Effect of Stay-at-Home Orders and Other COVID-Related Policies on Trauma Hospitalization Rates and Disparities in the United States: A Statewide Time-Series Analysis.. [PMID: 35898348 PMCID: PMC9327631 DOI: 10.1101/2022.07.11.22277511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background:

To combat the coronavirus pandemic, states implemented several public health policies to reduce infection and transmission. Increasing evidence suggests that these prevention strategies also have had a profound impact on non-COVID healthcare utilization. The goal of this study was to determine the impact of a statewide Stay-at-Home and other COVID-related policies on trauma hospitalizations, stratified by race/ethnicity, age, and sex.

Methods:

We used the North Carolina Trauma Registry, a statewide registry of trauma hospitalizations to 18 hospitals across North Carolina, including all North Carolina trauma centers, to calculate weekly assault, self-inflicted, unintentional motor vehicle collision (MVC), and other unintentional injury hospitalization rates between January 1, 2019 and December 31, 2020. Interrupted time-series design and segmented linear regression were used to estimate changes in hospitalizations rates after several COVID-related executive orders, overall and stratified by race/ethnicity, age, and gender. Hospitalization rates were compared after 1) U.S. declaration of a public health emergency; 2) North Carolina statewide Stay-at-Home order; 3) Stay-at-Home order lifted with restrictions (Phase 2: Safer-at-Home); and 4) further lifting of restrictions (Phase 2.5: Safer-at-Home).

Results.

There were 70,478 trauma hospitalizations in North Carolina from 2019–2020. In 2020, median age was 53 years old and 59% were male. Assault hospitalization rates (per 1,000,000 NC residents) increased after the Stay-at-Home order, but only among Black/African American residents (incidence rate difference [IRD]=7.9; other racial/ethnic groups’ IRDs ranged 0.9 to 1.7) and 18–44 year-old males (IRD=11.9; other sex/age groups’ IRDs ranged −0.5 to 3.6). After major restrictions were lifted, assault rates returned to pre-COVID levels. Unintentional injury hospitalizations decreased after the public health emergency, especially among older adults, but returned to 2019 levels within several months.

Conclusions:

Statewide Stay-at-Home orders put Black/African American residents at higher risk for assault hospitalizations, exacerbating pre-existing disparities. Fear of COVID-19 may have also led to decreases in unintentional non-MVC hospitalization rates, particularly among older adults. Policy makers must anticipate possible negative effects and develop approaches for mitigating harms that may disproportionately affect already disadvantaged communities.

Perceptions of Gender Disparities in Access to Surgical Care in Malawi: A Community Based Survey

BACKGROUND

Gender disparities in surgical care exist but have been minimally studied, particularly in low- and middle-income countries. This study explored perceptions and gender differences in health-seeking behavior and attitudes toward surgical care in Malawi among community members.

METHODS

A survey tool was administered to adults ≥18 years old at a central hospital, district hospital, and two marketplaces in Malawi from June 2018 to December 2018. Responses from men and women were compared using chi-squared tests.

RESULTS

Four hundred eighty-five adults participated in the survey, 244 (50.3%) men and 241 (49.7%) women. Women were more likely to state that fear of surgery might prevent them from seeking surgical care (29.1% of men, 43.6% of women, P = .0009). Both genders reported long wait times, medicine/physician shortages, and lack of information about when surgery is needed as potential barriers to seeking surgical care. More men stated that medical preference should be given to sons (17.1% of men, 9.3% of women, P = .01). Men were more likely to report that men should have the final word about household decisions (28.7% of men vs 19.5% of women, P < .0001) and were more likely to spend money independently (68.7% of married men, 37.5% of married women, P < .0001). Few participants reported believing gender equality had been achieved (61% of men and 66.8% of women).

CONCLUSIONS

A multi-pronged approach is needed to reduce gender disparities in surgical care in Malawi, including addressing paternalistic societal norms, education, and improving health infrastructure.

Pathologic complete response and survival after neoadjuvant chemotherapy in cT1-T2/N0 HER2+ breast cancer

