Prescription Opioid Initiation for Neuropathy, Headache, and Low Back Pain: A US Population-based Medicare Study

Neuropathy, headache, and low back pain (LBP) are common conditions requiring pain management. Yet little is known regarding whether access to specialists impacts opioid prescribing. We aimed to identify factors associated with opioid initiation among opioid-naïve older adults and evaluate how access to particular specialists impacts prescribing. This retrospective cohort study used a 20% Medicare sample from 2010 to 2017. Opioid initiation was defined as a first opioid prescription filled within 12 months after a diagnosis encounter. Disease-related opioid initiation was defined as a first opioid prescription filled within 7 days following a disease-specific claim. Logistic regression using generalized estimating equations was used to determine the association of patient demographics, provider types, and regional physician specialty density with disease-related opioid initiation, accounting for within-region correlation. We found opioid initiation steadily declined from 2010 to 2017 (neuropathy: 26-19%, headache: 31-20%, LBP: 45-32%), as did disease-related opioid initiation (4-3%, 12-7%, 29-19%) and 5 to 10% of initial disease-related prescriptions resulted in chronic opioid use within 12 months of initiation. Certain specialist visits were associated with a lower likelihood of disease-related opioid initiation compared with primary care. Residence in high neurologist density regions had a lower likelihood of disease-related opioid initiation (headache odds ratio [OR] .76 [95% CI: .63-.92]) and LBP (OR .7 [95% CI: .61-.81]) and high podiatrist density regions for neuropathy (OR .56 [95% CI: .41-.78]). We found that specialist visits and greater access to specialists were associated with a lower likelihood of disease-related opioid initiation. These data could inform strategies to perpetuate reductions in opioid use for these common pain conditions. PERSPECTIVE: This article presents how opioid initiation for opioid-naïve patients with newly diagnosed neuropathy, headache, and LBP varies across providers. Greater access to certain specialists decreased the likelihood of opioid initiation. Future work may consider interventions to support alternative treatments and better access to specialists in low-density regions.

Correction: Community-Led, Cross-Sector Partnership of Housing and Health Care to Promote Aging in Place (Unite Health Project): Protocol for a Prospective Observational Study

[This corrects the article DOI: 10.2196/47855.].

Patient Travel Distance to Neurologist Visits

BACKGROUND AND OBJECTIVES

The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care.

METHODS

We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel.

RESULTS

We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care.

DISCUSSION

We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Predictors of referral for long-term EEG monitoring for Medicare beneficiaries with drug-resistant epilepsy

OBJECTIVE

For people with drug-resistant epilepsy, the use of epilepsy surgery is low despite favorable odds of seizure freedom. To better understand surgery utilization, we explored factors associated with inpatient long-term EEG monitoring (LTM), the first step of the presurgical pathway.

METHODS

Using 2001-2018 Medicare files, we identified patients with incident drug-resistant epilepsy using validated criteria of ≥2 distinct antiseizure medication (ASM) prescriptions and ≥1 drug-resistant epilepsy encounter among patients with ≥2 years pre- and ≥1 year post-diagnosis Medicare enrollment. We used multilevel logistic regression to evaluate associations between LTM and patient, provider, and geographic factors. We then analyzed neurologist-diagnosed patients to further evaluate provider/environmental characteristics.

RESULTS

Of 12 044 patients with incident drug-resistant epilepsy diagnosis identified, 2% underwent surgery. Most (68%) were diagnosed by a neurologist. In total, 19% underwent LTM near/after drug-resistant epilepsy diagnosis; another 4% only underwent LTM much prior to diagnosis. Patient factors most strongly predicting LTM were age <65 (adjusted odds ratio 1.5 [95% confidence interval 1.3-1.8]), focal epilepsy (1.6 [1.4-1.9]), psychogenic non-epileptic spells diagnosis (1.6 [1.1-2.5]) prior hospitalization (1.7, [1.5-2]), and epilepsy center proximity (1.6 [1.3-1.9]). Additional predictors included female gender, Medicare/Medicaid non-dual eligibility, certain comorbidities, physician specialties, regional neurologist density, and prior LTM. Among neurologist-diagnosed patients, neurologist <10 years from graduation, near an epilepsy center, or epilepsy-specialized increased LTM likelihood (1.5 [1.3-1.9], 2.1 [1.8-2.5], 2.6 [2.1-3.1], respectively). In this model, 37% of variation in LTM completion near/after diagnosis was explained by individual neurologist practice and/or environment rather than measurable patient factors (intraclass correlation coefficient 0.37).

SIGNIFICANCE

A small proportion of Medicare beneficiaries with drug-resistant epilepsy completed LTM, a proxy for epilepsy surgery referral. While some patient factors and access measures predicted LTM, non-patient factors explained a sizable proportion of variance in LTM completion. To increase surgery utilization, these data suggest initiatives targeting better support of neurologist referral.

Association of the Stroke Ready Community-Based Participatory Research Intervention With Incidence of Acute Stroke Thrombolysis in Flint, Michigan

Importance

Acute stroke treatment rates in the US lag behind those in other high-income nations.

Objective

To assess whether a hospital emergency department (ED) and community intervention was associated with an increased proportion of patients with stroke receiving thrombolysis.

Design, Setting, and Participants

This nonrandomized controlled trial of the Stroke Ready intervention took place in Flint, Michigan, from October 2017 to March 2020. Participants included adults living in the community. Data analysis was completed from July 2022 to May 2023.

Intervention

Stroke Ready combined implementation science and community-based participatory research approaches. Acute stroke care was optimized in a safety-net ED, and then a community-wide, theory-based health behavior intervention, including peer-led workshops, mailers, and social media, was conducted.

Main Outcomes and Measures

The prespecified primary outcome was the proportion of patients hospitalized with ischemic stroke or transient ischemic attack from Flint who received thrombolysis before and after the intervention. The association between thrombolysis and the Stroke Ready combined intervention, including the ED and community components, was estimated using logistic regression models, clustering at the hospital level and adjusting for time and stroke type. In prespecified secondary analyses, the ED and community intervention were explored separately, adjusting for hospital, time, and stroke type.

Results

In total, 5970 people received in-person stroke preparedness workshops, corresponding to 9.7% of the adult population in Flint. There were 3327 ischemic stroke and TIA visits (1848 women [55.6%]; 1747 Black individuals [52.5%]; mean [SD] age, 67.8 [14.5] years) among patients from Flint seen in the relevant EDs, including 2305 in the preintervention period from July 2010 to September 2017 and 1022 in the postintervention period from October 2017 to March 2020. The proportion of thrombolysis usage increased from 4% in 2010 to 14% in 2020. The combined Stroke Ready intervention was not associated with thrombolysis use (adjusted odds ratio [OR], 1.13; 95% CI, 0.74-1.70; P = .58). The ED component was associated with an increase in thrombolysis use (adjusted OR, 1.63; 95% CI, 1.04-2.56; P = .03), but the community component was not (adjusted OR, 0.99; 95% CI, 0.96-1.01; P = .30).

Conclusions and Relevance

This nonrandomized controlled trial found that a multilevel ED and community stroke preparedness intervention was not associated with increased thrombolysis treatments. The ED intervention was associated with increased thrombolysis usage, suggesting that implementation strategies in partnership with safety-net hospitals may increase thrombolysis usage.

Trial Registration

ClinicalTrials.gov Identifier: NCT036455900.

Community-Led, Cross-Sector Partnership of Housing and Health Care to Promote Aging in Place (Unite Health Project): Protocol for a Prospective Observational Study

BACKGROUND

For many older Americans, aging in place is their preferred living arrangement. Minoritized and socioeconomically disadvantaged older adults are up to 3 times more likely to experience disability than other groups, which increases their likelihood of being unable to age in place. Bold ideas to facilitate aging in place, particularly among vulnerable populations, are needed. One such idea is the Unite care model, a community-initiated, academic-supported, cross-sector initiative that combines 2 sectors: housing and health care. The Unite care model colocates a federally qualified health center clinic on an older adult affordable housing campus in Flint, Michigan.

OBJECTIVE

There are two aims to this study. Aim 1 is to evaluate the implementation of the Unite care model in terms of acceptability, adoption, and penetration. Aim 2 is to determine which older adults use the care model and whether the care model promotes aging in place through risk factor reduction and improvement in the physical and social environment.

METHODS

We will assess the care model using a concurrent, exploratory mixed methods design. For aim 1, acceptability will be assessed through semistructured interviews with key stakeholder groups; adoption and penetration will be assessed using housing and health care records. For aim 2, residents residing in the Unite clinic building will participate in structured outcome assessments at 6 and 12 months. Risk factor reduction will be measured by change in systolic blood pressure from baseline to 12 months and change in the physical and social environment (item counts) will also be assessed from baseline to 12 months.

RESULTS

Data collection for aim 1 began in July 2021 and is anticipated to end in April 2023. Data collection for aim 2 began in June 2021 and concluded in November 2022. Data analysis for aim 1 is anticipated to begin in the summer of 2023 and analysis for aim 2 will begin in the spring of 2023.

CONCLUSIONS

If successful, the Unite care model could serve as a new care model to promote aging in place among older adults living in poverty and older Black Americans. The results of this proposal will inform whether larger scale testing of this new model of care is warranted.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47855.

Sociodemographic and Geographic Variation in Access to Neuro-Ophthalmologists in the United States

BACKGROUND

Neuro-ophthalmologists have expertise in rare and complex disorders, but the ability of patients to access neuro-ophthalmic care has not been examined at a nationwide level.

METHODS

Using the 2020 directory of all 502 members of the North American Neuro-Ophthalmology Society as a reference, we found the practice locations of 461 confirmed practicing members and converted each street address to latitude and longitude coordinates. We calculated the travel distance and time from each census tract to the nearest practice location and calculated population-weighted averages by state, region, and other prespecified factors. Choropleth maps were used to visualize the distribution of travel distances and times across the United States.

