Zip Code Income Research Articles

Atrial Fibrillation in young patients: Insights from the National Inpatient Sample

Abstract Background The burden of atrial fibrillation (AF) in young patients is not well characterized. We aimed to study trends in AF burden and management over time in patients aged 18-45 years. Methods We conducted a retrospective analysis of all primary AF hospitalizations in patients 18-45 years of age using the United States National Inpatient Sample (NIS) data from 01/01/2008 to 12/31/2019. We collected data on clinical and socioeconomic features including demographics, comorbidities, ZIP Code income, resource utilization, and various clinical outcomes. Quartile classification of the median household income of the zip code of the patient’s residence was used to classify socioeconomic status. Results The rate of AF hospitalizations decreased over time from 18.7 per 100,000 in 2008 to 13.0 per 100,000 in 2019 (p<0.001) (Figure 1). AF hospitalizations were higher amongst males compared to females (24.0 vs. 7.5 per 100,000), and higher in black patients compared to other ethnicities (20.4 for black vs. 15.6 for white vs. 8.5 Hispanic per 100,000) (Figure 2). The utilization of electrical cardioversion increased from 17.6% in 2008 to 21.9% in 2019 (p<0.001), and the utilization of catheter ablation decreased from 7.1% in 2008 to 4.3% in 2019 (p<0.001) (Figure 1). Men were more likely to undergo electrical cardioversion than women (20.1% vs. 14.8%, p <0.001). White patients were more likely to undergo electrical cardioversion (20.8% vs. 14.3%) and catheter ablation (6.1% vs. 3.3%, p <0.001) compared to black patients. Patients in the highest socioeconomic status quartile were more likely to undergo electrical cardioversion (21.9% vs. 16.4%, p<0.001) and catheter ablation (8.0% vs. 3.7%, p<0.001) compared to patients in the lowest socioeconomic status quartile. Conclusions We found significant differences in inpatient AF burden across different patient populations. We identified differences in inpatient AF management based on sex, ethnicity, and socioeconomic status. Further research is needed to better understand these differences, their impact on clinical outcomes, and strategies to improve healthcare disparities.

Hereditary Hemorrhagic Telangiectasia: Pregnancy and Delivery-Specific Considerations and Outcomes.

Prior studies have evaluated maternal outcomes in patients with hereditary hemorrhagic telangiectasia (HHT), yet pregnancy- and delivery-specific data remain limited. This study aims to evaluate pregnancy and delivery outcomes in patients with HHT. This retrospective cohort study used the Nationwide Readmissions Database to identify patients with HHT diagnosis on delivery between 2010 and 2021. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included nontransfusion SMM, preterm birth, stillbirth, prelabor rupture of membranes or preterm prelabor rupture of membranes, cesarean delivery, respiratory bleeding, cerebrovascular complications, patient disposition, and length of stay. Trends in the prevalence of HHT at delivery were assessed with logistic regression. Logistic regression analyses, adjusting for age, payer, zip code income, hospital size, and teaching status, were also used to produce adjusted relationships between HHT status and outcomes. The cohort of 21,698,861 delivered pregnancies corresponded to a national estimate of 44,325,599. Of those, 612 (national estimate: 1,265; 2.8 per 100,000) had a diagnosis of HHT. A steady rise in the HHT diagnosis rate during pregnancy from 2010 to 2021 (1.7 per 100,000 in 2010, 3.8 per 100,000 in 2021, p < 0.001 for trend) was seen. Patients with HHT were significantly more likely to experience SMM compared with patients without HHT (7.8 vs. 1.7%, adjusted relative risk [aRR]: 4.49 [95% confidence interval, CI: 3.06, 6.58]). Rates of preterm birth (14.2 vs. 8.5%, aRR: 1.57 [95% CI: 1.22, 2.03]), cesarean delivery (41.0 vs. 32.9%, aRR: 1.23 [95% CI: 1.07, 1.41]), respiratory bleeding (2.1 vs. <0.1%, aRR: 94.44 [56.64, 157.46]), and cerebrovascular complications (0.9 vs. <0.1%, aRR: 22.89 [9.89, 52.96]) were higher in patients with HHT than non-HHT patients. There was no difference in stillbirth rates between groups. Patients with HHT have higher rates of SMM and adverse delivery outcomes when compared with the baseline population. · There was a steady rise in the rates of HHT during pregnancy from 2010 to 2021.. · Patients with HHT are more likely to experience SMM.. · Patients with HHT are more likely to have a preterm delivery and cesarean delivery..

Relationship Between Insurance Status and Receipt of Cardiac Tests and Procedures During Hospitalization: A Cross-Sectional Study.

