Southern United States Region.

Co-infection with HIV/HPV and bio-behavioral risk factors (e.g., immunodeficiency, un-protected sex) increase likelihood for developing anal and other HPV-associated cancers among people living with HIV/AIDS (PLWHA). We explored knowledge, attitudes, and health communication regarding HPV-associated anal cancers among HIV/AIDS service organization (ASO) employees/volunteers delivering non-clinical services to PLWHA. Participants (n=59) were recruited from six ASOs located in the South United States Census region and completed a 118-item self-administered survey. For current analyses, outcome measures were knowledge, attitudes, and health communication regarding anal cancer. Descriptive statistics assessed outcome measures which were subsequently dichotomized into binary variables (i.e., high/favorable or low/unfavorable). Fisher's exact test examined associations between outcome measures and ASO employees/volunteers' sex/sexual orientation (i.e., heterosexual female, heterosexual male, LGBTI female, LGBTI male). Mean age for ASO employees/volunteers was 45.5 years (±13.5 SD). Participants were heterosexual females (45.7%), LGBTI males (27.3%), heterosexual males (13.5%), and LGBTI females (13.5%). Almost half (44.8%) had not heard about anal Pap screening and 39.0% did not think HPV can cause anal cancer. Overall, 73.9% had low knowledge scores. Participants (47.4%) were unsure or believed HPV vaccinations were non-protective against anal cancer while 94.9% had favorable health communication behaviors. Knowledge regarding anal cancer being linked to HPV (p=0.006) and health information seeking on anal cancer (p=0.000) were statistically significantly different by sex/sexual orientation. Fostering increased knowledge, favorable attitudes, and improved health communication behaviors among ASO employees/volunteers could facilitate dissemination and promotion of anal cancer prevention strategies (anal Pap screenings, HPV vaccinations) among PLWHA.

Antimicrobial Resistance Trends in Urine Escherichia coli Isolates From Adult and Adolescent Females in the United States From 2011 to 2019: Rising ESBL Strains and Impact on Patient Management.

BackgroundUncomplicated urinary tract infection (uUTI) is predominantly caused by Escherichia coli, which has increasing antimicrobial resistance (AMR) at the United States (US)-community level. As uUTI is often treated empirically, assessing AMR is challenging, and there are limited contemporary data characterizing period prevalence in the US.MethodsThis was a retrospective study of AMR using Becton, Dickinson and Company Insights Research Database (Franklin Lakes, New Jersey, US) data collected 2011–2019. Thirty-day, nonduplicate Escherichia coli urine isolates from US female outpatients (aged ≥12 years) were included. Isolates were evaluated for nonsusceptibility (intermediate/resistant) to trimethoprim-sulfamethoxazole, fluoroquinolones, or nitrofurantoin, and assessed for extended-spectrum β-lactamase production (ESBL+) and for ≥2 or ≥3 drug-resistance phenotypes. Generalized estimating equations were used to model AMR trends over time and by US census region.ResultsAmong 1 513 882 E. coli isolates, the overall prevalence of isolates nonsusceptible to trimethoprim-sulfamethoxazole, fluoroquinolones, and nitrofurantoin was 25.4%, 21.1%, and 3.8%, respectively. Among the isolates, 6.4% were ESBL+, 14.4% had ≥2 drug-resistance phenotypes, and 3.8% had ≥3. Modeling demonstrated a relative average yearly increase of 7.7% (95% confidence interval [CI], 7.2–8.2%) for ESBL+ isolates and 2.7% (95% CI, 2.2–3.2%) for ≥3 drug-phenotypes (both P < .0001). Modeling also demonstrated significant variation in AMR prevalence between US census regions (P < .001).ConclusionsPeriod prevalence of AMR among US outpatient urine-isolated E. coli was high, and for multidrug-resistance phenotypes increased during the study period with significant variation between census regions. Knowledge of regional AMR rates helps inform empiric treatment of community-onset uUTI and highlights the AMR burden to physicians.