Women with small HER2+ breast cancers may have excellent prognosis with adjuvant single-agent chemotherapy and HER2-targeted therapy. The role of de-escalated therapy in the neoadjuvant setting, however, remains uncertain. We conducted a cohort study of adult women with T1-2/cN0 HER2+ breast cancer diagnosed 2013–2016 in the National Cancer Database treated with neoadjuvant chemotherapy (NAC) and HER2-targeted therapy. Factors associated with pathologic complete response (pCR) and overall survival were examined. In total, 6994 patients were included, 32% cT1 and 68% cT2. Multi-agent NAC was given to 90% of women while single-agent NAC was given to 10% of women. pCR was achieved in 46% of cT2 patients and 43% of cT1, and in 46% of patients treated with multi-agent versus 38% single agent. Patients receiving multi-agent chemotherapy were younger, had fewer comorbidities, and had higher cT stage and grade. In all patients, pCR was associated with improved survival (p < 0.01). Multi-agent chemotherapy (OR 1.3, p = 0.003), hormone receptor negative (OR 2.6, p < 0.001), higher grade (OR 2.2, p < 0.001), younger age (OR 1.4, p = 0.011), and later year of diagnosis (OR 1.3, p = 0.005) were associated with achieving pCR. Multi-agent chemotherapy was associated with higher likelihood of pCR, but this effect was modest compared to other factors. Single-agent NAC with HER2-directed therapy in selected patients may provide excellent outcome with reduced toxicity, while allowing escalated therapy in the adjuvant setting for patients with residual disease. Prospective studies are needed to determine effects of de-escalation in the neoadjuvant setting on survival and optimal selection strategies.

COVID-19-Related Discrimination Among Racial/Ethnic Minorities and Other Marginalized Communities in the United States

Objectives. To determine the prevalence of COVID-19-related discrimination among major US racial/ethnic groups and estimate associations between discrimination, race/ethnicity, and other sociodemographic characteristics. Methods. We conducted a nationally representative online survey of 5500 American Indian/Alaska Native, Asian, Black/African American, Hawaiian/Pacific Islander, Latino (English and Spanish speaking), White, and multiracial adults from December 2020 to February 2021. Associations between sociodemographic characteristics and COVID-19-related discrimination were estimated via multinomial logistic regression. Results. A total of 22.1% of the participants reported experiencing discriminatory behaviors, and 42.7% reported that people acted afraid of them. All racial/ethnic minorities were more likely than White adults to experience COVID-19-related discrimination, with Asian and American Indian/Alaska Native adults being most likely to experience such discrimination (discriminatory behaviors: adjusted odd ratio [AOR] = 2.59; 95% confidence interval [CI] = 1.73, 3.89; and AOR = 2.67; 95% CI = 1.76, 4.04; people acting afraid: AOR = 1.54; 95% CI = 1.15, 2.07; and AOR = 1.84; 95% CI = 1.34, 2.51). Limited English proficiency, lower education, lower income, and residing in a big city or the East South Central census division also increased the prevalence of discrimination. Conclusions. COVID-19-related discrimination is common, and it appears that the pandemic has exacerbated preexisting resentment against racial/ethnic minorities and marginalized communities. Efforts are needed to minimize and discredit racially driven language and discrimination around COVID-19 and future epidemics. (Am J Public Health. 2022;112(3):453-466. https://doi.org/10.2105/AJPH.2021.306594).

Epidemiologic and Economic Burden of Achalasia in the United States

BACKGROUND & AIMS

Achalasia is a debilitating chronic condition of the esophagus. Currently there are no national estimates on the epidemiologic and economic burden of disease. We sought to estimate trends in incidence and prevalence of achalasia by age-sex strata, and to estimate the total direct medical costs attributed to achalasia in the United States.

METHODS

We conducted a cohort study using two administrative claims databases: IBM MarketScan Commercial Claims and Encounters database (2001-2018; age <65) and a 20% sample of nationwide Medicare enrollment and claims (2007-2015; age ≥65). Point prevalence was calculated on the first day of each calendar year; the incidence rate captured new cases developed in the ensuing year. Utilization rates of healthcare services and procedures were reported. Mean costs per patient were calculated and standardized to the corresponding U.S. Census Bureau population data to derive achalasia-specific total direct medical costs.

RESULTS

The crude prevalence of achalasia per 100,000 persons was 18.0 (95% CI, 17.4, 18.7) in MarketScan and 162.1 (95% CI, 157.6, 166.6) in Medicare. The crude incidence rate per 100,000 person-years was 10.5 (95% CI, 9.9, 11.1) in MarketScan and 26.0 (95% CI, 24.9, 27.2) in Medicare. Incidence and prevalence increased substantially over time in the Medicare cohort, and increased with more advanced age in both cohorts. Utilization of achalasia-specific healthcare was high; national estimates of total direct medical costs exceeded $408 million in 2018.

CONCLUSIONS

Achalasia has a higher epidemiologic and economic burden in the US than previously suggested, with diagnosis particularly increasing in older patients.

Sociodemographic and Clinical Predictors of Neoadjuvant Chemotherapy in cT1-T2/N0 HER2-Amplified Breast Cancer

BACKGROUND

The optimal treatment strategy for small node-negative human epidermal growth factor receptor 2-positive (HER2+) breast cancer remains controversial. Neoadjuvant chemotherapy may risk overtreatment, whereas surgery first fails to identify patients with residual disease in need of escalated adjuvant systemic therapy. We investigated patient characteristics associated with receipt of neoadjuvant chemotherapy.