Prior analyses of the relationship between insurance status and receipt of tests and procedures have yielded conflicting findings and have focused on outpatient care. We sought to characterize the relationship between primary payer and diagnostic and procedural intensity, comparing rates of cardiac tests and procedures in matched hospitalized Medicaid and commercially insured patients. We created a propensity score-matched sample of Medicaid and commercially insured adults hospitalized at all acute care hospitals in Kentucky, Maryland, New Jersey, and North Carolina from 2016 to 2018. The main outcome was receipt of a cardiac test or procedure: echocardiogram, stress test, cardiac catheterization (elective, in acute coronary syndrome, in ST-segment-elevation myocardial infarction), and pacemaker and subcutaneous cardiac rhythm monitor implantation. Generalized linear models with a hospital-specific indicator variable were estimated to calculate the adjusted odds of a commercially insured patient receiving a given test or procedure relative to a Medicaid patient. Models controlled for race, ethnicity, and zip code income quartile. Commercially insured patients were more likely to receive each cardiac test or procedure, with adjusted odds ratios ranging from 1.16 (95% CI, 1.00-1.34) for cardiac catheterization in ST-segment-elevation myocardial infarction to 1.40 (95% CI, 1.27-1.54) for pacemaker implantation. Hospitalized commercially insured patients were more likely to undergo a range of cardiac tests and procedures, some of which may represent low-value care. This may be driven by a combination of physician and patient preference, financial incentives, and social determinants of health. Our findings support the need for hospital payment models focused on increasing value and reducing inequities.

Financial Improvements From Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared With Standard of Care, “SAVE” Trial

Early-stage endometrial cancer is often treated with hysterectomy followed by adjuvant vaginal cuff brachytherapy (VCB). Financial toxicity from cancer treatment can impact treatment completion. The Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared to Standard of Care trial is a multicenter, prospective randomized trial of standard of care (SoC) VCB doses delivered in 3 to 5 fractions per the physician's discretion compared with a 2-fraction course. We report on secondary cost endpoints, quantifying the financial impacts of shorter treatment courses on institutions and participating patients. Technical (TechCs), professional, and total charges (TotCs) were collected prospectively and are reported as raw and Medicare-adjusted charges per patient. Distance to the treatment center and the median income for each patient's zip code were estimated. The Mann-Whitney U statistic, t test, and X2 test were used to compare characteristics between the 2 groups. One hundred eight patients were analyzed. SoC VCB was delivered in 3, 4, and 5 fractions for 27 of 54 patients (50%), 11 of 54 (20%), and 16 of 54 (30%), respectively. The median total distance traveled per patient for SoC versus experimental arms was 213 versus 137 miles (p = .12), and the median cost of commute for patients was $36.3 versus $18.0 (p = .11). Compared with 2-fraction treatment, 5-fraction treatment resulted in longer travel distances (median, 462 vs 137 miles; p < .01) and increased travel costs (median, $59.3 vs $18.0; p ≤ .01). Unadjusted raw professional charges in USD per patient did not differ between SoC versus experimental arms ($9159 vs $7532; p = .19). TechCs were significantly higher in the SoC arm ($35,734 vs $24,696; p ≤ .01), as were TotCs ($44,892 vs $32,228; p < .01;). Medicare-adjusted TechCs and TotCs were higher for the SoC arm. Two-fraction VCB resulted in fewer treatments per patient, reduced cost of travel compared with longer courses, and an adjusted reduction in health care expenditures compared with SoC.

Race and Ethnicity and Diagnostic Testing for Common Conditions in the Acute Care Setting

Overuse of diagnostic testing is pervasive, but the extent to which it varies by race and ethnicity in the acute care setting is poorly understood. To use a previously validated diagnostic intensity index to evaluate differences in diagnostic testing rates by race and ethnicity in the acute care setting, which may serve as a surrogate for diagnostic test overuse. This was a cross-sectional study of emergency department (ED) discharges, hospital observation stays, and hospital admissions using administrative claims among EDs and acute care hospitals in Kentucky, Maryland, North Carolina, and New Jersey, from 2016 through 2018. The diagnostic intensity index pairs nonspecific principal discharge diagnoses (nausea and vomiting, abdominal pain, chest pain, and syncope) with related diagnostic tests to estimate rates of nondiagnostic testing. Adults with an acute care encounter with a principal discharge diagnosis of interest were included. Data were analyzed from January to February 2024. Race and ethnicity (Asian, Black, Hispanic, White, other [including American Indian, multiracial, and multiethnic], and missing). Receipt of a diagnostic test. Generalized linear models with a hospital-specific indicator variable were estimated to calculate the adjusted odds ratio of receiving a test related to the principal discharge diagnosis by race and ethnicity, controlling for primary payer and zip code income quartile. Of 3 683 055 encounters (1 055 575 encounters [28.7%] for Black, 300 333 encounters [8.2%] for Hispanic, and 2 140 335 encounters [58.1%] for White patients; mean [SD] age of patients with encounters, 47.3 [18.8] years; 2 233 024 encounters among females [60.6%]), most (2 969 974 encounters [80.6%]) were ED discharges. Black compared with White patients discharged from the ED with a diagnosis of interest had an adjusted odds ratio of 0.74 (95% CI, 0.72-0.75) of having related diagnostic testing. No other racial or ethnic disparities of a similar magnitude were observed in any acute care settings. In this study, White patients discharged from the ED with a nonspecific diagnosis of interest were significantly more likely than Black patients to receive related diagnostic testing. The extent to which this represents diagnostic test overuse in White patients vs undertesting and missed diagnoses in Black patients deserves further study.