RESULTS

California had the most practicing neuro-ophthalmologists out of any state (50), whereas 4 states (DE, MT, SD, and WY) had none. Washington, DC and MA had the most neuro-ophthalmologists per capita. The average travel distance and time to the nearest neuro-ophthalmologists were found to be 40.90 miles and 46.50 minutes, respectively, although a large portion of western plains and mountain regions had travel times of over 120 minutes. Patients in rural areas had longer travel times than those in urban areas, and Native American patients had the longest travel times of any racial or ethnic group.

CONCLUSION

The travel time to see a neuro-ophthalmologist varies widely by state, region, and rurality, with Native American patients and rural patients being disproportionately affected. By identifying the areas with the greatest travel burdens, future policies can work to alleviate these potential barriers to care.

A Validated Method to Identify Neuro-Ophthalmologists in a Large Administrative Claims Database

BACKGROUND

Validated methods to identify neuro-ophthalmologists in administrative data do not exist. The development of such method will facilitate research on the quality of neuro-ophthalmic care and health care utilization for patients with neuro-ophthalmic conditions in the United States.

METHODS

Using nationally representative, 20% sample from Medicare carrier files from 2018, we identified all neurologists and ophthalmologists billing at least 1 office-based evaluation and management (E/M) outpatient visit claim in 2018. To isolate neuro-ophthalmologists, the National Provider Identifier numbers of neuro-ophthalmologists in the North American Neuro-Ophthalmology Society (NANOS) directory were collected and linked to Medicare files. The proportion of E/M visits with International Classification of Diseases-10 diagnosis codes that best distinguished neuro-ophthalmic care ("neuro-ophthalmology-specific codes" or NSC) was calculated for each physician. Multiple logistic regression models assessed predictors of neuro-ophthalmology specialty designation after accounting for proportion of ophthalmology, neurology, and NSC claims and primary specialty designation. Sensitivity, specificity, and positive predictive value (PPV) for varying proportions of E/M visits with NSC were calculated.

RESULTS

We identified 32,293 neurologists and ophthalmologists who billed at least 1 outpatient E/M visit claim in 2018 in Medicare. Of the 472 NANOS members with a valid individual National Provider Identifier, 399 (84.5%) had a Medicare outpatient E/M visit in 2018. The model containing only the proportion of E/M visits with NSC best predicted neuro-ophthalmology specialty designation (odds ratio 1.05 [95% confidence interval 1.04, 1.05]; P < 0.001; area under the receiver operating characteristic [AUROC] = 0.91). Model predictiveness for neuro-ophthalmology designation was maximized when 6% of all billed claims were for NSC (AUROC = 0.89; sensitivity: 84.0%; specificity: 93.9%), but PPV was low (14.9%). The threshold was unchanged when limited only to neurologists billing ≥1% ophthalmology claims or ophthalmologists billing ≥1% neurology claims, but PPV increased (33.3%).

CONCLUSIONS

Our study provides a validated method to identify neuro-ophthalmologists who can be further adapted for use in other administrative databases to facilitate future research of neuro-ophthalmic care delivery in the United States.

Reach Out Emergency Department: A Randomized Factorial Trial to Determine the Optimal Mobile Health Components to Reduce Blood Pressure

BACKGROUND

Mobile health (mHealth) strategies initiated in safety-net Emergency Departments may be one approach to address the US hypertension epidemic, but the optimal mHealth components or dose are unknown.

METHODS

Reach Out is an mHealth, health theory-based, 2×2×2 factorial trial among hypertensive patients evaluated in a safety-net Emergency Department in Flint, Michigan. Reach Out consisted of 3 mHealth components, each with 2 doses: (1) healthy behavior text messaging (yes versus no), (2) prompted self-measured blood pressure (BP) monitoring and feedback (weekly versus daily), and (3) facilitated primary care provider appointment scheduling and transportation (yes versus no). The primary outcome was a change in systolic BP from baseline to 12 months. In a complete case analysis, we fit a linear regression model and accounted for age, sex, race, and prior BP medications to explore the association between systolic BP and each mHealth component.

RESULTS

Among 488 randomized participants, 211 (43%) completed follow-up. Mean age was 45.5 years, 61% were women, 54% were Black people, 22% did not have a primary care doctor, 21% lacked transportation, and 51% were not taking antihypertensive medications. Overall, systolic BP declined after 6 months (-9.2 mm Hg [95% CI, -12.2 to -6.3]) and 12 months (-6.6 mm Hg, -9.3 to -3.8), without a difference across the 8 treatment arms. The higher dose of mHealth components were not associated with a greater change in systolic BP; healthy behavior text messages (point estimate, mmHG=-0.5 [95% CI, -6.0 to 5]; P=0.86), daily self-measured BP monitoring (point estimate, mmHG=1.9 [95% CI, -3.7 to 7.5]; P=0.50), and facilitated primary care provider scheduling and transportation (point estimate, mmHG=0 [95% CI, -5.5 to 5.6]; P=0.99).

CONCLUSIONS

Among participants with elevated BP recruited from an urban safety-net Emergency Department, BP declined over the 12-month intervention period. There was no difference in change in systolic BP among the 3 mHealth components. Reach Out demonstrated the feasibility of reaching medically underserved people with high BP cared for at a safety-net Emergency Departments, yet the efficacy of the Reach Out mHealth intervention components requires further study.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03422718.

Abstract TMP50: Increased Pre-stroke Emergency Department Visits And Post-stroke Readmissions For Mexican-Americans Compared To Non-hispanic Whites In The Brain Attack Surveillance In Corpus Christi (BASIC) Study

Introduction: Mexican Americans (MAs) use less preventative healthcare than NHWs and this may result in in more emergency department (ED) visits or readmissions. We sought to explore ethnic differences in ED and hospital utilization immediately before and after stroke.

Methods: BASIC is a stroke epidemiologic study in Corpus Christi TX. We performed probabilistic matching to identify hospital claims for all BASIC-identified index strokes (ischemic or ICH) from 2010-2020 continuously enrolled in Medicare fee-for-service (FFS). Matching was performed using demographics (including date of birth), stroke admission/discharge dates, vascular risk factors, comorbidities, and in-hospital procedures. All emergency department (ED) visits and hospital readmissions within 90 days before and after the index stroke were identified using Medicare claims. Logistic regression models were used to determine the association of MA ethnicity (compared to NHWs) with prior ED/inpatient visits and cox regression models were used to estimate the associations with subsequent ED visits/readmissions (censoring at death), adjusting for patient age, sex, stroke severity, and stroke type.

Results: We identified 1,180 incident BASIC strokes that could be matched with Medicare FFS inpatient claims: 84% with ischemic stroke, 46.2% NHWs vs 45.7% MAs, mean age 76.4, median (IQR) NIHSS 5 (2-13). Both ED visits and hospitalizations were relatively common before and after stroke (Table). Compared to NHWs, MAs were more likely to have ED visits before stroke than NHWs (OR 1.5, 95%CI [1.1-2.1]) and hospitalizations after stroke (HR 1.3, [1.1-1.7], but no ethinc differences were observed in pre-stroke hospitalizations or post-stroke ED visits. ( Table )

Conclusion: The increased rate of pre-stroke ED visits in MAs suggests the potential for missed opportunities to prevent stroke may exist and merits further scrutiny.

Predictors of Glucocorticoid Use for Acute Optic Neuritis in the United States, 2005-2019

PURPOSE

Acute optic neuritis (ON) is variably treated with glucocorticoids. We aimed to describe factors associated with glucocorticoid use.

METHODS

In this retrospective, longitudinal cohort study of insured patients in the United States (2005-2019), adults 18-50 years old with one inpatient or ≥2 outpatient diagnoses of ON within 90 days were included. Glucocorticoid use was classified as none, any dose, and high-dose (>100 mg prednisone equivalent ≥1 days). The primary outcome was glucocorticoid receipt within 90 days of the first ON diagnosis. Multivariable logistic regression models assessed the relationship between glucocorticoid use and sociodemographics, comorbidities, clinician specialty, visit number, and year.

RESULTS

Of 3026 people with ON, 65.8% were women (n = 1991), median age (interquartile range) was 38 years (31,44), and 68.6% were white (n = 2075). Glucocorticoids were received by 46% (n = 1385); 54.6% (n = 760/1385) of whom received high-dose. The odds of receiving glucocorticoids were higher among patients with multiple sclerosis (OR 1.61 [95%CI 1.28-2.04]; P < .001), MRI (OR 1.75 [95%CI 1.09-2.80]; P = .02), 3 (OR 1.80 [95%CI 1.46-2.22]; P < .001) or more (OR 4.08 [95%CI 3.37-4.95]; P < .001) outpatient ON visits, and in certain regions. Compared to ophthalmologists, patients diagnosed by neurologists (OR 1.36 [95%CI: 1.10-1.69], p = .005), emergency medicine (OR 3.97 [95%CI: 2.66-5.94]; P < .001) or inpatient clinicians (OR 2.94 [95%CI: 2.22-3.90]; P < .001) had higher odds of receiving glucocorticoids. Use increased 1.1% annually (P < .001).

CONCLUSIONS

Demyelinating disease, care intensity, setting, region, and clinician type were associated with glucocorticoid use for ON. To optimize care, future studies should explore reasons for ON care variation, and patient/clinician preferences.

National End-of-Life-Treatment Preferences are Stable Over Time: National Health and Aging Trends Study

CONTEXT

Advance Care Planning is a process of understanding and sharing preferences regarding future medical care.

OBJECTIVE

To explore individual and national stability of end-of-life treatment preferences among a sample of older adults.

METHODS

National Health and Aging Trends Study is a nationally representative sample of older adults. In 2012, a random sample, and in 2018, the entire sample were queried on end-of-life treatment preferences defined as acceptance or rejection of life prolonging treatment (LPT) if they had a serious illness and were at the end of their life and in severe pain or had severe disability. Using a cohort design, we explored individual trends in preferences for LPT among those with responses in both waves (pain scenario: N = 606, disability scenario: N = 628) and, using a serial cross-sectional design, national trends in LPT among the entire sample (1702 older adults in wave 2 and 4342 in wave 8).