Geographic access to brachytherapy services in the United States

PURPOSEDisparities in geographic access to medical care exist in nearly all fields of medicine including radiation oncology. We aim to update knowledge of the geographic distribution of radiation oncologists in the United States. METHODS AND MATERIALSWe used the Physician and Other Supplier Public Use File (PUF) from the Centers for Medicare & Medicaid Services (CMS) as well as the International Atomic Energy Agency (IAEA) Directory of Radiotherapy Centers (DIRAC) database to identify practices that either coded for or are marked as having access to brachytherapy services. Geographic analysis was performed on several levels including United States (US) Census region, Dartmouth Atlas Healthcare Referral Region, and the county level. RESULTSWe identified 327 providers that billed for a brachytherapy code during the calendar year 2018 and 564 facilities providing brachytherapy. Within the 306 HRRs in the US, 149 have access to brachytherapy. This represents 247.5 million people based on 2018 estimates of population from the US Census Bureau. This implies that 76.7% of people within the US live in an HRR with access to brachytherapy, and, conversely, that 75.3 million people (23.3%) do not. Numerically, counties in metropolitan areas were more likely to have access to brachytherapy than those outside of a metropolitan area. CONCLUSIONSGeographic disparities exist in access to brachytherapy; metropolitan counties are more likely to have access than non-metropolitan counties. We support continued development of databases of brachytherapy providers and programs that may support travel and lodging costs to minimize these disparities.

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry.

Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions. We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States? The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively. There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth. We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains. Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.

1686. Microbiology of Community-Onset Urinary Tract Infections in the United States, 2012-2017

BackgroundCommunity-onset urinary tract infections (coUTIs) are one of the most common indications for antibiotic prescribing. It is important to understand patient demographic factors associated with microorganisms causing coUTI and their antibiotic resistance profiles, to tailor antibiotic prescribing practices. We analyzed microbiology data to understand factors associated with coUTI in the United States (US).MethodsCoUTIs were identified in the Premier Healthcare Database and Cerner Health Facts among patients treated at participating healthcare facilities in the US between 2012-2017. Cases were defined by urine cultures yielding a bacterial organism and were collected in outpatient settings or within three days of hospitalization. Only the first specimen for each encounter was included in the analysis. Data on the organisms isolated, patient’s age, sex, and US census regions of the submitting facilities were described and compared using chi-square tests for associations. Encounters were classified as inpatient (INPT), observation (OBS), emergency department (ED), and outpatient (OTPT) based on the setting in which the culture was submitted.ResultsUsing data from 637 acute care hospitals, urine samples from 3,291,561 encounters were included, with 776,653 (25.7%) INPT, 1,063,219 (34.8%) ED, 107,760 (3.5%) OBS, and 1,092,658 (35.8%) OTPT. The pathogens most frequently associated with coUTIs were Escherichia coli (57.3%), Klebsiella pneumoniae (9.7%), Enterococcus faecalis (5.1%), Proteus mirabilis (4.9%), and Pseudomonas aeruginosa (2.9%). Female sex, age < 65y and OTPT and ED settings were associated with higher relative frequency of E. coli (all p < 0.0001). Male sex, INPT setting and age >65 y were associated with higher relative frequency of P. aeruginosa, P. mirabilis and E. faecalis (all p < 0.0001, Figure). K. pneumoniae was found at higher relative frequency in those >45y, and in INPT and OBS settings (all p < 0.0001).Figure. Distribution of pathogens most frequently associated with community onset urinary tract infections ConclusionUnderstanding patient factors associated with the microbiology of coUTIs is an important step in developing treatment recommendations and antibiotic stewardship efforts. Further analyses will include assessing the impact of major antibiotic resistance phenotypes, geographic and healthcare settings.Disclosures All Authors: No reported disclosures

Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States

BackgroundTransgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth experience pregnancy and have abortions. Scarce data have been published on individual abortion experiences or preferences of this understudied population.ObjectiveThis study aimed to fill existing evidence gaps on the abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States to inform policies and practices to improve access to and quality of abortion care for this population.Study DesignIn 2019, we recruited transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth at the age of ≥18 years from across the United States to participate in an online survey about sexual and reproductive health recruited through The Population Research in Identities and Disparities for Equality Study and online postings. We descriptively analyzed closed- and open-ended survey responses related to pregnancy history, abortion experiences, preferences for abortion method, recommendations to improve abortion care for transgender, nonbinary, and gender-expansive people, and respondent sociodemographic characteristics.ResultsMost of the 1694 respondents were <30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all 4 United States Census Regions. Overall, 210 respondents (12%) had ever been pregnant; these 210 reported 433 total pregnancies, of which 92 (21%) ended in abortion. For respondents’ most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (5%) were another method (primarily herbal). Most recent abortions took place at ≤9 weeks’ gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion over surgical abortion in a 3:1 ratio (n=703 vs n=217), but 514 respondents (30%) did not know which method they would prefer. The reasons for medication abortion preference among the 703 respondents included a belief that it is the least invasive method (n=553, 79%) and the most private method (n=388, 55%). To improve accessibility and quality of abortion care for transgender, nonbinary, and gender-expansive patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers use gender-neutral language, and that greater privacy be incorporated into the clinic.ConclusionThese data contribute substantially to the evidence base on individual experiences of and preferences for abortion care for transgender, nonbinary, and gender-expansive people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.

HPV-associated oropharyngeal cancer: Knowledge and attitude/beliefs among non-clinical staff at community-based HIV/AIDS Service Organizations (ASO) in the south United States (U.S.) census region.

This study describes knowledge and attitude/beliefs about HPV-associated oropharyngeal cancer among non-clinical staff, at community-based HIV/AIDS Service Organizations (ASOs) located in the Southern U.S. states of South Carolina and Texas. It also explores the difference in knowledge and attitude/beliefs between Texas-based (n=21) and South Carolina-based (n=30) ASO staff. The ASOs in our study provide comprehensive HIV prevention, supportive and care services to individuals living with HIV/AIDS or at risk for HIV/AIDS, through partnerships and collaborations. We collected data from the two Texas-based ASOs in 2018 and the three South Carolina-based ASOs in 2016 via a 118-item, self-administered needs assessment survey. Data were analysed using Stata/SE 15.1. Over half the study participants were females (59%), black (78%), heterosexual (61%) and mean age (years) 44.2±12.8 SD. Most participants (73%) believed that quitting smoking positively impacts health. Alarmingly though, only 32% were aware about HPV as a risk factor for oropharyngeal cancer, and over half (53%) were unsure about the success of the HPV vaccine in preventing oropharyngeal cancer. In addition, there were no statistically significant differences observed in the oropharyngeal cancer-related knowledge and attitudes/beliefs, between ASOs in Texas and South Carolina. ASO staff work closely with people living with HIV (PLWH), who are disproportionately affected by HPV-associated cancers. The low/poor knowledge and attitudes/beliefs regarding the role of HPV in causing oropharyngeal cancer ascertain the need for equipping community health workers with adequate education/training that improves their knowledge and attitudes/beliefs about the role of HPV in causing various forms of cancer.

Geographic disparities in access to glioblastoma treatment based on Hispanic ethnicity in the United States: Insights from a national database.