Impact of Patient Race/Ethnicity on Premium Intraocular Lens Utilization.

To evaluate the relationship between social determinants of health and the likelihood of receiving a premium intraocular lens (IOL) at the time of cataract surgery. Retrospective chart review of a single-center, academic ophthalmology practice over a one-year period, with a primary outcome measure of placement of either a premium or standard IOL. We used logistic regression to calculate the odds of receiving a premium IOL, stratifying patients based on self-identified race/ethnicity, age, sex, insurance type (private insurance vs. Medicare or Medicaid), estimated household income (based on median household income for zip code), and presence of ocular pathology. Compared with self-identified White patients, Black patients were least likely to receive premium IOLs (OR=0.220, 95% CI 0.137-0.340, P <0.001), followed by Hispanic patients (OR=0.308, 95% CI 0.104-0.730) and Asian patients (OR=0.479, 95% CI 0.302-0.734). Patients with Medicare or Medicaid insurance were also less likely to receive premium IOLs (OR 0.522, 95% CI 0.336-0.784). White patients in our practice were more likely to receive premium IOLs than non-White patients, even when controlling for age, sex, insurance type, estimated median household income, and presence of ocular comorbidities. The underlying reason for this disparity should be explored further.

Associations between hospital-level socioeconomic patient mix and rates of central line-associated bloodstream infections in short bowel syndrome: A retrospective cohort study.

Low neighborhood income is linked with increased hospitalizations for central line-associated bloodstream infections (CLABSIs) in pediatric short bowel syndrome (SBS). We assessed whether this relationship varies by hospital center. We performed a retrospective cohort study using the Pediatric Health Information System (2018-2023) database for patients <18 years old with SBS (N = 1210) at 24 hospitals in the United States. Using 2015 US Census data, we determined the estimated median household income of each patient's zip code. Hospital-level neighborhood income was defined as the median of the estimated median household income among patients at each hospital. We applied an extension of Cox regression to assess risk for CLABSI hospitalization. Among 1210 children with 5255 hospitalizations, most were <1 year on initial admission (53%), male (58%), and publicly insured (69%). Hospitals serving low-income neighborhoods served more female (46% vs 39%), Black (29% vs 22%), and Hispanic (22% vs 16%) patients with public insurance (72% vs 65%) residing in the southern United States (47% vs 21%). In univariate analysis, low hospital-level neighborhood income was associated with increased risk of CLABSI hospitalization (rate ratio [RR], 1.48; 95% CI, 1.21-1.83; P < 0.001). These findings persisted in multivariate analysis (RR, 1.43; 95% CI, 1.10-1.84; P < 0.01) after adjusting for race, ethnicity, insurance, region, and patient-level neighborhood income. Hospitals serving predominantly low-income neighborhoods bear a heavier burden of CLABSI hospitalizations for all their patients across the socioeconomic spectrum. Hospital initiatives focused on CLABSI prevention may be pivotal in addressing this disparity.

Risk Factors for Pediatric Intracranial Neoplasms in the Kids’ Inpatient Database