RESULTS

In the cohort study, individual preferences were stable over time (overall percent agreement = 86% for disability and 76% for pain scenarios), particularly for older adults who would reject LPT in wave 2 (overall agreement 92% for disability and 86% for pain). In the serial cross-sectional study, national trends in preferences for receipt of LPT were stable over time in the pain (27.4% vs. 27.0%, P = 0.80) and disability (15.8% vs. 15.7%, P = 0.99) scenarios.

CONCLUSIONS

We found that national trends in preferences for end-of-life treatment did not substantially change over time and may be stable within individual older adults.

Community Intent to Activate Emergency Medical Services May Be Associated with Regional tPA Treatment

INTRODUCTION

Acute stroke treatments are underutilized in the USA. Enhancing stroke preparedness, the recognition of stroke symptoms, and intent to call emergency medical services (EMS) could reduce delay in hospital arrival thereby increasing eligibility for time-sensitive stroke treatments. Whether higher stroke preparedness is associated with higher tissue plasminogen activator (tPA) treatment rates is however uncertain. We therefore set out to determine the contribution of stroke preparedness to regional variation in tPA treatment.

METHODS

The region was defined by hospital service area (HSA). Stroke preparedness was determined by using Behavioral Risk Factor Surveillance System survey questions assessing stroke symptom recognition and intent to call 911 in response to a stroke. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, and 2011, adjusting for number of stroke hospitalizations in each HSA (primary outcome). We performed multivariate linear regression to estimate the association of regional stroke preparedness on log-transformed tPA treatment rates controlling for demographic, EMS, and hospital characteristics.

RESULTS

The adjusted percentage of stroke patients receiving tPA ranged from 1.4% (MIN) to 11.3% (MAX) of stroke/TIA hospitalizations. Across HSAs, a median (IQR) of 86% (81-90%) of responses to a witnessed stroke indicated intent to call 911, and a median (IQR) of 4.4 (4.2-4.6) out of 6 stroke symptoms was recognized. Every 1% increase in an HSA's intent to call 911 was associated with a 0.44% increase in adjusted tPA treatment rate (p = 0.05). Lower accuracy of recognition of stroke symptoms was associated with higher adjusted tPA treatment rates (p = 0.05).

CONCLUSIONS

There was little regional variation in intent to call EMS and stroke symptom recognition. Intent to call EMS and stroke symptom recognition are modest contributors to regional variation in tPA treatment.

Evaluating online learning engagement of nursing students

BACKGROUND

Previous studies suggest that increased learning satisfaction may encourage learning engagement in an online learning environment.

OBJECTIVES

To evaluate the level of learning engagement and its relationship with students' perceived learning satisfaction in an online clinical nursing elective course.

DESIGN

A prospective interventional study.

SETTINGS

A nursing course was converted to an online format because of the coronavirus disease COVID pandemic.

PARTICIPANTS

Part-time post-registration nursing undergraduates enrolled in an elective online clinical course.

METHODS

Related teaching and learning strategies were deployed in the course using the Community of Inquiry framework. All students who completed the course were invited to complete an online survey that included a validated Online Student Engagement questionnaire (OSE). Pearson's correlations were used to determine the association between perceived learning satisfaction and learning engagement. A logistic regression model was used to explore the associations of gender, age, working experience and perceived learning satisfaction with higher learning engagement.

RESULTS

The questionnaires were completed by 56 of 68 students (82%). The Pearson's correlation coefficient between the mean perceived learning satisfaction and OSE scores was 0.75 (p < .001). Twenty-five students (45%) were identified as highly engaged, using a cut-off of ≥3.5 for the mean OSE score. The mean perceived learning satisfaction (SD) score differed significantly between highly engaged and not highly engaged students [4.02 (0.49) vs. 3.27 (0.62), p < .001]. The logistic regression model showed that a greater perceived learning satisfaction [adjusted odds ratio (OR): 17.2, 95% C.I.: 3.46-86.0, p = .001] was associated with an increased likelihood of higher learning engagement, and >1 year of working experience (adjusted OR: 0.11, 95% C.I.: 0.01-0.89, p = .0039) was associated with a decreased likelihood of higher learning engagement.

CONCLUSIONS

The study findings suggest that perceived learning satisfaction predicts learning engagement among nursing students in this online learning course.

Definitions of Drug-Resistant Epilepsy for Administrative Claims Data Research

OBJECTIVE

To assess accuracy of definitions of drug-resistant epilepsy applied to administrative claims data.

METHODS

We randomly sampled 450 patients from a tertiary health system with >1 epilepsy/convulsion encounter and >2 distinct antiseizure medications (ASMs) from 2014-2020 and >2 years of electronic medical records (EMR) data. We established a drug-resistant epilepsy diagnosis at a specific visit by reviewing EMR data and employing a rubric based in the 2010 International League Against Epilepsy definition. We performed logistic regressions to assess clinically-relevant predictors of drug-resistant epilepsy and to inform claims-based definitions.

RESULTS

Of 450 patients reviewed, 150 were excluded for insufficient EMR data. Of the 300 patients included, 98 (33%) met criteria for current drug-resistant epilepsy. The strongest predictors of current drug-resistant epilepsy were drug-resistant epilepsy diagnosis code (OR 16.9, 95% CI 8.8-32.2), >2 ASMs in the prior two years (OR 13.0, 95% CI 5.1-33.3), >3 non-gabapentinoid ASMs (OR 10.3, 95% CI 5.4-19.6), neurosurgery visit (OR 45.2, 95% CI 5.9-344.3), and epilepsy surgery (OR 30.7, 95% CI 7.1-133.3). We created claims-based drug-resistant epilepsy definitions to: 1) maximize overall predictiveness (drug-resistant epilepsy diagnosis; sensitivity 0.86, specificity 0.74, area under the receiver operating characteristics curve [AUROC] 0.80), 2) maximize sensitivity (drug-resistant epilepsy diagnosis or >3 ASMs; sensitivity 0.98, specificity 0.47, AUROC 0.72), and 3) maximize specificity (drug-resistant epilepsy diagnosis and >3 non-gabapentinoid ASMs; sensitivity 0.42, specificity 0.98, AUROC 0.70).

CONCLUSIONS

Our findings provide validation for several claims-based definitions of drug-resistant epilepsy that can be applied to a variety of research questions.

Severe myocardial bridge presenting as paroxysmal atrioventricular block

Chest pain complicated with electrocardiographic changes is not an uncommon scenario in emergency departments, which should be examined cautiously. We describe a 51-years-old man with a myocardial bridge of coronary artery presenting with simultaneous Mobitz type I atrioventricular block on electrocardiography. Echocardiography excluded valvular abnormality and systolic/diastolic dysfunction. Coronary angiography confirmed the diagnosis of a myocardial bridge at the middle segment of the left anterior descending artery, involving the most dominant septal perforator branch with marked systolic compression. The patient underwent coronary artery bypass grafting surgery and was followed up uneventfully at the outpatient department with medical treatment of diltiazem and clopidogrel. The present case is being reported to highlight that clinicians should be alert to such a congenital abnormality as a potential cause of repeated myocardial infarction and conduction abnormality.

High-efficiency picosecond mode-locked laser using a thulium-doped nanoengineered yttrium-alumina-silica fiber as the gain medium

We report the theoretical and experimental investigation of a self-starting mode-locked fiber laser with a nanoengineered Tm³⁺-doped yttrium-alumina-silica (YAS) fiber as the gain medium. The YAS fiber exhibits a higher capability of Tm³⁺ cluster elimination than commercial silica fibers. The Tm³⁺ fluorescence properties and YAS dispersion are well characterized. As a result, an efficient picosecond mode-locked fiber laser is demonstrated with a slope efficiency of 14.14% and maximum pulse energy of 1.27 nJ. To the best of our knowledge, this is the first mode-locked fiber laser based on a Tm³⁺-doped YAS fiber. The experimental observation is also supported by the numerical analysis.

Primary care providers perform more neurologic visits than neurologists among Medicare beneficiaries

RATIONALE, AIMS AND OBJECTIVES

Little is known about which medical providers, other than neurologists, are involved in the care of neurologic conditions. We aimed to describe the current distribution of outpatient neurologic care by provider type.

METHODS

We conducted a restrospective, cross-sectional analysis using a 20% national sample claims database that contains information on medical care utilizations from adult Fee-for-Service Medicare beneficiaries in 2015. We identified patient visits for evaluation and management services for common neurologic conditions and by medical provider type. The main outcome was the proportion of visits for neurologic conditions by medical provider type, both in aggregate and across neurologic conditions.

RESULTS

40% of neurologic visits were performed by primary care providers (PCPs) and 17.5% by neurologists. The most common neurologic conditions were back pain (49.3%), sleep disorders (8.0%), chronic pain/abnormality of gait (6.4%), peripheral neuropathy (5.9%), and stroke (5.5%). Neurologists cared for a large proportion of visits for Parkinson's disease (75.6% vs 20.8%), epilepsy (70.9% vs 26.6%), multiple sclerosis (63.9% vs 26.2%), other central NS disorders (54.2% vs 24.9%), and tremor/RLS/ALS (54.0% vs 31.2%) compared to PCPs. PCPs provided a greater proportion of visits for dizziness/vertigo (57.8% vs 9.3%) and headache/migraine (50.4% vs 35.0%) compared to neurologists.

CONCLUSIONS

PCPs perform more neurologic visits than neurologists. With the anticipated increased demand for neurologic care, strategies to optimize neurologic care delivery could consider expanding access to neurologists as well as supporting PCP care for neurologic conditions.

Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States

BACKGROUND

Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC.

RESEARCH QUESTION

How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival?

STUDY DESIGN AND METHODS

We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact.

RESULTS

Of 169,775 patients, 7%, 46%, 10%, 24%, and 12% underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI, 1.41-1.53), 1.29 (95% CI, 1.25-1.33), 1.18 (95% CI, 1.14-1.23), and 1.20 (95% CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95% CI, 1.28-1.42), 1.22 (95% CI, 1.17-1.26), 1.16 (95% CI, 1.11-1.22), and 1.17 (95% CI, 1.12-1.21), respectively (P < .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11% to 26% of the interinstitutional survival disparities.