Access to treatment for glioblastoma (GBM) can be impacted by multiple demographic parameters. Barriers specific to the Hispanic population of the United States (US) are not fully understood. Therefore, the aim of this study was to elucidate geographic disparities for access to GBM treatment in the US Hispanic population. All GBM patients with known Hispanic ethnicity status (and Caucasian race) in the US National Cancer Database (NCDB) between the years 2005-2016 were retrospectively reviewed. Treatment statuses of surgical resection, chemotherapy, radiation therapy and triple therapy (resection, chemotherapy and radiation) were summarized, and analyzed by comparison and regression analyses over US Census regions. A total cohort size of 40,232 Caucasian GBM patients were included, with 3,111 (8%) identifying as Hispanic. The odds of treatment by chemotherapy (OR 0.78, P < 0.01), radiation therapy (OR 0.82, P < 0.01) and triple therapy (OR 0.84, P < 0.01) were all significantly lower in the Hispanic group versus non-Hispanic group. The odds of being treated in the Hispanic group were significantly lower in multiple Census regions with respect to surgical resection (New England, OR 0.51; Mountain, OR 0.68), chemotherapy (East North Central, OR 0.77; Middle Atlantic, OR 0.71; Pacific, OR 0.77), radiation therapy (Middle Atlantic, OR 0.77) and triple therapy (New England, OR 0.49; Middle Atlantic, OR 0.87; Pacific, OR 0.84). Significant barriers to triple therapy in the Hispanic group within these regions were older age (OR 0.97; P < 0.01), treatment in a community facility (OR 0.85, P = 0.03), lack of insurance (OR 0.71, P = 0.03), yearly income < $40,227 (OR 0.69, P < 0.01), low education levels (OR 0.75, P = 0.03) and presence of co-morbidity (OR 0.82; P < 0.01). Currently in the US, there exists heterogenous geographic disparities for Hispanic GBM patients to access different treatments compared to non-Hispanic patients. Multiple circumstances can influence access to treatment within the Hispanic community of these regions, and greater investigation with more granularity required to reveal mechanisms in which these disparities may be addressed in the future.

Human parainfluenza virus circulation, United States, 2011–2019

BackgroundHuman parainfluenza viruses (HPIVs) cause upper and lower respiratory tract illnesses, most frequently among infants and young children, but also in the elderly. While seasonal patterns of HPIV types 1–3 have been described, less is known about national patterns of HPIV-4 circulation. ObjectivesTo describe patterns of HPIVs circulation in the United States (US). Study designWe used data from the National Respiratory and Enteric Virus Surveillance System (NREVSS), a voluntary passive laboratory-based surveillance system, to characterize the epidemiology and circulation patterns of HPIVs in the US during 2011–2019. We summarized the number of weekly aggregated HPIV detections nationally and by US census region, and used a subset of data submitted to NREVSS from public health laboratories and several clinical laboratories during 2015–2019 to analyze differences in patient demographics. ResultsDuring July 2011 - June 2019, 2,700,135 HPIV tests were reported; 122,852 (5 %) were positive for any HPIV including 22,446 for HPIV-1 (18 %), 17,474 for HPIV-2 (14 %), 67,649 for HPIV-3 (55 %), and 15,283 for HPIV-4 (13 %). HPIV testing increased substantially each year. The majority of detections occurred in children aged ≤ 2 years (36 %) with fluctuations in the distribution of age by type. ConclusionsHPIVs were detected year-round during 2011–2019, with type-specific year-to-year variations in circulation patterns. Among HPIV detections where age was known, the majority were aged ≤ 2 years. HPIV-4 exhibited an annual fall-winter seasonality, both nationally and regionally. Continued surveillance is needed to better understand national patterns of HPIV circulation.

Factors Associated With Frequent Opioid Use in Children With Acute Recurrent and Chronic Pancreatitis.

The aim of the study was to understand the association of frequent opioid use with disease phenotype and pain pattern and burden in children and adolescents with acute recurrent (ARP) or chronic pancreatitis (CP). Cross-sectional study of children <19 years with ARP or CP, at enrollment into the INSPPIRE cohort. We categorized patients as opioid "frequent use" (daily/weekly) or "nonfrequent use" (monthly or less, or no opioids), based on patient and parent self-report. Of 427 children with ARP or CP, 17% reported frequent opioid use. More children with CP (65%) reported frequent opioid use than with ARP (41%, P = 0.0002). In multivariate analysis, frequent opioid use was associated with older age at diagnosis (odds ratio [OR] 1.67 per 5 years, 95% confidence interval [CI] 1.13-2.47, P = 0.01), exocrine insufficiency (OR 2.44, 95% CI 1.13-5.24, P = 0.02), constant/severe pain (OR 4.14, 95% CI 2.06-8.34, P < 0.0001), and higher average pain impact score across all 6 functional domains (OR 1.62 per 1-point increase, 95% CI 1.28-2.06, P < 0.0001). Children with frequent opioid use also reported more missed school days, hospitalizations, and emergency room visits in the past year than children with no frequent use (P < 0.0002 for each). Participants in the US West and Midwest accounted for 83% of frequent opioid users but only 56% of the total cohort. In children with CP or ARP, frequent opioid use is associated with constant pain, more healthcare use, and higher levels of pain interference with functioning. Longitudinal and prospective research is needed to identify risk factors for frequent opioid use and to evaluate nonopioid interventions for reducing pain and disability in these children.