METHODS

Adult women with cT1-T2/N0, HER2+ breast cancer between 2013 and 2017 in the National Cancer Database who underwent surgery within 8 months of diagnosis were included. Patients were classified as receiving neoadjuvant chemotherapy versus a surgery-first approach. We assessed the sociodemographic and clinical predictors of neoadjuvant chemotherapy versus surgery first and associations between neoadjuvant chemotherapy and breast cancer treatments using multivariable regression models.

RESULTS

We identified 56,784 women, of whom 12,758 (22%) received neoadjuvant chemotherapy, 29,139 (53%) received adjuvant chemotherapy, 12,907 (24%) received no chemotherapy, and 1980 were missing chemotherapy information. After adjustment, cT2 stage was the strongest predictor of neoadjuvant chemotherapy compared with surgery first. Younger age and later diagnosis year were positively associated with receipt of neoadjuvant chemotherapy. In contrast, hormone receptor positivity, Black race, rural county, and government-funded or no health insurance were inversely associated with neoadjuvant chemotherapy. In multivariable analyses, patients who received neoadjuvant chemotherapy were more likely to have a mastectomy (vs. lumpectomy) and sentinel lymph node biopsy or no nodal surgery (vs. axillary lymph node dissection). Patients who received neoadjuvant chemotherapy were more likely to receive multi-agent (vs. single-agent) chemotherapy than those who received adjuvant chemotherapy.

CONCLUSIONS

Substantial differences in the utilization of neoadjuvant chemotherapy exist in women with HER2+ breast cancer, which reflect both clinical parameters and disparities. Optimal treatment strategies should be implemented equitably across sociodemographic groups.

Racial/ethnic disparities in intent to obtain a COVID-19 vaccine: A nationally representative United States survey

Black, Latino, Pacific Islander, and American Indian/Alaska Native adults are more likely than White adults to experience SARS-CoV-2-related infections, hospitalizations, and mortality. We assessed intent to be vaccinated and concerns among 7 U.S. racial/ethnic groups (1,000 Black/African American, 500 American Indian/Alaska Native, 1,000 Asian, 1,000 Latino (500 English- and 500 Spanish-speaking), 500 Pacific Islander, 500 multiracial, and 1,000 White adults) in a cross-sectional online survey conducted December 2020-February 2021, weighted to be nationally representative within groups. Intent to be vaccinated was ascertained with: "If a COVID-19 vaccine becomes available, how likely are you to get vaccinated?" (not at all/slightly/moderately/very/extremely likely). Respondents identified which concerns would keep them from being vaccinated: cost, not knowing where, safety, effectiveness, side-effects, and other. Multinomial logistic regression models assessed associations of race/ethnicity with odds of being extremely/very/moderately, slightly likely to be vaccinated (ref = not at all), controlling for demographics and health. Overall, 30% were extremely likely, 22% not at all likely, and 48% unsure. Compared to White respondents, American Indian/Alaska Native (Adjusted Odds Ratio (AOR) = 0.66, 95% CI, 0.47-0.92) and Black/African American (AOR = 0.54, 95% CI, 0.41-0.72) respondents were less likely, and Asian (AOR = 2.21, 95% CI, 1.61-3.02) and Spanish-speaking Latino respondents (AOR = 3.74, 95% CI, 2.51-5.55) were more likely to report being extremely likely to be vaccinated. Side-effects (52%) and safety (45%) were overriding concerns. Intent and vaccination rates are changing rapidly; these results constitute a comprehensive baseline for ongoing vaccination efforts among U.S. racial and ethnic groups.

Higher Admission Frailty Scores Predict Increased Mortality, Morbidity, and Healthcare Utilization in the Elderly Burn Population

The Rockwood Clinical Frailty Scale is a validated rapid assessment of frailty phenotype and predictor of mortality in the geriatric population. Using data from a large tertiary care burn center, we assessed the association between admission frailty in an elderly burn population and inpatient outcomes. This was a retrospective analysis of burn patients ≥ 65 years from 2015-2019. Patients were assigned to frailty subgroups based on comprehensive medical, social work, and therapy assessments. Cox proportional hazards regression was used to estimate associations between admission frailty and 30-day inpatient mortality. Our study included 644 patients (low frailty: 262, moderate frailty: 345, and high frailty: 37). Frailty was associated with higher median TBSA and age at admission. The 30-day cumulative incidence of mortality was 2.3%, 7.0%, and 24.3% among the low, moderate, and high frailty strata, respectively. After adjustment for age, TBSA, and inhalation injury, high frailty was associated with increased 30-day mortality, compared to low (HR 5.73; 95% CI 1.86, 17.62). Moderate frailty also appeared to increase 30-day mortality, although estimates were imprecise (HR 2.19; 95% CI 0.87-5.50). High frailty was associated with increased morbidity and healthcare utilization, including need for intensive care stay (68% vs 37% and 21%, p<0.001) and rehab or care facility at discharge (41% vs 25% and 6%, p<0.001), compared to moderate and low frailty subgroups. Our findings emphasize the need to consider pre-injury physiological state and the increased risk of death and morbidity in the elderly burn population.