INTERPRETATION

Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

Abstract P23: The Contribution of Stroke Preparedness to Regional Variation in Tissue Plasminogen Activator Treatment

Introduction: Unexplained regional variation exists in tissue plasminogen activator (tPA) treatment for stroke. Whether regional differences in stroke preparedness (stroke knowledge and intent to call 911) exist and contribute to tPA administration is unknown. We therefore sought to determine the contribution of stroke preparedness to regional variation in stroke treatment, as an association might support region-specific stroke preparedness interventions.

Methods: We performed a retrospective ecological cross-sectional study measuring the association of regional stroke preparedness and regional tPA administration. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, & 2011, adjusting for the number of stroke hospitalizations in each hospital service area (HSA) (primary outcome). We determined stroke preparedness from Behavior Risk Factor Surveillance System survey questions assessing stroke symptom knowledge (score range 0-6) and intent to call 911 (score range 0-1) (exposure of interest). The association between regional preparedness and tPA treatment was assessed using multiple linear regression, adjusting for regional characteristics (demographic factors, the presence of EMS bypass, number of primary stroke centers, and hospital stroke volume).

Results: There were 1738 HSAs. The adjusted percentage of stroke patients receiving tPA ranged from 1.37% (MIN) to 11.29% (MAX). Across HSAs, a median (IQR) of 86% (81%-90%) of responses to a witnessed stroke indicated intent to call 911 and a median (IQR) of 4.42 (4.24-4.59) out of 6 stroke symptoms were correctly recognized. Every 1% increase in accuracy in the question assessing intent to call 911 was associated with a 0.44% increase in adjusted tPA rate (p=0.049). Accurate stroke symptom recognition was not significantly associated with adjusted tPA rates across regions (p=0.05).

Conclusions: Overall, there was little regional variation in intent to call 911 and stroke symptom recognition. Intent to activate EMS in response to a witnessed stroke is likely a modest contributor to regional variation in tPA treatment.

Geographic Variation in Neurologist Density and Neurologic Care in the United States

OBJECTIVE

To describe geographic variation in neurologist density, neurologic conditions, and neurologist involvement in neurologic care.

METHODS

We used 20% 2015 Medicare data to summarize variation by Hospital Referral Region (HRR). Neurologic care was defined as office-based evaluation/management visits with a primary diagnosis of a neurologic condition.

RESULTS

Mean density of neurologists varied nearly 4-fold from the lowest to the highest density quintile (9.7 [95% confidence interval (CI) 9.2-10.2] vs 43.1 [95% CI 37.6-48.5] per 100,000 Medicare beneficiaries). The mean prevalence of patients with neurologic conditions did not substantially differ across neurologist density quintile regions (293 vs 311 per 1,000 beneficiaries in the lowest vs highest quintiles, respectively). Of patients with a neurologic condition, 23.5% were seen by a neurologist, ranging from 20.6% in the lowest quintile regions to 27.0% in the highest quintile regions (6.4% absolute difference). Most of the difference comprised dementia, pain, and stroke conditions seen by neurologists. In contrast, very little of the difference comprised Parkinson disease and multiple sclerosis, both of which had a very high proportion (>80%) of neurologist involvement even in the lowest quintile regions.

CONCLUSIONS

The supply of neurologists varies substantially by region, but the prevalence of neurologic conditions does not. As neurologist supply increases, access to neurologist care for certain neurologic conditions (dementia, pain, and stroke) increases much more than for others (Parkinson disease and multiple sclerosis). These data provide insight for policy makers when considering strategies in matching the demand for neurologic care with the appropriate supply of neurologists.

Chlorotrimethylsilane promoted one-flask heterocyclic synthesis of 1,2,4-triazoles from nitrilimines: Modeling studies and bioactivity evaluation of LH-21 and Rimonabant analogues

An efficient one-flask cascade method for synthesis of the multi-substituted 1,2,4-triazoles via chlorotrimethylsilane as a promoter was developed. Firstly, nitrilimines were transformed to hydrazonamides as intermediate in high yield by treatment with commercially available hexamethyldisilazane. Subsequently, the mixture was added with corresponding acyl chloride and heated in the presence of pyridine to give the corresponding multi-substituted 1,2,4-triazoles via chlorotrimethylsilane promoted heterocyclization reaction. The utility of method was demonstrated to synthesize CB₁ ligands including Rimonabant analogue 4c and LH-21 3 for modeling study. All synthesized compounds were subjected to the cAMP functional assay of CB₁/CB₂ receptor. Especially, compound 4g enhanced the reversal of cAMP reduction by CP59440 than LH-21 and Rimonabant analogue in CHO-hCB₁ cells. In addition, the docking results showed compound 4g fits the best position with CB₁ receptor. However, the ability to penetrate brain-blood barrier of compound 4g is similar with Rimonabant in MDCK-mdr1 permeability assay, which might cause CNS side effect. This study still provides the basis for further development of a potent and specific CB₁ antagonist.

Regional Variation in Billed Advance Care Planning Visits

BACKGROUND/OBJECTIVE

Advance care planning (ACP) is associated with improved patient and caregiver outcomes, but is underutilized. To encourage ACP, the Centers for Medicare & Medicaid Services implemented specific ACP visit reimbursement codes in 2016. To better understand the utilization of these ACP reimbursement codes, we explored regional variation in billed ACP visits.

DESIGN

We performed a retrospective cross-sectional analysis using a randomly sampled 5% cohort of Medicare fee-for-service (FFS) beneficiaries' claims files from 2017. Region was defined by hospital referral region.

SETTING

National Medicare FFS.

PARTICIPANTS

A total of 1.3 million Medicare beneficiaries aged 65 years and older.

MEASUREMENT

Receipt of billed ACP service, identified through Current Procedural Terminology code 99497 or 99498. Proportion of beneficiaries who received billed ACP service(s) by region was calculated. We fit a multilevel logistic regression model with a random regional intercept to determine the variation in billed ACP visits attributable to the region after accounting for patient (demographics, comorbidities, and medical care utilization) and regional factors (hospital size, emergency department visits, hospice utilization, and costs).

RESULTS

The study population included about 1.3 million beneficiaries, of which 32,137 (2.4%) had at least one billed ACP visit in 2017. There was substantial regional variation in the percentage of beneficiaries with billed ACP visits: lowest quintile region, less than 0.83%; subsequent regions, less than 1.6%, less than 2.4%, less than 3.3% to less than 8.4% in the highest quintile regions. A total of 15.4% of the variance in whether an older adult had a billed ACP visit was explained by the region. Although numerous regional factors were associated with billed ACP visits, none were strong predictors.

CONCLUSION

In 2017, we found wide regional variation in the use of billed ACP visits, although use overall was low in all regions. Increasing the understanding of the drivers and the effects of billed ACP visits could inform strategies for increasing ACP.

Disability in Community-Dwelling Older Adults: Exploring the Role of Stroke and Dementia

Objectives: We sought to determine the relative contributions of stroke, dementia, and their combination to disability and racial differences in disability among community-dwelling older adults. Methods: We performed a cross-sectional study of 6848 community-dwelling older adults. We evaluated the associations of stroke, dementia, and their combination with activities of daily living (ADL) limitations (range 0-7). We then explored the impact of stroke and dementia on race differences in ADL limitations using Poisson regression after accounting for sociodemographics and comorbidities. Results: After full adjustment, ADL limitations differed among older adults with stroke and dementia. Older adults without stroke or dementia had 0.32 (95% CI 0.29-0.35) ADL limitations compared to 0.64 (95% CI 0.54-0.73) with stroke, 1.36 (95% CI 1.20-1.53) with dementia and 1.84 (95% CI 1.54-2.15) with stroke and dementia. Overall, blacks had 0.27 (95%CI 0.19-0.36) more ADL limitations than whites. Models accounting for stroke led to a 3.7% (95%CI 2.98%-4.43%) reduction in race differences, while those for dementia led to a 29.26% (95%CI 28.53%-29.99%) reduction and the stroke-dementia combination -1.48% (95%CI -2.21% to -0.76) had little impact. Discussion: Older adults with stroke and dementia have greater disability than older adults with either of these conditions alone. However, the amount of disability experienced by older adults with stroke and dementia is less than the sum of the contributions from stroke and dementia. Dementia is likely a key contributor to race differences in disability.

Association Between Steroid-Sparing Therapy and the Risk of Perianal Fistulizing Complications Among Young Patients With Crohn Disease

IMPORTANCE

Perianal fistulizing complications (PFCs) develop in 15% to 30% of patients with Crohn disease (CD), are difficult to treat, worsen quality of life, increase cost of care, and commonly recur. Evidence-based strategies to prevent PFCs are lacking.

OBJECTIVES

To investigate the effectiveness of medical therapy for reducing risk of PFCs among young people with CD and to test the hypothesis that steroid-sparing therapy (SST) use would be associated with reduced risk of PFC development.

DESIGN, SETTING, AND PARTICIPANTS

In this comparative effectiveness analysis of commercial administrative claims from January 1, 2001, through June 30, 2016, patients who did or did not initiate SST were matched via propensity score to adjust for all available confounders. Using Optum's Clinformatics Data Mart, a deidentified database of US commercial administrative claims, all patients aged 5 to 24 years with CD (January 1, 2001, through June 30, 2016) were identified. The index date was the CD diagnosis date. Patients with PFCs or SST use at or before CD diagnosis were excluded. The dates of analysis were October 2017 to February 2020.

EXPOSURES

The primary exposure of interest was SST initiation, including immunomodulators and/or anti-tumor necrosis factor α (anti-TNFα) medications, initiated before either PFC development or the end of the study period.

MAIN OUTCOMES AND MEASURES

The primary outcome was PFC development. Propensity score matching was used to balance baseline characteristics. Cox proportional hazards multivariable regression analyses were used to estimate hazard ratios (HRs) with 95% CIs for PFC development.

