Zip Code-level Income Research Articles

Abstract 3946: Weaving equity into the fabric of health: A deep dive into race, social determinants of health and facility type in pancreatic adenocarcinoma care

Abstract Introduction: Pancreatic adenocarcinoma (PDAC) remains one of the deadliest malignancies, with significant differences in survival rates observed among various racial and ethnic groups. Despite advancements in care, ongoing racial disparities stress the need to uncover underlying causes. This study seeks to evaluate the interplay of race, social determinants of health, and treatment facility on overall survival (OS) of PDAC patients. Methods: In this retrospective cohort study, we identified PDAC patients from January 1, 2004, to December 31, 2019, using National Cancer Database (NCDB) data. Patients not receiving treatment (surgery, chemotherapy, or radiation) or who were missing race were excluded. We performed a multivariable cox proportional hazards regression to explore the race and all-cause mortality relationship, stratified by facility type and income status. Patients were divided into income quartiles (SES) with the lowest SES represented by median zip code level income ≤$40,227, while highest SES indicated income levels ≥$63,333. Treating facility type included community or academic hospital. A two-sided P-value <0.05 was considered significant. Results: The total cohort included 210,520 patients. The average age of the cohort was 66.4 (SD:10.7) years and most patients were white (80%, N=168,467), male (52.2%, N=109,844), treated at academic facility type (65.5%, N=136,623), and the highest SES was the largest (38.4%, N=71,205). In unadjusted analysis, Black patients had lower OS than Whites (HR: 1.05 (95% CI: 1.04-1.07, p<0.001)). As SES increases there was a corresponding decrease in hazards (p<0.001). In the multivariable subgroup analysis, survival were not significant for Black and White patients in highest SES at academic facilities (p=0.8). Of note, highest SES Black patients in community hospitals had worse survival than highest SES White patients (HR: 1.08 (95% CI:1.01-1.16, p=0.03)). However, lowest SES Blacks treated at academic facilities had superior survival compared to lowest SES Whites (HR: 0.93 (95% CI: 0.89-0.96, p<0.001)). Conclusion: Survival differences among Black individuals were linked to SES and facility type. Highest SES was not protective for Black patients treated at community hospitals compared to their White counterparts, indicating additional factors driving outcomes. These findings highlight the intricate influence of race, SES, and perhaps biology on survival outcomes. Addressing these complexities through targeted research and intervention is crucial for reducing health disparities and fostering a more equitable healthcare landscape. Citation Format: Christopher Wu, Zhixing Song, Ramsha Akhund, Chandler McLeod, Lauren Wood, Herbert Chen, J. Bart Rose, Smita Bhatia, Andrea Gillis. Weaving equity into the fabric of health: A deep dive into race, social determinants of health and facility type in pancreatic adenocarcinoma care [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 3946.

Contact tracing: Characteristics of COVID-19 cases that provided contacts.

This cross-sectional study evaluated COVID-19 contact tracing efforts to identify variations in contact tracing outcomes in different population subgroups. Contact tracing was a critical tool to slow the COVID-19 epidemic. A literature gap evaluating contact tracing elicitation exits, particularly on prioritized groups. We analyzed data from COVID-19 cases linking statewide case management, immunization, laboratory testing, and hospitalization databases in New York State (NYS) outside of New York City from February 1 to November 30, 2021. Focus was cases in home-based residential settings (excluding congregate care) and prioritized groups (educational institutions, large households, close quarters, higher-risk persons, hospitalized). The primary outcome was completed interviews that provided a contact. Of the 550,850 cases interviewed during the study period, 316,645 (57.5%) provided at least one contact. Adults aged 18 to 49 years were most likely to provide contacts than those aged 65 years and older (adjusted odds ratio [aOR], 1.42; 95% confidence interval [CI], 1.39-1.45). Compared to unvaccinated cases, boosted individuals (aOR, 1.61; 95% CI, 1.50-1.73) were most likely to provide contacts, followed by persons with only a primary vaccine series (aOR, 1.3; 95%CI, 1.28-1.33) and partially vaccinated (aOR, 1.21; 95%CI, 1.18-1.24). Repeat cases (aOR, 1.07; 95%CI, 1.01-1.14), pregnant persons (aOR, 1.26; 95% CI, 1,19-1.34), those with underlying conditions (aOR 1.22; 95%CI, 1.20-1.23), and those in K-12 settings (aOR 1.55; 95%CI, 1.50-1.61) were more likely to provide contacts. There was no clear association between hospitalized, while zip code level income may (aOR, 1.006; 95%CI, 1.003, 1.009). Persons from larger households were more likely to provide contacts: aOR for two or more persons vs. one person households ranged from 2.49 to 4.7 (95%CI, 2.20-4.78). Our findings indicate success in eliciting contacts from prioritized groups and identify variable contact elicitation outcomes from different population groups. These results may serve as a tool for future contact tracing efforts.

Clinical Features and Treatment Response to Topical Steroids in Ethnic and Racial Minority Patients With Eosinophilic Esophagitis.

