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Sakowitz S, Bakhtiyar SS, Mallick S, Porter G, Ali K, Vadlakonda A, Curry J, Benharash P. Persistent Racial Disparities in Morbidity Following Major Elective Operations. Am Surg 2024; 90:2913-2920. [PMID: 38820594 DOI: 10.1177/00031348241257462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Introduction: Despite considerable national attention, racial disparities in surgical outcomes persist. We sought to consider whether race-based inequities in outcomes following major elective surgery have improved in the contemporary era. Methods: All adult hospitalization records for elective coronary artery bypass grafting, abdominal aortic aneurysm repair, colectomy, and hip replacement were tabulated from the 2016-2020 National Inpatient Sample. Patients were stratified by Black or White race. To consider the evolution in outcomes, we included an interaction term between race and year. We designated centers in the top quartile of annual procedural volume as high-volume hospitals (HVH). Results: Of ∼2,838,485 patients, 245,405 (8.6%) were of Black race. Following risk-adjustment, Black race was linked with similar odds of in-hospital mortality, but increased likelihood of major complications (Adjusted Odds Ratio [AOR] 1.41, 95%Confidence Interval [CI] 1.36-1.47). From 2016-2020, overall risk-adjusted rates of major complications declined (patients of White race: 9.2% to 8.4%; patients of Black race 11.8% to 10.8%, both P < .001). Yet, the delta in risk of adverse outcomes between patients of White and Black race did not significantly change. Of the cohort, 158,060 (8.4%) were treated at HVH. Following adjustment, Black race remained associated with greater odds of morbidity (AOR 1.37, CI 1.23-1.52; Ref:White). The race-based difference in risk of complications at HVH did not significantly change from 2016 to 2020. Conclusion: While overall rates of complications following major elective procedures declined from 2016 to 2020, patients of Black race faced persistently greater risk of adverse outcomes. Novel interventions are needed to address persistent racial disparities and ensure acceptable outcomes for all patients.
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Affiliation(s)
- Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Department of Surgery, University of Colorado, Denver, Aurora, CO, USA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Giselle Porter
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Konmal Ali
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Joanna Curry
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
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2
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Franco A, Ditonno F, Manfredi C, Sturgis MR, Bologna E, Licari LC, Feng CL, De Nunzio C, Antonelli A, De Sio M, Leonardo C, Djaladat H, Vourganti S, Cherullo EE, Olweny E, Autorino R. Open versus Minimally Invasive Nephroureterectomy: Contemporary Analysis from a Wide National Population-Based Database. Ann Surg Oncol 2024; 31:7212-7219. [PMID: 38879671 DOI: 10.1245/s10434-024-15565-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/21/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND It is generally perceived that minimally invasive nephroureterectomy (MINU), especially in the form of robotic-assisted laparoscopy, is gaining an increasing role in many institutions. OBJECTIVE The aim of our study was to investigate contemporary trends in the adoption of MINU in the United States compared with open nephroureterectomy (ONU). METHODS Patients who underwent ONU or MINU between 2011 and 2021 were retrospectively analyzed using PearlDiver Mariner, an all-payer insurance claims database. International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical procedure, patients' characteristics, social determinants of health (SDOH), and perioperative complications. The primary objective assessed different trends and costs in NU adoption, while secondary objectives analyzed factors influencing the postoperative complications, including SDOH. Outcomes were compared using multivariable regression models. RESULTS Overall, 15,240 patients underwent ONU (n = 7675) and MINU (n = 7565). Utilization of ONU declined over the study period, whereas that of MINU increased from 29 to 72% (p = 0.01). The 60-day postoperative complication rate was 23% for ONU and 19% for MINU (p < 0.001). At multivariable analysis, ONU showed a significantly higher risk of postoperative complications (odds ratio 1.33, 95% CI 1.20-1.48). Approximately 5% and 9% of patients reported at least one SDOH at baseline for both ONU and MINU (p < 0.001). CONCLUSIONS Contemporary trend analysis of a large national dataset confirms that there has been a significant shift towards MINU, which is gradually replacing ONU. A minimally invasive approach is associated with lower risk of complications. SDOH are non-clinical factors that currently do not have an impact on the outcomes of nephroureterectomy.
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Affiliation(s)
- Antonio Franco
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Francesco Ditonno
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
- Department of Urology, University of Verona, Verona, Italy
| | - Celeste Manfredi
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
- Urology Unit, Department of Woman, Child and General and Specialized Surgery, "Luigi Vanvitelli" University, Naples, Italy
| | - Morgan R Sturgis
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Eugenio Bologna
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
- Urology Unit, Department of Maternal-Child and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Leslie Claire Licari
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
- Urology Unit, Department of Maternal-Child and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Carol L Feng
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | | | - Alessandro Antonelli
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Marco De Sio
- Urology Unit, Department of Woman, Child and General and Specialized Surgery, "Luigi Vanvitelli" University, Naples, Italy
| | - Costantino Leonardo
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Hooman Djaladat
- Norris Comprehensive Cancer Center, Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | | | - Edward E Cherullo
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Ephrem Olweny
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
| | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL, USA.
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3
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Franco A, Lombardo R, Ditonno F, Bologna E, Licari LC, Nabulsi O, Ioos D, Gallo G, Tema G, Cicione A, Nacchia A, Tubaro A, De Nunzio C, Cherullo EE, Autorino R. Open versus Minimally Invasive Partial Nephrectomy: Trends and Outcomes from a Wide National Population-Based Database. J Clin Med 2024; 13:5454. [PMID: 39336941 PMCID: PMC11431951 DOI: 10.3390/jcm13185454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/26/2024] [Accepted: 09/02/2024] [Indexed: 09/30/2024] Open
Abstract
Objectives: To investigate temporal trends and overall complication rates among open partial nephrectomy (OPN) and minimally invasive partial nephrectomy (MIPN), including the impact of social determinants of health (SDOH) on postoperative outcomes. Methods: Patients who underwent OPN or MIPN between 2011 and 2021 were retrospectively analyzed by using PearlDiver-Mariner, an all-payer insurance claims database. The International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical operation, patient's characteristics (age, sex, region, insurance plan), postoperative complications and SDOH, categorized in education, healthcare, environmental, social, and economic domains. Outcomes were compared using multivariable regression models. Results: Overall, 65,325 patients underwent OPN (n = 23,377) or MIPN (n = 41,948). OPN adoption declined over the study period, whereas that of MIPN increased from 24% to 34% (p = 0.001). The 60-day postoperative complication rate was 15% for the open and 9% for the minimally invasive approach. Approximately 16% and 11% of patients reported at least one SDOH at baseline for OPN and MIPN, respectively. SDOH were associated with higher odds of postoperative complications (OPN = OR: 1.11, 95% CI: 1.01-1.25; MIPN = OR: 1.31, 95% CI: 1.18-1.46). The open approach showed a significantly higher risk of postoperative complications (OR: 1.62, 95% CI: 1.54-1.70) compared to the minimally invasive one. Conclusions: Our findings confirm that MIPN is gradually replacing OPN, which carries a higher risk of complications. SDOH are significant predictors of postoperative complications following PN, regardless of the approach.
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Affiliation(s)
- Antonio Franco
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, 00185 Rome, Italy
| | - Riccardo Lombardo
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, 00185 Rome, Italy
| | - Francesco Ditonno
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
- Department of Urology, University of Verona, 37129 Verona, Italy
| | - Eugenio Bologna
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
- Urology Unit, Department of Maternal-Child and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Leslie Claire Licari
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
- Urology Unit, Department of Maternal-Child and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, 00161 Rome, Italy
| | - Omar Nabulsi
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Darren Ioos
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Giacomo Gallo
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, 00185 Rome, Italy
| | - Giorgia Tema
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, 00185 Rome, Italy
| | - Antonio Cicione
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, 00185 Rome, Italy
| | - Antonio Nacchia
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, 00185 Rome, Italy
| | - Andrea Tubaro
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, 00185 Rome, Italy
| | - Cosimo De Nunzio
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, 00185 Rome, Italy
| | - Edward E Cherullo
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Riccardo Autorino
- Department of Urology, Rush University Medical Center, Chicago, IL 60612, USA
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4
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Diaz A, Pawlik TM. Poverty and Its Impact on Surgical Care. Adv Surg 2024; 58:35-47. [PMID: 39089785 DOI: 10.1016/j.yasu.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
In this article, the authors explore the intricate relationship between poverty and surgical care, underscoring its multifaceted nature and its profound impact on access and outcomes. Poverty extends beyond financial constraints to encompass barriers related to healthcare infrastructure, geographic isolation, education, mental health, and social determinants of health, resulting in persistent disparities in access to high-quality surgical care, especially for those in persistently impoverished areas and access-sensitive surgical conditions. Additionally, the authors delve into the complex intersection of poverty, race, and ethnicity, emphasizing the heightened risks faced by minority patients in surgical care.
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Affiliation(s)
- Adrian Diaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, James Comprehensive Cancer Center, Columbus, OH 43210, USA.
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Ditonno F, Franco A, Manfredi C, Sturgis MR, Feng CL, Roadman DF, Mossak SM, Bologna E, Licari LC, De Nunzio C, Corsi NJ, Rogers C, Abdollah F, Antonelli A, Cherullo EE, Olweny EO, Autorino R. Trends and Costs of Minimally Invasive Surgery for Kidney Cancer in the US: A Population-based Study. Urology 2024; 189:41-48. [PMID: 38670274 DOI: 10.1016/j.urology.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE To analyze temporal trends and costs associated with the use of minimally invasive surgery (MIS) for kidney cancer in the US over the past decade. To examine the impact of social determinants of health (SDOH) on perioperative outcomes. METHODS The PearlDiver Mariner, a national database of insurance billing records, was queried for this retrospective observational cohort analysis. The MIS population was identified and stratified according to treatment modality, using International Classification of Diseases and current procedural terminology codes. SDOH were assessed using International Classification of Diseases codes. Negative binomial regression was used to evaluate the overall number of renal MIS and Cochran-Armitage tests to compare the utilization of different treatment modalities, over the study period. Multivariable logistic regression analysis identified predictors of perioperative complications. RESULTS A total of 80,821 MIS for kidney cancer were included. Minimally invasive partial nephrectomy adoption as a fraction of total MIS increased significantly (slope of regression line, reg. = 0.026, P <.001). Minimally invasive radical nephrectomy ($26.9k ± 40.9k) and renal ablation ($18.9k ± 31.6k) were the most expensive and cheapest procedures, respectively. No statistically significant difference was observed in terms of number of complications (P = .06) and presence of SDOH (P = .07) among the treatment groups. At multivariable analysis, patients with SDOH undergoing minimally invasive radical nephrectomy had higher odds of perioperative complications, while renal ablation had a significantly lower probability of perioperative complications. CONCLUSION This study describes the current management of kidney cancer in the US, offering a socioeconomic perspective on the impact of this disease in everyday clinical practice.
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Affiliation(s)
- Francesco Ditonno
- Department of Urology, Rush University Medical Center, Chicago, IL; Department of Urology, University of Verona, Verona, Italy
| | - Antonio Franco
- Department of Urology, Rush University Medical Center, Chicago, IL; Department of Urology, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Celeste Manfredi
- Department of Urology, Rush University Medical Center, Chicago, IL; Urology Unit, Department of Woman, Child and General and Specialized Surgery, "Luigi Vanvitelli" University, Naples, Italy
| | - Morgan R Sturgis
- Department of Urology, Rush University Medical Center, Chicago, IL
| | - Carol L Feng
- Department of Urology, Rush University Medical Center, Chicago, IL
| | - Daniel F Roadman
- Department of Urology, Rush University Medical Center, Chicago, IL
| | - Spencer M Mossak
- Department of Urology, Rush University Medical Center, Chicago, IL
| | - Eugenio Bologna
- Department of Urology, Rush University Medical Center, Chicago, IL; Urology Unit, Department of Maternal-Child and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Leslie Claire Licari
- Department of Urology, Rush University Medical Center, Chicago, IL; Urology Unit, Department of Maternal-Child and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I Hospital, Rome, Italy
| | - Cosimo De Nunzio
- Department of Urology, Sant'Andrea Hospital, La Sapienza University, Rome, Italy
| | - Nicholas J Corsi
- VUI Center for Outcomes Research, Analysis, and Evaluation, Henry Ford Health System, Detroit, MI
| | - Craig Rogers
- VUI Center for Outcomes Research, Analysis, and Evaluation, Henry Ford Health System, Detroit, MI
| | - Firas Abdollah
- VUI Center for Outcomes Research, Analysis, and Evaluation, Henry Ford Health System, Detroit, MI
| | | | | | - Ephrem O Olweny
- Department of Urology, Rush University Medical Center, Chicago, IL
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6
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Branche C, Sakowitz S, Porter G, Cho NY, Chervu N, Mallick S, Bakhtiyar SS, Benharash P. Utilization of minimally invasive colectomy at safety-net hospitals in the United States. Surgery 2024; 176:172-179. [PMID: 38729887 DOI: 10.1016/j.surg.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Prior literature has reported inferior surgical outcomes and reduced access to minimally invasive procedures at safety-net hospitals. However, this relationship has not yet been elucidated for elective colectomy. We sought to characterize the association between safety-net hospitals and likelihood of minimally invasive resection, perioperative outcomes, and costs. METHODS All adult (≥18 years) hospitalization records entailing elective colectomy were identified in the 2016-2020 National Inpatient Sample. Centers in the top quartile of safety-net burden were considered safety-net hospitals (others: non-safety-net hospitals). Multivariable regression models were developed to assess the impact of safety-net hospitals status on key outcomes. RESULTS Of ∼532,640 patients, 95,570 (17.9%) were treated at safety-net hospitals. The safety-net hospitals cohort was younger and more often of Black race or Hispanic ethnicity. After adjustment, care at safety-net hospitals remained independently associated with reduced odds of minimally invasive surgery (adjusted odds ratio 0.92; 95% confidence interval 0.87-0.97). The interaction between safety-net hospital status and race was significant, such that Black race remained linked with lower odds of minimally invasive surgery at safety-net hospitals (reference: White race). Additionally, safety-net hospitals was associated with greater likelihood of in-hospital mortality (adjusted odds ratio 1.34, confidence interval 1.04-1.74) and any perioperative complication (adjusted odds ratio 1.15, confidence interval 1.08-1.22), as well as increased length of stay (β+0.26 days, confidence interval 0.17-0.35) and costs (β+$2,510, confidence interval 2,020-3,000). CONCLUSION Care at safety-net hospitals was linked with lower odds of minimally invasive colectomy, as well as greater complications and costs. Black patients treated at safety-net hospitals demonstrated reduced likelihood of minimally invasive surgery, relative to White patients. Further investigation is needed to elucidate the root causes of these disparities in care.