Obesity Increases the Risk of Hospital Readmission Following Intestinal Surgery for Children With Crohn Disease

OBJECTIVES

Obese habitus can lead to adverse outcomes for colorectal surgeries due to technical challenges and pro-inflammatory immune mediators associated with excess adipose tissue. Surgical planning, pre-operative risk stratification, and patient counseling of pediatric Crohn disease (CD) patients are limited by the scarcity of data on this topic. We sought to determine the association between obesity and hospital readmission in children with CD undergoing intestinal resection.

METHODS

We used the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database to identify pediatric CD patients undergoing intestinal resection between 2012 and 2018. We calculated age- and sex-adjusted body mass index (BMI) z scores using CDC population statistics. We used logistic regression to evaluate the association between obesity and readmission compared to average-BMI patients adjusting for age, race, sex, steroid exposure, disease activity, and surgery type.

RESULTS

We evaluated 1258 pediatric CD intestinal resections occurring between 2012 and 2018. Patients were predominantly adolescent (91%), white (84%), and male (56%). Those with average BMI comprised 50% of the cohort, 31% were underweight, 11% overweight, and 8% obese. The overall 30-day hospital readmission rate was 8.8%. Compared to those with average BMI, obese children had a 2-fold (adjusted odds ratio 1.9, 95% confidence interval 1.0-3.8) increase in risk of hospital readmission.

CONCLUSIONS

Obese patients undergoing intestinal resection face a higher risk of 30-day hospital readmission compared to average-BMI patients. These results can inform pre-surgical risk counseling and underscore the need for long-term weight management strategies to aid in risk reduction for obese children with CD at risk of future surgery.

Association of Preoperative Depression and Anxiety With Long-term Opioid Use After Hysterectomy for Benign Indications

OBJECTIVE

To assess whether preoperative depression or anxiety is associated with increased risk of long-term, postoperative opioid use after hysterectomy among women who are opioid-naïve.

METHODS

We conducted an observational cohort study of 289,233 opioid-naïve adult women (18 years or older) undergoing hysterectomy for benign indications from 2010 to 2017 using IBM MarketScan databases. Opioid use and refills in the 180 days after surgery and preoperative depression and anxiety were assessed. Secondary outcomes included 30-day incidence of emergency department visits, readmission, and 180-day incidence of opioid complications. The association of depression and anxiety were compared using inverse-probability of treatment weighted log-binomial and proportional Cox regression.

RESULTS

Twenty-one percent of women had preoperative depression or anxiety, and 82% of the entire cohort had a perioperative opioid fill (16% before surgery, 66% after surgery). Although perioperative opioid fills were relatively similar across the two groups (risk ratio [RR] 1.07, 95% CI 1.06-1.07), women with depression or anxiety were significantly more likely to have a postoperative opioid fill at every studied time period (RRs 1.44-1.50). Differences were greater when restricted to persistent use (RRs 1.49-2.61). Although opioid complications were rare, women with depression were substantially more likely to be diagnosed with opioid dependence (hazard ratio [HR] 5.54, 95% CI 4.12-7.44), and opioid use disorder (HR 4.20, 95% CI 1.97-8.96).

CONCLUSION

Perioperative opioid fills are common after hysterectomy. Women with preoperative anxiety and depression are more likely to experience persistent use and opioid-related complications.

A Comparison of Adult and Pediatric Enhanced Recovery after Surgery Pathways: A Move for Standardization

BACKGROUND

Enhanced recovery protocols (ERP) are a multimodal approach to standardize perioperative care. To substantiate the benefit of a pediatric-centered pathway, we compared outcomes of children treated with pediatric ERP (pERP) versus adult (aERP) pathways. We aimed to compare components of each pathway to create a new comprehensive pERP to reduce variation in care.

METHODS

Retrospective study of children (≤18 y) undergoing elective colorectal surgery from August 2015 to April 2019 at a single institution managed with pERP versus aERP. Multivariable linear and logistic regression, adjusting for demographics and operation characteristics, were used to compare outcomes.