Differences in eosinophilic esophagitis (EoE) presentation and outcomes by ethnicity or race remain understudied. We aimed to determine whether EoE patients of Hispanic/Latinx ethnicity or non-White race have differences in presentation at diagnosis or response to topical corticosteroid (tCS) treatment. This retrospective cohort study included subjects of any age with a new diagnosis of EoE and documentation of ethnicity or race. For those who had treatment with tCS and follow-up endoscopy/biopsy, we assessed histologic response (<15 eosinophils/hpf), global symptom response, and endoscopic response. Hispanic EoE patients were compared with non-Hispanics at baseline and before and after treatment. The same analyses were repeated for White vs non-Whites. Of 1,026 EoE patients with ethnicity data, just 23 (2%) were Hispanic. Most clinical features at presentation were similar to non-Hispanic EoE patients but histologic response to tCS was numerically lower (38% vs 57%). Non-White EoE patients (13%) were younger at diagnosis and had less insurance, lower zip code-level income, shorter symptom duration, more vomiting, less dysphagia and food impaction, fewer typical endoscopic features, and less dilation. Of 475 patients with race data treated with tCS, non-Whites had a significantly lower histologic response rate (41% vs 59%; P = 0.01), and odds of histologic response remained lower after controlling for potential confounders (adjusted odds ratio 0.40, 95% confidence intervals: 0.19-0.87). Few EoE patients at our center were Hispanic, and they had similar clinical presentations as non-Hispanics. The non-White EoE group was larger, and presentation was less dysphagia-specific. Non-White patients were also less than half as likely to respond to tCS.

Association of Medicaid expansion with treatment receipt, delays in treatment initiation, and survival among young adult women with breast cancer.

1509 Background: Medicaid expansion under the Affordable Care Act has been shown to increase insurance coverage and early-stage cancer diagnoses for young adults (YAs), the age group with the highest uninsured rate. We examined whether Medicaid expansion was associated with increased receipt of timely, guideline-concordant treatment and survival among YA women newly diagnosed with breast cancer, the most common YA cancer diagnosis. Methods: Using the National Cancer Database, we identified 51,675 women aged 18-39 years who were diagnosed with breast cancer in 2011-2018. We applied the difference-in-differences (DD) method to estimate outcome changes pre vs. post Medicaid expansion, in expansion- vs. non-expansion states. Linear probability models estimated associations of Medicaid expansion with receipt of guideline-concordant treatment – including any endocrine therapy among women with ER-positive or PR-positive breast cancer, and any chemotherapy or targeted therapy among women with ER-negative and PR-negative breast cancer – and initiation of guideline-concordant treatment (surgery, chemotherapy, or targeted therapy for stage I-III diagnoses, and systemic therapy for stage IV diagnoses) &lt;60 days after diagnosis. Flexible parametric survival models were used to estimate 2-year overall survival. DD models also adjusted for age, race/ethnicity, rurality, zip code-level income, comorbidity, and diagnosis year, with standard errors clustered at the state level. Analyses were stratified by stage at diagnosis (stage I-III vs. IV). Results: Of the subset of women with stage I-III ER-positive or PR-positive breast cancer, the percentage receiving endocrine therapy increased in expansion states (85.20% pre-expansion to 86.46% post-expansion), but decreased in non-expansion states (84.32% to 82.79%), resulting in a net increase of 2.42 percentage points (ppt; 95% CI = 0.56 to 4.28) associated with Medicaid expansion in the adjusted DD model. Among all women with stage I-III breast cancer, the percentage with treatment initiation &lt;60 days after diagnosis decreased less in expansion states (84.10% pre-expansion to 82.36% post-expansion) than in non-expansion states (86.95% to 83.98%), resulting in a net reduction of 1.61 ppt (95% CI = 0.05 to 3.18) in treatment delays associated with Medicaid expansion. Notably, the 2-year overall survival increased in expansion states (96.84% pre-expansion to 96.99% post-expansion), but decreased in non-expansion states (97.24% to 96.30%), resulting in a net survival increase of 1.00 ppt (95% CI = 0.21 to 1.79) associated with Medicaid expansion. Conclusions: Among YA women with stage I-III breast cancer, Medicaid expansion was associated with increased receipt of guideline-concordant treatment, reduced delays in treatment initiation, and improved 2-year survival.

Association of Medicaid expansion with timely receipt of treatment and survival among patients with HER2-enriched breast cancer.