RESULTS

Among 2214 young people with CD without PFCs identified, the mean (SD) age at CD diagnosis was 17.0 (4.5) years, and 1151 (52.0%) were male. Among the cohort, 1242 patients (56.1%) initiated SST before PFC development or the end of 24-month follow-up. After propensity score matching, 972 patients remained in each treatment group. Overall, 384 of 1944 (19.8%) developed PFCs within 2 years of the index date. The use of SST was associated with a 59% decreased risk of PFC development (hazard ratio [HR], 0.41; 95% CI, 0.33-0.52; P < .001) in 2 years compared with no SST use. Among those who developed PFCs, 55% fewer SST users underwent ostomy than SST nonusers. The use of immunomodulators alone, anti-TNFα alone, and combination therapy was associated with 52% (HR, 0.48; 95% CI, 0.37-0.62; P < .001), 47% (HR, 0.53; 95% CI, 0.36-0.78; P = .001), and 83% (HR, 0.17; 95% CI, 0.09-0.30; P < .001) reductions in the risk of 2-year PFC development, respectively, compared with no SST use.

CONCLUSIONS AND RELEVANCE

In this study, PFC development was common among young patients with CD. The use of SST was lower than expected. Compared with no SST, patients who initiated SST were 59% less likely to develop PFCs and fewer underwent ostomy. These results indicate that PFCs may be preventable and emphasize the importance of considering SST for all patients with CD.

Genetic testing utilization for patients with neurologic disease and the limitations of claims data

Objective

To determine the utilization of genetic testing in patients seen by a neurologist within a large private insurance population.

Methods

Using the Optum health care claims database, we identified a cross-sectional cohort of patients who had been evaluated by a neurologist no more than 30 days before initial genetic testing. Within this group, we then categorized genetic testing between 2014 and 2016 on the basis of the Current Procedural Terminology (CPT) codes related to molecular and genetic testing. We also evaluated the International Classification of Disease Version 9 Clinical Code Classifications (ICD-9 CCS) associated with testing.

Results

From 2014 to 2016, a total of 45,014 claims were placed for 29,951 patients who had been evaluated by a neurologist within the preceding 30 days. Of these, 29,926 (66.5%) were associated with codes that were too nonspecific to infer what test was actually performed. Among those claims where the test was clearly identifiable, 7,307 (16.2%) were likely obtained for purposes of neurologic diagnosis, whereas the remainder (17.2%) was obtained for non-neurological purposes. An additional 3,793 claims (8.4%) wherein the test ordered could not be clearly identified were associated with a neurology-related ICD-9 CCS.

Conclusions

Accurate assessment of genetic testing utilization using claims data is not possible given the high prevalence of nonspecific codes. Reducing the ambiguity surrounding the CPT codes and the actual testing performed will become even more important as more genetic tests become available.

Abstract WP221: Very Brief Intervention Improves Stroke Response in a Randomized Trial: Stroke Ready Very Brief Intervention

Introduction: Stroke pre-hospital delay has not improved over time.

Hypothesis: Stroke Ready, a very brief (5 minute), theory based, peer-led, stroke preparedness intervention, will increase stroke response compared with a control intervention.

Methods: We performed a randomized, single-blind controlled trial among adults in Flint, MI. The stroke preparedness intervention group received a Stroke Ready pamphlet and action plan, while the control group received stroke prevention materials - both delivered during a one-to-one interaction with a trained peer educator. Research staff, blinded to group intervention assignment, assessed baseline and immediate post-intervention outcomes. Primary outcome was change in stroke response (behavioral intent to call 911) using a community-modified stroke action test (range 0-12). Secondary outcome was change in stroke symptom recognition (range 0-8). We conducted descriptive analyses and used a linear regression model to evaluate the effect of the intervention on stroke response after adjustment for pre-intervention intent, age, education, race, marital status, history of stroke, stroke in someone they know and psychological constructs.

Results: We enrolled 129 participants (74 intervention; 55 control). Mean age was 60 years (SD 14); 61% were women, 89% were African American and 19% were not high school graduates. Intervention participants had greater improvement in stroke response than control participants (figure 1), which remained after full adjustment (improvement in average score for stroke response was 1.7 higher in intervention participants than control participants, 95% CI 0.9-2.5, p<0.0001). There was no difference in stroke symptom recognition (figure 1).

Conclusion: The Stroke Ready very brief intervention increased stroke response. This new approach using a very brief, one-to-one interaction with trained peer educators is a promising, scalable, intervention to increase stroke response.

The impact of the Patient Protection and Affordable Care Act on insurance coverage and cancer-directed treatment in HIV-infected patients with cancer in the United States

BACKGROUND

To the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act (ACA) on people living with HIV and cancer (PLWHC), who have lower cancer treatment rates and worse cancer outcomes. To investigate this research gap, the authors examined the effects of the ACA on insurance coverage and receipt of cancer treatment among PLWHC in the United States.

METHODS

HIV-infected individuals aged 18 to 64 years old with cancer diagnosed between 2011 and 2015 were identified in the National Cancer Data Base. Health insurance coverage and cancer treatment receipt were compared before and after implementation of the ACA in non-Medicaid expansion and Medicaid expansion states using difference-in-differences analysis.

RESULTS

Of the 4794 PLWHC analyzed, approximately 49% resided in nonexpansion states and were more often uninsured (16.7% vs 4.2%), nonwhite (65.2% vs 60.2%), and of low income (36.3% vs 26.9%) compared with those in Medicaid expansion states. After 2014, the percentage of uninsured individuals decreased in expansion states (from 4.9% to 3%; P = .01) and nonexpansion states (from 17.6% to 14.6%; P = .06), possibly due to increased Medicaid coverage in expansion states (from 36.9% to 39.2%) and increased private insurance coverage in nonexpansion states (from 29.5% to 34.7%). There was no significant difference in cancer treatment receipt noted between Medicaid expansion and nonexpansion states. However, the percentage of PLWHC treated at academic facilities increased significantly only in expansion states (from 40.2% to 46.7% [P < .0001]; difference-in-differences analysis: 7.2 percentage points [P = .02]).

CONCLUSIONS

The implementation of the ACA was associated with improved insurance coverage among PLWHC. Lack of insurance still is common in non-Medicaid expansion states. Patients with minority or low socioeconomic status more often resided in nonexpansion states, thereby highlighting the need for further insurance expansion.

P5644Hypoglycemic episodes increase the risk of ventricular arrhythmias and sudden cardiac arrest in patients with type 2 diabetes - a nationwide cohort study

Background

Hypoglycemic episode (HE) increases the risk of cardiovascular mortality. The impact of HE on the risk of sudden death remains unclear. We hypothesized that HE increases the risks of ventricular arrhythmia (VA) and sudden cardiac arrest (SCA), and that anti-diabetic agents (ADAs) causing hypoglycemia also increase the risks of VA and SCA.

Methods

Patients aged ≥20 years with newly diagnosed diabetes were identified from the Taiwan National Insurance Database. HE was defined as the presentation of hypoglycemic coma or specified/unspecified hypoglycemia. For control group, we included diabetic patients without HE, and they were frequency-matched to the HE group at a 4:1 ratio. The primary outcome was the occurrence of any event of VA (including ventricular tachycardia and fibrillation) and SCA during the defined follow-up periods. Multivariate Cox hazards regression model was used to evaluate the hazard ratio (HR) for VA or SCA.

Results

A total of 54,303 diabetic patients were screened with 1,037 of them in the HE group, and 4,148 in the control group. During a mean follow-up period of 3.3±2.5 years, 29 VA/SCA events had occurred. Compared to the control group, the HE group had a higher incidence of VA/SCA (adjusted HR: 2.42, p=0.04). Diabetic patients medicated with insulin for glycemic control increased the risk of VA/SCA compared to those without insulin (adjusted HR: 3.05, p=0.01).

Kaplan-Meier survival curves

Conclusions

HEs in patients with diabetes increased the risks of VA and SCA compared to those without. Their use of insulin also independently increased the risk of VA/SCA.

Advanced stage at diagnosis and elevated mortality among US patients with cancer infected with HIV in the National Cancer Data Base

BACKGROUND

People living with HIV (PLWH) are at an increased risk of developing several cancers, but to the authors' knowledge less is known regarding how HIV impacts the rate of progression to advanced cancer or death.

METHODS

The authors compared stage of disease at the time of presentation and mortality after diagnosis between 14,453 PLWH and 6,368,126 HIV-uninfected patients diagnosed with cancers of the oral cavity, stomach, colorectum, anus, liver, pancreas, lung, female breast, cervix, prostate, bladder, kidney, and thyroid and melanoma using data from the National Cancer Data Base (2004-2014). Polytomous logistic regression and Cox proportional hazards regression were used to evaluate the association between HIV, cancer stage, and stage-adjusted mortality after diagnosis, respectively. Regression models accounted for the type of health facility at which cancer treatment was administered and the type of individual health insurance.

RESULTS

HIV-infected patients with cancer were found to be more likely to be uninsured (HIV-infected: 5.0% vs HIV-uninfected: 3.3%; P < .0001) and were less likely to have private health insurance (25.4% vs 44.7%; P < .0001). Compared with those not infected with HIV, the odds of being diagnosed at an advanced stage of disease were significantly elevated in PLWH for melanoma and cancers of the oral cavity, liver, female breast, prostate, and thyroid (odds ratio for stage IV vs stage I range, 1.24-2.06). PLWH who were diagnosed with stage I to stage III disease experienced elevated mortality after diagnosis across 13 of the 14 cancer sites evaluated, with hazard ratios ranging from 1.20 (95% CI, 1.14-1.26) for lung cancer to 1.85 (95% CI, 1.68-2.04), 1.85 (95% CI, 1.51-2.27), and 2.93 (95% CI, 2.08-4.13), respectively, for cancers of the female breast, cervix, and thyroid.

CONCLUSIONS

PLWH were more likely to be diagnosed with advanced-stage cancers and to experience elevated mortality after a cancer diagnosis, even after accounting for health care-related factors.

Pre-treatment quality of life as a predictor of distant metastasis-free survival and overall survival in patients with head and neck cancer who underwent free flap reconstruction

PURPOSE

This study examined the prognostic associations of pre-treatment quality of life (QoL) with overall survival (OS) and distant metastasis-free survival (DFMS) among patients with head and neck cancer (HNC) who underwent free flap reconstruction.

