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Beaulieu-Jones BR, Ha EJ, Fefferman A, Wang J, Chung SH, Tseng JF, Merrill A, Sachs TE, Ko NY, Cassidy MR. Association of Race, Ethnicity, Language, and Insurance with Time to Treatment Initiation Among Women with Breast Cancer at an Urban, Academic, Safety-Net Hospital. Ann Surg Oncol 2024; 31:1608-1614. [PMID: 38017122 DOI: 10.1245/s10434-023-14612-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/31/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Initial treatment for nonmetastatic breast cancer is resection or neoadjuvant systemic therapy, depending on tumor biology and patient factors. Delays in treatment have been shown to impact survival and quality of life. Little has been published on the performance of safety-net hospitals in delivering timely care for all patients. METHODS We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2019 at an academic, safety-net hospital. Time to treatment initiation was calculated for all patients. Consistent with a recently published Committee on Cancer timeliness metric, a treatment delay was defined as time from tissue diagnosis to treatment of greater than 60 days. RESULTS A total of 799 eligible women with stage 1-3 breast cancer met study criteria. Median age was 60 years, 55.7% were non-white, 35.5% were non-English-speaking, 18.9% were Hispanic, and 49.4% were Medicaid/uninsured. Median time to treatment was 41 days (IQR 27-56 days), while 81.1% of patients initiated treatment within 60 days. The frequency of treatment delays did not vary by race, ethnicity, insurance, or language. Diagnosis year was inversely associated with the occurrence of a treatment delay (OR: 0.944, 95% CI 0.893-0.997, p value: 0.039). CONCLUSION At our institution, race, ethnicity, insurance, and language were not associated with treatment delay. Additional research is needed to determine how our safety-net hospital delivered timely care to all patients with breast cancer, as reducing delays in care may be one mechanism by which health systems can mitigate disparities in the treatment of breast cancer.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, MA, USA
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Emily J Ha
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Ann Fefferman
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Judy Wang
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sophie H Chung
- Department of Surgery, Boston Medical Center, Boston, MA, USA
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jennifer F Tseng
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Andrea Merrill
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Teviah E Sachs
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Naomi Y Ko
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Section of Hematology and Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Michael R Cassidy
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
- Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, MA, USA.
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Mootz AR, Ozcan BB, Polat DS, Acevedo Z, Xi Y, Unni N, Nwachukwu C, Dogan BE. A Tale of Two Hospitals: Effect of Access to Care Through a Safety Net Hospital on Adjuvant Therapy, Imaging Compliance and 5-Year Survival Rates Compared to the University Hospital Served by the Same Breast Cancer Clinical Teams. Acad Radiol 2024:S1076-6332(24)00052-7. [PMID: 38365491 DOI: 10.1016/j.acra.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/18/2024]
Abstract
RATIONALE AND OBJECTIVES To compare rates of guideline-concordant care, imaging surveillance, recurrence and survival outcomes between a safety-net (SNH) and tertiary-care University Hospital (UH) served by the same breast cancer clinical teams. MATERIALS AND METHODS 647 women with newly diagnosed breast cancer treated in affiliated SNH and UH between 11.1.2014 and 3.31.2017 were reviewed. Patient demographics, completion of guideline-concordant adjuvant chemotherapy, radiation and hormonal therapy were recorded. Two multivariable logistic regression models were performed to investigate the effect of hospital and race on cancer stage. Kaplan-Meier log-rank and Cox-regression were used to analyze five-year recurrence-free (RFS) and overall survival (OS) between hospitals and races, (p < 0.05 significant). RESULTS Patients in SNH were younger (mean SNH 53.2 vs UH 57.9, p < 0.001) and had higher rates of cT3/T4 disease (SNH 19% vs UH 5.5%, p < 0.001). Patients in the UH had higher rates of bilateral mastectomy (SNH 17.6% vs UH 40.1% p < 0.001) while there was no difference in the positive surgical margin rate (SNH 5.0% vs UH 7.6%, p = 0.20), completion of adjuvant radiation (SNH 96.9% vs UH 98.7%, p = 0.2) and endocrine therapy (SNH 60.8% vs UH 66.2%, p = 0.20). SNH patients were less compliant with mammography surveillance (SNH 64.1% vs UH 75.1%, p = 0.02) and adjuvant chemotherapy (SNH 79.1% vs UH 96.3%, p < 0.01). RFS was lower in the SNH (SNH 54 months vs UH 57 months, HR 1.90, 95% CI: 1.18-3.94, p = 0.01) while OS was not significantly different (SNH 90.5% vs UH 94.2%, HR 1.78, 95% CI: 0.97-3.26, p = 0.06). CONCLUSION In patients experiencing health care disparities, having access to guideline-concordant care through SNH resulted in non-inferior OS to those in tertiary-care UH.