Introduction: In children and adolescents, brain and central nervous system (CNS) tumors are the leading types of cancers. Past studies have found differing rates of intracranial cancers among races and identified additional cancer risk factors. This study aimed to see if these differences can be substantiated with further investigation of the latest version (2019) of the Kids’ Inpatient Database (KID). Methods: A total of 7,818 pediatric patients <21 years old in KID with ICD-10 codes consisting of malignant neoplasms of the brain, brainstem, and cerebral meninges (C700, C709–C719) were queried. Modifiable risk factors evaluated include: hospital region, insurance type, hospital city size, the average income of patient zip code, and location/teaching status of a hospital. Non-modifiable risk factors were race and sex at birth. Dependent variables were tested in Excel and GraphPad Prism 9 using a χ2 test with Yates’ continuity correction and Tukey’s one-way and two-way ANOVAs. Results: Mortality rates of females (2.88%) compared to males (1.99%) were significant (p < 0.05). Mortality was (4.17%) in black patients compared to (1.68%) for white (p < 0.0001), Hispanic mortality (2.95%) compared to white (p < 0.01), and mortality of Asian/Pacific Islander (3.86%) compared to white (p < 0.01). Black patients had significantly higher mortality than white, Hispanic, Asian/Pacific Islander, Native American, and other races overall (p < 0.01). There was no significant difference in the mortality rates between children’s hospitals and large hospitals for any race. After accounting for patient race, mortality was still not significantly different for patients with Medicaid insurance compared to non-Medicaid insurance types. Of the children treated at children’s hospitals, the most transferred in from outside hospitals were Native American (20.00%) followed by Asian/Pacific Islander (15.09%) then Hispanic patients (13.67%). A significant difference between races was also seen regarding length of stay (p < 0.001) and number of charges (p < 0.001). Conclusion: These findings confirm prior studies suggesting gender and race are significant factors in mortality rates for children with intracranial neoplasms. However, the findings do not identify the root causes of these discrepancies but may serve as an impetus for clinicians, healthcare administrators, and governmental leaders to improve national resource allocation to better care for pediatric patients with intracranial neoplasms.

Impact of frailty on hospitalized patients with prostate cancer: A retrospective analysis.

e23054 Background: The impact of Hospital frailty risk score on outcomes in hospitalized patients with prostate cancer has not been previously studied. This research aimed to examine the association between frailty and prostate cancer outcomes. Methods: This retrospective study utilized hospitalization data from the National Inpatient Sample (NIS) between January 1, 2020, and December 31, 2020. Data of patients with a primary or secondary discharge diagnosis of prostate cancer (ICD10-CM codes C61.0, D07.5, and Z85.46) were obtained. The objective was to evaluate the correlation between frailty and prostate cancer. Multivariate analysis was performed, stratified by race, age, Charlson index, median annual income in the patient's zip code, hospital bed size, teaching status, and census division of the hospital. Results: A total of 51,980 hospitalizations for prostate cancer were identified, with 72.7% in the intermediate to high frailty score (IHFS) group and 27.3% in the low frailty score (LFS) group. The IHFS group had a higher unadjusted in-hospital mortality rate than the LFS group (5.85% vs. 1.2%). Patients with IHFS had increased odds of adjusted mortality compared to those with LFS (adjusted odds ratio [aOR] = 4.45, 95% Cl [3.80-5.22], P &lt; 0.01). Hispanic and Black race patients also had increased odds of adjusted mortality compared to Caucasian race patients (aOR = 1.42, 95%CI [1.19-1.70], P &lt; 0.01); aOR = 1.16, 95%CI [1.00-1.32], P = 0.037, respectively). Additionally, the IHFS group had longer lengths of stay (5.65 ± 0.038 vs. 3.26 ± 0.28 days) and higher adjusted total costs ($66,107 ± 850 vs. $64,308 ± 1066) compared to the LFS group. Conclusions: Patients with prostate cancer and a high hospital frailty risk score exhibited significantly higher mortality rates, longer lengths of stay, and increased total adjusted costs. Frailty assessment plays a crucial role in predicting outcomes in patients with prostate cancer. Physicians can use frailty assessment to stratify patients based on risk and improve their ability to anticipate consequences.

Changes in Facility Share of Medicaid-insured Patients With Urologic Cancers Following Implementation of the Patient Protection and Affordable Care Act

ObjectivesTo examine Medicaid-insurance acceptance at facilities treating urologic cancers following implementation of the Affordable Care Act (ACA). MethodsWe conducted a retrospective, longitudinal study with a pre-post design. We accessed 2010-2017 data from the National Cancer Database, calculating the facility-level change in proportion of urologic cancer patients with Medicaid following implementation of the ACA. We used multivariable logistic regression to assess baseline clinical and demographic factors associated with changes in the proportion of patients at a facility insured through Medicaid. ResultsWe identified 630 facilities, including 287 in Medicaid expansion states and 343 in non-expansion states associated with 436,082 urologic cancer patients. The mean facility-level change in proportion of patients with Medicaid was +5.8% (95% CI 5.0-6.5%) in expansion states versus +0.6% (95% CI 0.2-0.9%) in non-expansion states. There were 179 facilities that experienced a decrease in the post-ACA period, representing 13.6% of facilities in expansion states and 40.8% in non-expansion states (p<0.001). Factors associated with a decrease in proportion of urologic cancer patients insured by Medicaid included non-expansion state status (OR 8.9, 95% CI 5.3-15.6, p<0.001), higher baseline proportion of patients with Medicaid (highest quartile versus lowest: OR 4.6, 95% CI 2.3-9.4, p<0.001) and high income zip code (highest versus lowest quartile: OR 3.1, 95% CI 1.5-6.6, p<0.001). ConclusionsUrologic cancer care for Medicaid-insured Americans remains unevenly distributed across cancer care centers, even in states that expanded coverage. Our findings suggest that this variation may reflect the effort of some facilities to reduce their financial exposure to increased numbers of Medicaid patients in the wake of ACA-supported state expansions.