RESULTS

Out of 100 hospitalizations (72 patients) were identified, including 37 treated with pERP. pERP patients were, on average, younger (13 versus 16 y), more likely to be ASA III (70% versus 30%), and more likely to receive regional (32% versus 3%) or neuraxial (35% versus 8%) anesthesia. Epidural use was an independent risk factor for longer length of stay (P = 0.000). After adjustment, pERP patients had similar LOS and time to oral intake, but shorter foley duration. pERP patients used significantly fewer opioids and were less likely to return to the operating room within 30 d. 30-d readmissions and ED visits were also lower, but this was not statistically significant.

CONCLUSIONS

At our institution, data from both ERPs contributed formation of a synthesized pathway and reflected the pERP approach to opioid utilization and the aERP approach to earlier enteral nutrition.

Surgical Axillary Staging Before Neoadjuvant Chemotherapy: Who Gets It and Why We Should Avoid It

BACKGROUND

Surgical axillary staging demonstrating positive nodal disease before neoadjuvant chemotherapy (NAC) necessitates axillary lymph node dissection (ALND) post-NAC. Despite evidence supporting post-NAC surgical staging, we hypothesized that there is persistent use of pre-NAC staging and that it is associated with aggressive clinicopathologic features and a higher rate of subsequent ALND.

PATIENTS AND METHODS

Stage I-III breast cancer patients who underwent lymph node staging surgery and received NAC between 2013 and 2017 in the National Cancer Database were included. Sequence of staging surgery and chemotherapy administration was determined. Multivariable regression was used to assess characteristics associated with pre-NAC staging. Rate of ALND was compared between those who had pre- and post-NAC surgical axillary staging.

RESULTS

In total, 120,538 met inclusion; 68% received NAC first and 32% had pre-NAC staging. Pre-NAC staging surgery was associated with younger age (age < 30 versus 40-49 years, HR 1.1) and decreased with older age (ages 70-79/80+ versus 40-49 years, HR 0.86 and 0.73). Advancing clinical T stage, lobular subtype, higher grade, and HR+/HER2- subtype were also associated with pre-NAC surgical staging. Women who underwent pre-NAC surgical staging were more likely to undergo ALND.

CONCLUSIONS

Over 30% of women underwent surgical axillary staging prior to NAC, resulting in higher rates of ALND in this cohort. While certain features suggestive of aggressive behavior (grade and T stage) were associated with pre-NAC surgical axillary staging, women with more aggressive tumor subtypes (triple negative/HER2+) were less likely to undergo pre-NAC surgical axillary staging. Pre-NAC surgical axillary staging should be performed only in rare circumstances to avoid unnecessary ALND.

Socioeconomic factors in timing of esophagectomy and association with outcomes

BACKGROUND AND OBJECTIVES

Disparities in esophageal cancer are well-established. The standard treatment for locally advanced esophageal cancer is chemoradiation followed by surgery. We sought to evaluate the association between socioeconomic factors, time to surgery, and patient outcomes.

METHODS

All patients ≥18 years old diagnosed with T2/3/4 or node-positive esophageal cancer between 2004 and 2016 and who underwent chemoradiation and esophagectomy in the National Cancer Database were included. Multivariable regression was used to assess the association between socioeconomic variables and time to surgery (grouped into <56, 56-84, and 85-112 days).

RESULTS

A total of 12 157 patients were included. Five-year overall survival was 39%, 35%, and 35% for the three groups examined. Postoperative 30- and 90-day mortality was increased in both the 56-84 days to surgery group (odds ratio [OR]: 1.30 and 1.20, respectively) and the 85-112 days group (OR: 1.37 and 1.56, respectively) when compared to <56 days. Patients of a minority race, public insurance, or lower income were more likely to have a longer time to surgery.

CONCLUSION

Longer time to surgery is associated with increased postoperative mortality and is more common in patients with lower socioeconomic status. Further research exploring reasons for delays to esophagectomy among disadvantaged patients could help target interventions to reduce disparities.

Associations Between Career Satisfaction, Personal Life Factors, and Work-Life Integration Practices Among US Surgeons by Gender

Importance

Burnout among US surgeons is alarmingly high, particularly among women, and work-life integration conflicts contribute to career dissatisfaction.

Objective

To evaluate associations between surgical career satisfaction and personal life factors such as time requirements for outside interests, household chores, and parenting responsibilities and to explore similarities and differences between men and women.

Design, Setting, and Participants

This cross-sectional survey study of practicing US surgeons was conducted between June 4 and August 1, 2018. The 257-item online survey was sent to 25 748 fellows of the American College of Surgeons. A 31-item subanalysis was performed from August 13 to November 4, 2019.

Main Outcomes and Measures

Degree of career satisfaction was measured on a 5-point Likert scale. Professional and personal life factors associated with career satisfaction were evaluated with gender-stratified multivariable proportional odds models.