METHODS

A cohort of 127 HNC patients who received free flap reconstruction between November 2010 and June 2014 at a hospital were recruited. Pre-treatment QoL was measured by the University of Washington Quality of Life Questionnaire, which contains six physical domains, including speech, swallowing, appearance, saliva, taste and chewing, as well as the six social-emotional domains of pain, activity, recreation, shoulder, mood, and anxiety. Cox regression analyses were performed.

RESULTS

Results showed that pre-treatment QoL was predictive of OS and DMFS. Of the domains, swallowing, chewing, speech, taste, saliva, pain and shoulder were demonstrated to be significant predictors of OS. Additionally, swallowing, chewing, speech, pain and activity were demonstrated making significant contributions to DMFS.

CONCLUSION

Our data supported that physical domains of pre-treatment QoL were predictors for OS and DFMS in HNC patients with free-flap reconstruction. Longitudinal studies are warranted to clarify the prognostic abilities of social-emotional domains. Information on pre-treatment QoL should be taken into account to individualize care plan for these patients, and hence prolong their survival.

[The role and mechanism of 2-deoxyglucose in reversing osimertinib-acquired resistance of non-small cell lung cancer cell line]

Objective: To explore the role and mechanism of 2-deoxyglucose (2-dg) in reversing osimertinib- acquired resistance of non-small cell lung cancer(NSCLC)cell line. Methods: The NSCLC line H1975 (purchased from the American Type Culture Collection) was conducted by induction method in vitro to construct the osimertinib-resistance NSCLC cell line H1975-OR. The osimertinib-resistance of H1975-OR cell line was examined by 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, colony-formation assay, Ki67 incorporation assay and the expression of apoptosis-related protein. The glycolysis level was assayed by the lactic acid production measured in the culture medium supernatant of H1975 and H1975-OR. The expression of glycolysis key enzymes (HK2, GLUT1, P-PKM2) and apoptosis-related protein (BIM, Bcl-2) were detected by Western blot. The cells were divided into control group, 2-deoxyglucose (4 mmol/L) monotherapy group, osimertinib (3 μmol/L) monotherapy group and 2-deoxyglucose (4 mmol/L)+ osimertinib (3 μmol/L) combination therapy group, then the apoptosis rate of cells was measured by flow cytometry to evaluate the pro-apoptotic ability of drugs. Date were analyzed by Independent-Samples t-test using SPSS 16.0 statistical software. Results: The glycolysis level of osimertinib-sensitive cell line H1975 was lower than that of osimertinib-resistance cell line H1975-OR [the yield of lactic acid, respectively, was (21.0±0.9) and (26.5±2.8) mmol·L(-1)·10(4)cells(-1), P<0.05]. The osimertinib- acquired resistance of H1975-OR could be reversed by 4 mmol/L 2-deoxyglucose(the IC(50) value of osimertinib in H1975-OR cell line decreased from (7.0±1.9) μmol/L to (1.4±0.1) μmol/L, which was close to the IC(50) value of osimertinib in H1975 cell line (1.0±0.2) μmol/L. The apoptosis rate of H1975-OR was significantly higher in 2-deoxyglucose + osimertinib combination therapy group (26.7±2.4)%, compared to control group (5.1±0.7)%, 2-deoxyglucose monotherapy group (6.1±2.5)% and osimertinib monotherapy group (11.4±2.7)%(all P<0.05). The expression of pro-apoptotic protein BIM in H1975-OR was significantly higher in 2-deoxyglucose+ osimertinib combination therapy group (177.8±28.1)% and the expression of anti-apoptotic protein Bcl-2 in H1975-OR was significantly lower in 2-deoxyglucose+ osimertinib combination therapy group (24.6±5.2)%, compared to control group (100±0)%, all P<0.05. Conclusion: 2-deoxyglucose can reverse the acquired resistance of NSCLC cell line to osimertinib, which may be related to the inhibition of cell glycolysis and the induction of apoptosis.

Claims data analyses unable to properly characterize the value of neurologists in epilepsy care

OBJECTIVE

To determine the association of a neurologist visit with health care use and cost outcomes for patients with incident epilepsy.

METHODS

Using health care claims data for individuals insured by United Healthcare from 2001 to 2016, we identified patients with incident epilepsy. The population was defined by an epilepsy/convulsion diagnosis code (ICD codes 345.xx/780.3x, G40.xx/R56.xx), an antiepileptic prescription filled within the succeeding 2 years, and neither criterion met in the 2 preceding years. Cases were defined as patients who had a neurologist encounter for epilepsy within 1 year after an incident diagnosis; a control cohort was constructed with propensity score matching. Primary outcomes were emergency room (ER) visits and hospitalizations for epilepsy. Secondary outcomes included measures of cost (epilepsy related, not epilepsy related, and antiepileptic drugs) and care escalation (including EEG evaluation and epilepsy surgery).

RESULTS

After participant identification and propensity score matching, there were 3,400 cases and 3,400 controls. Epilepsy-related ER visits were more likely for cases than controls (year 1: 5.9% vs 2.3%, p < 0.001), as were hospitalizations (year 1: 2.1% vs 0.7%, p < 0.001). Total medical costs for epilepsy care, nonepilepsy care, and antiepileptic drugs were greater for cases (p ≤ 0.001). EEG evaluation and epilepsy surgery occurred more commonly for cases (p ≤ 0.001).

CONCLUSIONS

Patients with epilepsy who visited a neurologist had greater subsequent health care use, medical costs, and care escalation than controls. This comparison using administrative claims is plausibly confounded by case disease severity, as suggested by higher nonepilepsy care costs. Linking patient-centered outcomes to claims data may provide the clinical resolution to assess care value within a heterogeneous population.

ROLE OF CANCER HISTORY AND GENDER IN MAJOR HEALTH INSURANCE TRANSITIONS: A LONGITUDINAL NATIONALLY REPRESENTATIVE STUDY

PURPOSE –

To examine associations by gender between cancer history and major health insurance transitions (gains and losses), and relationships between insurance transitions and access to care.

METHODOLOGY –

Longitudinal 2008-2013 Medical Expenditure Panel Survey data pooled yielding 2,223 cancer survivors and 50,692 individuals with no cancer history ages 18-63 years upon survey entry, with gender-specific sub-analyses. Access-to-care implications of insurance loss or gain were compared by cancer history and gender.

FINDINGS –

Initially uninsured cancer survivors were significantly more likely to gain insurance coverage than individuals with no cancer history (RR: 1.25; 95% CI: 1.08-1.44). Females in particular were significantly more likely to gain insurance (unmarried RR: 1.16; 95% CI: 1.06-1.28; married RR: 1.09; 95% CI: 1.02-1.16). Significantly higher rates of difficulty accessing needed medical care and prescription medications were reported by those remaining uninsured, those who lost insurance, and women in general. Remaining uninsured, losing insurance, and male gender were associated with lack of a usual source of care.

RESEARCH IMPLICATIONS –

Additional outreach to disadvantaged populations is needed to improve access to affordable insurance and medical care. Future longitudinal studies should assess whether major Affordable Care Act (ACA) provisions enacted after the 2008-2013 study period (or those of ACA's replacement) are addressing these important issues.

ORIGINALITY –

Loss of health insurance coverage can reduce health care access resulting in poor health outcomes. Cancer survivors may be particularly at risk of insurance coverage gaps due to the long-term chronic disease trajectory. This study is novel in exploring associations between cancer history by gender and health insurance transitions, both gains and losses, in a national non-elderly adult sample.

The impact of dependent coverage expansion under the Affordable Care Act on time to breast cancer treatment among young women

INTRODUCTION

Breast cancer in young women tends to be more aggressive, but timely treatment may not be always available, particularly to those without health insurance. We aim to examine whether the dependent coverage expansion under the Affordable Care Act (ACA-DCE) implemented in 2010 was associated with changes in time to treatment among women diagnosed with early stage breast cancer.

METHODS

A total of 7,176 patients diagnosed with early stage breast cancer in 2007-2009 (pre-ACA) and 2011-2013 (post-ACA) were identified from the National Cancer Database. A quasi-experimental design difference-in-differences (DD) approach was used, with patients aged 19-25 (targeted by the policy) considered as the intervention group, and patients aged 26-34 years (not affected by the policy) as the control group. Changes in the following treatment outcomes were examined: time from diagnosis to surgery, time from surgery to adjuvant chemotherapy, and time from adjuvant chemotherapy to radiation.

RESULTS

Compared with the control group of patients aged 26-34, young patients aged 19-25 experienced a statistically nonsignificant decrease of 2.7 percentage points (95% CI [-1.2, 6.5]) in the uninsured rate. This did not translate into more reduction in delays to surgery (DD = 2.7 days, 95% CI [-3.2, 8.3]), chemotherapy (DD = -1.0 days, 95% CI [-7.2, 5.2]) or radiation (DD = 5.3 days, 95% CI [-15.6, 26.3]) in the younger cohort than the older cohort.

CONCLUSIONS AND RELEVANCE

No significant changes in time to treatment were found among young women diagnosed with early stage breast cancer after the implementation of the ACA-DCE. Future studies examining impacts of health care policy reform on breast cancer care are warranted to include patients from low-income families and to consider effects from Medicaid expansion.

Trends in reporting histological subtyping of renal cell carcinoma: association with cancer center type

Histological classification of renal cell carcinoma (RCC) has become increasingly important for clinical management. We identified 295483 RCC diagnosed from 1998-2014 in the National Cancer Database (NCDB) to examine temporal trends in proportions of RCC with unspecified histology and several specific histologies from the 1998 and 2004 World Health Organization classifications of RCC. Further, multivariable log binomial analysis of 101062 RCC diagnosed from 2010 to 2014 was used to determine whether the association of diagnosing/treating facility type and the proportion of unspecified RCC is independent of patient demographic and clinical factors. Between 1998 and 2014, the proportion of histologically unspecified RCC decreased substantially in all facility types, with the decrease smallest in community programs (from 86.0% to 28.1%) and largest in National Cancer Institute-designated centers (from 85.1% to 9.8%). These decreases were offset by increases in percentages of papillary, clear cell, and chromophobe RCC cases. During 2010 to 2014, relative to community programs, RCCs were 21% less likely to be reported as unspecified histology (adjusted prevalence ratio [aPR] = 0.79; 95% CI, 0.68-0.92) in comprehensive community programs, 32% less likely in integrated network programs (aPR = 0.68; 95% CI, 0.57-0.92) and academic programs (aPR = 0.68; 95% CI, 0.54-0.87), and 63% less likely (aPR = 0.37; 95% CI, 0.26-0.52) in National Cancer Institute -designated programs. These results have implications for the optimal selection of targeted systemic therapies for patients with advanced disease, and for the potential value of cancer registry data in pathology quality improvement programs to promote more rapid and consistent adoption of new classifications of RCC and other neoplasms.