6539 Background: HER2-enriched breast cancer (estrogen and progesterone receptors negative and HER2-positive) has no worse prognosis than other breast cancers if it is treated with HER2-targeted therapy. Medicaid expansion under the Affordable Care Act (ACA) has been shown to be associated with improved access to care and outcomes for many cancers, but its impact on care for HER2-enriched breast cancer is unknown. To fill this gap, we examined the association of Medicaid expansion with receipt of guideline-concordant treatment, time to treatment, and survival among newly diagnosed nonelderly women with HER2-enriched breast cancer. Methods: Women aged 18-62 years newly diagnosed with HER2-enriched breast cancer between 2010 and 2018 were identified from the National Cancer Database. Our primary outcomes included receipt of stage-based guideline-concordant treatment, initiation of treatment &lt;60 days, and stage-specific 2-year overall survival. A difference-in-differences (DD) approach compared outcome changes following the expansion in Medicaid expansion vs. non-expansion states. A linear probability model estimated treatment outcome, and a flexible parametric survival model evaluated survival. All models were clustered at the state level and adjusted for age group, race/ethnicity, rurality of residence, zip code-level income, comorbidity, and diagnosis year. Results: A total of 31,354 patients with HER2-enriched breast cancer were included, including 19,255 in expansion states and 12,099 in non-expansion states. Compared to patients in expansion states, patients in non-expansion states were more likely to be racial/ethnic minorities, uninsured, and diagnosed at late-stage. Medicaid expansion was not significantly associated with changes in receipt of surgery for stage I-III disease but was associated with an increase of 4.42 percentage points (ppt, 95% CI: 0.09, 8.74) in receipt of chemotherapy/targeted therapy for stage IV disease, with an increase from 90.4% pre-expansion to 92.8% post-expansion in expansion states and a decrease from 93.7% to 91.9% in non-expansion states. Medicaid expansion was also significantly associated with a 2.41 ppt increase in initiating guideline-concordant treatment within 60 days (95% CI: 0.66, 4.17; 83.5% to 82.5% in expansion states vs. 86.6% to 83.7% in non-expansion states), and a 1.18 ppt increase in two-year survival rate (95% CI: 0.03, 2.33; 94.0% to 94.9% in expansion states vs. 94.3% to 94.1% in non-expansion states). The increase in two-year survival associated with Medicaid expansion was most prominent for stage III patients (DD=3.63 ppt; 95% CI: 0.64, 6.62). Conclusions: Medicaid expansion was associated with increased receipt of timely treatment and improved 2-year survival among nonelderly women newly diagnosed with HER2-enriched breast cancer.

Abstract 744: Treatment inequities among patients diagnosed with Hodgkin's lymphoma with and without HIV (2018-2019): an analysis of the US National Cancer Database

Abstract Background: People living with HIV (PLWH) with Hodgkin’s lymphoma(HL) have similar response and survival rates to people without HIV when standard of care therapies are given. However, PLWH with HL are less likely to receive cancer treatment for unclear reasons. Our objective was to examine the role of social determinants of health(SDOH) with non-receipt of cancer treatment among PLWH with HL. Methods: Using the U.S. National Cancer Database, we identified 11,517 persons aged 18-90 years, diagnosed with HL (ICD-O-3 codes; C770-779) between 2018-2019. Most patients were diagnosed with classical HL(9650; n=4534, 39%) or nodular sclerosis classical Hodgkin’s lymphoma (9663; n=4725, 41%). As per NCCN guidelines, receipt of first-line treatment was defined as receiving any chemotherapy, radiotherapy or a combination of both. We compared treatment receipt by HIV status and associations of SDOH (e.g., zip-code median household income) with non-receipt of treatment among those with and without HIV. Using multivariable logistic regression, we evaluated the association of treatment receipt with HIV status after adjustment for age, sex, and stage at diagnosis. We stratified this model by zip-code level income, education and race/ethnicity to evaluate the role of SDOH in this exposure-outcome relationship. For each model, we calculated cluster-robust standard errors to account for non-independence within clusters at the facility level to adjust for correlated patient characteristics within hospitals. Results: Our sample (n=11,517) included 60% adults aged 50 years or below, 55% men, 71% NH-White and 14% NH-Black. About one-third were treated at an academic/research program and 57% were privately insured. PLWH included 6% of the population. Overall, 12% did not receive first-line recommended treatment and were less likely to receive treatment compared to those without HIV (13% vs. 9%, p=0.012). We identified the following characteristics amongst PLWH to be more likely not to receive treatment compared to those without HIV, persons who were: aged 40 years or younger(13% vs. 6%, p=0.001), male(15% vs. 9%, p&amp;lt;0.001), NH-White(13% vs. 8%) and NH-Black(14% vs. 11%) persons(p&amp;lt;0.001), persons residing in areas with lower levels of educational attainment (20% vs. 10%, p&amp;lt;0.001) and low income areas (14% vs 9%, p&amp;lt;0.001), and were Medicaid insured (17% vs. 8%, p&amp;lt;.001). Stratifying by area-level education, this association persisted among those residing in areas with lower levels of education and income. Conclusion: PLWH with HL were less likely to receive cancer treatment and continue to experience inequities in cancer treatment receipt, with SDOH playing a potential role in inequitable cancer care delivery. Citation Format: Jessica Yasmine Islam, Jennifer McGee, Yi Guo, Marlene Camacho-Rivera, Lubomir Sokol, Susan T. Vadaparampil, Gita Suneja. Treatment inequities among patients diagnosed with Hodgkin's lymphoma with and without HIV (2018-2019): an analysis of the US National Cancer Database [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 744.