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Affiliation(s)
- Corynn Branche
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Stanford University, Palo Alto, CA. https://twitter.com/CoreLabUCLA
| | - Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, CA. https://twitter.com/sarasakowitz
| | - Giselle Porter
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Nam Yong Cho
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Nikhil Chervu
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, CA; Department of Surgery, University of California, Los Angeles, CA.
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Keirns DL, Verplancke K, McMahon K, Eaton V, Silberstein P. Demographic differences in early vs. late-stage laryngeal squamous cell carcinoma. Am J Otolaryngol 2024; 45:104282. [PMID: 38604102 DOI: 10.1016/j.amjoto.2024.104282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 04/01/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE This study aims to evaluate how various demographic factors impact the stage at diagnosis and, therefore, prognosis of laryngeal cancer. MATERIALS AND METHODS Using the National Cancer Database, 96,409 patients were diagnosed with laryngeal squamous cell carcinoma between 2004 and 2020. Early (stage 0 or I) vs. late-stage (stage IV) cancers were compared based on demographic variables utilizing Chi-square and multivariate analysis with a significance of p < 0.05. RESULTS Female, Black, and generally older patients were more likely to have late-stage cancer than their counterparts. When compared with a community cancer program, patients treated at other facility types were more likely to be diagnosed late. Patients with private insurance, Medicare, or other government insurance were all less likely to have late-stage cancer compared to patients without insurance. Compared to patients in the lowest median household income quartile, patients in the third quartile and fourth quartile were diagnosed earlier. Patients living in an area with the lowest level of high school degree attainment were most likely to be diagnosed late. Living in a more populous area was associated with a lower chance of being diagnosed late. Increasing Charlson-Deyo Score was associated with a stronger likelihood of being diagnosed at a later stage. CONCLUSION Patients who are female, Black, uninsured, have a low household income, live in less populated and less educated areas, are treated at non-community cancer programs, and have more comorbid conditions have later stage diagnoses. This data contributes to understanding inequities in healthcare.
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Affiliation(s)
- Darby L Keirns
- Creighton University School of Medicine, Omaha, NE, USA.
| | | | - Kevin McMahon
- Creighton University School of Medicine, Omaha, NE, USA
| | - Vincent Eaton
- Creighton University School of Medicine, Omaha, NE, USA
| | - Peter Silberstein
- Department of Medicine, Hematology and Oncology, School of Medicine, Creighton University, Omaha, NE, USA
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Guram K, Huang J, Mouchati C, Abdallah N, Jani C, Navani V, Xie W, El Zarif T, Adib E, Gebrael G, Agarwal N, Li H, Labaki C, Labban M, Ruiz Morales JM, Choueiri TK, Chin Heng DY, Mittal A, Hansen AR, Rose BS, McKay RR. Comparison of outcomes for Hispanic and non-Hispanic patients with advanced renal cell carcinoma in the International Metastatic Renal Cell Carcinoma Database. Cancer 2024; 130:2003-2013. [PMID: 38297953 DOI: 10.1002/cncr.35216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/03/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND Existing data on the impact of Hispanic ethnicity on outcomes for patients with renal cell carcinoma (RCC) is mixed. The authors investigated outcomes of Hispanic and non-Hispanic White (NHW) patients with advanced RCC receiving systemic therapy at large academic cancer centers using the International Metastatic Renal Cell Carcinoma Database (IMDC). METHODS Eligible patients included non-Black Hispanic and NHW patients with locally advanced or metastatic RCC initiating systemic therapy. Overall survival (OS) and time to first-line treatment failure (TTF) were calculated using the Kaplan-Meier method. The effect of ethnicity on OS and TTF were estimated by Cox regression hazard ratios (HRs). RESULTS A total of 1563 patients (181 Hispanic and 1382 NHW) (mostly males [73.8%] with clear cell RCC [81.5%] treated with tyrosine kinase inhibitor [TKI] monotherapy [69.9%]) were included. IMDC risk groups were similar between groups. Hispanic patients were younger at initial diagnosis (median 57 vs. 59 years, p = .015) and less likely to have greater than one metastatic site (60.8% vs. 76.8%, p < .001) or bone metastases (23.8% vs. 33.4%, p = .009). Median OS and TTF was 38.0 months (95% confidence interval [CI], 28.1-59.2) versus 35.7 months (95% CI, 31.9-39.2) and 7.8 months (95% CI, 6.2-9.0) versus 7.5 months (95% CI, 6.9-8.1), respectively, in Hispanic versus NHW patients. In multivariable Cox regression analysis, no statistically significant differences were observed in OS (adjusted hazard ratio [HR], 1.07; 95% CI, 0.86-1.31, p = .56) or TTF (adjusted HR, 1.06; 95% CI, 0.89-1.26, p = .50). CONCLUSIONS The authors did not observe statistically significant differences in OS or TTF between Hispanic and NHW patients with advanced RCC. Receiving treatment at tertiary cancer centers may mitigate observed disparities in cancer outcomes.
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Affiliation(s)
- Kripa Guram
- University of California, San Diego Health, La Jolla, California, USA
| | - Jiaming Huang
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christian Mouchati
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Nour Abdallah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Chinmay Jani
- Mount Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
- University of Miami-Sylvester Comprehensive Cancer Center/Jackson Health System, Miami, Florida, USA
| | - Vishal Navani
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Wanling Xie
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Talal El Zarif
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elio Adib
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Georges Gebrael
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Haoran Li
- Department of Medical Oncology, University of Kansas Cancer Center, Kansas City, Kansas, USA
| | - Chris Labaki
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Muhieddine Labban
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Toni K Choueiri
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Yick Chin Heng
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
- University of Calgary, Calgary, Alberta, Canada
| | - Abhenil Mittal
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Aaron R Hansen
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Brent S Rose
- University of California, San Diego Health, La Jolla, California, USA
| | - Rana R McKay
- University of California, San Diego Health, La Jolla, California, USA
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9
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da Costa WL, Tan MC, Camp ER, Thrift AP. Patient- and system-level factors associated with racial/ethnic disparities in the delivery of guideline-concordant therapy among US patients with gastric cancer. J Surg Oncol 2024; 129:1542-1553. [PMID: 38752435 DOI: 10.1002/jso.27683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 04/11/2024] [Accepted: 05/06/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Disparities in gastric cancer (GC) outcomes show a higher disease burden among minorities. We aimed to evaluate the associations between sociodemographic and system-level factors and guideline-concordant treatment among GC patients. METHODS Cohort study with GC patients in the National Cancer Data Base (2006-2018) treated with upfront resection or neoadjuvant therapy (NAT). We used logistic regression to identify associations between deviations from guideline-concordant therapy and patient- and system-level factors, and Cox regression models to assess risk of death. RESULTS The cohort included 43 597 GC patients treated with endoscopic resection (8.9%), surgery only (47.1%), surgery and adjuvant therapy (20.6%), or NAT followed by surgery (23.5%). A total of 31 470 patients (72.2%) received guideline-concordant therapy. Relative to Non-Hispanic Whites (NHWs), Non-Hispanic Blacks (NHBs) (odds ratio [OR] 1.19, [95% confidence intervals 1.10-1.28]) and Asian/Pacific Islanders (APIs) (OR 1.12 [1.03-1.23]) had an increased risk of deviations from treatment guidelines. Medicare/Medicaid increased the risk of deviations while treatment at high-volume facilities decreased its risk for all races/ethnicities. Deviations from guidelines were associated with an increased risk of death (hazard ratio 1.56 [1.50-1.63]. CONCLUSIONS Racial disparities in the delivery of guideline-concordant therapy among GC patients are affected by several sociodemographic factors at the patient- and system-level.
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Affiliation(s)
- Wilson L da Costa
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, Texas, USA
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
| | - Mimi C Tan
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - E Ramsay Camp
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
- Department of Surgery, Division of Surgical Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Aaron P Thrift
- Department of Medicine, Section of Epidemiology and Population Sciences, Baylor College of Medicine, Houston, Texas, USA
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas, USA
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10
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Akosman I, Kumar N, Mortenson R, Lans A, De La Garza Ramos R, Eleswarapu A, Yassari R, Fourman MS. Racial Differences in Perioperative Complications, Readmissions, and Mortalities After Elective Spine Surgery in the United States: A Systematic Review Using AI-Assisted Bibliometric Analysis. Global Spine J 2024; 14:750-766. [PMID: 37363960 PMCID: PMC10802512 DOI: 10.1177/21925682231186759] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
STUDY DESIGN Systematic Review and Meta-analysis. OBJECTIVES To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States. METHODS PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients. RESULTS 53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included. CONCLUSIONS AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.
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Affiliation(s)
| | - Neerav Kumar
- Weill Cornell School of Medicine, New York, NY, USA
| | | | - Amanda Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Ananth Eleswarapu
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Reza Yassari
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Mitchell S. Fourman
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
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11
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Blackstone EC, Daly BJ. The Need for Specialized Oncology Training for Clinical Ethicists. HEC Forum 2024; 36:45-59. [PMID: 35426566 DOI: 10.1007/s10730-022-09477-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 01/22/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
Numerous ethical issues are raised in cancer treatment and research. Informed consent is challenging due to complex treatment modalities and prognostic uncertainty. Busy oncology clinics limit the ability of oncologists to spend time reinforcing patient understanding and facilitating end-of-life planning. Despite these issues and the ethics consultations they generate, clinical ethicists receive little if any focused education about cancer and its treatment. As the field of clinical ethics develops standards for training, we argue that a basic knowledge of cancer should be included and offer an example of what cancer ethics training components might look like. We further suggest some specific steps to increase collaboration between clinical ethicists and oncology providers in the outpatient setting to facilitate informed consent and proactively identify ethical issues.
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Affiliation(s)
- Eric C Blackstone
- Department of Bioethics, Case Western Reserve University, 10900 Euclid Avenue, 44106, Cleveland, OH, USA.
| | - Barbara J Daly
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, 44106, Cleveland, OH, USA
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12
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Abboah-Offei M, Bayuo J, Salifu Y, Afolabi O, Akudjedu TN. Experiences and perceptions of men following breast cancer diagnosis: a mixed method systematic review. BMC Cancer 2024; 24:179. [PMID: 38317128 PMCID: PMC10845771 DOI: 10.1186/s12885-024-11911-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/22/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Men with breast cancer experience unique physical and emotional challenges. However, a thorough understanding of these experiences including the psychosocial effects and supportive care needs have received less attention. In some settings, men with breast cancer experience stigma within the healthcare system and their care needs are not prioritised. This influences the level of professional support offered, consequently worsening their health and well-being outcomes. This review explored the variabilities in the experiences and treatment modalities of male breast cancer (MBC) across different contexts. METHODS All primary study designs including qualitative, quantitative, and mixed methods studies that reported on the experiences, treatment approaches and outcomes of MBC were included in this systematic review. Six databases (Embase, Medline, PsycINFO, Global Health, CINAHL and Web of Science) were searched for articles from January 2000 to September 2023. A results-based convergence synthesis was used for data analysis and reported using PRISMA guidelines. RESULTS Of the studies screened (n = 29,687), forty-four fulfilled the predetermined criteria and were included. Our findings relating to the experiences and treatment approaches of MBC are broadly themed into three parts. Theme 1-Navigating through a threat to masculinity: describes how males experienced the illness reflecting on detection, diagnosis, coming to terms with breast cancer, and disclosure. Theme 2- Navigating through treatment: captures the experiences of undergoing breast cancer treatment/ management following their diagnosis. Theme 3-Coping and support systems: describes how MBC patients coped with the disease, treatment process, aftercare/rehabilitative care, and the available support structures. CONCLUSIONS Men experience a myriad of issues following a breast cancer diagnosis, especially with their masculinity. Awareness creation efforts of MBC among the public and healthcare practitioners are urgently required, which could change the perception of men in promoting early diagnosis, adherence to treatments, post-treatment monitoring, oncological results and a better quality of life. Considerations for training, education and development of specialised guidelines for healthcare practitioners on MBC would provide the necessary knowledge and skills to enhance their practice through the adoption of person-centred and male-specific care strategies. Professional care intervention and support for MBC should not end after the diagnosis phase but should extend to the entire treatment continuum and aftercare including future research focusing on MBC specific clinical trials. TRIAL REGISTRATION PROSPERO Registration No. CRD42021228778.
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Affiliation(s)
- Mary Abboah-Offei
- School of Health and Social Care, Edinburgh Napier University, Sighthill Court, Sighthill Campus, Edinburgh, UK
| | - Jonathan Bayuo
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong Special Administrative Region, Hongkong, China
| | - Yakubu Salifu
- International Observatory On End of Life Care (IOELC), Faculty of Health and Medicine, Division of Health Research, Lancaster University, Lancaster, LA1 4AT, UK.
| | - Oladayo Afolabi
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, WC2R 2LS, UK
| | - Theophilus N Akudjedu
- Institute of Medical Imaging & Visualisation, Department of Medical Science & Public Health, Faculty of Health & Social Science, Bournemouth University, Bournemouth, UK
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13
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Bradley CJ, Liang R, Lindrooth RC, Sabik LM, Perraillon MC. Building Data Infrastructure for Disease-Focused Health Economics Research. Med Care 2023; 61:S147-S152. [PMID: 37963034 PMCID: PMC10635336 DOI: 10.1097/mlr.0000000000001904] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Data infrastructure for cancer research is centered on registries that are often augmented with payer or hospital discharge databases, but these linkages are limited. A recent alternative in some states is to augment registry data with All-Payer Claims Databases (APCDs). These linkages capture patient-centered economic outcomes, including those driven by insurance and influence health equity, and can serve as a prototype for health economics research. OBJECTIVES To describe and assess the utility of a linkage between the Colorado APCD and Colorado Central Cancer Registry (CCCR) data for 2012-2017. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES This cohort study of 91,883 insured patients evaluated the Colorado APCD-CCCR linkage on its suitability to assess demographics, area-level data, insurance, and out-of-pocket expenses 3 and 6 months after cancer diagnosis. RESULTS The linkage had high validity, with over 90% of patients in the CCCR linked to the APCD, but gaps in APCD health plans limited available claims at diagnosis. We highlight the advantages of the CCCR-APCD, such as granular race and ethnicity classification, area-level data, the ability to capture supplemental plans, medical and pharmacy out-of-pocket expenses, and transitions in insurance plans. CONCLUSIONS Linked data between registries and APCDs can be a cornerstone of a robust data infrastructure and spur innovations in health economics research on cost, quality, and outcomes. A larger infrastructure could comprise a network of state APCDs that maintain linkages for research and surveillance.