Impact of Socioeconomic Factors on Time to Surgery for Distal Radius Fractures.

Delay in care secondary to socioeconomic status (SES) and demographic factors represents an area for potential improvement. Reducing time to surgery in distal radius fracture (DRF) fixation may improve outcomes while reducing cost. The purpose of this study is to investigate the effect of SES on time to surgery in our study population. Patients undergoing outpatient DRF surgery within an academic healthcare system during a 4-year period were reviewed. Time to surgery and demographic factors were analyzed. The US Census Bureau was used to determine median household income (MHI) for a patient's ZIP code; patients were stratified into three groups based on MHI. A total of 413 patients met inclusion criteria. SES (14.7 d in the low-SES group, 14.0 d in the mid-SES group, and 11.1 d in the high-SES group, P = 0.00063), insurance (11.7 d for insured versus 16.3 d for Medicaid/uninsured, P < 0.0001), race (non-White group: 15.2 d versus White group: 10.9 d, P < 0.0001), and treatment facility (16.2 d at county hospital versus 10.9 d at university hospital, P < 0.0001) were associated with time to surgery in univariate analysis. Multivariate analysis found that only treatment facility was associated with time to surgery. Non-White, uninsured/Medicaid individuals residing in low-SES areas may be more likely to receive care at a safety-net facility and are at greatest risk for delay in time to surgery. Measures aimed to reduce barriers to care, increase healthcare coverage, and improve patient education should be initiated to mitigate these disparities.

Relationships between socioeconomic status and cardiovascular outcomes in patients with complete heart block

BackgroundLiterature illustrates an association between adverse outcomes and lower socioeconomic status (SES) in patients with critical cardiovascular presentations; however. limited data exist on complete heart block (CHB) outcomes in the context of SES. ObjectivesThe purpose of this study was to assess the association of SES (using zip code income quartiles) with the outcomes of CHB cases. MethodsWe queried the 2016–2019 Nationwide Inpatient Sample and identified CHB as the primary diagnosis. We compared in-hospital outcomes based on zip code mean income quartiles (≤2 [< $59,000] vs ≥3). The primary outcome was mortality. Secondary outcomes included total and early permanent pacemaker (PPM) and temporary pacemaker (TPM) use, cardiogenic shock, palliative care involvement, mechanical ventilation use, length of stay (LOS), and total charges. Multivariable regression models were used to adjust for potential confounders. ResultsOf 150,265 CHB hospitalizations, 76,635 (51%) involved patients with a lower income quartile. Lower quartiles were associated with lower odds of early PPM use (adjusted odds ratio [aOR] 0.86; 95% confidence interval [CI] 0.81–0.90) and higher odds of in-hospital mortality (aOR 1.23; 95% CI 1.05–1.46), total TPM use (aOR 1.08; 95% CI 1.02–1.14), palliative care (aOR 1.2; 95% CI 1.02–1.43), mechanical ventilation use (aOR 1.11; 95% CI 1.01–1.23), cardiogenic shock (aOR 1.15; 95% CI 1.01–1.31), and longer LOS (4 days vs 3.6 days; P <.001) compared to patients in higher quartiles. ConclusionPatients with lower income admitted for CHB were less likely to receive an early PPM and had higher adverse outcomes compared to patients with higher income.

Abstract 6473: Evaluation of bladder cancer patients' utilization of urologic telehealth services