32381 Analysis of utilization of skin cancer screenings and screening motivations among national SPOT Skin Cancer program screenees from 2018 to 2019

Information on motivations for participation in the AAD SPOT Skin Cancer screenings is lacking, and understanding differences in motivations may help elucidate potential disparities in free skin cancer screening in the United States, informing the program where resources may be most needed. Records from 116,595 screenees were analyzed from 2018-2019, including demographic information, history of regular dermatologist and/or screening, and motivation(s) for screening attendance. Most screenees were White (86.3%), female (61.8%), and had completed at least a college education (69.6%). Higher ZIP code level income per $10,000 increments was associated with a higher likelihood of having a regular dermatologist or having been to a prior screening (adjusted odds ratio [aOR] = 1.04, P < .001 and aOR = 1.05, P < .001, respectively). “No regular dermatologist” or “not having been to a prior screening” were screening motivations more commonly reported by non-Whites versus Whites, those with less education versus graduate-level education, and those living in the Midwest versus Northeast. Having a concerning spot and no dermatologist were the most common motivations for attending a screening (36.3% and 26.2%, respectively). Screenees who had attended a prior screening were less likely than those who had not to report a spot of concern (aOR = 0.75, P < .001). The program appears effective in addressing its intended target of screenees with a concerning spot but had not obtained expert skin examination. A major limitation is screenee self-selection. Nonetheless, our data suggest the screenings could possibly be optimized by targeting individuals without a dermatologist, are uninsured/underinsured, reside in lower-income areas, and/or in the Midwest.

A Mixed-Methods Assessment of Residential Housing Tenants' Concerns about Property Habitability and the Implementation of Habitability Laws in Southern Nevada.

Housing is a key health determinant. Habitability laws set minimum standards for adequate housing. However, accessing them to ensure adequate housing may be a challenge for many tenants. This paper explores the need for rental housing policy that would better support adequate and safe housing, particularly for low-income renters. A mixed-methods approach assessed residential tenant habitability concerns in Clark County, Nevada, through calls relayed to the Clark County Landlord–Tenant Hotline (CCLTH). Of the 2865 calls, 74.3% were from ZIP codes that were 80% of the median income and below. There was a significant relationship between the ZIP code-level income and the reporting of at least one essential habitability concern. Of the 266 participants that responded to a follow-up call, 34.6% reported that their complaint was resolved and there was no association between resolution and income. Qualitative data analysis from phone interviews revealed two central themes: (1) resources to navigate landlord–tenant laws are limiting and (2) housing policies need to be strengthened to help tenants and keep people housed. Understanding tenant concerns regarding substandard housing and related inequities can help inform rental housing policy and its implementation to promote healthy homes and improve health outcomes for communities burdened by poor rental housing conditions.

Abstract 12985: Genetic Susceptibility for Coronary Artery Disease Accentuates the Cardiovascular Disease Risk Associated With Air Pollution

Introduction: Air pollution (particulate matter of diameter &lt;2.5 μm, PM 2.5 ) and genetic risk for coronary artery disease (CAD) each associate with cardiovascular disease (CVD). It is unknown whether genetic risk for CAD enhances CVD risk associated with air pollution exposure. Hypothesis: We tested the hypothesis that high genetic risk for CAD accentuates the adverse impact of air pollution on CVD, (as coronary artery calcium [CAC]) and major adverse cardiovascular events [MACE]). Methods: Participants (N=9340, median age 66 yrs, 49% male) in the Mass General Brigham Biobank with genetic and air pollution data were studied. Genome wide polygenic risk score for CAD (PRS CAD ) and principal components of ancestry (PCI) were determined. Average PM 2.5 exposure one year before each person’s enrollment was derived using home addresses and Environmental Protection Agency data. CAC was assessed on those with available CT images (N=548). MACE and CVD risk factors were evaluated via International Classification of Diseases codes. Socioeconomic status (SES) was assessed as residential zip code level income using US Census data. The presence of an interaction between high PM 2.5 and PRS CAD vs. MACE was tested. Results: The Combination of high PRS CAD and PM 2.5 (both ≥ median vs. others) associated with greater CAC [standardized β (95% CI): 0.13 (0.06, 0.19), p=0.0002, Fig.1A ] after adjusting for age, sex, and PCI and with further adjustment for CVD risk factors (p=0.007). Over 5 years median follow up, 1139 subjects experienced first time MACE. Combined high PRS CAD and PM 2.5 also associated with higher MACE risk [OR (95% CI): 1.20 (1.15, 1.25), p&lt;0.001, p (interaction) &lt;0.001, Fig.1B ] after adjusting for age, sex, and PCI and with further adjustment for CVD risk factors (p&lt;0.001) and SES (p&lt;0.001). Conclusions: Among individuals exposed to air pollution, genetic risk for CAD accentuates CAC and MACE risk in a graded manner. Genetic context may impact the health effects of air pollution.

Residential distance from the reporting hospital and survival among adolescents, and young adults diagnosed with CNS tumors.