Phosphorylation of threonine residues on Shc promotes ligand binding and mediates crosstalk between MAPK and Akt pathways in breast cancer cells

Scaffold proteins play important roles in regulating signalling network fidelity, the absence of which is often the basis for diseases such as cancer. In the present work, we show that the prototypical scaffold protein Shc is phosphorylated by the extracellular signal-regulated kinase, Erk. In addition, Shc threonine phosphorylation is specifically up-regulated in two selected triple-negative breast cancer (TNBC) cell lines. To explore how Erk-mediated threonine phosphorylation on Shc might play a role in the dysregulation of signalling events, we investigated how Shc affects pathways downstream of EGF receptor. Using an in vitro model and biophysical analysis, we show that Shc threonine phosphorylation is responsible for elevated Akt and Erk signalling, potentially through the recruitment of the 14-3-3 ζ and Pin-1 proteins.

Factors That Contributed to Black-White Disparities in Survival Among Nonelderly Women With Breast Cancer Between 2004 and 2013

Purpose

To estimate the contribution of differences in demographics, comorbidity, insurance, tumor characteristics, and treatment to the overall mortality disparity between nonelderly black and white women diagnosed with early-stage breast cancer.

Patients and Methods

Excess relative risk of all-cause death in black versus white women diagnosed with stage I to III breast cancer, expressed as a percentage and stratified by hormone receptor status for each variable (demographics, comorbidity, insurance, tumor characteristics, and treatment) in sequentially, propensity-scored, optimally matched patients by using multivariable hazard ratios (HRs).

Results

We identified 563,497 white and black women 18 to 64 years of age diagnosed with stage I to III breast cancer from 2004 to 2013 in the National Cancer Data Base. Among women with hormone receptor–positive disease, who represented 78.5% of all patients, the HR for death in black versus white women in the demographics-matched model was 2.05 (95% CI, 1.94 to 2.17). The HR decreased to 1.93 (95% CI, 1.83 to 2.04), 1.54 (95% CI, 1.47 to 1.62), 1.30 (95% CI, 1.24 to 1.36), and 1.25 (95% CI, 1.19 to 1.31) when sequentially matched for comorbidity, insurance, tumor characteristics, and treatment, respectively. These factors combined accounted for 76.3% of the total excess risk of death in black patients; insurance accounted for 37.0% of the total excess, followed by tumor characteristics (23.2%), comorbidities (11.3%), and treatment (4.8%). Results generally were similar among women with hormone receptor–negative disease, although the HRs were substantially smaller.

Conclusion

Matching by insurance explained one third of the excess risk of death among nonelderly black versus white women diagnosed with early-stage breast cancer; matching by tumor characteristics explained approximately one fifth of the excess risk. Efforts to focus on equalization of access to care could substantially reduce ethnic/racial disparities in overall survival among nonelderly women diagnosed with breast cancer.

Hepatic Portal Venous Gas in a Patient with Penetrating Injuries

Hepatic portal venous gas (HPVG) refers to the branching area of low attenuation extending to within 2 cm of the liver capsule in computed tomography scan. The most common causes of HPVG are mesenteric ischaemia in adults and necrotising enterocolitis in infants. HPVG in trauma patients is mostly reported in cases of blunt abdominal trauma. We present a deceased patient who had chest and abdominal wall penetrating injuries with concomitant hypovolemic shock. A computed tomography scan revealed HPVG and pulmonary artery air emboli. The mechanism of the presentation of HPVG in this patient and the possible cause of death would be discussed. (Hong Kong j.emerg.med. 2013;20:382-384)

Changes in Insurance Coverage and Stage at Diagnosis Among Nonelderly Patients With Cancer After the Affordable Care Act

Purpose

To examine change in the percent uninsured and early-stage diagnosis among nonelderly patients with newly diagnosed cancer after the Affordable Care Act (ACA).

Patients and Methods

By using the National Cancer Data Base, we estimated absolute change (APC) and relative change in percent uninsured among patients with newly diagnosed cancer age 18 to 64 years between 2011 to the third quarter of 2013 (pre-ACA implementation) and the second to fourth quarter of 2014 (post-ACA) in Medicaid expansion and nonexpansion states by family income level. We also examined demographics-adjusted difference in differences in APC between Medicaid expansion and nonexpansion states. We similarly examined changes in insurance and early-stage diagnosis for the 15 leading cancers in men and women (top 17 cancers total).

Results

Between the pre-ACA and post-ACA periods, percent uninsured among patients with newly diagnosed cancer decreased in all income categories in both Medicaid expansion and nonexpansion states. However, the decrease was largest in low-income patients who resided in expansion states (9.6% to 3.6%; APC, −6.0%; 95% CI, −6.5% to −5.5%) versus their counterparts who resided in nonexpansion states (14.7% to 13.3%; APC, −1.4%; 95% CI, −2.0% to −0.7%), with an adjusted difference in differences of −3.3 (95% CI, −4.0 to −2.5). By cancer type, the largest decrease in percent uninsured occurred in patients with smoking- or infection-related cancers. A small but statistically significant shift was found toward early-stage diagnosis for colorectal, lung, female breast, and pancreatic cancer and melanoma in patients who resided in expansion states.

Conclusion

Percent uninsured among nonelderly patients with newly diagnosed cancer declined substantially after the ACA, especially among low-income people who resided in Medicaid expansion states. A trend toward early-stage diagnosis for select cancers in expansion states also was found. These results reinforce the importance of policies directed at providing affordable coverage to low-income, vulnerable populations.

Trends in Diagnosis of Gleason Score 2 Through 4 Prostate Cancer in the National Cancer Database, 1990–2013

Context.—

The incidence of prostate cancer with Gleason scores 2 through 4 has been decreasing for decades, largely because of evolving criteria for Gleason scores, including the 2005 International Society of Urological Pathology recommendation that scores of 2 through 4 should rarely, if ever, be diagnosed based on needle biopsy. Whether trends in assigning Gleason scores 2 through 4 vary by facility type and patient characteristics is unknown.

Objective.—

To assess trends in prostate cancer grading among various categories of treatment facilities.

Design.—

Analyses of National Cancer Database records from 1990 through 2013 for 434 612 prostate cancers diagnosed by core needle biopsy, including multivariable regression for 106 331 patients with clinical T1c disease diagnosed from 2004 through 2013.

Results.—

The proportion of prostate core needle biopsies with Gleason scores 2 through 4 declined from 11 476 of 53 850 (21.3%) (1990–1994) to 96 of 43 566 (0.2%) (2010–2013). The proportions of American Joint Committee on Cancer category T1c needle biopsies assigned Gleason scores 2 through 4 were 416 of 12 796 (3.3%) and 9 of 7194 (0.1%) during 2004 and 2013, respectively. Declines occurred earliest at National Cancer Institute–designated programs and latest at community programs. A multivariable logistic model adjusting for patient demographic and clinical variables and restricted to T1c cancers diagnosed in needle biopsies from 2004 through 2013 showed that facility type is independently associated with the likelihood of cancers in such specimens being assigned Gleason scores of 2 through 4, with community centers having a statistically significant odds ratio of 5.99 relative to National Cancer Institute–designated centers.

Conclusions.—

These results strongly suggest differences in Gleason grading by pathologists practicing in different facility categories and variations in their promptness of adopting International Society of Urological Pathology recommendations.

[Effect and mechanism of silibinin on the inhibition of ALK positive NSCLC cells by sensitizing crizotinib]

Objective: To explore the synergistic effect of silibinin combined with crizotinib on anaplastic lymphoma kinase positive (ALK+ ) non-small cell lung cancer (NSCLC) cells and its mechanism. Methods: H2228 and H3122 cells were treated with silibinin, crizotinib alone or in combination. Cell proliferation was measured by 3-(4, 5-Dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) assay and colony formation assay. Migration or invasion ability was tested by wound healing assay or transwell assay, respectively. Expressions of E-Cadherin and vimentin protein were examined by immunofluorescence staining. The protein expressions of ALK, p-ALK, E-Cadherin and Vimentin were detected by western blotting.The anti-cancer effect of silibinin combined with crizotinib in vivo was determined by subcutaneously injecting 2×10(6) H2228 cells into immunodeficient nude mice. Results: The result of MTT assay showed that the cell viability of H2228 or H3122 treated with 100 μmol/L silibinin was (88.38±4.10)% or (72.27±3.62)%, respectively, marginally decreased compared with that of the control. The 50% inhibitory concentration (IC(50)) of H2228 cells treated with crizotinib alone or combined with 100 μmol/L silibinin was (917.10±7.75) nmol/L or (238.73±7.67) nmol/L, respectively. The IC(50) of H3122 cells treated with crizotinib alone or combined with 100 μmol/L silibinin was (472.50±15.70) nmol/L or (206.10±12.01) nmol/L, respectively. The IC(50s) of H2228 and H3122 cells were significantly decreased by combined treatment of crizotinib and silibinin compared to crizotinib treatment alone (P<0.01). When compared with the control group, colony forming ratios of H2228 cells were (83.34±2.72)% in 100 μmol/L silibinin treatment group, (69.42±3.06)% in 400 nmol/L crizotinib treatment group and (27.32±1.42)% in combined treatment group. When compared with the control group, colony forming ratios of H3122 cells were (84.45±5.67)% in 100 μmol/L silibinin treatment group, (45.02±5.83)% in 400 nmol/L crizotinib treatment group and (17.43±3.83)% in combined treatment group. Silibinin combined with crizotinib treatment significantly inhibited the colony formation ability of H2228 and H3122 cells (P<0.01). Migration and invasion results showed that combined treatment of crizotinib and silibinin markedly inhibited the migration and invasion ability of H2228 cells (P<0.01). Western blot results indicated that treated with silibinin alone or in combination of crozitinib for 48 hours, the protein level of E-cadherin in H2228 cells was upregulated, while the expressions of p-ALK and vimentin were downregulated, without obvious alteration of ALK protein expression. In the xenograft model, the mean tumor weight was (9.40±2.58)g in crizotinib treatment group and (4.58±1.07)g in the combined treatment group. The inhibitory effect of tumor growth in vivo of combined treatment was significantly superior to that of crizotinib treatment alone (P<0.05). Conclusion: Silibinin enhances the inhibitory effect of crizotinib on ALK positive NSCLC cells, which may be associated with suppression of ALK activity and mesenchymal-epithelial transition.