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Affiliation(s)
- Cathy J. Bradley
- University of Colorado Cancer Center Aurora, CO
- Colorado School of Public Health, Department of Health Systems, Management, and Policy Aurora, CO
| | - Rifei Liang
- University of Colorado Cancer Center Aurora, CO
| | - Richard C. Lindrooth
- Colorado School of Public Health, Department of Health Systems, Management, and Policy Aurora, CO
| | - Lindsay M. Sabik
- University of Pittsburgh School of Public Health, Department of Health Policy and Management, Pittsburgh, PA
| | - Marcelo C. Perraillon
- University of Colorado Cancer Center Aurora, CO
- Colorado School of Public Health, Department of Health Systems, Management, and Policy Aurora, CO
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14
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Thuo N, Martins T, Manley E, Standifer M, Sultan DH, Faris NR, Hill A, Thompson M, Jeremiah R, Al Achkar M. Factors leading to disparity in lung cancer diagnosis among black/African American communities in the USA: a qualitative study. BMJ Open 2023; 13:e073886. [PMID: 37899158 PMCID: PMC10619042 DOI: 10.1136/bmjopen-2023-073886] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 09/29/2023] [Indexed: 10/31/2023] Open
Abstract
OBJECTIVE This study has two objectives: first, to explore the diagnostic experiences of black/African American (BAA) patients with lung cancer to pinpoint pitfalls, suboptimal experiences and instances of discrimination leading to disparities in outcomes compared with patients of other ethnic backgrounds, especially white patients. The second objective is to identify the underlying causes contributing to health disparities in the diagnosis of lung cancer among BAA patients. METHODS We employed a phenomenological research approach, guiding in-depth interviews with patients self-identifying as BAA diagnosed with lung cancer, as well as caregivers, healthcare professionals and community advocates knowledgeable about BAA experiences with lung cancer. We performed thematic analysis to identify experiences at patient, primary care and specialist levels. Contributing factors were identified using the National Institute of Minority Health and Health Disparities (NIMHD) health disparity model. RESULTS From March to November 2021, we conducted individual interviews with 19 participants, including 9 patients/caregivers and 10 providers/advocates. Participants reported recurring and increased pain before seeking treatment, treatment for non-cancer illnesses, delays in diagnostic tests and referrals, poor communication and bias when dealing with specialists and primary care providers. Factors contributing to suboptimal experiences included reluctance by insurers to cover costs, provider unwillingness to conduct comprehensive testing, provider bias in recommending treatment, high healthcare costs, and lack of healthcare facilities and qualified staff to provide necessary support. However, some participants reported positive experiences due to their insurance, availability of services and having an empowered support structure. CONCLUSIONS BAA patients and caregivers encountered suboptimal experiences during their care. The NIMHD model is a useful framework to organise factors contributing to these experiences that may be leading to health disparities. Additional research is needed to fully capture the extent of these experiences and identify ways to improve BAA patient experiences in the lung cancer diagnosis pathway.
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Affiliation(s)
- Nicholas Thuo
- Family Medicine, Univeristy of Washington, Seattle, WA, USA
| | - Tanimola Martins
- Health and Community Science, University of Exeter, Exeter, UK
- Health and Community Science, University of Exeter, Exeter, UK
| | | | - Maisha Standifer
- Health Policy, Morehouse School of Medicine, Atlanta, Georgia, USA
| | | | - Nicholas R Faris
- Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee, USA
| | - Angela Hill
- Pharmacotherapuetics and Clinical Research, University of South Florida, Tampa, Florida, USA
| | | | - Rohan Jeremiah
- Global Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Morhaf Al Achkar
- Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, MI, USA
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Piña D, Kalistratova V, Boozé Z, Voort WV, Conry K, Fine J, Holland J, Wick J, Ortega B, Javidan Y, Roberto R, Klineberg E, Lipa S, Le H. Sociodemographic Characteristics of Patients Undergoing Surgery for Metastatic Disease of the Spine. J Am Acad Orthop Surg 2023; 31:e675-e684. [PMID: 37311424 DOI: 10.5435/jaaos-d-22-01147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/11/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Some patients, particularly those who are socioeconomically deprived, are diagnosed with primary and/or metastatic cancer only after presenting to the emergency department. Our objective was to determine sociodemographic characteristics of patients undergoing surgery for metastatic spine disease at our institution. METHODS This retrospective case series included patients 18 years and older who presented to the emergency department with metastatic spine disease requiring surgery. Demographics and survival data were collected. Sociodemographic characteristics were estimated using the Social Deprivation Index (SDI) and Area Deprivation Index (ADI) for the state of California. Univariate log-rank tests and Kaplan-Meier curves were used to assess differences in survival for predictors of interest. RESULTS Between 2015 and 2021, 64 patients underwent surgery for metastatic disease of the spine. The mean age was 61.0 ± 12.5 years, with 60.9% being male (n = 39). In this cohort, 89.1% of patients were non-Hispanic (n = 57), 71.9% were White (n = 46), and 62.5% were insured by Medicare/Medicaid (n = 40). The mean SDI and ADI were 61.5 ± 28.0 and 7.7 ± 2.2, respectively. 28.1% of patients (n = 18) were diagnosed with primary cancer for the first time while 39.1% of patients (n = 25) were diagnosed with metastatic cancer for the first time. During index hospitalization, 37.5% of patients (n = 24) received palliative care consult. The 3-month, 6-month, and all-time mortality rates were 26.7% (n = 17), 39.5% (n = 23), and 50% (n = 32), respectively, with 10.9% of patients (n = 7) dying during their admission. Payor plan was significant at 3 months ( P = 0.02), and palliative consultation was significant at 3 months ( P = 0.007) and 6 months ( P = 0.03). No notable association was observed with SDI and ADI in quantiles or as continuous variables. DISCUSSION In this study, 28.1% of patients were diagnosed with cancer for the first time. Three-month and 6-month mortality rates for patients undergoing surgery were 26.7% and 39.5%, respectively. Furthermore, mortality was markedly associated with palliative care consultation and insurance status, but not with SDI and ADI. LEVEL OF EVIDENCE Retrospective case series, Level III evidence.
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Affiliation(s)
- Dagoberto Piña
- From the University of California, Davis School of Medicine, Sacramento, CA (Piña, Kalistratova, and Boozé), University of Louisville, School of Medicine, Louisville, KY (Holland), Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, CA (Piña, Voort, Conry, Wick, Ortega, Javidan, Roberto, Klineberg, and Le), Department of Public Health Sciences, University of California, Davis, Sacramento, CA (Fine), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Lipa)
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16
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Calthorpe L, Romero-Hernandez F, Casey M, Nunez M, Conroy PC, Hirose K, Kim A, Kirkwood K, Maker AV, Corvera C, Nakakura E, Alseidi A, Adam MA. National Practice Patterns in Malignant Peritoneal Mesothelioma: Updates in Management and Survival. Ann Surg Oncol 2023; 30:5119-5129. [PMID: 37140748 DOI: 10.1245/s10434-023-13528-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/03/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Malignant peritoneal mesothelioma (MPM) is a rare malignancy with a historically poor prognosis. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as an effective therapy for patients with peritoneal malignancies. A contemporary analysis of trends in management of and survival from MPM is warranted. METHODS Patients with MPM were identified from the National Cancer Database (2004-2018). Patients were categorized by treatment (CRS-HIPEC, CRS-chemotherapy, CRS only, chemotherapy only, no treatment), and joinpoint regression was employed to compute the annual percent change (APC) in treatment over time. Multivariable Cox proportional hazards models were used to analyze factors associated with survival. RESULTS Of 2683 patients with MPM, 19.1% underwent CRS-HIPEC, and 21.1% received no treatment. Joinpoint regression revealed a statistically significant increase in the proportion of patients undergoing CRS-HIPEC over time (APC 3.21, p = 0.01), and a concurrent decrease in the proportion of patients who underwent no treatment (APC - 2.21, p = 0.02). Median overall survival was 19.5 months. Factors independently associated with survival included CRS-HIPEC, CRS, histology, sex, age, race, Charlson Comorbidity Index, insurance, and hospital type. Although there was a strong association between year of diagnosis and survival on univariate analysis (2016-2018 HR 0.67, p < 0.001), this association was attenuated after adjustment for treatment. CONCLUSIONS CRS-HIPEC is increasingly employed as a treatment for MPM. In parallel, there has been a decrease in patients receiving no treatment with an increase in overall survival. These findings suggest that patients with MPM may be receiving more appropriate therapy; however, a substantial proportion of patients may remain undertreated.
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Affiliation(s)
- Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Megan Casey
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Miguel Nunez
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Patricia C Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alex Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kimberly Kirkwood
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Carlos Corvera
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Nakakura
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Mohamed Abdelgadir Adam
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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Kauke-Navarro M, Knoedler L, Knoedler S, Diatta F, Huelsboemer L, Stoegner VA, Mookerjee VG, Panayi AC, Butler PD, Pomahac B. Ensuring Racial and Ethnic Inclusivity in Facial Vascularized Composite Allotransplantation. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5178. [PMID: 37577247 PMCID: PMC10419650 DOI: 10.1097/gox.0000000000005178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/22/2023] [Indexed: 08/15/2023]
Abstract
Facial vascularized composite allotransplantation (fVCA) represents a valuable surgical option for reconstruction of the most devastating facial defects. There is a mounting body of evidence suggesting that healthcare disparities exist for a variety of other surgical and nonsurgical procedures. We aimed to investigate the potential existence of racial and ethnic disparities in the field of fVCA. Methods A comprehensive literature review was conducted by the authors of this review on PubMed/MEDLINE, and Embase databases from database inception to December 1, 2022 for studies published in the English and French languages. The search terms were (1) "face" OR "facial" AND (2) "transplant" OR "VCA" OR "vascularized composite allotransplantation" OR "vascularized composite allograft" OR "graft." Results Upon assessment of the racial and ethnic demographics of the 47 global cases of fVCA between 2005 and 2020, 36 were White, 10 were Asian, and one was Black. Sixteen of the 17 fVCA procedures performed in the United States involved White patients. The other patient self-identified as Black, equaling 6% of all US fVCA recipients. Conclusion Our analysis showed that the ethnic and racial distribution of fVCA has not proportionally reflected the racial and ethnic demographics of the general US population, underscoring the risk of such healthcare imbalances. Although large-scale studies are needed before drawing definitive conclusions, leaders in the field should take preventive steps to avoid potential disparities. Further investigations into the factors that facilitate or prohibit access to fVCA referral and surgery will be necessary moving forward.
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Affiliation(s)
- Martin Kauke-Navarro
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Leonard Knoedler
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Technical University of Munich, Munich, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Fortunay Diatta
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Lioba Huelsboemer
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Viola A. Stoegner
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Vikram G. Mookerjee
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Adriana C. Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Burn Center, Microsurgery, University of Heidelberg, Ludwigshafen, Germany
| | - Paris D. Butler
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
| | - Bohdan Pomahac
- From the Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, Conn
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18
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Abella MKIL, Lee AY, Kitamura RK, Ahn HJ, Woo RK. Disparities and Risk Factors for Surgical Complication in American Indians and Native Hawaiians. J Surg Res 2023; 288:99-107. [PMID: 36963299 DOI: 10.1016/j.jss.2023.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/25/2023] [Accepted: 02/18/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION American Indian and Alaskan Natives (AIAN) and Native Hawaiian and Pacific Islanders (NHPI) research is limited, particularly in postoperative surgical outcomes. This study analyzes disparities in AIAN and NHPI surgical complications across all surgical types and identifies factors that contribute to postoperative complications. METHODS This retrospective cohort study examined all surgeries from 2011 to 2020 in the National Surgical Quality Improvement Program, queried by race. Multivariable models analyzed the association of race and ethnicity and 30-day postoperative complication. Next, multivariable models were used to identify preoperative variables associated with postoperative complications, specifically in AIAN and NHPI patients. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated. RESULTS AIAN patients were associated with higher odds of postoperative complication (AOR: 1.008 [CI: 1.005-1.011], P < 0.001) compared to non-Hispanic white patients. The comorbidities that were of higher incidence in AIAN patients, which also adversely contributed to postoperative complication, included dependent functional status, diabetes, congestive heart failure (CHF), open wounds, preoperative weight loss, bleeding disorders, preoperative transfusion, sepsis, hypoalbuminemia, along with an active smoking status and ASA ≥3. In NHPI patients, dependent functional status, CHF, renal failure, preoperative transfusion, open wounds, and sepsis were of higher incidence and significantly contributed to postoperative complication. CONCLUSIONS Surgical outcome disparities exist particularly in AIAN patients. Identification of modifiable patient risk factors may benefit perioperative care for AIAN and NHPI patients, which are historically understudied racial groups.
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Affiliation(s)
| | - Anson Y Lee
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Riley K Kitamura
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Queen's Medical Center, Honolulu, Hawaii
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Russell K Woo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Kapi'olani Medical Center for Women and Children, Hawai'i Pacific Health, Honolulu, Hawaii
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Abella MKIL, Lee AY, Agonias K, Maka P, Ahn HJ, Woo RK. Racial Disparities in General Surgery Outcomes. J Surg Res 2023; 288:261-268. [PMID: 37030184 DOI: 10.1016/j.jss.2023.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/21/2023] [Accepted: 03/09/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION While disparities in Black and Hispanic and Latino patients undergoing general surgeries are well described, most analyses leave out Asian, American Indian or Alaskan Native (AIAN), and native Hawaiian or Pacific Islander patients. This study identified general surgery outcomes for each racial group in the National Surgical Quality Improvement Program. METHODS National Surgical Quality Improvement Program was queried to identify all procedures conducted by a general surgeon from 2017 to 2020 (n = 2,664,197). Multivariable regression models were used to investigate the impact of race and ethnicity on 30-day mortality, readmission, reoperation, major and minor medical complications, and non-home discharge destinations. Adjusted odds ratios (AOR) and 95% confidence intervals were calculated. RESULTS Compared to non-Hispanic White patients, Black patients had higher odds of readmission and reoperation, and Hispanic and Latino patients had higher odds of major and minor complications. AIAN patients had higher odds of mortality (AOR: 1.003 (1.002-1.005), P < 0.001), major complication (AOR: 1.013 (1.006-1.020), P < 0.001), reoperation (AOR: 1.009, (1.005-1.013), P < 0.001), and non-home discharge destination (AOR: 1.006 (1.001-1.012), P = 0.025), while native Hawaiian or Pacific Islander patients had lower odds of readmission (AOR: 0.991 (0.983-0.999), P = 0.035) and non-home discharge destination (AOR: 0.983 (0.975-0.990), P < 0.001) compared to non-Hispanic White patients. Asian patients had lower odds of each adverse outcome. CONCLUSIONS Black, Hispanic and Latino, and AIAN patients are at higher odds for poor postoperative results than non-Hispanic White patients. AIANs had some of the highest odds of mortality, major complications, reoperation, and non-home discharge. Social health determinants and policy adjustments must be targeted to ensure optimal operative results for all patients.