Prior research shows that residential distance to a treatment facility may be an important factor in central nervous system (CNS) tumor outcomes. Our goal was to examine residential distance to the reporting hospital and overall survival in adolescents and young adults (AYA) diagnosed with CNS tumors. National Cancer Database data on AYA 15-39years old diagnosed with CNS and Other Intracranial and Intraspinal Neoplasms (CNS tumors) from 2010 to 2014 were obtained. Distance between the case's residence at diagnosis or initial treatment and the reporting hospital was classified in miles as short (≤ 12.5), intermediate (> 12.5 and < 50), and long (≥ 50). Cox proportional hazards regression models were used for analyses. Among 9335 AYA diagnosed with CNS tumors, hazard ratios (HRs) were 1.06 (95% CI 0.96-1.17) and 0.82 (95% CI 0.73-0.93) for those with residences at intermediate and long vs. short distances, respectively, after adjusting for age, sex, race/ethnicity, and zip-code level education and income. After adjusting for the facility volume of CNS tumor patients, the association was attenuated for long vs. short distance residences (HR 0.92, 95% CI 0.81-1.04). The HRs varied by tumor type, race/ethnicity, and zip-code level income with significantly lower hazards of death for those with residences at long vs. short distances for low-grade astrocytic tumors, ependymomas, non-Hispanic Whites, and those from higher-income areas. Living at long distances for CNS tumor care may be associated with better survival in AYA patients. This may be explained by travel to facilities with more experience treating CNS tumors.

Associations of Race, Insurance, and Zip Code-Level Income with Nonadherence Diagnoses in Primary and Specialty Diabetes Care.

Evidence suggests that clinicians may view or label patients as nonadherent in a biased manner. Therefore, we performed a retrospective cohort analysis exploring associations between patient demographics and zip code-level income with the International Classification of Diseases, Tenth Version (ICD-10) diagnoses for nonadherence among type 2 diabetes mellitus (T2DM) patients, comparing primary and specialty care settings. Providers in the primary care group included internal medicine and family medicine physicians. In the specialty care group, providers included endocrinologists and diabetologists only. Participants were identified from 5 primary care and 4 endocrinology sites in the University of Pennsylvania Health System between January 1, 2015, and January 1, 2019. Demographics, hemoglobin A1c (HbA1c), and ICD-10 codes for T2DM and nonadherence were extracted from the electronic health record and analyzed in October 2019. Log-binomial regression models were used to estimate patients' risk of nonadherence labeling by race, insurance, and zip code-level median household income, controlling for patient characteristics and HbA1c as a proxy for diabetes self-management. Results were compared between primary and specialty care sites. A total of 6072 patients aged 18-70 years were included in this study. Black race, Medicare, and Medicaid were associated with increased nonadherence labeling while controlling for patient characteristics ([ARR = 2.48, 95% CI: 2.01, 3.04], [ARR = 1.82, 95% CI: 1.50, 2.18], [ARR = 1.61, 95% CI: 1.32, 1.93], respectively). The results remained significant on adjustment with zip code-level income and showed no differences between primary and specialty sites. Lower-income zip codes showed a significant association with increased rates of nonadherence labeling. Black race, non-private insurance, and lower-income zip codes were associated with disproportionately high rates of nonadherence labeling in both primary and specialty management of T2DM, possibly suggestive of racial or class bias.

More than treatment refusal: an NCDB analysis of the impact of endometrial cancer treatment refusal on racial survival disparities

<h3>Objectives:</h3> Disparities in adjuvant treatment between Black and White women with endometrial cancer (EC) are well documented and contribute to worse outcomes among Black women. However, factors leading to disparate treatment patterns are understudied. We examined whether patient refusal of adjuvant treatment (chemotherapy or radiation) differed between Black and White women and whether refusal differences mediate racial disparities in EC survival. <h3>Methods:</h3> We used the National Cancer Database (NCDB), a hospital-based registry covering ~70% of U.S. cancer diagnoses, to identify non-Hispanic Black (NHB) and non-Hispanic White (NHW) women diagnosed with EC from 2004 to 2015 who either received or refused chemotherapy or radiation. NCDB data are abstracted from medical records by tumor registrars. We used logistic regression to estimate adjusted odds ratios (aOR) of patient refusal of treatment associated with race, and accelerated failure time models to estimate differences in overall survival (OS) by race. We used causal mediation analysis to estimate how much of the difference in OS by race could be attributed to racial differences in treatment refusal. We considered the overall study populations as well as strata defined by histology, and adjusted for factors assessed at diagnosis, including age, comorbidity burden, insurance, hospital characteristics, stage, histology, and zip code-level income and education. <h3>Results:</h3> We identified 49,518 women (83% NHW, 17% NHB) who received adjuvant chemotherapy and 12,710 women with documented refusal (90% NHW, 10% NHB). After adjusting for covariates, NHB women were more likely to refuse chemotherapy than NHW women (aOR=1.12, p=0.005), particularly among those with low-grade endometrioid (aOR = 1.22, p=0.02) or serous (aOR = 1.38, p<0.001) EC. Mean OS for NHB women was 43.5 months shorter than for NHW women. Of this disparity, 0.9 months of may be attributable to differences in chemotherapy refusal (p=0.01). Among women with serous EC, NHB race was associated with 17.6 months shorter OS, with 1 month potentially attributable to refusal differences (p=0.002). We identified 66,839 women (88% NHW, 12% NHB) receiving adjuvant radiation and 4,471 (88% NHW, 12% NHB) who refused. Among women with serous EC, NHB women were more likely to refuse radiation (OR = 1.39, p=0.01), and NHB women had mean OS 13.2 months shorter than NHW women, 0.4 months of which may be attributable to differences in treatment refusal (p=0.03). <h3>Conclusions:</h3> We observed differences in treatment refusal by race, and those differences may be responsible for up to 1 month of the OS disparity between NHW and NHB women. This represents a small fraction of the dramatic racial disparity in EC survival. While a better understanding of the reasons for patient treatment refusal and subsequent intervention may help improve outcomes for some women, other causes of disparate outcomes warrant further investigation.