Results

Among 3807 respondents, 3166 self-identified as male (83%) and 639 (17%) as female. Fewer women reported career satisfaction (483 [77%] vs 2514 [82%]) and relatively more women reported problematic interruption of personal life owing to work (315 [50%] vs 1381 [45%]). A higher proportion of women reported being primarily responsible for meal preparation (282 [46%] vs 355 [12%]) and housekeeping (149 [24%] vs 161 [5%]). On multivariable analyses, factors independently associated with career satisfaction were generally similar between genders. Stronger collegial support of work-life integration efforts was significantly associated with higher career satisfaction for both genders (P < .001), although the odds ratio (OR) for women was higher than for men (OR, 4.52; 95% CI, 2.60-7.87 vs OR, 2.45; 95% CI, 1.88-3.21). For men and women, increasing age was significantly associated with higher career satisfaction (men: OR, 1.04; 95% CI, 1.03-1.05; P < .001; women: OR, 1.04; 95% CI, 1.02-1.06; P = .001), and insufficient time for family owing to work was associated with lower satisfaction (men: OR, 0.66; 95% CI, 0.49-0.90; P = 009; women: OR, 0.49; 95% CI, 0.30-0.81; P = .006). For women only, there was a significant association between primary responsibility for at least 1 household chore and lower career satisfaction (OR, 0.66; 95% CI, 0.45-0.98; P = .04).

Conclusions and Relevance

In this study, although women had relatively lower surgical career satisfaction than men, the associations between career satisfaction and personal life factors were largely similar. Collegial support of work-life integration efforts appeared to be the most influential factor, particularly for women. Optimization of work-life integration may not only decrease physician burnout but also promote gender equity in surgery.

Use and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism in the Medicare population

BACKGROUND

Few studies assess use of parathyroidectomy among older adults with symptomatic primary hyperparathyroidism. Our objective was to determine national usage and disparities in parathyroidectomy for symptomatic primary hyperparathyroidism among insured older adults.

METHODS

We identified older adult patients with symptomatic primary hyperparathyroidism using Medicare claims (2006-2017). Primary study variables were race/ethnicity, rurality, and zip-code socioeconomic status. We calculated cumulative incidence of parathyroidectomy and used multivariable Cox proportional hazards regression models to assess the adjusted association of our study variables with parathyroidectomy.

RESULTS

We included 94,803 patients. The median age at primary hyperparathyroidism diagnosis was 76 years (interquartile range 71-82). The majority of patients were female (72%), non-Hispanic White (82%), from metropolitan areas (82%), and had a Charlson Comorbidity score ≥3 (62%). Nine percent of patients (n = 8,251) underwent parathyroidectomy during follow-up. After adjustment, non-Hispanic Black patients, compared to non-Hispanic White (hazard ratio 0.80; 95% confidence interval 0.74, 0.87), and living in a low socioeconomic status neighborhood (low socioeconomic status vs highest socioeconomic status hazard ratio 0.89; 95% confidence interval 0.83, 0.95) were both associated with lower incidences of parathyroidectomy. Patients from non-metropolitan areas were more likely to undergo parathyroidectomy.

CONCLUSION

Parathyroidectomy is underused for symptomatic primary hyperparathyroidism in older adults. Quality improvement efforts, rooted in equitable care, should be undertaken to increase access to parathyroidectomy for this disease.

Effect of government-issued state of emergency and reopening orders on cardiovascular hospitalizations during the COVID-19 pandemic

OBJECTIVE

Little is known about the effect of government-issued State of Emergency (SOE) and Reopening orders on health care behaviors. We aimed to determine the effect of SOE and Phase 1 of Reopening orders on hospitalizations for acute myocardial infarction (AMI) or acute decompensated heart failure (ADHF).

METHODS

Hospitalizations for AMI and ADHF in the UNC Health system, which includes 10 hospitals in both urban and rural counties, were identified. An interrupted time series design was used to compare weekly hospitalization rates for eight weeks before the March 10th SOE declaration, eight weeks between the SOE order and Phase 1 of Reopening order, and the subsequent eight weeks.

RESULTS

Overall, 3,792 hospitalizations for AMI and 7,223 for ADHF were identified. Rates before March 10th were stable. AMI/ADHF hospitalizations declined about 6% per week in both urban and rural hospitals from March 11th to May 5th. Larger declines in hospitalizations were seen in adults ≥65 years old (-8% per week), women (-7% per week), and White individuals (-6% per week). After the Reopening order, AMI/ADHF hospitalizations increased by 8% per week in urban centers and 9% per week in rural centers, including a significant increase in each demographic group. The decline and rebound in acute CV hospitalizations were most pronounced in the two weeks following the government orders.

CONCLUSIONS

AMI and ADHF hospitalization rates closely correlated to SOE and Reopening orders. These data highlight the impact of public health measures on individuals seeking care for essential services; future policies may benefit from clarity regarding when individuals should present for care.