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Affiliation(s)
| | - Anson Y Lee
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Keinan Agonias
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Piueti Maka
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii
| | - Hyeong Jun Ahn
- Department of Quantitative Health Sciences, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Russell K Woo
- John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii; Kapi'olani Medical Center for Women and Children, Hawai'i Pacific Health, Honolulu, Hawaii
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20
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Findlay MC, Bauer SZ, Khan M, Kim RB, Park S, Alexander H, Karsy M. Are There Racial and Ethnic Health Disparities Among Outcomes After Anterior Cranial Fossa Surgery? A Propensity Score-Matched American College of Surgeons National Surgical Quality Improvement Program Study. Neurosurgery 2023; 93:176-185. [PMID: 36762909 DOI: 10.1227/neu.0000000000002397] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/07/2022] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Race-based health care outcomes remain to be described in anterior cranial fossa (ACF) surgery. OBJECTIVE To determine whether race predicts worse outcomes after ACF surgery. METHODS A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program data for 2005 to 2020. Current Procedural Terminology and International Classification of Diseases-9 codes were used to identify ACF tumor cases. Propensity score matching was performed to compare White and minority patients to assess the robustness of unmatched findings. A subanalysis of pituitary adenoma (PA) resections was also performed. RESULTS In an unmatched analysis of 1370 patients who underwent ACF surgery (67.9% White, 17.4% Black, 6.6% Asian/Pacific Islander, and 6.3% Hispanic), minority groups had higher rates of comorbidities. Unmatched multivariate analysis found Hispanic patients bore a 1.86 odds ratio (OR) of minor complications, Black and Asian and Pacific Islander patients bore 1.49 and 1.71 ORs, respectively, for extended length of stay, and Black patients bore a 3.78 OR for urinary tract infection (UTI). Matched analysis found that minority patients had higher UTI rates ( P = .02) and a 4.11 OR of UTI. In PA cases specifically, minority groups had higher comorbidities and length of stay in addition to extended length of stay odds (1.84 OR). CONCLUSION Although most ACF surgery outcomes were unaffected by race, minority groups had more minor postoperative complications than White patients, particularly UTI. Similar disparities were observed among PA cases. Higher rates of comorbidities may also have led to longer hospital stays. Further study is needed to understand what actions might be necessary to address any race-associated health disparities in ACF surgery.
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Affiliation(s)
| | - Sawyer Z Bauer
- School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Majid Khan
- School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Robert B Kim
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Seojin Park
- New York University, New York, New York, USA
| | - Hepzibha Alexander
- Division of Neurosurgery, Ascension Providence Hospital, Michigan State University, College of Human Medicine, Southfield, Michigan, USA
| | - Michael Karsy
- School of Medicine, University of Nevada, Reno, Nevada, USA
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Patel SR, Suero-Abreu GA, Ai A, Ramachandran MK, Meza K, Florez N. Inequity in care delivery in cardio-oncology: dissecting disparities in underrepresented populations. Front Oncol 2023; 13:1124447. [PMID: 37361603 PMCID: PMC10289233 DOI: 10.3389/fonc.2023.1124447] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 05/03/2023] [Indexed: 06/28/2023] Open
Abstract
It is well known that patients with cancer have a significantly higher cardiovascular mortality risk than the general population. Cardio-oncology has emerged to focus on these issues including risk reduction, detection, monitoring, and treatment of cardiovascular disease or complications in patients with cancer. The rapid advances in early detection and drug development in oncology, along with socioeconomic differences, racial inequities, lack of support, and barriers to accessing quality medical care, have created disparities in various marginalized populations. In this review, we will discuss the factors contributing to disparities in cardio-oncologic care in distinct populations, including Hispanic/Latinx, Black, Asian and Pacific Islander, indigenous populations, sex and gender minorities, and immigrants. Some factors that contribute to differences in outcomes in cardio-oncology include the prevalence of cancer screening rates, genetic cardiac/oncologic risk factors, cultural stressors, tobacco exposure rates, and physical inactivity. We will also discuss the barriers to cardio-oncologic care in these communities from the racial and socioeconomic context. Appropriate and timely cardiovascular and cancer care in minority groups is a critical component in addressing these disparities, and there need to be urgent efforts to address this widening gap.
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Affiliation(s)
- Shruti Rajesh Patel
- Department of Medicine, Division of Oncology, Stanford University and Stanford Cancer Institute, Stanford, CA, United States
| | | | - Angela Ai
- Olive View-University of California, Los Angeles Medical Center, Los Angeles, CA, United States
| | - Maya K. Ramachandran
- Department of Medicine, Division of Oncology, Stanford University and Stanford Cancer Institute, Stanford, CA, United States
| | - Kelly Meza
- Dana Farber Cancer Institute, Boston, MA, United States
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22
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Masters RK, Tilstra AM, Simon DH, Coleman-Minahan K. Differences in Determinants: Racialized Obstetric Care and Increases in U.S. State Labor Induction Rates. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2023; 64:174-191. [PMID: 37098856 PMCID: PMC10848243 DOI: 10.1177/00221465231165284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Induction of labor (IOL) rates in the United States have nearly tripled since 1990. We examine official U.S. birth records to document increases in states' IOL rates among pregnancies to Black, Latina, and White women. We test if the increases are associated with changes in demographic characteristics and risk factors among states' racial-ethnic childbearing populations. Among pregnancies to White women, increases in state IOL rates are strongly associated with changes in risk factors among White childbearing populations. However, the rising IOL rates among pregnancies to Black and Latina women are not due to changing factors in their own populations but are instead driven by changing factors among states' White childbearing populations. The results suggest systemic racism may be shaping U.S. obstetric care whereby care is not "centered at the margins" but is instead responsive to characteristics in states' White populations.
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Affiliation(s)
- Ryan K. Masters
- University of Colorado Boulder, Boulder, CO, USA
- University of Colorado Population Center, Boulder, CO, USA
| | - Andrea M. Tilstra
- University of Colorado Population Center, Boulder, CO, USA
- Oxford University, Oxford, UK
| | - Daniel H. Simon
- University of Colorado Boulder, Boulder, CO, USA
- University of Colorado Population Center, Boulder, CO, USA
| | - Kate Coleman-Minahan
- University of Colorado Population Center, Boulder, CO, USA
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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23
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Diaz A, Valbuena VSM, Dimick JB, Ibrahim AM. Association of Neighborhood Deprivation, Race, and Postoperative Outcomes: Improvement in Neighborhood Deprivation is Associated With Worsening Surgical Disparities. Ann Surg 2023; 277:958-963. [PMID: 35797617 DOI: 10.1097/sla.0000000000005475] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION While there is a broad understanding that patient factors, hospital characteristics, and an individual's neighborhoods all contribute to the observed disparities, the relationship between these factors remains unclear. The purpose of this study was to evaluate the association of neighborhood deprivation improve postoperative outcomes for White and Black Medicare beneficiaries equally. METHODS We performed a cross-sectional Retrospective cohort study from 2014 to 2018 of 1372,487 White and Black Medicare beneficiaries aged 65 and older who underwent an inpatient colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair. We compared postoperative complications, readmission, and mortality by race across neighborhood deprivation. Outcomes were risk-adjusted using a multivariable logistical regression model accounting for patient factors (age, sex, Elixhauser comorbidities), admission type (elective, urgent, emergency), type of operation, and each neighborhoods Area Deprivation Index; a modern-day measure of neighborhood disadvantage that includes education, employment, housing quality, and poverty measures. RESULTS Overall, 1372,487 Medicare beneficiaries with mean age 72.1 years, 50.3% female, 91.2% White, residing in 1107,051 unique neighborhoods underwent 1 of 5 operations. The proportion of Black beneficiaries was 6.5% within the lowest deprivation neighborhoods and increased to 16.9% within the highest deprivation neighborhoods ( P <0.001). The interaction between beneficiary neighborhood and race demonstrated that the association of neighborhood on outcomes varied by race. Specifically, White beneficiaries had 1.5% absolute mortality decrease from the highest to lowest deprivation neighborhoods [odds ratio (OR):1.32, 95% confidence interval (CI): 1.27-1.38; P <0.001], whereas Black beneficiaries had a 0.72% absolute mortality decrease from the highest to lowest deprivation neighborhoods (OR: 1.13, 95% CI: 1.02-1.24; P =0.018). Similarly, White beneficiaries had 3.6% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.23, 95% CI: 1.21-1.28; P <0.001) while Black beneficiaries had a 1.2%% absolute decrease in complication rate from the highest to lowest deprivation neighborhoods (OR: 1.07, 95% CI: 1.01-1.13; P =0.017). For 30-day readmission rates, White beneficiaries realized a 2.3% absolute decrease from the highest to lowest deprivation neighborhoods (OR: 1.19, 95% CI: 1.02-1.24; P <0.001), whereas Black beneficiaries saw no change (OR: 1.03, 95% CI: 0.97-1.10; P =0.269). CONCLUSIONS AND RELEVANCE Lower neighborhood deprivation is associated with improved outcomes across both White and Black Medicare beneficiaries; however, improvement in neighborhood deprivation disproportionately favored White beneficiaries. These findings provide a cautionary example of the misperception of the protective effect of higher social class for Black patients and provide a cautionary example that improvements in neighborhoods may have disparate health impact on its members.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University, Columbus, OH
- IHPI Clinician Scholars Program, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
| | | | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Andrew M Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Taubman College of Architecture & Urban Planning, University of Michigan, Ann Arbor, MI
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Chervu N, Branche C, Verma A, Vadlakonda A, Bakhtiyar SS, Hadaya J, Benharash P. Association of insurance status with financial toxicity and outcome disparities after penetrating trauma and assault. Surgery 2023; 173:1493-1498. [PMID: 37031053 DOI: 10.1016/j.surg.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Financial toxicity, or the impact out-of-pocket medical expenses have on the quality of life, has not been widely enumerated in the trauma literature. We characterized the relationship between insurance status and the risk of financial toxicity after trauma and associated risk factors. METHODS Adults admitted for gunshot wounds, other penetrating injuries, or blunt assault were identified from the 2015 to 2019 National Inpatient Sample. The outcome of interest was a risk of financial toxicity with separate regression models for uninsured and insured populations. RESULTS Of an estimated 775,665 patients, 21.2% were at risk of financial toxicity. Patients at risk of financial toxicity were younger, more commonly male, less commonly White, and had a lower Elixhauser Index (Table 1). A higher proportion of uninsured patients were at risk of financial toxicity (40.8% vs 17.7%, P < .001) than insured patients. Whereas the proportion of uninsured patients at risk of financial toxicity significantly increased from 2015 to 2019, it was unchanged in insured patients. After adjustment, non-income demographic and clinical factors were not associated with the risk of financial toxicity amongst the insured. Conversely, the Black or Hispanic race, gunshot wounds, and any in-hospital complications were some factors associated with increased risk of financial toxicity in uninsured patients. CONCLUSION An increasingly larger proportion of uninsured patients are at risk of financial toxicity after trauma. The risk of financial toxicity among the uninsured was more complex than in the insured and associated with race, gunshot wounds, and complications. Increasing insurance access and the adoption of trauma-informed care practices should be used to address financial toxicity in this population.
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Affiliation(s)
- Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Corynn Branche
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA. https://twitter.com/arjun_ver
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, University of Colorado, Aurora, CO. https://twitter.com/Aortologist
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California-Los Angeles, CA; Department of Surgery, David Geffen School of Medicine, University of California-Los Angeles, CA. https://twitter.com/CoreLabUCLA
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Mittal A, Le A, Kahlam A, Haider SF, Prasath V, Khrais A, Chokshi R. Pancreatic Cancer Biopsy Modalities: Comparing Insurance Status, Length of Stay, and Hospital Complications Based on Percutaneous, Endoscopic, and Surgical Biopsy Methods. Cureus 2023; 15:e39660. [PMID: 37388621 PMCID: PMC10306347 DOI: 10.7759/cureus.39660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Pancreatic cancer is diagnosed histologically through percutaneous biopsy (PB), endoscopic biopsy (EB), or surgical biopsy (SB). Factors and outcomes associated with method type are not clearly understood. We aimed to evaluate the relationship between insurance status, length of hospital stay (LOS), complications, and different pancreatic biopsy modalities. STUDY The 2001-2013 database from the National (Nationwide) Inpatient Sample (NIS) was queried for those with pancreatic cancer who underwent biopsies using International Classification of Diseases, Ninth Revision (ICD-9) codes. Data regarding insurance status, hospital stay, demographics, and complications were analyzed using chi-square and multivariate analysis with α < 0.001. RESULTS A total of 824,162 patients with pancreatic cancer were identified. Uninsured and Medicaid patients were more likely to get PB compared to SB. Patients were more likely to have acute renal failure (ARF) with an EB compared to SB. Patients were more likely to have a urinary tract infection (UTI) with EB or PB compared to SB. All biopsy types were less likely to have pneumonia; pancreatitis was more prevalent in EB compared to PB and SB. CONCLUSIONS Uninsured and Medicaid patients were most likely to have a PB compared to EB despite unclear indications which may represent an underlying discrepancy in healthcare utilization. EB patients had the shortest LOS while SB patients stayed three more days; those who underwent a combination of biopsies had the greatest LOS. Patients with EB were more likely to develop ARF, UTI, and pancreatitis than SB, possibly attributed to the advanced nature of endoscopic ultrasound. It is important to establish appropriate algorithm contributors to guide decision-making.
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Affiliation(s)
- Anmol Mittal
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Alexander Le
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Aaron Kahlam
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Syed F Haider
- Department of General Surgery, Rutgers University New Jersey Medical School, Newark, USA
| | - Vishnu Prasath
- Department of General Surgery, Rutgers University New Jersey Medical School, Newark, USA
| | - Ayham Khrais
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Ravi Chokshi
- Department of Surgical Oncology, Rutgers University New Jersey Medical School, Newark, USA
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Hirsch JA, Zhao Y, Melly S, Moore KA, Berger N, Quinn J, Rundle A, Lovasi GS. National trends and disparities in retail food environments in the USA between 1990 and 2014. Public Health Nutr 2023; 26:1052-1062. [PMID: 36644895 PMCID: PMC10191888 DOI: 10.1017/s1368980023000058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 09/29/2022] [Accepted: 11/25/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To describe national disparities in retail food environments by neighbourhood composition (race/ethnicity and socio-economic status) across time and space. DESIGN We examined built food environments (retail outlets) between 1990 and 2014 for census tracts in the contiguous USA (n 71 547). We measured retail food environment as counts of all food stores, all unhealthy food sources (including fast food, convenience stores, bakeries and ice cream) and healthy food stores (including supermarkets, fruit and vegetable markets) from National Establishment Time Series business data. Changes in food environment were mapped to display spatial patterns. Multi-level Poisson models, clustered by tract, estimated time trends in counts of food stores with a land area offset and independent variables population density, racial composition (categorised as predominantly one race/ethnicity (>60 %) or mixed), and inflation-adjusted income tertile. SETTING The contiguous USA between 1990 and 2014. PARTICIPANTS All census tracts (n 71 547). RESULTS All food stores and unhealthy food sources increased, while the subcategory healthy food remained relatively stable. In models adjusting for population density, predominantly non-Hispanic Black, Hispanic, Asian and mixed tracts had significantly more destinations of all food categories than predominantly non-Hispanic White tracts. This disparity increased over time, predominantly driven by larger increases in unhealthy food sources for tracts which were not predominantly non-Hispanic White. Income and food store access were inversely related, although disparities narrowed over time. CONCLUSIONS Our findings illustrate a national food landscape with both persistent and shifting spatial patterns in the availability of establishments across neighbourhoods with different racial/ethnic and socio-economic compositions.