Patient and Hospital Factors Associated With Differences in Mortality Rates Among Black and White US Medicare Beneficiaries Hospitalized With COVID-19 Infection

Black patients hospitalized with COVID-19 may have worse outcomes than White patients because of excess individual risk or because Black patients are disproportionately cared for in hospitals with worse outcomes for all. To examine differences in COVID-19 hospital mortality rates between Black and White patients and to assess whether the mortality rates reflect differences in patient characteristics by race or by the hospitals to which Black and White patients are admitted. This cohort study assessed Medicare beneficiaries admitted with a diagnosis of COVID-19 to 1188 US hospitals from January 1, 2020, through September 21, 2020. Hospital admission for a diagnosis of COVID-19. The primary composite outcome was inpatient death or discharge to hospice within 30 days of admission. We estimated the association of patient-level characteristics (including age, sex, zip code-level income, comorbidities, admission from a nursing facility, and days since January 1, 2020) with differences in mortality or discharge to hospice among Black and White patients. To examine the association with the hospital itself, we adjusted for the specific hospitals to which patients were admitted. We used simulation modeling to estimate the mortality among Black patients had they instead been admitted to the hospitals where White patients were admitted. Of the 44 217 Medicare beneficiaries included in the study, 24 281 (55%) were women; mean (SD) age was 76.3 (10.5) years; 33 459 participants (76%) were White, and 10 758 (24%) were Black. Overall, 2634 (8%) White patients and 1100 (10%) Black patients died as inpatients, and 1670 (5%) White patients and 350 (3%) Black patients were discharged to hospice within 30 days of hospitalization, for a total mortality-equivalent rate of 12.86% for White patients and 13.48% for Black patients. Black patients had similar odds of dying or being discharged to hospice (odds ratio [OR], 1.06; 95% CI, 0.99-1.12) in an unadjusted comparison with White patients. After adjustment for clinical and sociodemographic patient characteristics, Black patients were more likely to die or be discharged to hospice (OR, 1.11; 95% CI, 1.03-1.19). This difference became indistinguishable when adjustment was made for the hospitals where care was delivered (odds ratio, 1.02; 95% CI, 0.94-1.10). In simulations, if Black patients in this sample were instead admitted to the same hospitals as White patients in the same distribution, their rate of mortality or discharge to hospice would decline from the observed rate of 13.48% to the simulated rate of 12.23% (95% CI for difference, 1.20%-1.30%). This cohort study found that Black patients hospitalized with COVID-19 had higher rates of hospital mortality or discharge to hospice than White patients after adjustment for the personal characteristics of those patients. However, those differences were explained by differences in the hospitals to which Black and White patients were admitted.

Racial and socioeconomic disparities in ocular surface squamous neoplasia: a National Cancer Database analysis

ABSTRACT Purpose A retrospective population-based study to investigate racial and socioeconomic disparities in patients diagnosed with ocular surface squamous neoplasia (OSSN). Methods To explore racial disparity, we selected OSSN patients with known age, insurance, gender and zip code-level income and education from the National Cancer Database (NCDB). Comparisons of clinical and socioeconomic variables stratified by race were made with the chi-square or Mann-Whitney tests. Survival outcome was examined a Cox regression model. Results Of the 2,402 identified patients from 2004 to 2015, 117 were black. Unadjusted differences were found between groups in regard to age, histology, insurance, income, and education. Black patients in comparison to white patients were younger (mean age: 62 years vs. 70 years; p < .001), represented a higher proportion of Medicaid use (10.3% vs. 3.2%; p < .001) or uninsured (10.3% vs. 2.7%; p < .001), and were more likely to reside in areas of low educational attainment (32.5% vs. 16.1% of whites; p < .001). Multivariate analysis found significantly higher risk of death in patients who were male (HR: 1.66, 95% CI 1.37–2.01) or black (HR: 1.57, 95% CI 1.03–2.38). Conclusion Disparities in socioeconomic factors were observed in black patients with OSSN. OSSN occurred earlier in blacks, who were also socioeconomically disadvantaged and faced higher risk of death.

Potentially Preventable Hospitalizations Among Older Adults: 2010-2014.