The Changing Landscape of Diabetes Mortality in the United States Across Region and Rurality, 1999-2016.

This brief report examines place-based differences in diabetes mortality in order to understand whether disparities in diabetes mortality have changed across United States Census regions and levels of rurality over time. We use data from the National Center for Health Statistics from 1999 to 2016 to analyze changes in diabetes mortality over time and across geographical regions of the United States. We find evidence that diabetes mortality has declined in the United States over the past 2 decades, but that improvements in mortality vary considerably by place. Improvements are observed in urban America and in the Northeast and Midwest while diabetes mortality has remained largely unchanged in rural areas, particularly in the rural South. Diabetes is one of the leading causes of death in the United States, but important differences have emerged in the burden of this disease. Reductions in diabetes mortality are lagging in rural areas, and the rural South in particular, relative to other areas of the country. Continued innovations in care and targeted interventions in rural areas are warranted.

Regional Variation in Rivalry: Canadians Really are Friendlier

Spectator sports embody social group conflict, where consumers periodically interact with opposing fans, thereby providing outlets for negative brand affect in the form of acrimony toward rivals. To assess the regional nature of rivalry, this study compared 5,145 sports consumers across the four United States Census regions and Canada, including five professional leagues. Consistent with regional personality clustering, fans of Canadian teams harbor less acrimony toward rivals, and fans of teams in the Northeastern US generally exhibit the most acrimony. When developing events and promotional partnerships, sports marketers and sponsors should recognize regional differences in how consumers react to rivals.

709. Activity of Key β-Lactam Agents Against Gram-Negative Bacilli From ICU Patients with Lower Respiratory Tract Infections, SMART United States 2015–2017

BackgroundRelebactam (REL), formerly MK-7655, is a β-lactamase inhibitor of class A and C β-lactamases that is in clinical development in combination with imipenem (IMI). In this study, we evaluated the activity of IMI/REL against Gram-negative bacilli and resistant phenotypes collected in the United States as part of the SMART surveillance program from patients with lower respiratory tract infections (RTI) in ICUs, where antimicrobial resistance is typically higher than in non-ICU wards.MethodsIn 2015–2017, 26 hospitals in the United States each collected up to 100 consecutive Gram-negative pathogens from RTI per year. Antimicrobial susceptibility was determined for 1,298 non-Proteeae Enterobacteriaceae (NPE) and 638 P. aeruginosaisolates collected in ICUs, using CLSI broth microdilution and breakpoints; for comparison purposes, the IMI susceptible breakpoint was applied to IMI/REL. Proteeae were excluded due to intrinsic nonsusceptibility to IMI. Susceptibility was calculated for the 4 United States census regions and overall.ResultsSusceptibility of NPE was lowest in the Midwest to ceftazidime (81%) and cefepime (87%) and highest in the Northeast (88% and 94%, respectively); susceptibility to imipenem (89–93%) and piperacillin–tazobactam (86–90%) showed less variability across regions. Susceptibility of P. aeruginosa to the four agents was lowest in the West region (57–65%) and highest in the Northeast (68–76%). Susceptibilities to IMI/REL of NPE and P. aeruginosa as well as of phenotypes nonsusceptible (NS) to β-lactams are shown below. ConclusionThe studied β-lactams showed some variability in activity against pathogens from RTI patients in ICUs across census regions, whereas IMI/REL maintained activity in all regions against NPE (>96%) and P. aeruginosa (90–95%). IMI/REL remained active against ≥98% of resistant phenotypes of NPE, except the imipenem-NS subset (67.5% susceptible), which was composed mainly of Serratia spp., and remained active against 77–82% of resistant phenotypes of P. aeruginosa, including 77.2% of imipenem-NS isolates. IMI/REL may provide a valuable therapeutic option for the treatment of ICU patients with respiratory tract infections caused by organisms resistant to commonly used β-lactams.Disclosures S. Lob, IHMA, Inc.: Employee, Salary. Merck: Consultant, Consulting fee. K. Kazmierczak, Merck: Consultant, Consulting fee. IHMA, Inc.: Employee, Salary. D. Hoban, IHMA, Inc.: Employee, Salary. Merck: Consultant, Consulting fee. M. Hackel, IHMA, Inc.: Employee, Salary. Merck: Consultant, Consulting fee. K. Young, Merck: Employee and Shareholder, Dividends and Salary. M. Motyl, Merck: Employee and Shareholder, Dividends and Salary. D. Sahm, IHMA, Inc.: Employee, Salary. Merck: Consultant, Consulting fee.