Potential to Mitigate Disparities in Access to Kidney Transplant in the Hispanic/Latino Population With a Specialized Clinic: Single Center Study Representing Single State Data

BACKGROUND

We sought to evaluate potential disparities in kidney transplant rates in a single state in the United States. We studied the potential to mitigate disparities with a specialized clinic using it as a model presentation.

METHODS

Based on data from the United States Renal Data System and Organ Procurement and Transplantation Network, we estimated the yearly end-stage renal disease and waitlist addition, stratified by race/ethnicity from 2000 to 2018. Institution rates were analyzed similarly, and the implementation of a focused Latino clinic was evaluated.

RESULTS

The number of patients added to the national transplant waitlist has increased by 40% in non-Latino whites and by 160% in Latinos from 2000 to 2017. Comparing the period from 2000 to 2004 to 2015 to 2018 in North Carolina, the waitlist increased for Latino patients by 482% and non-Latino whites by 23%. One year after a designated Latino transplant clinic at our institution, there was a 125% increase in the number of Latino referrals for kidney transplant evaluation, a 142% increase in the number of waitlisted Latino patients, and an increase in kidney transplants of 145%.

CONCLUSION

With the increasing number of patients in the Latino community who are diagnosed with end-stage renal disease, there is a direct benefit for a culturally competent program that addresses access to transplants.

Gender Bias in Surgical Oncology Fellowship Recommendation Letters: Gaining Progress

OBJECTIVE

Gender bias has been identified in letters of recommendation (LOR) in many different surgical training fields. Among surgeons, women comprise over 30% of the full-time faculty positions nationally and surgical oncology is one of the most gender diverse surgical subspecialties. We sought to determine if bias existed in LOR submitted to a Complex General Surgical Oncology (CGSO) fellowship.

DESIGN

LOR for the CGSO fellowship were retrospectively analyzed from applicants at a single institution over an 8-year period (2013-2020). The linguistic content of the letters was analyzed using Linguistic Inquiry and Word Count (LIWC2015), a validated text analysis program. Using multivariable analysis, LOR were compared by gender of both applicant and letter writer to explore the association between gender and the characteristics of the applicants and letter writers.

SETTING

University of North Carolina at Chapel Hill (UNC), Division of Surgical Oncology and Endocrine Surgery.

PARTICIPANTS

Applicants interviewed for the CSGO fellowship program at the UNC from 2013 to 2020 as well as all applicants from the 2018 application cycle, regardless of interview status.

RESULTS

About 841 letters from 219 interviewed applicants throughout the 2013 to 2020 surgical oncology fellowship application cycles were included. No difference in authenticity, clout, analytic thinking, or emotional tone of the letters was seen when comparing men and women applicants. Of the 41 word categories analyzed, only "references to achievement" in LOR written for women was significantly higher when compared to LOR written for men (p = 0.01). Interestingly, significantly more women applicants had at least 1 LOR written by a woman (p = 0.04). A subset analysis of all applicants regardless of interview status from the 2018 cycle included 294 LOR from 77 applicants. With the inclusion of noninterviewed applicants, LOR for men had more analytic tone than LOR for women (p = 0.02), otherwise there were no significant differences between the groups.

CONCLUSIONS

Very few differences in LOR were found for applicants at a CGSO fellowship program based on applicant or letter writer gender. The lack of gender bias demonstrates progress within the field of surgical oncology, likely a result of recent work and educational effort in this area. Efforts to expand this progress into other surgical sub-specialties are necessary.

Performance of ABCD-10 and SCORTEN mortality prediction models in a cohort of patients with Stevens-Johnson syndrome/toxic epidermal necrolysis

BACKGROUND

Age, bicarbonate, cancer, dialysis, 10% body surface area risk model (ABCD-10) has recently been proposed as an alternative to the SCORe of toxic epidermal necrolysis (SCORTEN) model for predicting in-hospital mortality in patients with Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN). In contrast to SCORTEN, ABCD-10 incorporates prior dialysis and upweights the impact of cancer.

OBJECTIVE

To determine the performance of ABCD-10 compared with that of SCORTEN in mortality prediction at a large, tertiary burn center.

METHODS

A retrospective analysis of 192 patients with SJS/TEN admitted to the North Carolina Jaycee Burn Center from January 1, 2009, to December 31, 2019, was conducted. Data on these patients were collected using the burn registry and a manual chart review. The performance of both the mortality prediction models was assessed using univariate logistic regression and the Hosmer-Lemeshow test.