We undertook a study to examine national trends in potentially preventable hospitalizations-those for ambulatory care-sensitive conditions that could have been avoided if patients had timely access to primary care-across 3,200 counties and various subpopulations of older adults in the United States. We used 2010-2014 Medicare claims data to examine trends in potentially preventable hospitalizations among beneficiaries aged 65 years and older and developed heat maps to examine county-level variation. We used a generalized estimating equation and adjusted the model for demographics, comorbidities, dual eligibility (Medicare and Medicaid), ZIP code-level income, and county-level number of primary care physicians and hospitals. Across the 3,200 study counties, potentially preventable hospitalizations decreased in 327 counties, increased in 123 counties, and did not change in the rest. At the population level, the adjusted rate of potentially preventable hospitalizations declined by 3.45 percentage points from 19.42% (95% CI, 18.4%-20.5%) in 2010 to 15.97% (95% CI, 15.3%-16.6%) in 2014; it declined by 2.93, 2.87, and 3.33 percentage points among White, Black, and Hispanic patients to 14.96% (95% CI, 14.67%-15.24%), 17.92% (95% CI, 17.27%-18.58%), and 17.10% (95% CI, 16.25%-18.0%), respectively. Similarly, the rate for dually eligible patients fell by 3.71 percentage points from 21.62% (95% CI, 20.5%-22.8%) in 2010 to 17.91% (95% CI, 17.2%-18.7%) in 2014. (P <.001 for all). During 2010-2014, rates of potentially preventable hospitalization did not change in the majority of counties. At the population level, although the rate declined among all subpopulations, dually eligible patients and Black and Hispanic patients continued to have substantially higher rates compared with non-dually eligible and White patients, respectively.

Long-term air pollution exposure and incident dementia in older adults in the Gingko Evaluation of Memory Study

Introduction: Air pollution is associated with reduced cognitive performance and accelerated cognitive decline in older adults. Less is known regarding air pollution’s contribution to all-cause dementia, Alzheimer’s disease (AD), and vascular dementia (VaD). Methods: Over 3,000 adults aged 75 years and older residing in four communities in the United States participated in the Ginkgo Evaluation of Memory Study (GEMS) between 2000-2008. Rigorous evaluations of dementia occurred every six months, and cases were identified by expert panel based on neuropsychological battery, neurological examination, and magnetic resonance imaging results. Fine particulate matter (PM2.5) concentrations were predicted from a spatiotemporal model incorporating land-use regression and spatial smoothing approaches. Estimates were based on residential address histories obtained up to twenty years prior to study entry using the commercially available LexisNexis database. Cox models adjusted for age and date of randomization, site, gender, treatment assignment, education, smoking, and zip code level income were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Results: Mean follow-up time was 5.7 years for the 2,511 GEMS participants free of mild cognitive impairment and dementia at study entry who had information on exposure, dementia status, and relevant covariates. An approximate interquartile range (2 µg/m3) increase in mean PM2.5 exposure twenty years prior to study entry was associated with a 19% greater risk of all-cause dementia (HR: 1.19; 95% CI: 1.03, 1.37) in adjusted analyses. Risks appeared stronger for VaD and mixed VaD/AD (HR: 1.25; 95% CI: 0.96, 1.62) than for AD only (HR: 1.15; 95% CI: 0.97, 1.37). Conclusions: Preliminary results indicate a strong association between air pollution exposure and all-cause dementia and that PM2.5 exposure may be particularly important in dementia with vascular features. Findings provide evidence that air pollution exposure reductions may be a key target for reducing the burden of dementia in older adults.

Racial and ethnic disparities in clinical presentation and prognosis of conjunctival cancer.

e13086 Background: To investigate racial and epidemiological disparities in presentation and prognosis of conjunctival cancer in a retrospective population-based study. Methods: Non-Hispanic white (NHW) and African American patients with squamous cell carcinoma or melanoma of the conjunctiva or cornea with known age, insurance, gender, zip code-level income and education, and tumor size were selected from the National Cancer Database (NCDB). Patients were stratified based on race and ethnicity into two mutually exclusive groups, and unadjusted comparisons were made with the Chi-square or Mann-Whitney tests. Survival was examined with the Kaplan-Meier method and a Cox regression model was employed after checking that the proportional hazards assumption was met for all pertinent variables. SAS version 9.4 was used for all analyses and p&lt; 0.05 was considered significant. Results: Of the 2,192 identified patients from 2004 to 2014, 104 were African American. Unadjusted differences were found between groups in regard to age, histology, insurance, income, and education. African American patients in comparison to NHW were younger (median age: 61 years vs. 71 years; p&lt; 0.001), had a higher proportion of Medicaid (10.6% vs. 3.4%) or no insurance (11.5% vs. 2.7%), and resided in areas with lower levels of education (36.5% of African American patients vs. 17.0% of NHW patients were from areas with greater than 21% of the population with no high school degree). It was also found that African Americans had higher proportion of squamous cell carcinoma than NHW (69.9% vs. 81.7%; p= 0.007). In general, risk of death was higher for older African American males with no private insurance, and for those from areas of lowest level of income. Conclusions: Disparities in socioeconomic factors were observed in the African American population. In addition, the overall incidence of conjunctival and corneal cancer occurs at a younger age in African Americans, who also face poorer prognoses. This association between social inequality and poor outcome warrant further investigation.