Abstract Introduction: Infection control practices and public policy in response to the COVID-19 pandemic shifted healthcare practices towards a telemedicine format. Even two years after peak onset of the pandemic, many clinics, including our own institution, maintain a working telehealth option for patient visits. Our objective was to evaluate patient utilization of telehealth visits versus in-person visits at our institution and whether this was impacted by clinical stage, rural/urban status, distance from a large urban academic center, payor status, or comorbidities. Methods: Medical Record Numbers for all patients with bladder cancer were pulled via the Qlik platform from the period 7/1/2019-2/28/2022. Chart review was conducted to pull clinical data on patients including telehealth versus in person visits, demographic data, clinical stage, comorbidities (diabetes, smoking status, BMI), rural/urban status by zip code (&amp;gt;50,000, &amp;lt;50,000 individuals) and income levels by zip code (25K-49.9K, 50K-99.9K, &amp;lt;100K), payor status (Medicare, Managed care, Medicaid, other government, ODRC, or self-pay), patient distance, and gas savings/carbon footprint. Results: 430 patients completed in person visits while 268 completed telehealth visits. There was no statistically significant difference for in person visits vs. telehealth visits regarding patients’ race (p=0.541), ethnicity (p=0.394) age (p=0.862), urban/rural status (p=0.507), payor status (p=0.127), mean zip code income (p=0.175), and comorbidities (p=0.626 for diabetes, p = 0.706 for smoking, p = 0.459 for BMI), and clinical stage (p=0.07). There was a statistically significant difference in mean distance (14.85 miles versus 26.86 miles, p&amp;lt;0.01). Conclusion: Patients’ with bladder cancer receive care from their urologist via in person visits versus telehealth at similar rates irrespective of their urban/rural status, demographics, payor status, relevant comorbidities, or relative income. Patients are more likely to engage in care with their urologist via telehealth if they live farther from a large urban academic center, which produces an economical and environmental impact via gas/time savings and reduced carbon footprint. Citation Format: Steven Goldenthal, Tasha Posid, Victor Heh, Dairon Denis-Diaz, Hafsa Asif, Chase Arnold, Henry Gold, Tae-Hee Kim, Amara Ndumele, Sabrina Amin, Matthew Lierz, Vivian Xu, Tyler Cronin, Aliza Khuhro, Cheryl Lee. Evaluation of bladder cancer patients' utilization of urologic telehealth services [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6473.

Long-term persistence to onabotulinumtoxinA to prevent chronic migraine: results from 11 years of patient data from a tertiary headache center.

To determine if patients with chronic migraine continue onabotulinumtoxinA (onabotA) long-term. We performed a retrospective cohort analysis using aggregated, de-identified patient data from the Stanford Headache Center. We included patients in California who received at least one prescription for onabotA during the years of 2011-2021. The primary outcome was the number of onabotA treatments each patient received. Secondary outcomes included sex, age, race, ethnicity, body mass index (BMI), distance to the treatment facility, and zip code income quartile. A total of 1551 patients received a mean of 7.60 ± 7.26 treatments and a median of 5 treatments, with 16.2% of patients receiving only one treatment and 10.6% receiving at least 19. Time-to-event survival analysis suggested 26.0% of patients would complete at least 29 treatments if able. Younger age and female sex were associated with statistically significant differences between quartile groups of number of onabotA treatments (P = .007, P = .015). BMI, distance to treatment facility, and zip code income quartile were not statistically significantly different between quartile groups (P > .500 for all). Prescriptions of both triptans and non-onabotA preventive medications showed a statistically significant increase with each higher quartile of number of onabotA treatments (P < .001; P < .001). We show long-term persistence to onabotA is high and that distance to treatment facility and income are not factors in continuation. Our work also demonstrates that as patients continue onabotA over time, there may be an increased need for adjunctive or alternative treatments.

Demographics and clinical features associated with rates of electronic message utilization in the primary care setting

IntroductionElectronic messages are growing as an important form of patient-provider communication, particularly in the primary care setting. However, adoption of healthcare technology has been under-utilized by underserved patient populations. The purpose of this study was to describe how adoption and utilization of electronic messaging occurred within a large primary care urban-based patient population. MethodsIn this retrospective study, the frequency of electronic messages initiated by adult outpatient primary care patients was observed. Patients were classified as either non-portal adopters, non-message utilizers, low message utilizers, and high message utilizers. Logistic regression modeling was used to compare factors associated with message utilization rates to determine disparities in access. ResultsAmong a sample of 27,453 ethnically diverse adult patients from the Houston, Texas Metropolitan area, 33,497 unique messages were sent (1.22 messages/patient). Message burden was predominantly derived by a small number of high utilizers (individuals who sent 3 or more messages), who comprised 15.7 % of the study population (n = 4302) but accounted for 77 % of the message volume (n = 25,776). These high utilizers were typically older, White, English speaking, from middle to upper income zip codes, had higher number of comorbidities, and a higher number of clinical visits. ConclusionsMost inbox messages were generated by a small number of patients. While it was reassuring to see older and sicker individuals utilizing electronic messaging, patients from minority and/or lower income background utilized electronic messaging much less. This may propagate systematic bias and decrease the level of care for traditionally underserved patients.