Evaluation of the Integrated Plastic and Reconstructive Surgery Prerequisite Core Surgical Training Experience: A Residents' Perspective.

A key educational component of the integrated plastic and reconstructive surgery (PRS) training model is the prerequisite, or core, experiences. The aim of this study is to assess the integrated PRS residents' experience with this early part of training. A 20-question survey was developed and piloted before deployment to integrated PRS training programs from 4 United States Census regions. Respondents were asked to characterize their prerequisite clinical and operative experiences. Results were analyzed using pairwise correlation statistics and logistic regression modeling following Bonferroni correction for multiple hypothesis testing. One hundred ninety six residents (22 programs) participated in the study (response rate, 65.3%). The majority of residents were satisfied with their prerequisite experiences. Most did not take the American Board of Surgery In-Training Examination, which was perceived as noncontributory to PRS training. The majority of residents preferred to have fewer prerequisite experiences. Operative hours per week were predictive of resident satisfaction with the clinical and operative prerequisite experiences (both P < 0.001). Perception of general surgery program director investment in PRS education was also predictive of resident satisfaction with clinical and operative experiences (P = 0.05 and P < 0.001, respectively). The present study demonstrates that PRS residents are satisfied with the quality of prerequisite training but prefer less overall. Reevaluation of the benefits of the American Board of Surgery In-Training Examination and individual essential rotations for resident education would be welcomed. Furthermore, this study identifies the residents' clinical and operative experience and perceived general surgery program director involvement as important determinants of integrated resident satisfaction with prerequisite training.

740: Contribution of previable infant deaths to infant mortality rates among US census regions

Variation in reporting of early gestation births has the potential to influence infant mortality rate (IMR) calculations and affect regional IMR comparisons. We aim to quantify differences in the contribution of early previable live births (<20 weeks) to United States (US) regional IMRs. Population-based cohort study of all US live births and infant deaths, 2007-2014, using CDC Linked Birth/Infant Death records from WONDER database, which reports births from 17-47 wks. We compared the proportion of infant deaths attributable to birth <20 wk vs 20-47 wk across four US census regions (North, South, Midwest, and West). We calculated adjusted IMR representing only births ≥20 wks. Difference between reported and adjusted IMRs (ΔIMR) was compared between US regions with X2. Percentage of infant deaths attributable to birth <20wk was 6.3%, 6.3%, 5.3%, and 4.1% of total deaths for the Northeast, Midwest, South, and West, respectively, p<0.0001. The contribution of these deaths to each region’s IMR was 0.34, 0.42, 0.37, and 0.2 per 1000, respectively. A standardized IMR definition of births ≥20wk yielded less regional variation and lower IMRs of 5.1, 6.2, 6.6, and 4.9 per 1000. Recording <20wk deliveries as live births contributes significantly to IMR as all result in infant death. These may be considered miscarriage by some providers and not be recorded as live births. We demonstrate that standardized IMR reporting defining live birth at ≥20wk results in more consistent IMRs among US regions. We identified a higher IMR difference in regions that currently report the highest IMRs, the Midwest and South. Standardized reporting would result in US IMR rates comparable to the Healthy People 2020 goal of 6.0 per 1000. Since IMR is an important indicator of population health, with significant governmental policy implications, validity of regional and international comparisons could be strengthened through standardization of infant death reporting in the US.