A US National Study of the Association Between Income and Ambulance Response Time in Cardiac Arrest

Emergency medical services (EMS) provide critical prehospital care, and disparities in response times to time-sensitive conditions, such as cardiac arrest, may contribute to disparities in patient outcomes. To investigate whether ambulance 9-1-1 times were longer in low-income vs high-income areas and to compare response times with national benchmarks of 4, 8, or 15 minutes across income quartiles. A retrospective cross-sectional study was performed of the 2014 National Emergency Medical Services Information System data in June 2017 using negative binomial and logistic regressions to examine the association between zip code-level income and EMS response times. The study used ambulance 9-1-1 response data for out-of-hospital cardiac arrest from 46 of 50 state repositories (92.0%) in the United States. The sample included 63 600 cardiac arrest encounters of patients who did not die on scene and were transported to the hospital. Four time measures were examined, including response time, on-scene time, transport time, and total EMS time. The study compared response times with EMS response time benchmarks for responding to cardiac arrest calls within 4, 8, and 15 minutes. The study sample included 63 600 cardiac arrest encounters of patients (mean [SD] age, 60.6 [19.0] years; 57.9% male), with 37 550 patients (59.0%) from high-income areas and 8192 patients (12.9%) from low-income areas. High-income areas had greater proportions of white patients (70.1% vs 62.2%), male patients (58.8% vs 54.1%), privately insured patients (29.4% vs 15.9%), and uninsured patients (15.3% vs 7.9%), while low-income areas had a greater proportion of Medicaid-insured patients (38.3% vs 15.8%). The mean (SD) total EMS time was 37.5 (13.6) minutes in the highest zip code income quartile and 43.0 (18.8) minutes in the lowest. After controlling for urban zip code, weekday, and time of day in regression analyses, total EMS time remained 10% longer (95% CI, 9%-11%; P < .001), translating to 3.8 minutes longer in the poorest zip codes. The EMS response time to patients in high-income zip codes was more likely to meet 8-minute and 15-minute cutoffs compared with low-income zip codes. Patients with cardiac arrest from the poorest neighborhoods had longer EMS times compared with those from the wealthiest, and response times were less likely to meet national benchmarks in low-income areas, which may lead to increased disparities in prehospital delivery of care over time.

861. Health Disparities in HIV and Pregnancy

BackgroundHIV infection in pregnant females confers a higher risk of morbidity and obstetric complications. Widespread use of anti-retroviral therapy (ART) has dramatically decreased vertical HIV transmission. US HIV-infected pregnant females continue to be at higher risk for obstetric complications compared with nonHIV infected females. This study will be conducted with the objective to estimate the current US morbidity and mortality in HIV-infected pregnant females as well as incidence of obstetric complications in this patient population.MethodsThe National Inpatient Sample (NIS) was utilized to identify hospitalizations associated with pregnancy from 2002 to 2014. The aggregation of hospitalizations was stratified into 2 groups based on HIV status to determine whether there were differences in demographic factors, complications, and mortality. All analyses accounted for the NIS sampling design.ResultsThere were 39,404,956 pregnancy-related hospitalizations identified; of which, 51,762 were also associated with a positive HIV status. There were differences in complications for those with and without HIV, which included eclampsia (1.27% vs. 0.45%; P < 0.001), preterm labor (11.81% vs. 6.41%; P < 0.001), gestational diabetes (0.92% vs. 0.38%; P < 0.001), group B strep (0.03% vs. <0.01%; P < 0.001), and Gram-negative infection (0.07% vs. 0.03%; P = 0.013). After adjusting for mortality risk, calendar year, age, race and ethnicity, insurance, and zip-code level income, it was found that a positive HIV status was associated with a 91.1% increased odds of mortality (95% CI: 3.9%–351.5%; P = 0.037).ConclusionAs ART are readily available, we expected better outcomes for our HIV-positive pregnant females. Our results are concerning that there is such an increase rate of mortality and health disparity in HIV-positive pregnant females. As this is a retrospective study, there are limitation and further studies need to be conducted.Disclosures All authors: No reported disclosures.

Individual education, area income, and mortality and recurrence of myocardial infarction in a Medicare cohort: the National Longitudinal Mortality Study.

BackgroundThe Medicare program provides universal access to hospital care for the elderly; however, mortality disparities may still persist in this population. The association of individual education and area income with survival and recurrence post Myocardial Infarction (MI) was assessed in a national sample.MethodsIndividual level education from the National Longitudinal Mortality Study was linked to Medicare and National Death Index records over the period of 1991-2001 to test the association of individual education and zip code tabulation area median income with survival and recurrence post-MI. Survival was partitioned into 3 periods: in-hospital, discharge to 1 year, and 1 year to 5 years and recurrence was partitioned into two periods: 28 day to 1 year, and 1 year to 5 years.ResultsFirst MIs were found in 8,043 women and 7,929 men. In women and men 66-79 years of age, less than a high school education compared with a college degree or more was associated with 1-5 year mortality in both women (HRR 1.61, 95% confidence interval 1.03-2.50) and men (HRR 1.37, 1.06-1.76). Education was also associated with 1-5 year recurrence in men (HRR 1.68, 1.18-2.41, < High School compared with college degree or more), but not women. Across the spectrum of survival and recurrence periods median zip code level income was inconsistently associated with outcomes. Associations were limited to discharge-1 year survival (RR lowest versus highest quintile 1.31, 95% confidence interval 1.03-1.67) and 28 day-1 year recurrence (RR lowest versus highest quintile 1.72, 95% confidence interval 1.14-2.57) in older men.ConclusionsDespite the Medicare entitlement program, disparities related to individual socioeconomic status remain. Additional research is needed to elucidate the barriers and mechanisms to eliminating health disparities among the elderly.