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Affiliation(s)
- Jana A Hirsch
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, 3600 Market Street 7th Floor Suite, Philadelphia, PA19104, USA
- Department of Epidemiology & Biostatistics, Dornsife School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA19104, USA
| | - Yuzhe Zhao
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, 3600 Market Street 7th Floor Suite, Philadelphia, PA19104, USA
| | - Steven Melly
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, 3600 Market Street 7th Floor Suite, Philadelphia, PA19104, USA
| | - Kari A Moore
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, 3600 Market Street 7th Floor Suite, Philadelphia, PA19104, USA
| | - Nicolas Berger
- Department of Epidemiology and Public Health, Sciensano (Belgian Scientific Institute of Public Health), Ixelles, Belgium
- Population Health Innovation Lab, Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | - James Quinn
- Built Environment and Health Research Group, Mailman School of Public Health, Columbia University, New York, USA
| | - Andrew Rundle
- Built Environment and Health Research Group, Mailman School of Public Health, Columbia University, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Gina S Lovasi
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, 3600 Market Street 7th Floor Suite, Philadelphia, PA19104, USA
- Department of Epidemiology & Biostatistics, Dornsife School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA19104, USA
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27
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Holler E, Campbell NL, Boustani M, Dexter P, Ben Miled Z, Owora A. Racial disparities in the pharmacological treatment of insomnia: A time-to-event analysis using real-world data. Sleep Health 2023; 9:128-135. [PMID: 36858835 DOI: 10.1016/j.sleh.2023.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/19/2022] [Accepted: 02/09/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE Examine the association between race and time to pharmacologic treatment of insomnia in a large multi-institutional cohort. METHODS Retrospective analysis of electronic medical records from a regional health information exchange. Eligible patients included adults with at least one healthcare visit per year from 2010 to 2019, a new insomnia diagnosis code during the study period, and no prior insomnia diagnosis codes or medications. A Cox frailty model was used to examine the association between race and time to an insomnia medication after diagnosis. RESULTS In total, 9557 patients were analyzed, 7773 (81.3%) of whom where White, 1294 (13.5%) Black, 238 (2.5%) Other, and 252 (2.6%) unknown race. About 6.2% of Black and 8% of Other race patients received an order for a Food and Drug Administration-approved insomnia medication after diagnosis compared with 13.5% of White patients. Black patients were significantly less likely to have an order for a Food and Drug Administration-approved insomnia medication at all time points (adjusted hazard ratio [aHR] range: 0.37-0.73), and patients reporting Other race were less likely to have received an order at 2 (aHR 0.51, 95% confidence interval [CI] 0.28-0.94), 3 (aHR 0.33, 95% CI 0.13-0.79), and 4 years (aHR 0.21, 95% CI 0.06-0.71) of follow-up. Similar results were observed in a sensitivity analysis including off-label medications. CONCLUSIONS Patients belonging to racial minority groups are less likely to be prescribed an insomnia medication than White patients after accounting for sociodemographic and clinical factors. Further research is needed to determine the extent to which patient preferences and physician perceptions affect these prescribing patterns and investigate potential disparities in nonpharmacologic treatment.
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Affiliation(s)
- Emma Holler
- Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, Indiana, USA.
| | - Noll L Campbell
- College of Pharmacy and Health Sciences, Purdue University, West Lafayette, Indiana, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA; Center for Healthcare Innovation and Implementation Science, Indiana University, Indianapolis, Indiana, USA
| | - Malaz Boustani
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA; Center for Healthcare Innovation and Implementation Science, Indiana University, Indianapolis, Indiana, USA; Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul Dexter
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Clem McDonald Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Zina Ben Miled
- Department of Electrical and Computer Engineering, Indiana University Purdue University at Indianapolis, Indianapolis, Indiana, USA
| | - Arthur Owora
- Department of Epidemiology and Biostatistics, Indiana University Bloomington, Bloomington, Indiana, USA
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Kumar P, Del Rosario M, Chang J, Ziogas A, Jafari MD, Bristow RE, Tanjasiri SP, Zell JA. Population-Based Analysis of National Comprehensive Cancer Network (NCCN) Guideline Adherence for Patients with Anal Squamous Cell Carcinoma in California. Cancers (Basel) 2023; 15:cancers15051465. [PMID: 36900256 PMCID: PMC10000877 DOI: 10.3390/cancers15051465] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/02/2023] Open
Abstract
PURPOSE We analyzed adherence to the National Comprehensive Cancer Network treatment guidelines for anal squamous cell carcinoma in California and the associated impacts on survival. METHODS This was a retrospective study of patients in the California Cancer Registry aged 18 to 79 years with recent diagnoses of anal squamous cell carcinoma. Predefined criteria were used to determine adherence. Adjusted odds ratios and 95% confidence intervals were estimated for those receiving adherent care. Disease-specific survival (DSS) and overall survival (OS) were examined with a Cox proportional hazards model. RESULTS 4740 patients were analyzed. Female sex was positively associated with adherent care. Medicaid status and low socioeconomic status were negatively associated with adherent care. Non-adherent care was associated with worse OS (Adjusted HR 1.87, 95% CI = 1.66, 2.12, p < 0.0001). DSS was worse in patients receiving non-adherent care (Adjusted HR 1.96, 95% CI = 1.56, 2.46, p < 0.0001). Female sex was associated with improved DSS and OS. Black race, Medicare/Medicaid, and low socioeconomic status were associated with worse OS. CONCLUSIONS Male patients, those with Medicaid insurance, or those with low socioeconomic status are less likely to receive adherent care. Adherent care was associated with improved DSS and OS in anal carcinoma patients.
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Affiliation(s)
- Priyanka Kumar
- Department of Internal Medicine, University of California, Irvine, CA 92868-3201, USA
- Correspondence: ; Tel.: +1-714-456-5691; Fax: +1-714-456-8874
| | | | - Jenny Chang
- Department of Internal Medicine, University of California, Irvine, CA 92868-3201, USA
| | - Argyrios Ziogas
- Department of Internal Medicine, University of California, Irvine, CA 92868-3201, USA
| | - Mehraneh D. Jafari
- Department of Surgery, Section of Colon and Rectal Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Robert E. Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, CA 92868-3201, USA
| | - Sora Park Tanjasiri
- Department of Epidemiology & Biostatistics, University of California, Irvine, CA 92868-3201, USA
- Division of Hematology-Oncology, Department of Medicine, University of California, Irvine, CA 92868-3201, USA
| | - Jason A. Zell
- Division of Hematology-Oncology, Department of Medicine, University of California, Irvine, CA 92868-3201, USA
- Chao Family Comprehensive Cancer Center, University of California, Irvine, CA 92868-3201, USA
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Grunvald MW, Underhill JM, Skertich NJ, Williams MD, Aquina CT, Bhama AR, Hayden DM, Becerra AZ. Mediating Factors Between Race and Time to Treatment in Colorectal Cancer. Dis Colon Rectum 2023; 66:331-336. [PMID: 34933318 DOI: 10.1097/dcr.0000000000002214] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Previous disparities research has demonstrated that underrepresented racial minority patients have worse colorectal cancer outcomes and that they experience unnecessary delays in time to treatment. These delays may explain worse colorectal cancer outcomes for minority patients and serve as a marker of inequalities in our healthcare system. OBJECTIVE This study aims to quantify the mechanisms that contribute to this disparity in treatment delay. DESIGN This is a retrospective analysis of colorectal cancer patients who underwent elective resection from 2004 to 2017. A causal inference mediation analysis using the counterfactual framework was utilized to estimate the extent to which racial disparities among patient factors explain the racial disparities in time to treatment. Mediators included income, education, comorbidities, insurance, and hospital type. SETTINGS This study was conducted at hospitals participating in the National Cancer Database. PATIENTS Stage I-III colorectal cancer patients, ≥18 years old, who underwent elective resection from 2004 through 2017 were included. MAIN OUTCOMES MEASURES The primary measures were indirect effects of mediators between race and delayed time to treatment. RESULTS Of the 504,405 patients (370,051 colon and 134,354 rectal), 10%, 5%, and 4% were black, Hispanic, and other. In multivariable models, compared to white patients, these patients had 25%, 27%, and 17% greater odds of delayed treatment. Mediation analyses suggested that 43%, 20%, and 31% of the treatment delay among them could be removed if an intervention equalized income, education, comorbidities, insurance, and hospital type to that of white patients. Treatment at an academic hospital explained 15% to 32% of the racial disparity and was the most potent mediator. LIMITATIONS This study was limited by its retrospective design and failure to capture all meaningful mediators. CONCLUSIONS Black, Hispanic, and other colorectal cancer patients experience treatment delays when compared to white patients. Equalization of the mediators used in this study could reduce treatment delays by 20% to 43% depending on the racial/ethnic group. Future research should identify other causes of racial disparities in treatment delay and intervene accordingly. See Video Abstract at http://links.lww.com/DCR/B871 . FACTORES MEDIADORES ENTRE LA RAZA Y EL TIEMPO HASTA EL TRATAMIENTO EN EL CNCER COLORECTAL ANTECEDENTES:Investigaciones anteriores sobre disparidades han demostrado que los pacientes de minorías raciales subrepresentados tienen peores resultados de cáncer colorrectal y que experimentan retrasos innecesarios en el tiempo de tratamiento. Estos retrasos pueden explicar los peores resultados del cáncer colorrectal para los pacientes de minorías y servir como un marcador de desigualdades en nuestro sistema de salud.OBJETIVO:Este estudio tiene como objetivo cuantificar los mecanismos que contribuyen a esta disparidad en el retraso del tratamiento.DISEÑO:Este es un análisis retrospectivo de pacientes con cáncer colorrectal que se sometieron a resección electiva entre 2004 y 2017. Se utilizó un análisis de mediación de inferencia causal utilizando el marco contra factual para estimar hasta qué punto las disparidades raciales entre los factores del paciente explican las disparidades raciales en el tiempo hasta el tratamiento. Los mediadores incluyeron ingresos económicos, educación, comorbilidades, seguro médico y tipo de hospital.AJUSTES:Este estudio se realizó en hospitales que participan en la Base de datos nacional del cáncer.PACIENTES:Se incluyeron pacientes con cáncer colorrectal en estadio I-III, ≥18 años, que se sometieron a resección electiva entre 2004 y 2017.PRINCIPALES RESULTADOS MEDIDAS:Las principales mediciones fueron el efecto indirecto de los mediadores entre la raza y el retraso en el tratamiento.RESULTADOS:De los 504,405 pacientes (370,051 de colon, 134,354 rectal), 10%, 5%, 4% eran negros, hispanos, y otros, respectivamente. En modelos multivariables, en comparación con los pacientes blancos, estos pacientes tenían un 25%, 27%, y 17% más de probabilidades de retrasar el tratamiento. Los análisis de medición sugirieron que el 43%, 20%, 31% del retraso del tratamiento entre, respectivamente, podría eliminarse si una intervención igualara los ingresos económicos, la educación, las comorbilidades, el seguro médico y el tipo de hospital a los de los pacientes blancos. El tratamiento en un hospital académico demostró entre el 15% y el 32% de la disparidad racial y fue el mediador más potente.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo; falla en capturar a todos los mediadores significativos.CONCLUSIONES:Los pacientes negros, hispanos y otros con cáncer colorrectal experimentan retrasos en el tratamiento en comparación con los pacientes blancos. La igualación de los mediadores utilizados en este estudio podría reducir los retrasos en el tratamiento en un 20-43%, según el grupo racial / étnico. Las investigaciones futuras deberían identificar otras causas de disparidades raciales en el retraso del tratamiento e intervenir sobre ellas. Consulte Video Resumen en http://links.lww.com/DCR/B871 . (Traducción-Dr. Yolanda Colorado ).
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Affiliation(s)
- Miles W Grunvald
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Joshua M Underhill
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Michael D Williams
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Anuradha R Bhama
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Dana M Hayden
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH.
