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Greenberg AL, Brand NR, Zambeli-Ljepović A, Barnes KE, Chiou SH, Rhoads KF, Adam MA, Sarin A. Exploring the complexity and spectrum of racial/ethnic disparities in colon cancer management. Int J Equity Health 2023; 22:68. [PMID: 37060065 PMCID: PMC10105474 DOI: 10.1186/s12939-023-01883-w] [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: 09/18/2022] [Accepted: 04/04/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Colorectal cancer is a leading cause of morbidity and mortality across U.S. racial/ethnic groups. Existing studies often focus on a particular race/ethnicity or single domain within the care continuum. Granular exploration of disparities among different racial/ethnic groups across the entire colon cancer care continuum is needed. We aimed to characterize differences in colon cancer outcomes by race/ethnicity across each stage of the care continuum. METHODS We used the 2010-2017 National Cancer Database to examine differences in outcomes by race/ethnicity across six domains: clinical stage at presentation; timing of surgery; access to minimally invasive surgery; post-operative outcomes; utilization of chemotherapy; and cumulative incidence of death. Analysis was via multivariable logistic or median regression, with select demographics, hospital factors, and treatment details as covariates. RESULTS 326,003 patients (49.6% female, 24.0% non-White, including 12.7% Black, 6.1% Hispanic/Spanish, 1.3% East Asian, 0.9% Southeast Asian, 0.4% South Asian, 0.3% AIAE, and 0.2% NHOPI) met inclusion criteria. Relative to non-Hispanic White patients: Southeast Asian (OR 1.39, p < 0.01), Hispanic/Spanish (OR 1.11 p < 0.01), and Black (OR 1.09, p < 0.01) patients had increased odds of presenting with advanced clinical stage. Southeast Asian (OR 1.37, p < 0.01), East Asian (OR 1.27, p = 0.05), Hispanic/Spanish (OR 1.05 p = 0.02), and Black (OR 1.05, p < 0.01) patients had increased odds of advanced pathologic stage. Black patients had increased odds of experiencing a surgical delay (OR 1.33, p < 0.01); receiving non-robotic surgery (OR 1.12, p < 0.01); having post-surgical complications (OR 1.29, p < 0.01); initiating chemotherapy more than 90 days post-surgery (OR 1.24, p < 0.01); and omitting chemotherapy altogether (OR 1.12, p = 0.05). Black patients had significantly higher cumulative incidence of death at every pathologic stage relative to non-Hispanic White patients when adjusting for non-modifiable patient factors (p < 0.05, all stages), but these differences were no longer statistically significant when also adjusting for modifiable factors such as insurance status and income. CONCLUSIONS Non-White patients disproportionately experience advanced stage at presentation. Disparities for Black patients are seen across the entire colon cancer care continuum. Targeted interventions may be appropriate for some groups; however, major system-level transformation is needed to address disparities experienced by Black patients.
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Affiliation(s)
- Anya L Greenberg
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Nathan R Brand
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Alan Zambeli-Ljepović
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Katherine E Barnes
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Sy Han Chiou
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Kim F Rhoads
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Mohamed A Adam
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Ankit Sarin
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA.
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Hammond G, Waken RJ, Johnson DY, Towfighi A, Joynt Maddox KE. Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years. Stroke 2022; 53:1711-1719. [PMID: 35172607 PMCID: PMC9324215 DOI: 10.1161/strokeaha.121.035006] [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: 03/10/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. METHODS Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. RESULTS The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37-0.50]) and endovascular therapy (aOR, 0.60 [0.46-0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75-0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84-0.91]), while White patients from rural areas (aOR, 1.14 [1.10-1.19]) had the highest mortality of all groups. CONCLUSIONS Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.
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Affiliation(s)
- Gmerice Hammond
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - RJ Waken
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - Daniel Y. Johnson
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - Amytis Towfighi
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Karen E. Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
- Center for Health Economics and Policy, Institute for Public Health at Washington University, St. Louis, MO
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Pulvers JN, Watson JDG. If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke? Front Neurol 2017. [PMID: 29209269 DOI: 10.3389/fneur.2017.00617/full] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
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Affiliation(s)
- Jeremy N Pulvers
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| | - John D G Watson
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
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Pulvers JN, Watson JDG. If Time Is Brain Where Is the Improvement in Prehospital Time after Stroke? Front Neurol 2017; 8:617. [PMID: 29209269 PMCID: PMC5701972 DOI: 10.3389/fneur.2017.00617] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/06/2017] [Indexed: 01/19/2023] Open
Abstract
Despite the availability of thrombolytic and endovascular therapy for acute ischemic stroke, many patients are ineligible due to delayed hospital arrival. The identification of factors related to either early or delayed hospital arrival may reveal potential targets of intervention to reduce prehospital delay and improve access to time-critical thrombolysis and clot retrieval therapy. Here, we have reviewed studies reporting on factors associated with either early or delayed hospital arrival after stroke, together with an analysis of stroke onset to hospital arrival times. Much effort in the stroke treatment community has been devoted to reducing door-to-needle times with encouraging improvements. However, this review has revealed that the median onset-to-door times and the percentage of stroke patients arriving before the logistically critical 3 h have shown little improvement in the past two decades. Major factors affecting prehospital time were related to emergency medical pathways, stroke symptomatology, patient and bystander behavior, patient health characteristics, and stroke treatment awareness. Interventions addressing these factors may prove effective in reducing prehospital delay, allowing prompt diagnosis, which in turn may increase the rates and/or efficacy of acute treatments such as thrombolysis and clot retrieval therapy and thereby improve stroke outcomes.