State Variation in the Receipt of a Contralateral Prophylactic Mastectomy Among Women Who Received a Diagnosis of Invasive Unilateral Early-Stage Breast Cancer in the United States, 2004-2012

Importance

The use of contralateral prophylactic mastectomies (CPMs) among patients with invasive unilateral breast cancer has increased substantially during the past decade in the United States despite the lack of evidence for survival benefit. However, whether this trend varies by state or whether it is correlated with changes in proportions of reconstructive surgery among these patients is unclear.

Objective

To determine state variation in the temporal trend and in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery.

Design, Setting, and Participants

A retrospective cohort study of 1.2 million women 20 years of age or older diagnosed with invasive unilateral early-stage breast cancer and treated with surgery from January 1, 2004, through December 31, 2012, in 45 states and the District of Columbia as compiled by the North American Association of Central Cancer Registries. Data analysis was performed from August 1, 2015, to August 31, 2016.

Exposure

Contralateral prophylactic mastectomy.

Main Outcomes and Measures

Temporal changes in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery by age and state, overall and in relation to changes in the proportions of those who underwent reconstructive surgery.

Results

Among the 1 224 947 women with early-stage breast cancer treated with surgery, the proportion who underwent a CPM nationally increased between 2004 and 2012 from 3.6% (4013 of 113 001) to 10.4% (12 890 of 124 231) for those 45 years or older and from 10.5% (1879 of 17 862) to 33.3% (5237 of 15 745) for those aged 20 to 44 years. The increase was evident in all states, although the magnitude of the increase varied substantially across states. For example, among women 20 to 44 years of age, the proportion who underwent a CPM from 2004-2006 to 2010-2012 increased from 14.9% (317 of 2121) to 24.8% (436 of 1755) (prevalence ratio [PR], 1.66; 95% CI, 1.46-1.89) in New Jersey compared with an increase from 9.8% (162 of 1657) to 32.2% (495 of 1538) (PR, 3.29; 95% CI, 2.80-3.88) in Virginia. In this age group, CPM proportions for the period from 2010 to 2012 were over 42% in the contiguous states of Nebraska, Missouri, Colorado, Iowa, and South Dakota. From 2004 to 2012, the proportion of reconstructive surgical procedures among women aged 20 to 44 years who were diagnosed with early-stage breast cancer and received a CPM increased in many states; however, it did not correlate with the proportion of women who received a CPM.

Conclusions and Relevance

The increase in the proportion of CPMs among women with early-stage unilateral breast cancer treated with surgery varied substantially across states. Notably, in 5 contiguous Midwest states, nearly half of young women with invasive early-stage breast cancer underwent a CPM from 2010 to 2012. Future studies should examine the reasons for the geographic variation and increasing trend in the use of CPMs.

Severe hypoglycemia and hip fracture in patients with type 2 diabetes: a nationwide population-based cohort study

Hypoglycemia is a major concern in glycemic control. Using the Taiwan National Health Insurance Research Database, we found that the risk of hip fracture was associated with emergency or hospitalization visits of severe hypoglycemia in patients with type 2 diabetes; greater visits were associated with higher incidence of hip fracture.

INTRODUCTION

The objective of the study was to assess the risk of hip fracture among patients with type 2 diabetes mellitus (T2DM) and severe hypoglycemia.

METHODS

Using the National Health Insurance Research database in Taiwan, we identified 2588 patients with T2DM who had developed severe hypoglycemia from 2001 to 2009. A comparison cohort who had never developed severe hypoglycemia was frequency matched at a ratio of approximately 1:2. Multivariate Cox proportional hazard regression analysis was used to evaluate the risk of hip fracture.

RESULTS

During a median follow-up period of 3.9 years, there were 219 hip fracture events in 5173 comparison cohorts and 148 hip fracture events in 2588 hypoglycemia cohorts. The incidence of hip fracture was higher in patients with severe hypoglycemia than without severe hypoglycemia (17.19 vs. 8.83 per 1000 person-years; adjusted HR 1.71, 95% CI = 1.35-2.16). Approximately half of the individuals developed hip fracture within 2 years from the first occurrence of severe hypoglycemia. There was a significant associated trend towards increased hip fracture risk with increasing average visit of severe hypoglycemia per year (p for trend <0.001). Medication analysis showed that patients taking sulfonylurea alone, insulin alone, and insulin secretagogues combined with insulin had a higher associated risk to develop hip fracture.

CONCLUSIONS

Severe hypoglycemia was associated with a higher risk to develop hip fracture. The more the visits of severe hypoglycemia per year indicated the higher associated risk in patients with T2DM. Fall is likely an important reason for severe hypoglycemia in relation to increased risk of hip fracture.

Racial and Ethnic Disparities in Interval Colorectal Cancer Incidence: A Population-Based Cohort Study

BACKGROUND

Interval colorectal cancer (CRC) accounts for 3% to 8% of all cases of CRC in the United States. Data on interval CRC by race/ethnicity are scant.

OBJECTIVE

To examine whether risk for interval CRC among Medicare patients differs by race/ethnicity and whether this potential variation is accounted for by differences in the quality of colonoscopy, as measured by physicians' polyp detection rate (PDR).

DESIGN

Population-based cohort study.

SETTING

Medicare program.

PARTICIPANTS

Patients aged 66 to 75 years who received colonoscopy between 2002 and 2011 and were followed through 2013.

MEASUREMENTS

Kaplan-Meier curves and adjusted Cox models were used to estimate cumulative probabilities and hazard ratios (HRs) of interval CRC, defined as a CRC diagnosis 6 to 59 months after colonoscopy.

RESULTS

There were 2735 cases of interval CRC identified over 235 146 person-years of follow-up. A higher proportion of black persons (52.8%) than white persons (46.2%) received colonoscopy from physicians with a lower PDR. This rate was significantly associated with interval CRC risk. The probability of interval CRC by the end of follow-up was 7.1% in black persons and 5.8% in white persons. Compared with white persons, black persons had significantly higher risk for interval CRC (HR, 1.31 [95% CI, 1.13 to 1.51]); the disparity was more pronounced for cancer of the rectum (HR, 1.70 [CI, 1.25 to 2.31]) and distal colon (HR, 1.45 [CI, 1.00 to 2.11]) than for cancer of the proximal colon (HR, 1.17 [CI, 0.96 to 1.42]). Adjustment for PDR did not alter HRs by race/ethnicity, but differences between black persons and white persons were greater among physicians with higher PDRs.

LIMITATION

Colonoscopy and polypectomy were identified by using billing codes.

CONCLUSION

Among elderly Medicare enrollees, the risk for interval CRC was higher in black persons than in white persons; the difference was more pronounced for cancer of the distal colon and rectum and for physicians with higher PDRs.

PRIMARY FUNDING SOURCE

American Cancer Society.

Changes in stage at diagnosis of screenable cancers after the Affordable Care Act

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Background: Extensive evidence links inadequate insurance with later stage at cancer diagnosis, particularly for cancers that can be detected by screening. The Affordable Care Act (ACA) implemented in 2014 has substantially increased insurance coverage for Americans 18-64 years old. This study aims to examine any changes in stage at diagnosis after the ACA for the following cancers for which screening is recommended for individuals at risk: female breast cancer, colorectal cancer, cervical cancer, prostate cancer, and lung cancer. Methods: We used National Cancer Data Base, a nationally hospital-based cancer registry capturing 70% new cancer cases in the US each year, to identify nonelderly cancer patients with screening-appropriate age who were diagnosed during 2013-2014. The percentage of stage I disease was calculated for each cancer type before (2013 Q1-Q3) and after (2014 Q2-Q4) the ACA. 2013 Q4-2014 Q1 was excluded as a washout/phase-in period. Prevalence ratios (PR) and 95% confidence intervals (CI) were calculated using log-binomial models controlling for age, race/ethnicity and sex if applicable. Results: 121,855 female breast cancer patients aged 40-64 years, 39,568 colorectal cancer patients aged 50-64 years, 11,265 cervical cancer patients aged 21-64 years, 59,626 prostate cancer patients aged 50-64 years, and 41,504 lung cancer patients aged 55-64 years were identified. After the implementation of the ACA, the percentage of stage I disease increased statistically significantly for female breast cancer (47.8% vs. 48.9%; PR = 1.02 [95%CI 1.01-1.03]), colorectal cancer (22.8% vs. 23.7%; PR = 1.04 [95%CI 1-1.08]), and lung cancer (16.6% vs. 17.7%; PR = 1.06 [95% CI 1.02-1.11]). A shift to stage I disease was also observed for cervical cancer (47.2% vs. 48.7%; PR = 1.02 [95% CI 0.98-1.06]) although not statistically significant. In contrast, the percentage of stage I decreased for prostate cancer (18.5% vs. 17.2%; PR = 0.93 [95%CI 0.9-0.96]) in 2014. Conclusions: The implementation of the ACA is associated with a shift to early stage at diagnosis for all screenable cancers except prostate cancer, which may reflect the recent US Preventive Services Task Force recommendations against routine prostate cancer screening.