RESULTS

The overall mortality was 22% (n = 43). Nine (5%) patients had cancer, and 7 (4%) had undergone prior dialysis; neither factor was associated with mortality (P = .11 and P = .62, respectively). SCORTEN was well calibrated to predict inpatient mortality (P = .82), whereas ABCD-10 appeared to have a poorer fit (P < .001) in these patients. Both the models showed good discrimination.

LIMITATIONS

Small sample size.

CONCLUSION

SCORTEN was a better predictor of inpatient mortality than ABCD-10 in a North American cohort of patients treated at the tertiary burn center.

Socioeconomic disparities in ostomy reversal among older adults with diverticulitis are more substantial among non-Hispanic Black patients

BACKGROUND

While ostomies for diverticulitis are often intended to be temporary, ostomy reversal rates can be as low as 46%. There are few comprehensive studies evaluating the effects of socioeconomic status as a disparity in ostomy reversal. We hypothesized that among the elderly Medicare population undergoing partial colectomy for diverticulitis, lower socioeconomic status would be associated with reduced reversal rates.

METHODS

Retrospective cohort study using a 20% representative sample of Medicare beneficiaries >65 years old with diverticulitis who received ostomies between January 1, 2010, to December 31, 2017. We evaluated the effect of neighborhood socioeconomic status, measured by the Social Deprivation Index, on ostomy reversal within 1 year. Secondary outcomes were complications and mortality.

RESULTS

Of 10,572 patients, ostomy reversals ranged from 21.2% (low socioeconomic status) to 29.8% (highest socioeconomic status), with a shorter time to reversal among higher socioeconomic status groups. Patients with low socioeconomic status were less likely to have their ostomies reversed, compared with the highest socioeconomic status group (hazard ratio 0.83, 95% confidence interval 0.74-0.93) and were more likely to die (hazard ratio 1.21, 95% confidence interval 1.10-1.33). When stratified by race/ethnicity and socioeconomic status, non-Hispanic White patients at every socioeconomic status had a higher reversal rate than non-Hispanic Black patients (White patients 32.0%-24.8% vs Black patients 19.6%-14.7%). Socioeconomic status appeared to have a higher relative impact among non-Hispanic Black patients.

CONCLUSION

Among Medicare diverticulitis patients, ostomy reversal rates are low. Patients with lower socioeconomic status are less likely to undergo stoma reversal and are more likely to die; Black patients are least likely to have an ostomy reversal.

Association Between Alcohol, Substance Use, and Inpatient Burn Outcomes

The use of alcohol and illicit substances has been associated with impaired judgment and health, but the effect on inpatient outcomes after burn injury remains unsettled. Our objective was to evaluate the effect of alcohol and illicit substance use on our inpatient burn outcomes. Adult patients admitted with burn injury-including inhalation injury only-between January 1, 2014 and June 30, 2019 were eligible for inclusion. Alcohol use and illicit drug use were identified on admission. Outcomes of interest included requiring mechanical ventilation, admission to the intensive care unit, length of stay, and inpatient mortality. Multivariable linear and logistic regression models were used to estimate the effects of use on inpatient outcomes. A total of 3476 patients were included in our analyses; 8% (n = 284) tested positive for alcohol, 10% (n = 364) tested positive for cocaine, and 27% (n = 930) tested positive for marijuana and at admission. Two hundred and eighty adults (18% of all positive patients) tested positive for at least two substances. Patients who tested positive for alcohol had longer lengths of stay and were more likely to be admitted to the intensive care unit. Patients who tested positive for cocaine had longer overall and intensive care unit lengths of stay. No differences in inpatient outcomes were seen among patients who tested positive for marijuana. Neither alcohol nor illicit substance use appears to affect inpatient mortality after burns. Alcohol and cocaine use significantly increased overall length of stay. Marijuana use had no impact on inpatient outcomes.

Does acral lentiginous melanoma subtype account for differences in patterns of care in Black patients?

BACKGROUND

Melanoma-specific outcomes for Black patients are worse when compared to non-Hispanic white (NHW) patients. We sought to evaluate whether acral lentiginous melanoma, seen more commonly in Black patients, was associated with racial disparities in outcomes METHODS: The National Cancer Database was analyzed for major subtypes of stage I-IV melanoma diagnosed from 2004 to 2016. The association between Black race and (Siegel et al., Jan) 1 acral melanoma diagnosis and (Bradford et al., Apr) 2 receipt of major amputation for surgical management of melanoma was evaluated using multivariable logistic regression.

RESULTS

251,864 patients were included (1453 Black). Black patients had increased odds of acral melanoma (odds ratio [OR] = 27.6, 95% CI]: 24.4, 31.2) compared to NHW patients. Black patients still had higher odds ratios of major amputation across all stages after adjusting for acral histology and other potential confounders CONCLUSIONS: Increased prevalence of acral melanoma in Black patients does not fully account for increased receipt of major amputation.