Concurrent Alcohol and Opioid Intoxication in Emergency Department Patients Leads to Greater Resource Utilization

Background: Concurrent alcohol intoxication can complicate emergency department (ED) presentations for opioid-related adverse events. We sought to determine if there was a difference in resource utilization among patients who presented to the ED with concurrent opioid and alcohol intoxication compared to opioid intoxication alone. Methods: Using linked state-wide databases from the Maryland Healthcare Cost and Utilization Project (HCUP), we identified patients with a diagnosis of opioid intoxication treated in the ED from 2016 to 2018. We measured healthcare utilization for each patient in the ED settings for one year after the initial ED visit and estimated direct costs. We performed logistic regression comparing patients presented with co-intoxication to those without. Results: Of 12,295 patients who presented to the ED for opioid intoxication during the study period, 703 (5.7%) had concurrent alcohol intoxication. Patients with co-intoxication had more recurrent ED visits (340 vs 247.4 per 1000 patients, p < 0.05), higher index ED visit admission rates (26.9% vs 19.4%, p < 0.001), but similar overall costs ($3736 vs $2861, p < 0.05) at one year. Co-intoxication was associated with suicidal ideation (OR = 1.58, 95% CI 1.51–1.65), high zip code income (OR = 1.16, 95% CI 1.12–1.21), and higher rates of intoxication with all classes of drugs analyzed (p < 0.001). Conclusion: Our study demonstrated that mental health disorders, socioeconomic status, and increased ED utilization are associated with co-intoxication of opioids and alcohol presenting to the ED. Further research is needed to elucidate factors responsible for the increased resource use in this population.

Advance care planning for patients undergoing gastrostomy tube procedures; prevalence, outcomes, and disparities

BackgroundAdvanced care planning (ACP) is the process of establishing goals for end-of-life care. We aimed to examine ACP's prevalence, associated factors, and impact in a cohort of patients undergoing gastrostomy tube procedures. MethodsAdult patients who underwent gastrostomy tube placement from 2016 to 2021 ​at a tertiary center were identified. Variables evaluated included age, sex, race, comorbidities, and median income of patient home zip code. Primary outcomes included the presence of ACP, length of stay (LOS), and 90-day mortality. Analysis was performed using independent T tests, Mann Whitney U-tests, and Chi Square analysis. ACP, LOS, and 90-day mortality were analyzed with multivariate analysis. Results877 patients underwent gastrostomy tube placement and 10.6 ​% had ACP. Black race was an isolated factor negatively associated with ACP (OR 0.423, p ​= ​0.013). There was no difference in the proportion of patients with or without ACP who died within 90 days of the procedure (17 ​% vs. 15 ​%, p ​= ​0.836). Average LOS was 6 days shorter for patients with ACP (p ​< ​0.001). ConclusionThis study highlights the significant underutilization and racial disparity in ACP, and found that ACP does not negatively impact outcomes or perioperative mortality for patients undergoing gastrostomy tube placement.