Carbon Monoxide Poisoning in the Veterans Health Administration, 2010 - 2016

ObjectiveTo describe characteristics of Veterans Health Administration(VHA) patients with ICD 9/10 CM inpatient discharge and/oremergency department (ED)/urgent care outpatient encounter codesfor carbon monoxide (CO) poisoning.IntroductionIt is estimated that in the United States (US), unintentional non-firerelated CO poisoning causes an average of 439 deaths annually, and in2007 confirmed CO poisoning cases resulted in 21,304 ED visits and2,302 hospitalizations (71 per million and 8 per million population,respectively)1. Despite the significant risk of morbidity and mortalityassociated with CO poisoning, existing surveillance systems in theUnited States are limited. This study is the first to focus specificallyon CO poisoning trends within the VHA population.MethodsQueries were performed in VA PraedicoTMPublic HealthSurveillance System for inpatient discharges and emergency roomand urgent care outpatient visits with ICD 9/10 CM codes for COpoisoning from 1/1/2010 – 6/30/2016. A dataset of unique patientencounters with CO poisoning was compiled and further classified asaccidental, self-harm or unspecified. Patients with carboxyhemoglobin(COHb) blood level measurements≥10%2for the same timeframewere extracted and merged with the CO poisoning dataset.We analyzed for demographic, geographic and seasonal variables.Rates were calculated using total unique users of VHA care formatching time frame and geographic area as denominators.ResultsThere were a total of 671 unique VHA patients identified with COpoisoning. Of these, 298 (44%) were classified as accidental, 104(15%) self-harm, and 269 (40%) unspecified. A total of 6 patientsdied within 30 days of their coded diagnosis, however only 1 ofthese was directly attributable to CO poisoning. The overall rate ofCO poisoning over the study time frame was 18 per million uniqueusers of VHA care. CO poisoning diagnoses were obtained from396 (59%) outpatients, 216 (32%) inpatients, and 59 (9%) patientswith both and outpatient visit and inpatient admission. Patientswith self-harm classification were less likely to be seen in the ED(only 24 (6%) unique patients compared to 190 (48%) accidental and182 (46%) unspecified classifications). Of patients seen in the ED andsubsequently admitted, patients with the classification of accidentalpoisoning made up the largest percentage with 36 unique patients(61%). There were 71 (11%) females compared to 600 (89%) males.The highest represented age group was 45-64 with 342 unique patients(51%). Rates by US Census Region were highest in the Midwestand Northeast (27 and 23 per million unique users, respectively)compared to the West and South (15 and 13 per million uniqueusers, respectively) (Figure 1). Accidental CO poisonings showed aseasonal pattern with peaks occurring in late fall, winter, and earlyspring months (Figure 2). CO poisonings classified as unspecifiedhad a similar but less pronounced pattern, while those classified asself-harm were too few to observe any pattern over time. COHb bloodlevels≥10% were present in 111 (17%) of patients with CO poisoningcodes. Of patients with COHb measures≥10%, those with self-harmclassification were least represented with only 7 unique patients (6%).Accidental and unspecified classifications were equally representedwith 53 (48%) and 51 (46%) unique patients, respectively.ConclusionsThe impact of CO poisoning on the VHA patient population hasnot been well studied. The geographic distribution of the majorityof cases in the Midwest and Northeast, and the seasonal distributionof accidental cases in colder months seems to be appropriate withrespect to what is known of unintentional CO poisoning as oftenassociated with heat-generating sources3. Opportunities for furtherinvestigation include how potential CO poisoning cases are evaluatedin VHA given the low percentage of cases with COHb blood levelmeasurements.