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De la Garza Ramos R, Javed K, Ryvlin J, Gelfand Y, Murthy S, Yassari R. Are There Racial or Socioeconomic Disparities in Ambulatory Outcome or Survival After Oncologic Spine Surgery for Metastatic Cancer? Results From a Medically Underserved Center. Clin Orthop Relat Res 2023; 481:301-307. [PMID: 36198109 PMCID: PMC9831169 DOI: 10.1097/corr.0000000000002445] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Disparities among patients with cancer are well documented. Recent studies suggest these disparities also affect patients undergoing metastatic spinal tumor surgery. However, it is unclear whether social factors are associated with ambulatory outcomes or overall survival. QUESTIONS/PURPOSES In patients undergoing metastatic spinal tumor surgery, (1) Are race, Social Vulnerability Index (SVI) score, or insurance status associated with a lower likelihood of postoperative ambulation? (2) Are race, SVI score, or insurance status associated with shorter overall survival? METHODS Between April 2012 and June 2021, we surgically treated 148 patients for metastatic cord compression or spinal mechanical instability because of cancer. Inclusion criteria were patients with complete demographic, social, oncologic, and follow-up data and patients who were followed until death or for at least 3 months postoperatively. Based on these criteria, 12% (18 of 148) were excluded because they had incomplete data and another 7% (11 of 148) were excluded because they were lost before the minimum study follow-up interval, leaving 80% (119) for analysis. Collected social data included self-reported race (White, Black, Hispanic or Latino, or other), SVI score, and primary insurance (Medicare, Medicaid, or private). The median age of the group was 62 years (interquartile range [IQR] 53 to 70 years), and 58% of patients were men (69 of 119). The race distribution was 45% Black (54 of 119), 32% Hispanic or Latino (38 of 119), 16% White (19 of 119), and 7% other (eight of 119). The median SVI score was 89.8 (IQR 73.8 to 98.5), and 74% of patients (88) were categorized as having high vulnerability. The insurance distribution was as follows: Medicare: 43%, Medicaid: 36%, and private insurance: 21%. The primary outcome variable was complete inability to ambulate postoperatively and the secondary outcome was median overall survival. Exploratory data analysis, univariate and multivariate logistic regression, and univariate and multivariate Cox regression analyses were performed. RESULTS After controlling for race, SVI score, insurance status, primary cancer, and modified Bauer score, the only factor independently associated with postoperative nonambulation was preoperative nonambulatory status (odds ratio 59.3 [95% confidence interval (CI) 13.2 to 266.1]; p < 0.001). After controlling for variables such as performance status, BMI, primary cancer, modified Bauer score, and insurance status, factors independently associated with survival included Eastern Cooperative Oncology Group performance status (hazard ratio [HR] 1.4 [95% CI 1.1 to 2.0]; p = 0.03), prostate cancer (HR 0.4 [95% CI 0.1 to 0.9]; p = 0.03), and hematologic cancer (HR 0.3 [95% CI 0.1 to 0.8]; p = 0.02). Race, SVI score, and insurance status were not associated with overall survival. CONCLUSION In this study, we found no difference in ambulatory outcome for patients based on their race, SVI score, or insurance status. Likewise, no differences in postoperative survival were found. These findings suggest that despite differences in presentation or short-term outcome reported in other investigations, the social factors we explored were not associated with the likelihood of a patient being nonambulatory postoperatively or shorter survival after spinal tumor surgery. Research studies that analyze race as a covariate of interest should take care to explore metrics of socioeconomic deprivation (such as the SVI score) to avoid drawing misleading conclusions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Rafael De la Garza Ramos
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Kainaat Javed
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Jessica Ryvlin
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Yaroslav Gelfand
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Saikiran Murthy
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Reza Yassari
- Spine Research Group, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
- Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
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Caston NE, Waters AR, Williams CP, Biddell C, Spees L, Gallagher K, Angove R, Anderson E, Balch A, Wheeler S, Rocque GB. Patient-reported discrimination among limited-resourced cancer survivors: a brief report. J Psychosoc Oncol 2022; 41:630-641. [PMID: 36519613 PMCID: PMC10617020 DOI: 10.1080/07347332.2022.2154186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE Healthcare discrimination has been associated with health disparities including lower cancer screenings, higher medical mistrust, and strained patient-provider relationships. Our study sought to understand patient-reported discrimination among cancer survivors with limited resources living in the United States. DESIGN AND METHODS We used cross-sectional survey data distributed by the Patient Advocate Foundation (PAF) in 12/2020 and 07/2021. Respondents reported source and reason of healthcare discrimination. Age, sex, race and ethnicity, annual household income, Rural-Urban Commuting Area (RUCA), Area Deprivation Index (ADI), employment status, cancer type, and number of comorbidities were independent variables of interest. The association between these variables and patient-reported healthcare discrimination was estimated using risk ratios (RRs) and 95% confidence intervals (CIs) from a multivariable modified Poisson regression model with robust standard errors. FINDINGS A total of 587 cancer survivors were included in our analysis. Most respondents were female (72%) and aged ≥56 (62%); while 33% were Black, Indigenous, or Person of Color. Overall, 23% reported receipt of discrimination, with the majority reporting doctor, nurse, or healthcare provider as the source (58%). Most common reasons for discrimination included disease status (42%), income/ability to pay (36%), and race and ethnicity (17%). In the adjusted model, retired survivors were 62% less likely to report discrimination compared to those employed (RR 0.38; 95% CI 0.23-0.64). Additionally, survivors with ≥3 comorbidities were 86% more likely to report discrimination compared to those survivors with no non-cancer comorbidities (RR 1.86; 95% CI 1.26-2.72). IMPLICATIONS Cancer survivors with limited resources reported substantial discrimination most often from a healthcare provider and most commonly for disease status and income. Discrimination should be mitigated to provide equitable and high-quality cancer care.
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Affiliation(s)
- Nicole E. Caston
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Austin R. Waters
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina (UNC), Chapel Hill, NC, USA
| | - Courtney P. Williams
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Caitlin Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina (UNC), Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC, USA
| | - Lisa Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina (UNC), Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC, USA
| | | | | | | | - Alan Balch
- Patient Advocate Foundation, Hampton, VA, USA
| | - Stephanie Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina (UNC), Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC, USA
| | - Gabrielle B. Rocque
- Division of Hematology and Oncology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
- O’Neal Comprehensive Cancer Center, UAB, Birmingham, AL, USA
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Heiden BT, Eaton DB, Chang SH, Yan Y, Baumann AA, Schoen MW, Patel MR, Kreisel D, Nava RG, Meyers BF, Kozower BD, Puri V. Racial Disparities in the Surgical Treatment of Clinical Stage I Non-Small Cell Lung Cancer Among Veterans. Chest 2022; 162:920-929. [PMID: 35405111 PMCID: PMC9562435 DOI: 10.1016/j.chest.2022.03.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Prior studies in the civilian population have reported racial disparities in lung cancer outcomes following surgical treatment, including inferior quality of care and worse survival. It is unclear if racial disparities exist in the Veterans Health Administration (VHA), the largest integrated health care system in the United States. RESEARCH QUESTION Do racial disparities affect early-stage non-small cell lung cancer (NSCLC) outcomes following surgical treatment within the VHA? STUDY DESIGN AND METHODS This retrospective cohort study was conducted in veterans with clinical stage I NSCLC undergoing surgical treatment in the VHA system. Demographic characteristics, access to care, surgical quality measures, and short- and long-term oncologic outcomes between White and Black veterans were evaluated. RESULTS From 2006 to 2016, a total of 18,800 veterans with clinical stage I NSCLC were included. The rates of definitive surgical treatment were similar between Black (57.3%) and White (58.1%) veterans (P = .42). The final study cohort included 9,842 patients receiving surgical treatment, of whom 8,356 (84.9%) were White and 1,486 (15.1%) were Black. Black patients were younger and more likely to smoke, although comorbidities were similar between the two groups. Black patients were somewhat less likely to receive adequate lymph node sampling (30.6% vs 33.3%; P = .050); however, other access-to-care metrics and surgical quality measures, including rates of anatomic lobectomy (71.9% vs 69.4%; P = .189) and positive margins (3.2% vs 3.1%; P = .955), were similar between the two groups. Although Black veterans were less likely to experience major postoperative complications, there was no difference in 30-day readmission, 30-day mortality, or disease-free survival between the two groups. Black patients had significantly better risk-adjusted overall survival (hazard ratio, 0.802; 95% CI, 0.729-0.883; P < .001). INTERPRETATION Among veterans with NSCLC undergoing surgical treatment through the VHA, Black patients received comparable care with equivalent if not superior outcomes compared with White patients.
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Affiliation(s)
- Brendan T Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
| | | | - Su-Hsin Chang
- VA St. Louis Health Care System, St. Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Yan Yan
- VA St. Louis Health Care System, St. Louis, MO; Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ana A Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Martin W Schoen
- VA St. Louis Health Care System, St. Louis, MO; Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO; VA St. Louis Health Care System, St. Louis, MO
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Jawad MU, Zeitlinger LN, Bewley AF, O’Donnell EF, Traven SA, Carr-Ascher JR, Monjazeb AM, Canter RJ, Thorpe SW, Randall RL. Head and Neck Cutaneous Soft-Tissue Sarcoma Demonstrate Sex and Racial/Ethnic Disparities in Incidence and Socioeconomic Disparities in Survival. J Clin Med 2022; 11:jcm11185475. [PMID: 36143122 PMCID: PMC9501210 DOI: 10.3390/jcm11185475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Cutaneous soft-tissue sarcoma (CSTS) of the head and neck are rare and are known to have aggressive clinical course. The current study utilizes a population-based registry in the U.S. to characterize these malignancies and explore disparities. Methods: National Cancer Institute’s (NCI) Surveillance, Epidemiology and End Result (SEER) database from 2000 to 2018 was queried to report incidence and survival data in 4253 cases in the U.S. Results: Males were 5.37 times more likely and Non-Hispanic-White people (NHW) were 4.62 times more likely than females and Non-Hispanic-Black people (NHB) to develop CSTS of the head and neck. The overall incidence was 0.27 per 100,000 persons in 2018, with a significant increase since 2000. Advanced age and stage, histologic group other than ‘fibromatous sarcoma’ and lower SES groups were independent factors for worse overall survival. Conclusions: CSTS of the head and neck demonstrate sex and racial/ethnic disparities in incidence and socioeconomic disparities in overall survival. Level of evidence: II.
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Affiliation(s)
- Muhammad Umar Jawad
- Department of Orthopaedic Surgery, Good Samaritan Regional Medical Center, Corvallis, OR 97333, USA
| | - Lauren N. Zeitlinger
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA 95817, USA
| | - Arnaud F. Bewley
- Department of Otolaryngology, University of California-Davis, Sacramento, CA 95817, USA
| | - Edmond F. O’Donnell
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA 95817, USA
| | - Sophia A. Traven
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA 95817, USA
| | - Janai R. Carr-Ascher
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA 95817, USA
- Department of Medicine, University of California-Davis, Sacramento, CA 95817, USA
| | - Arta M. Monjazeb
- Department of Radiation Oncology, University of California-Davis, Sacramento, CA 95817, USA
| | - Robert J. Canter
- Department of Surgery-General, University of California-Davis, Sacramento, CA 95817, USA
| | - Steven W. Thorpe
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA 95817, USA
| | - R. Lor Randall
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, CA 95817, USA
- Correspondence:
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Farrow LD, Scarcella MJ, Wentt CL, Jones MH, Spindler KP, Briskin I, Leo BM, McCoy BW, Miniaci AA, Parker RD, Rosneck JT, Sabo FM, Saluan PM, Serna A, Stearns KL, Strnad GJ, Williams JS. Evaluation of Health Care Disparities in Patients With Anterior Cruciate Ligament Injury: Does Race and Insurance Matter? Orthop J Sports Med 2022; 10:23259671221117486. [PMID: 36199832 PMCID: PMC9528024 DOI: 10.1177/23259671221117486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 05/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background: It is unknown whether race- or insurance-based disparities in health care exist regarding baseline knee pain, knee function, complete meniscal tear, or articular cartilage damage in patients who undergo anterior cruciate ligament reconstruction (ACLR). Hypothesis: Black patients and patients with Medicaid evaluated for ACLR would have worse baseline knee pain, worse knee function, and greater odds of having a complete meniscal tear. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of patients (N = 1463; 81% White, 14% Black, 5% Other race; median age, 22 years) who underwent ACLR between February 2015 and December 2018 was selected from an institutional database. Patients who underwent concomitant procedures and patients of undisclosed race or self-pay status were excluded. The associations of race with preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) Pain subscale, KOOS Function subscale, and intraoperatively assessed complete meniscal tear (tear that extended through both the superior and the inferior meniscal surfaces) were determined via multivariate modeling with adjustment for age, sex, insurance status, years of education, smoking status, body mass index (BMI), meniscal tear location, and Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS). Results: The 3 factors most strongly associated with worse KOOS Pain and KOOS Function were lower VR-12 MCS score, increased BMI, and increased age. Except for age, the other two factors had an unequal distribution between Black and White patients. Univariate analysis demonstrated equal baseline median KOOS Pain scores (Black, 72.2; White, 72.2) and KOOS Function scores (Black, 68.2; White, 68.2). After adjusting for confounding variables, there was no significant difference between Black and White patients in KOOS Pain, KOOS Function, or complete meniscal tears. Insurance status was not a significant predictor of KOOS Pain, KOOS Function, or complete meniscal tear. Conclusion: There were clinically significant differences between Black and White patients evaluated for ACLR. After accounting for confounding factors, no difference was observed between Black and White patients in knee pain, knee function, or complete meniscal tear. Insurance was not a clinically significant predictor of knee pain, knee function, or complete meniscal tear.
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Affiliation(s)
- Lutul D. Farrow
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Christa L. Wentt
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Morgan H. Jones
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Kurt P. Spindler
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Isaac Briskin
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian M. Leo
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Brett W. McCoy
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - James T. Rosneck
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Frank M. Sabo
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Paul M. Saluan
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Alfred Serna
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
| | - Kim L. Stearns
- Investigation performed at Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
There is extensive research demonstrating significant variation in the utilization of surgery and outcomes from surgery, including differences in mortality, complications, readmission, and failure to rescue. Literature suggests that these variations exist across as well as within small area geographies in the United States. There is also significant evidence of variation in access and outcomes from surgery that is attributable to race. Emerging research is demonstrating that there may be some variation attributable to a patient's social determinants of health and their lived averment. Those affected must work together to determine rate of utilization and how much variation is acceptable.
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Affiliation(s)
- Adrian Diaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA.
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Zhong P, Yang B, Pan F, Hu F. Temporal trends in Black-White disparities in cancer surgery and cancer-specific survival in the United States between 2007 and 2015. Cancer Med 2022; 12:3509-3519. [PMID: 35968573 PMCID: PMC9939184 DOI: 10.1002/cam4.5141] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/16/2022] [Accepted: 08/02/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The American Society of Clinical Oncology (ASCO) has strived to address racial/ethnic disparities in cancer care since 2009. Surgery plays a pivotal role in cancer care; however, it is unclear whether and how racial/ethnic disparities in cancer surgery have changed over time. METHODS This cohort study included 1,113,256 White and Black cancer patients across 9 years (2007-2015) using patient data extracted from the Surveillance, Epidemiology, and End Results (SEER)-18 registries. Patient data were included from 2007 to adjust insurance status and by 2015 to obtain at least a 3-year survival follow-up (until 2018). The primary outcome was a surgical intervention. The secondary outcomes were the use of (neo)adjuvant chemotherapy and cancer-specific survival (CSS). Adjusted associations of the race (Black/White) with the outcomes were measured in each cancer type and year. RESULTS The gap between surgery rates for Black and White patients narrowed overall, from an adjusted odds ratio (aOR) of 0.621 (0.592-0.652) in 2007 to 0.734 (0.702-0.768) in 2015. However, the racial gap persisted in the surgery rates for lung, breast, prostate, esophageal, and ovarian cancers. In surgically treated patients with lymph node metastasis, Black patients with colorectal cancer (CRC) were less likely to receive (neo)adjuvant chemotherapy than White patients. Black patients undergoing surgery were more likely to have a worse CSS rate than White patients undergoing surgery. In breast cancer patients, the overall trend was narrow, but continuously present, with an adjusted hazard ratio (aHR) of 1.224 (1.278-1.173) in 2007 and 1.042 (1.132-0.96) in 2015. CONCLUSIONS Overall, progress has been made toward narrowing the Black-White gap in cancer surgical opportunity and survival. Future efforts should be directed toward those specific cancers for which the Black-White gap continues. Additionally, it is worth addressing the Black-White gap regarding the use of (neo)adjuvant chemotherapy for CRC treatment.