Real World Outcomes of Black Americans with Mantle Cell Lymphoma

Introduction Mantle cell lymphoma (MCL) is a rare subtype of non-Hodgkin lymphoma (NHL), accounting for approximately 6-8% of all NHL cases. MCL generally affects older, White, male patients, having a significantly lower incidence in Black patients. Thus, clinical outcomes of Black Americans with MCL are poorly characterized, though multiple sources have reported relatively poor survival outcomes when compared to their White counterparts. We aimed to evaluate the overall survival outcomes and explore potential factors contributing to poor survival outcomes for Black patients with MCL in the United States. Methods The National Cancer Database was used to identify MCL patients diagnosed from 2004-2020. Demographic and treatment characteristics were compared between White and Black MCL patients, by self-identified race. Patients of other races were excluded. Kaplan Meier and adjusted Cox regression survival analysis were used to compare overall survival (OS) by race, and stratified for age ≤ 65 or age &amp;gt; 65 years old. Finally, a propensity matched analysis was performed to compare OS in Black and White Americans matched by age, comorbidity burden, insurance status, and zip code income. Results A total of 34,872 patients with MCL were identified, of which 93.1% (N=32,407) were White, 4.2% (N=1,465) were Black, and 1.7% (N=942) identified as another race and were excluded from the dataset. Black patients were more likely to be female (34% Black vs. 29% White), have a younger age at diagnosis (mean age 65 years [SD ± 13] vs. 68 years [SD ± 12], p&amp;lt;0.001), more likely to have ≥1 co-morbidity (30% vs. 23%), and more likely to be uninsured (4% vs. 2%) when compared to White patients. Both Black and White patients had equal rates of stage IV disease (68% vs. 68%) and receipt of systemic therapy at diagnosis (84% vs. 84%), however White patients were more likely to receive stem cell transplant compared to Black patients (13% vs.11%). With a median follow-up of 40 months, the median OS for all MCL patients was 70 months (95% CI 66-71). Compared to White patients of the same age, Black patients age ≤ 65 years had worse median OS (116 months [95% CI 92-139] vs. 140 [95% CI 134-146] months for White patients) along with decreased 1-year (87% vs. 90%), 5-year (62% vs. 70%) and 10-year OS (38% vs. 55%), (all p &amp;lt;0.001). For MCL patients age &amp;gt; 65 years old, Black MCL patients had shorter median OS compared to their White counterparts (36 months [95% CI 28-43] vs. 43 months [95% CI 41-44]), and decreased 1-year (70% vs. 75%) and 5-year OS (40% vs. 41%) (all p=0.030), though by ten years there was no survival disparity. On age-adjusted cox regression, Black race was associated with increased hazard for all-cause death for MCL patients (hazard ratio [HR] 1.17, CI 1.08-1.26; p&amp;lt;0.001). However, when Black and White patients were 1:1 propensity score matched by age, co-morbidity score, insurance status, and income quartile of zip code, there was no significant difference in risk of death by race alone (HR 0.99, CI 0.91-1.08; p=0.61). Conclusion This is the largest study to-date evaluating outcomes among Black patients with MCL. Patients who are Black with MCL are more likely to present at a younger age, have female predominance, and have worse overall survival outcomes than White patients of similar age. Notably, we found that this survival difference was lost when controlling for surrogate markers of healthcare access, such as insurance and income. This study highlights existing disparities for Black patients with MCL, which appear to be related to socioeconomic disparities that may impact access to treatment, supportive care, and other vital aspects of care for MCL. Future studies may seek to evaluate the role of known high risk features for MCL such as TP53 status or blastoid/pleomorphic morphology in these populations. Interventions aimed at improving healthcare access for underserved populations, including racial minorities, are essential.

Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery.

Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.

Socioeconomic factors affecting outcomes in total shoulder arthroplasty

BackgroundA lack of comprehensive research on socioeconomic factors affecting total shoulder arthroplasty (TSA) outcomes has demonstrated the need for further study. The purpose of this study is to determine the effects of socioeconomic factors such as ethnicity, income, and insurance status on the outcomes following TSA. MethodsAll anatomic TSA and reverse TSA cases from the National Inpatient Sample (NIS; N = 128,376) database from 2011 to 2019 as well as the Nationwide Readmission Database (NRD; N = 103,023) from 2010 to 2019 were analyzed. Self-identified ethnicities assessed in NIS included Caucasian (CC), African American (AA), and Hispanic (H), and ethnicities were compared to Caucasians. NRD cases were assessed by insurance status (Medicare, Medicaid, and private) and zip code income Quartiles (Q1-4, with Q1 being the lowest). Insurance types and Q1-3 were compared to private insurance and Q4, respectively. Demographic data, quantitative variables, and binary categorical variables were analyzed using chi-square test of independence, one-way ANOVA with Tukey-Kramer post hoc analyses, and binary logistic regression, respectively. ResultsFor NIS, AA had the highest percent Q1 and comorbidities of all ethnicities (P < .001), increased lengths of stay and hospital stay extensions (both P < .001). The majority of H were Q1 (P < .001) with increased comorbidities (P < .001), lengths of stay (P < .001), stay extensions (P = .027) and complications (P = .043). For NRD, Medicare patients had a 1.5 times higher mean comorbidity score (P < .001) and increased risk of complication (P = .007), readmission (P < .001), revision (P = .028), hospital stay extension (P < .001), and discharge to a new facility (P < .001). Similarly, Medicaid patients had a 1.6 times increased mean comorbidity score (P < .001), and the highest risk of the following adverse outcomes: length of stay extension (odds ratio [OR]: 1.43, P < .001), complication (OR: 1.24, P = .017), and readmission (OR: 1.18; P = .041). Additionally, they had an increased risk of discharge to a new facility (OR: 1.78, P < .001). Comparing TSA patients in the Q1-3 to Q4, first quartile income was significantly associated with increased risk of hospital stay extension (P = .043), complication (P < .001), and readmission (P < .001). Second and third quartile patients had increased risks of any complication (Q2: P = .003; Q3: P = .016). ConclusionThe socioeconomic factors studied - ethnicity (AA and H), zip code income (Q1, Q2, and Q3), and insurance status (Medicare or Medicaid) - were all shown to have significantly increased risk for adverse outcomes following TSA. Private insurance status, CC, and zip code income Q4 were all predictive of significantly less adverse outcomes. Further study is needed to assess specific social differences associated with these results.