Substance use, treatment, and demographic characteristics of pregnant women entering treatment for opioid use disorder differ by United States census region

Opioid use disorder (OUD) among pregnant women increased substantially between 1992 and 2012 across the United States, with the greatest increases occurring in the southern states. We analyzed the 2013 Treatment Episodes Database-Admissions to determine how substances used, characteristics of treatment, and demographics of pregnant women entering treatment for opioid use disorder vary between geographical regions. Analyses were restricted to cases where women reported being pregnant at the time of admission and reported opioids as the primary substance problem leading to the treatment admission. Characteristics were compared between U.S. census regions using Chi-square tests and logistic regression with the South census region as the reference group. Compared to the South, pregnant women admitted for OUD treatment in other regions were 33–79% less likely to use benzodiazepines, twice as likely to be admitted to medication assisted treatment (MAT), 2–3 times more likely to use heroin, and up to 1.5 times more likely to inject drugs. Fewer women in the South reported having medical insurance, education beyond high school, and being married. There is a need in the southern U.S. for policies and treatment programs to target reducing concomitant opioid and benzodiazepine use, increasing access to, and utilization of, MAT, and increasing access to medical insurance.

State and local policies related to sexual orientation in the United States.

Poorer health suffered by lesbian, gay, and bisexual (LGB) populations may be associated with public policies. We collected the laws that in 2013 prohibited discrimination based on sexual orientation from 50 United States (US) states, the District of Columbia (Washington, DC or DC), and the 30 most populous US metropolitan areas. To facilitate future research, we coded certain aspects of these laws to create a dataset. We generated descriptive statistics by jurisdiction type and tested for regional differences in state law using Chi-square tests. Sixteen (31.4per cent) states prohibited discrimination by all employers based on sexual orientation, 25 states (49.0per cent) in public employment, 18 states (35.3per cent) in government contracting, and 21 states (41.2per cent) in private employment. Twenty-one states prohibited discrimination (41.2per cent) in housing practices (selling and renting), and 17 (33.3per cent) in public accommodations. Local (county/city) laws prohibiting discrimination were less common. State laws differed significantly by US census region - West, Midwest, Northeast, and South. Future analyses of these data could examine the impact of these laws on various outcomes, including health among LGB populations.

Predictors of negotiated NIH indirect rates at US institutions.

BackgroundThe United States (US) Department of Health and Human Services and the Office of Naval Research negotiate institutional rates for payments of overhead costs associated with administration and space usage, commonly known as indirect rates. Such payments account for a large proportion of spending by the National Institutes of Health (NIH). Little has been published about differences in rates and their predictors.MethodsNegotiated indirect rates for on-campus research grants were requested from the Council on Governmental Relations for the 100 institutions with greatest NIH funding in 2010. NIH funding, cost of living (ACCRA Index for 2008), public vs. private status, negotiating governmental organization (Department of Health and Human Services or Office of Naval Research), US Census Region, and year were assessed as predictors of institutional indirect rates using generalized estimating equations with all variables included in the model.ResultsOverall, 72 institutions participated, with 207 reported indirect rates for the years 2006, 2008, and 2010. Indirect rates ranged from 36.3% to 78%, with an average of 54.5%. Mean rates increased from 53.6% in 2006 to 55.4% in 2010 (p<0.001). In multivariable models, private institutions had 6.2% (95% CI 3.7%-8.7%; p<0.001) higher indirect rates than public institutions. Rates in the Northeast were highest (Midwest 4.0% lower; West 4.9% lower; South 5.2% lower). Greater NIH funding (p = 0.025) and cost of living (p = 0.034) also predicted indirect rates while negotiating governmental organization did not (p = 0.414).ConclusionsNegotiated indirect rates for governmental research grants to academic centers vary widely. Although the association between indirect rates and cost of living may be justified, the cause of variation in rates by region, public-private status, and NIH funding levels is unclear.