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Affiliation(s)
- Peijie Zhong
- Clinical Medical CollegeSouthwest Medical UniversityLuzhouChina
- Department of Gastroenterology and HepatologyHuaihe Hospital of Henan UniversityKaifengChina
| | - Bo Yang
- Department of Interventional MedicineThe Affiliated hospital of Southwest Medical UniversityLuzhouChina
| | - Feng Pan
- Department of Interventional MedicineThe Affiliated hospital of Southwest Medical UniversityLuzhouChina
| | - Fang Hu
- Department of Interventional MedicineThe Affiliated hospital of Southwest Medical UniversityLuzhouChina
- College of nursingSouthwest Medical UniversityLuzhouChina
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Ramkumar N, Colla CH, Wang Q, O’Malley AJ, Wong SL, Brooks GA. Association of Rurality, Race and Ethnicity, and Socioeconomic Status With the Surgical Management of Colon Cancer and Postoperative Outcomes Among Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2229247. [PMID: 36040737 PMCID: PMC9428741 DOI: 10.1001/jamanetworkopen.2022.29247] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/09/2022] [Indexed: 01/13/2023] Open
Abstract
Importance Rural patients with colon cancer experience worse outcomes than urban patients, but the extent to which disparities are explained by social determinants is not known. Objectives To evaluate the association of rurality with surgical treatment and outcomes of colon cancer and to investigate the intersection of rurality with race and ethnicity and socioeconomic status. Design, Settings, and Participants This cohort study included fee-for-service Medicare beneficiaries 65 years or older diagnosed with incident, nonmetastatic colon cancer between April 1, 2016, and September 30, 2018, with follow-up until December 31, 2018. Data were analyzed from August 3, 2020, to April 30, 2021. Exposures Rurality of patient's residence, categorized as metropolitan, micropolitan, or small town or rural, using Rural-Urban Commuting Area codes. Main Outcomes and Measures Receipt of surgery, emergent surgery, or minimally invasive surgery (MIS); 90-day surgical complications; and 90-day mortality. Results Among 57 710 Medicare beneficiaries with incident, nonmetastatic colon cancer, 46.6% were men, 53.4% were women, and the mean (SD) age was 76.6 (7.2) years. In terms of race and ethnicity, 3.7% were Hispanic, 6.4% were non-Hispanic Black (hereinafter Black), 86.1% were non-Hispanic White (hereinafter White), and 3.8% were American Indian or Alaska Native, Asian or Pacific Islander, or unknown race or ethnicity. Patients residing in nonmetropolitan areas were more likely to undergo surgical resection than those residing in metropolitan areas (69.2% vs 63.9%; P < .001). Black race was independently associated with lower hazard of surgical resection (hazard ratio, 0.92 [95% CI, 0.88-0.95]). Race and ethnicity and measures of socioeconomic status did not modify the association of rurality with surgery. Beneficiaries from small town and rural areas had higher odds of undergoing emergent surgery (adjusted odds ratio [OR], 1.32 [95% CI, 1.20-1.44]) but lower odds of undergoing MIS (adjusted OR, 0.75 [95% CI, 0.70-0.80]), with similar findings for patients residing in micropolitan areas. Members of racial and ethnic minority groups who resided in small town and rural settings experienced higher odds of postoperative surgical complications (P = .001 for interaction) and mortality (P = .001 for interaction). Notably, White patients who resided in small town and rural areas experienced lower odds of postoperative mortality than their White metropolitan counterparts (adjusted OR, 0.81 [95% CI, 0.71-0.92]), but Black patients who resided in small town and rural areas had significantly higher odds of postoperative mortality (adjusted OR, 1.86 [95% CI, 1.16-2.97]) than their Black metropolitan counterparts. Conclusions and Relevance These findings suggest that Medicare beneficiaries from small town and rural areas were more likely to undergo surgery for nonmetastatic colon cancer than metropolitan beneficiaries but also more likely to undergo emergent surgery and less likely to have MIS. The experiences of rural patients varied by race; rurality was associated with higher postoperative mortality for Black patients but not for other racial and ethnic groups.
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Affiliation(s)
- Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Congressional Budget Office, Washington, DC
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Biomedical Data Sciences, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Sandra L. Wong
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Congressional Budget Office, Washington, DC
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Gabriel A. Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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da Costa WL, Camp ER, Thrift AP. Sociodemographic and Facility-Related Disparities in the Delivery of Guideline-Concordant Therapy Among Patients With Esophageal Adenocarcinoma. JCO Oncol Pract 2022; 18:e1181-e1197. [DOI: 10.1200/op.21.00912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Evidence on health disparities among patients treated with multimodality therapy protocols is still limited. We aimed to evaluate the associations between patient-level and system-level factors and the receipt of guideline-concordant therapy among patients with esophageal adenocarcinoma (EA). METHODS: This is a national cohort study of patients with stage I-III EA in the National Cancer Database (2006-2018) treated with either upfront resection or neoadjuvant therapy followed by surgery. Clinical and pathologic staging data were used for defining guideline-concordant therapy. Logistic regression models were built to identify independent associations between deviations from treatment guidelines and clinical, sociodemographic, and hospital-related factors. RESULTS: Among 18,803 patients with EA treated at 1,049 hospitals, 4,511 had an endoscopic resection, 4,866 had upfront resection, and 9,426 had neoadjuvant therapy followed by surgery. A total of 16,002 patients (85.1%) received guideline-concordant therapy. Patients who were age 70 years or older (odds ratio [OR] 1.35; 95% CI, 1.14 to 1.60), had a Charlson-Deyo modified score of ≥ 1, and were treated at hospitals with a safety-net burden of ≥ 10% (OR 1.13; 95% CI, 1.02 to 1.25) had higher risk of deviations from guidelines, whereas treatment at high-volume facilities (OR 0.84; 95% CI, 0.74 to 0.95) and diagnosis after 2011 decreased this risk. Relative to cT0-1N0 patients, those with cT2N0 disease had the highest risk of deviations from guideline-concordant therapy (OR 3.76; 95% CI, 3.30 to 4.29). Among patients treated at high-volume facilities, safety-net burden over 10% increased the risk of deviations (OR 1.26; 95% CI, 1.01 to 1.57). CONCLUSION: The delivery of guideline-concordant therapy among patients with EA varies significantly across clinical stage groups and is associated with several sociodemographic disparities. This knowledge should be a resource for future quality improvement strategies intended to address inequitable care within vulnerable populations.
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Affiliation(s)
- Wilson L. da Costa
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - E. Ramsay Camp
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
- Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Aaron P. Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, TX
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
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Miller SM, Wilson LE, Greiner MA, Pritchard JE, Zhang T, Kaye DR, Cohen HJ, Becher RD, Maerz LL, Dinan MA. Evaluation of mild cognitive impairment and dementia in patients with metastatic renal cell carcinoma. J Geriatr Oncol 2022; 13:635-643. [PMID: 34996724 PMCID: PMC9232862 DOI: 10.1016/j.jgo.2021.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 12/07/2021] [Accepted: 12/14/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Dementia and cancer are both more common in adults as they age. As new cancer treatments become more popular, it is important to consider how these treatments might affect older patients. This study evaluates metastatic renal cell carcinoma (mRCC) as a risk factor for older adults developing mild cognitive impairment or dementia (MCI/D) and the impact of mRCC-directed therapies on the development of MCI/D. METHODS We identified patients diagnosed with mRCC in a Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset from 2007 to 2015 and matched them to non-cancer controls. Exclusion criteria included age < 65 years at mRCC diagnosis and diagnosis of MCI/D within the year preceding mRCC diagnosis. The main outcome was time to incident MCI/D within one year of mRCC diagnosis for cases or cohort entry for non-cancer controls. Cox proportional hazards models were used to measure associations between mRCC and incident MCI/D as well as associations of oral anticancer agent (OAA) use with MCI/D development within the mRCC group. RESULTS Patients with mRCC (n = 2533) were matched to non-cancer controls (n = 7027). mRCC (hazard ratio [HR] 8.52, p < .001), being older (HR 1.05 per 1-year age increase, p < .001), and identifying as Black (HR 1.92, p = .047) were predictive of developing MCI/D. In addition, neither those initiating treatment with OAAs nor those who underwent nephrectomy were more likely to develop MCI/D. CONCLUSIONS Patients with mRCC were more likely to develop MCI/D than those without mRCC. The medical and surgical therapies evaluated were not associated with increased incidence of MCI/D. The increased incidence of MCI/D in older adults with mRCC may be the result of the pathology itself or risk factors common to the two disease processes.
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Affiliation(s)
- Samuel M Miller
- National Clinician Scholars Program, Yale University, USA; Department of Surgery, Yale University, USA.
| | - Lauren E Wilson
- Department of Population Health Sciences, Duke University, USA
| | | | | | - Tian Zhang
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center, USA
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University, USA
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Ng AP, Sanaiha Y, Verma A, Lee C, Akhavan A, Cohen JG, Benharash P. Insurance-based disparities and risk of financial toxicity among patients undergoing gynecologic cancer operations. Gynecol Oncol 2022; 166:200-206. [PMID: 35660294 DOI: 10.1016/j.ygyno.2022.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/18/2022] [Accepted: 05/22/2022] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the risk of financial toxicity (FT) among inpatients undergoing gynecologic cancer resections and the association of insurance status with clinical and financial outcomes. METHODS Using the 2008-2019 National Inpatient Sample, we identified adult hospitalizations for hysterectomy or oophorectomy with a diagnosis of cancer. Hospitalization costs, length of stay (LOS), mortality, and complications were assessed by insurance status. Risk of FT was defined as health expenditure exceeding 40% of post-subsistence income. Multivariable regressions were used to analyze costs and factors associated with FT risk. RESULTS Of 462,529 patients, 49.4% had government-funded insurance, 44.3% private, and 3.2% were uninsured. Compared to insured, uninsured patients were more commonly Black and Hispanic, admitted emergently, and underwent open operations. Uninsured patients experienced similar mortality but greater rates of complications, LOS, and costs. Overall, ovarian cancer resections had the highest median costs of $17,258 (interquartile range: 12,187-25,491) compared to cervical and uterine. Approximately 52.8% of uninsured and 15.4% of insured patients were at risk of FT. As costs increased across both cohorts over the 12-year study period, the disparity in FT risk by payer status broadened. After risk adjustment, perioperative complications were associated with nearly 2-fold increased risk of FT among uninsured (adjusted odds ratio 1.75, 95% confidence interval 1.46-2.09, p < 0.001). Among the insured, Black and Hispanic race, public insurance, and open operative approach exhibited greater odds of FT. CONCLUSION Patients undergoing gynecologic cancer operations are at substantial risk of FT, particularly those uninsured. Targeted cost-mitigation strategies are warranted to minimize financial burden.
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Affiliation(s)
- Ayesha P Ng
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Cory Lee
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Aaron Akhavan
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Joshua G Cohen
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America.
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Social Determinants of Health in Oncology: Towards a More Personalized and Equitable Delivery of Cancer Care. Am J Clin Oncol 2022; 45:273-278. [PMID: 35532746 DOI: 10.1097/coc.0000000000000914] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Social determinants of health (SDOH) are defined as the set of modifiable social and physical risk factors that affect health. It is known that SDOH directly influence the population's overall health, but their effects on patients with cancer are considerably less elucidated. Here, we review the literature describing the effects of SDOH outlined by the Healthy People 2020 framework on patients diagnosed with cancer. We have found that while some SDOH are well-defined in cancer patients, evidence surrounding several variables is scarce. In addition, we have found that many SDOH are associated with disparities at the screening stage, indicating that upstream interventions are necessary before addressing the clinical outcomes themselves. Further investigation is warranted to understand how SDOH affect screenings and outcomes in multiple disciplines of oncology and types of cancers as well as explore how SDOH affect the treatments sought by these vulnerable patients.
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K. C. M, Oral E, Rung AL, Trapido EJ, Rozek LS, Fontham ETH, Bensen JT, Farnan L, Steck SE, Song L, Mohler JL, Peters ES. Neighborhood deprivation and risk of mortality among men with prostate cancer: Findings from a long-term follow-up study. Prostate 2022; 82:783-792. [PMID: 35201637 PMCID: PMC9306458 DOI: 10.1002/pros.24320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/10/2022] [Accepted: 02/04/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND The overall survival rate of prostate cancer (PCa) has improved over the past decades. However, huge socioeconomic and racial disparities in overall and prostate cancer-specific mortality exist. The neighborhood-level factors including socioeconomic disadvantage and lack of access to care may contribute to disparities in cancer mortality. This study examines the impact of neighborhood deprivation on mortality among PCa survivors. METHODS North Carolina-Louisiana Prostate Cancer Project (PCaP) data were used. A total of 2113 men, 1046 AA and 1067 EA, with PCa were included in the analysis. Neighborhood deprivation was measured by the Area Deprivation Index (ADI) at the census block group level using data from the US Census Bureau. Quintiles of ADI were created. Cox proportional hazards and competing risk models with mixed effects were performed to estimate the effect of neighborhood deprivation on all-cause and PCa-specific mortality adjusted for age, race, study site, insurance status, and comorbidities. RESULTS Participants living in the most deprived neighborhoods had an increased risk for all-cause mortality (quintiles 4 + 5: adjusted hazard ratio [aHR] = 1.51, 95% confidence interval [CI] = 1.16-1.96) compared to those in the least deprived (quintile 1) neighborhoods. The risk of prostate cancer-specific mortality was also higher among those living in the deprived neighborhoods (quintiles 4 + 5: aHR = 1.90, 95% CI = 1.10-3.50) than those in the least deprived neighborhood. CONCLUSIONS The findings suggest neighborhood-level resources or health interventions are essential to improve survival among men with PCa. Additional research should focus on the mechanisms of how the neighborhood environment affects mortality.
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Affiliation(s)
- Madhav K. C.