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Affiliation(s)
- Jeremy N Pulvers
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
| | - John D G Watson
- Sydney Adventist Hospital Clinical School, Sydney Medical School, The University of Sydney, Wahroonga, NSW, Australia
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Boan AD, Feng WW, Ovbiagele B, Bachman DL, Ellis C, Adams RJ, Kautz SA, Lackland DT. Persistent racial disparity in stroke hospitalization and economic impact in young adults in the buckle of stroke belt. Stroke 2014; 45:1932-8. [PMID: 24947293 DOI: 10.1161/strokeaha.114.004853] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 05/06/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Mounting evidence points to a decline in stroke incidence. However, little is known about recent patterns of stroke hospitalization within the buckle of the stroke belt. This study aims to investigate the age- and race-specific secular trends in stroke hospitalization rates, inpatient stroke mortality rates, and related hospitalization charges during the past decade in South Carolina. METHODS Patients from 2001 to 2010 were identified from the State Inpatient Hospital Discharge Database with a primary discharge diagnosis of stroke (International Classification of Diseases, Ninth Revision codes: 430-434, 436, 437.1). Age- and race-stroke-specific hospitalization rates, hospital charges, charges associated with racial disparity, and 30-day stroke mortality rates were compared between blacks and whites. RESULTS Of the 84,179 stroke hospitalizations, 31,137 (37.0%) were from patients aged<65 years and 29,846 (35.5%) were blacks. Stroke hospitalization rates decreased in the older population (aged≥65 years) for both blacks and whites (P<0.001) but increased among the younger group (aged<65 years; P=0.004); however, this increase was mainly driven by a 17.3% rise among blacks (P=0.001), with no difference seen among whites (P=0.84). Of hospital charges totaling $2.77 billion, $453.2 million (16.4%) are associated with racial disparity (79.6% from patients aged<65 years). Thirty-day stroke mortality rates decreased in all age-race-stroke-specific groups (P<0.001). CONCLUSIONS The stroke hospitalization rate increased in the young blacks only, which results in a severe and persistent racial disparity. It highlights the urgent need for a racial disparity reduction in the younger population to alleviate the healthcare burden.
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Affiliation(s)
- Andrea D Boan
- From the Department of Neuroscience, Medical University of South Carolina (MUSC) Stroke Center, Charleston, SC (A.D.B., W.F., B.O., D.L.B., R.J.A., S.A.K., D.T.L.); Department of Health Science & Research, Medical University of South Carolina, Charleston (W.F., C.E., S.A.K.); and Ralph H. Johnson VA Medical Center, Charleston, SC (B.O., S.A.K.)
| | - Wuwei Wayne Feng
- From the Department of Neuroscience, Medical University of South Carolina (MUSC) Stroke Center, Charleston, SC (A.D.B., W.F., B.O., D.L.B., R.J.A., S.A.K., D.T.L.); Department of Health Science & Research, Medical University of South Carolina, Charleston (W.F., C.E., S.A.K.); and Ralph H. Johnson VA Medical Center, Charleston, SC (B.O., S.A.K.).
| | - Bruce Ovbiagele
- From the Department of Neuroscience, Medical University of South Carolina (MUSC) Stroke Center, Charleston, SC (A.D.B., W.F., B.O., D.L.B., R.J.A., S.A.K., D.T.L.); Department of Health Science & Research, Medical University of South Carolina, Charleston (W.F., C.E., S.A.K.); and Ralph H. Johnson VA Medical Center, Charleston, SC (B.O., S.A.K.)
| | - David L Bachman
- From the Department of Neuroscience, Medical University of South Carolina (MUSC) Stroke Center, Charleston, SC (A.D.B., W.F., B.O., D.L.B., R.J.A., S.A.K., D.T.L.); Department of Health Science & Research, Medical University of South Carolina, Charleston (W.F., C.E., S.A.K.); and Ralph H. Johnson VA Medical Center, Charleston, SC (B.O., S.A.K.)
| | - Charles Ellis
- From the Department of Neuroscience, Medical University of South Carolina (MUSC) Stroke Center, Charleston, SC (A.D.B., W.F., B.O., D.L.B., R.J.A., S.A.K., D.T.L.); Department of Health Science & Research, Medical University of South Carolina, Charleston (W.F., C.E., S.A.K.); and Ralph H. Johnson VA Medical Center, Charleston, SC (B.O., S.A.K.)
| | - Robert J Adams
- From the Department of Neuroscience, Medical University of South Carolina (MUSC) Stroke Center, Charleston, SC (A.D.B., W.F., B.O., D.L.B., R.J.A., S.A.K., D.T.L.); Department of Health Science & Research, Medical University of South Carolina, Charleston (W.F., C.E., S.A.K.); and Ralph H. Johnson VA Medical Center, Charleston, SC (B.O., S.A.K.)
| | - Steven A Kautz
- From the Department of Neuroscience, Medical University of South Carolina (MUSC) Stroke Center, Charleston, SC (A.D.B., W.F., B.O., D.L.B., R.J.A., S.A.K., D.T.L.); Department of Health Science & Research, Medical University of South Carolina, Charleston (W.F., C.E., S.A.K.); and Ralph H. Johnson VA Medical Center, Charleston, SC (B.O., S.A.K.)
| | - Daniel T Lackland
- From the Department of Neuroscience, Medical University of South Carolina (MUSC) Stroke Center, Charleston, SC (A.D.B., W.F., B.O., D.L.B., R.J.A., S.A.K., D.T.L.); Department of Health Science & Research, Medical University of South Carolina, Charleston (W.F., C.E., S.A.K.); and Ralph H. Johnson VA Medical Center, Charleston, SC (B.O., S.A.K.)
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