- Department of Internal Medicine, Yale School of MedicineCancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterNew HavenConnecticutUSA
- Department of Epidemiology, School of public HealthEpidemiology Program, Louisiana State University Health Sciences Center‐New OrleansNew OrleansLouisianaUSA
| | - Evrim Oral
- Department of Biostatistics, School of Public HealthBiostatistics Program, Louisiana State University Health Sciences Center‐New OrleansNew OrleansLouisianaUSA
| | - Ariane L. Rung
- Department of Epidemiology, School of public HealthEpidemiology Program, Louisiana State University Health Sciences Center‐New OrleansNew OrleansLouisianaUSA
| | - Edward J. Trapido
- Department of Epidemiology, School of public HealthEpidemiology Program, Louisiana State University Health Sciences Center‐New OrleansNew OrleansLouisianaUSA
| | - Laura S. Rozek
- Department of Environmental Health SciencesUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Elizabeth T. H. Fontham
- Department of Epidemiology, School of public HealthEpidemiology Program, Louisiana State University Health Sciences Center‐New OrleansNew OrleansLouisianaUSA
| | - Jeannette T. Bensen
- Department of EpidemiologyGillings School of Global Public Health, University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Lineberger Comprehensive Cancer Center, School of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Laura Farnan
- Lineberger Comprehensive Cancer Center, School of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Susan E. Steck
- Department of Epidemiology and BiostatisticsArnold School of Public Health, University of South CarolinaColumbiaSouth CarolinaUSA
| | - Lixin Song
- School of NursingUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - James L. Mohler
- Department of UrologyRoswell Park Comprehensive Cancer CenterNew YorkNew YorkUSA
| | - Edward S. Peters
- Department of Epidemiology, School of public HealthEpidemiology Program, Louisiana State University Health Sciences Center‐New OrleansNew OrleansLouisianaUSA
- Department of EpidemiologyCollege of Public HealthUniversity of Nebraska Medical CenterOmahaNebraskaUSA
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Cantos A, Eguia E, Wang X, Abood G, Knab LM. Impact of sociodemographic factors on outcomes in patients with peritoneal malignancies following cytoreduction and chemoperfusion. J Surg Oncol 2022; 125:1285-1291. [PMID: 35253223 PMCID: PMC9314066 DOI: 10.1002/jso.26843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/26/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives Sociodemographic factors have been shown to impact surgical outcomes. However, the effects of these factors on patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) are not well known. This study aims to evaluate the impact of sociodemographic factors on patients undergoing CRS/HIPEC. Methods Adult patients at a tertiary center who underwent CRS/HIPEC were evaluated. Perioperative variables were collected and analyzed. A national database was also used to evaluate patients undergoing CRS/HIPEC. Results There were 90 patients who underwent CRS/HIPEC (32% non‐White). There was no statistically significant difference in postoperative complications, length of stay, or discharge disposition based upon race (white vs. non‐White patients), socioeconomic status (SES), or insurance type. Nationally, we found that Black and Hispanic patients were less likely to undergo CRS/HIPEC than Non‐Hispanic white patients (Black: odds ratio [OR]: 0.60, [confidence interval {CI}: 0.39–0.94]; Hispanic: OR: 0.52, [CI: 0.28–0.98]). However, there were no significant differences in postoperative complications based upon race/ethnicity. Conclusion Sociodemographic factors including race, SES, and insurance status did not impact postoperative outcomes in patients undergoing CRS/HIPEC at our single institution. On a national level, Black and Hispanic patients underwent CRS/HIPEC at lower rates compared to white patients.
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Affiliation(s)
- Adriana Cantos
- Department of Surgery Loyola University Chicago Stritch School of Medicine Maywood Illinois USA
| | - Emanuel Eguia
- Department of Surgery Loyola University Medical Center Maywood Illinois USA
| | - Xuanji Wang
- Department of Surgery Loyola University Medical Center Maywood Illinois USA
| | - Gerard Abood
- Department of Surgery Loyola University Medical Center Maywood Illinois USA
| | - Lawrence M. Knab
- Department of Surgery Loyola University Medical Center Maywood Illinois USA
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Penny CL, Tanino SM, Mosca PJ. Racial Disparities in Surgery for Malignant Bowel Obstruction. Ann Surg Oncol 2022; 29:3122-3133. [PMID: 35041096 DOI: 10.1245/s10434-021-11161-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Operative management of patients with malignant bowel obstruction (MBO) may provide effective palliation, but is associated with substantial risks. This study aimed to analyze racial and ethnic differences in surgical outcomes for patients with MBO. METHODS This retrospective study, using National Surgical Quality Improvement Program (NSQIP) registry data from 2010 to 2019, compared differences in outcomes by race and ethnicity for 2762 patients undergoing surgery for MBO. Multivariable logistic regression controlled for relevant covariates. RESULTS Black patients (n = 407) had higher rates of preoperative comorbidity and were more likely than White patients (n = 2081) to have major complications (28.5% vs 21.8%; p = 0.0031), overall complications (47.4% vs 40.4%; p = 0.0087), a longer median hospital stay (12 days; interquartile range [IQR, 8-19 days] vs 10 days [IQR, 7-17 days]; p = 0.0007), and unplanned readmission (17.1% vs 12.9%; p = 0.0266). Black patients had a similar mortality rate to that of White patients and were less frequently discharged to home (67.6% vs 73.0%; p = 0.0315). Differences in morbidity between Black patients and White patients persisted after controlling for potentially confounding variables. Hispanic patients had lower mortality than White patients (6.3% vs 13.1%; p = 0.0130) and a longer hospital stay (12 days [IQR, 8-18 days] vs 10 days [IQR, 7-17 days]; p = 0.0313). Outcomes did not differ between Asian patients and White patients. CONCLUSIONS This study demonstrated significant disparities for Black patients undergoing surgery for MBO. Understanding and addressing what drives these differences, including systemic inequalities such as access to care and racial biases, is essential to the achievement of more equitable, higher-quality patient care.
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Affiliation(s)
- Caitlin L Penny
- Duke University School of Medicine, Duke Health, Durham, NC, USA
| | - Sean M Tanino
- Duke University School of Medicine, Duke Health, Durham, NC, USA
| | - Paul J Mosca
- Duke University School of Medicine, Duke Health, Durham, NC, USA. .,Department of Surgery, Duke Health, Durham, NC, USA. .,Duke Network Services, Duke Health, Durham, NC, USA.
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Elshami M, Hue JJ, Hoehn RS, Rothermel LD, Hardacre JM, Ammori JB, Winter JM, Ocuin LM. Black race is independently associated with underutilization of preoperative chemotherapy in clinical stage T2 or higher gastric adenocarcinoma. Surgery 2022; 171:1562-1569. [PMID: 34991911 DOI: 10.1016/j.surg.2021.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/18/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Consensus guidelines recommend for perioperative chemotherapy and surgery for patients with clinical stage (cT) T2 or greater gastric adenocarcinoma. We compared adherence to guidelines in these patients stratified by race. METHODS Non-Hispanic White and Black patients with resected ≥cT2 gastric adenocarcinoma were identified within the National Cancer Database (2008-2017). We compared administration of preoperative chemotherapy by race, adjusting for clinicodemographic variables. We performed marginal standardization of logistic regression to calculate adjusted probabilities of administration of preoperative chemotherapy in patients under the age of 80 years with insurance. RESULTS A total of 13,850 patients were identified (White = 12,161; Black = 1,689). Black race was associated with lower likelihood of receiving preoperative chemotherapy than White race (odds ratio = 0.46, 95% confidence interval: 0.39-0.54). Other factors associated with lower likelihood of preoperative chemotherapy included age ≥70 years, female sex, treatment at community facilities, non-private or no health insurance, and cT4 disease. Factors associated with higher likelihood of preoperative chemotherapy included treatment at high-volume facilities, longer distance to facility, higher education and income levels, cT3 disease, and cN+ disease. In patients <80 years with insurance, marginal standardization models demonstrated that Black race was associated with a lower adjusted probability of receiving preoperative chemotherapy regardless of age, insurance payor, facility type/volume, distance to facility, cT stage, cN stage, sex, and education/income levels. CONCLUSION Black race was associated with underutilization of preoperative chemotherapy for cT2 or greater gastric cancer, in discordance to published guidelines. The etiology of these disparities is multifactorial, and correcting the root causes represents a critical area for improvement.
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Affiliation(s)
- Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Richard S Hoehn
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH.
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Shahian DM, Badhwar V, O'Brien SM, Habib RH, Han J, McDonald DE, Antman MS, Higgins RSD, Preventza O, Estrera AL, Calhoon JH, Grondin SC, Cooke DT. Social Risk Factors in Society of Thoracic Surgeons Risk Models Part 1: Concepts, Indicator Variables, and Controversies. Ann Thorac Surg 2022; 113:1703-1717. [PMID: 34998732 DOI: 10.1016/j.athoracsur.2021.11.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/01/2022]
Affiliation(s)
- David M Shahian
- Division of Cardiac Surgery, Department of Surgery, and Center for Quality and Safety, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown WV
| | | | | | - Jane Han
- Society of Thoracic Surgeons, Chicago, IL
| | | | | | - Robert S D Higgins
- Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore, MD
| | - Ourania Preventza
- Baylor College of Medicine, Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX
| | - Anthony L Estrera
- McGovern Medical School at UTHealth; Memorial Hermann Heart and Vascular Institute; Houston, TX
| | - John H Calhoon
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio
| | - Sean C Grondin
- Cumming School of Medicine, University of Calgary, and Foothills Medical Centre, Calgary, Alberta, Canada
| | - David T Cooke
- Division of General Thoracic Surgery, UC Davis Health, Sacramento, CA
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Jackson HN, Hadley CC, Khan AB, Gadot R, Bayley JC, Shetty A, Mandel J, Jalali A, Gallagher KK, Sweeney AD, Harmanci AO, Harmanci AS, Klisch T, Gopinath SP, Rao G, Yoshor D, Patel AJ. Racial and Socioeconomic Disparities in Patients With Meningioma: A Retrospective Cohort Study. Neurosurgery 2022; 90:114-123. [PMID: 34982878 PMCID: PMC9514723 DOI: 10.1227/neu.0000000000001751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Meningiomas are the most common intracranial neoplasms. Although genomic analysis has helped elucidate differences in survival, there is evidence that racial disparities may influence outcomes. African Americans have a higher incidence of meningiomas and poorer survival outcomes. The etiology of these disparities remains unclear, but may include a combination of pathophysiology and other factors. OBJECTIVE To determine factors that contribute to different clinical outcomes in racial populations. METHODS We retrospectively reviewed 305 patients who underwent resection for meningiomas at a single tertiary care facility. We used descriptive statistics and univariate, multivariable, and Kaplan-Meier analyses to study clinical, radiographical, and histopathological differences. RESULTS Minority patients were more likely to present through the emergency department than an outpatient clinic (P < .0001). They were more likely to present with more advanced clinical symptoms with lower Karnofsky Performance scores, more frequently had peritumoral edema (P = .0031), and experienced longer postoperative stays in the hospital (P = .0053), and African-American patients had higher hospitalization costs (P = .046) and were more likely to be publicly insured. Extent of resection was an independent predictor of recurrence freedom (P = .039). Presentation in clinic setting trended toward an association with recurrence-free survival (P = .055). We observed no significant difference in gross total resection rates, postoperative recurrence, or recurrence-free survival. CONCLUSION Minority patients are more likely to present with severe symptoms, require longer perioperative hospitalization, and generate higher hospitalization costs. This may be due to socioeconomic factors that affect access to health care. Targeting barriers to access, especially to subspecialty care, may facilitate more appropriate and timely diagnosis, thereby improving patient care and outcomes.
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Affiliation(s)
- Hudin N Jackson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Caroline C Hadley
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - A Basit Khan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ron Gadot
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - James C Bayley
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Arya Shetty
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jacob Mandel
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Ali Jalali
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - K Kelly Gallagher
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Otolaryngology, Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Alex D Sweeney
- Department of Otolaryngology, Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Arif O Harmanci
- Center for Computational Systems Medicine, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Akdes S Harmanci
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Tiemo Klisch
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA.,Jan and Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas, USA
| | - Shankar P Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ganesh Rao
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel Yoshor
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Akash J Patel
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Otolaryngology, Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA.,Jan and Duncan Neurological Research Institute, Texas Children's Hospital, Houston, Texas, USA
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Cardinal T, Strickland BA, Bonney PA, Lechtholz-Zey E, Mendoza J, Pangal DJ, Mack W, Giannotta S, Zada G. Disparities in the Surgical Treatment of Cerebrovascular Pathologies: A Contemporary Systematic Review. World Neurosurg 2021; 158:244-257.e1. [PMID: 34856403 DOI: 10.1016/j.wneu.2021.11.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This systematic review analyzes contemporary literature on racial/ethnic, insurance, and socioeconomic disparities within cerebrovascular surgery in the United States to determine areas for improvement. METHODS We conducted an electronic database search of literature published between January 1990 and July 2020 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies analyzing a racial/ethnic, insurance, or socioeconomic disparity within adult cerebrovascular surgery. RESULTS Of 2873 articles screened for eligibility by title and abstract, 970 underwent full-text independent review by 3 authors. Twenty-seven additional articles were identified through references to generate a final list of 47 included studies for analysis. Forty-six were retrospective reviews and 1 was a prospective observational cohort study, thereby comprising Levels III and IV of evidence. Studies investigated carotid artery stenting (11/47, 23%), carotid endarterectomy (22/47, 46.8%), mechanical thrombectomy (8/47, 17%), and endovascular aneurysm coiling or surgical aneurysm clipping (20/47, 42.6%). Minority and underinsured patients were less likely to receive surgical treatment. Non-White patients were more likely to experience a postoperative complication, although this significance was lost in some studies using multivariate analyses to account for complication risk factors. White and privately insured patients generally experienced shorter length of hospital stay, had lower rates of in-hospital mortality, and underwent routine discharge. Twenty-five papers (53%) reported no disparities within at least one examined metric. CONCLUSIONS This comprehensive contemporary systematic review demonstrates the existence of disparity gaps within the field of adult cerebrovascular surgery. It highlights the importance of continued investigation into sources of disparity and efforts to promote equity within the field.
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Affiliation(s)
- Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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Lechtholz-Zey E, Bonney PA, Cardinal T, Mendoza J, Strickland BA, Pangal DJ, Giannotta S, Durham S, Zada G. Systematic Review of Racial, Socioeconomic, and Insurance Status Disparities in the Treatment of Pediatric Neurosurgical Diseases in the United States. World Neurosurg 2021; 158:65-83. [PMID: 34718199 DOI: 10.1016/j.wneu.2021.10.150] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Increasing light is being shed on how race, insurance, and socioeconomic status (SES) may be related to outcomes from disease in the United States. To better understand the impact of these health care disparities in pediatric neurosurgery, we performed a systematic review of the literature. METHODS We conducted a systematic review using PRISMA guidelines and MeSH terms involving neurosurgical conditions and racial, ethnic, and SES disparities. Three independent reviewers screened articles and analyzed texts selected for full analysis. RESULTS Thirty-eight studies were included in the final analysis, of which all but 2 were retrospective database reviews. Thirty-four studies analyzed race, 22 analyzed insurance status, and 13 analyzed SES/income. Overall, nonwhite patients, patients with public insurance, and patients from lower SES were shown to have reduced access to treatment and greater rates of adverse outcomes. Nonwhite patients were more likely to present at an older age with more severe disease, less likely to undergo surgery at a high-volume surgical center, and more likely to experience postoperative morbidity and mortality. Underinsured and publicly insured patients were more likely to experience delay in surgical referral, less likely to undergo surgical treatment, and more likely to experience inpatient mortality. CONCLUSIONS Health care disparities are present within multiple populations of patients receiving pediatric neurosurgical care. This review highlights the need for continued investigation into identifying and addressing health care disparities in pediatric neurosurgery patients.
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Affiliation(s)
- Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Susan Durham
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; Division of Neurosurgery, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
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