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Affiliation(s)
- Ann R Mootz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA.
| | - B Bersu Ozcan
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - Dogan S Polat
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - Zachary Acevedo
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - Yin Xi
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
| | - Nisha Unni
- Department of Internal Medicine, Hematology/Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Chika Nwachukwu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA; Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California, USA
| | - Basak E Dogan
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas, USA
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Madsen J, Vila C, Anand P, Lau KHV. Social Work in Outpatient Neurology at a Safety-Net Hospital: A 200-Hour Profile. J Immigr Minor Health 2024; 26:247-252. [PMID: 37676447 DOI: 10.1007/s10903-023-01533-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/08/2023]
Abstract
Social work plays a critical role in preventive health and mitigation of healthcare disparities, but few studies focus on its role in multi-specialty clinics serving marginalized populations. We aimed to characterize the role of outpatient neurology social work at an urban, safety-net hospital. In December 2021, we introduced a dedicated social worker to a neurology clinic primarily caring for an underserved patient population. We logged and characterized the first 200 consecutive hours of patient encounters, classifying interventions based on a recently popularized 10-category scheme in social work literature derived from natural language processing and machine learning algorithms. We characterized 125 encounters with neurology patients referred to social work. The neurology social worker spent the greatest amount of time on care coordination (40%), followed by housing insecurity (14%) and applications and reporting (11%). Interventions that required the most time per case included housing (129 min), applications and reporting (120 min), care coordination (96 min). The majority of interventions were directly related to the patient's underlying neurologic disorder, highlighting the importance of a neurology-specific social worker. Embedding a social worker in a multi-specialty neurology clinic may address many of the root causes of neurologic health disparities.
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Affiliation(s)
- Jennifer Madsen
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Neurology C-3, Boston, MA, 02118, USA
| | - Cayla Vila
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Neurology C-3, Boston, MA, 02118, USA
| | - Pria Anand
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Neurology C-3, Boston, MA, 02118, USA
| | - K H Vincent Lau
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, 72 East Concord Street, Neurology C-3, Boston, MA, 02118, USA.
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Fefferman A, Beaulieu-Jones BR, Shewmaker G, Zhang T, Sachs T, Merrill A, Ko NY, Cassidy MR. Association of Race, Ethnicity, Insurance, and Language and Rate of Breast-Conserving Therapy Among Women With Nonmetastatic Breast Cancer at an Urban, Safety-Net Hospital. J Surg Res 2023; 291:403-413. [PMID: 37517348 DOI: 10.1016/j.jss.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/20/2023] [Accepted: 06/13/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Breast-conserving therapy (BCT), specifically breast-conserving surgery (BCS) and adjuvant radiation, provides an equivalent alternative to mastectomy for eligible patients. However, previous studies have shown that BCT is underused in the United States, particularly among marginalized demographic groups. In this study, we examine the association between race, ethnicity, insurance, and language and rate of BCS among patients treated at an academic, safety-net hospital. MATERIALS AND METHODS We conducted a retrospective cohort study of 520 women with nonmetastatic breast cancer diagnosed and treated at an academic, safety-net hospital (2009-2014). We assessed eligibility for BCT and then differences in the rate of BCT among eligible patients by race, ethnicity, insurance, and language. Reasons for not undergoing BCT were documented. RESULTS Median age was 60 y; 55.9% were non-White, 31.9% were non-English-speaking, 15.6% were Hispanic, and 47.4% were Medicaid/uninsured. Three hundred seventy one (86.3%) underwent BCS; within this group, 324 (87.3%) completed adjuvant radiation. Among patients undergoing mastectomy, 30 patients (36.7%) were eligible for BCT; within this group, reasons for mastectomy included patient preference (n = 28) and to avoid possible re-excision or adjuvant radiation in patients with significant comorbidities (n = 2). Eligibility for BCT varied by ethnicity (Hispanic [100%], Non-Hispanic [92%], P = 0.02), but not race, language, or insurance. Among eligible patients, rate of BCS varied by age (<50 y [84.9%], ≥50 y [92.9%], P = 0.01) and ethnicity (Hispanic [98.5%], Non-Hispanic [91.3%], P = 0.04), but not race, language, or insurance. CONCLUSIONS At our safety-net hospital, the rate of BCS among eligible patients did not vary by race, language, or insurance. Excluding two highly comorbid patients, all patients who underwent mastectomy despite being eligible for BCT were counseled regarding BCS and expressed a preference for mastectomy. Further research is needed to understand the value of BCT in the treatment of breast cancer, to ensure informed decision-making, address potential misconceptions regarding BCT, and advance equitable care for all patients.
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Affiliation(s)
- Ann Fefferman
- Boston University School of Medicine, Boston, Massachusetts
| | - Brendin R Beaulieu-Jones
- Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | | | - Tina Zhang
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Teviah Sachs
- Boston University School of Medicine, Boston, Massachusetts; Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, Massachusetts
| | - Andrea Merrill
- Boston University School of Medicine, Boston, Massachusetts; Section of Hematology & Oncology, Boston Medical Center, Boston University, Boston, Massachusetts
| | - Naomi Y Ko
- Boston University School of Medicine, Boston, Massachusetts; Section of Hematology & Oncology, Boston Medical Center, Boston University, Boston, Massachusetts
| | - Michael R Cassidy
- Boston University School of Medicine, Boston, Massachusetts; Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, Massachusetts.
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Beaulieu-Jones BR, Shewmaker G, Fefferman A, Kenzik K, Zhang T, Drake FT, Sachs TE, Hirsch AE, Merrill A, Ko NY, Cassidy MR. Mitigating disparities in breast cancer treatment at an academic safety-net hospital. Breast Cancer Res Treat 2023; 198:597-606. [PMID: 36826701 DOI: 10.1007/s10549-023-06875-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/01/2023] [Indexed: 02/25/2023]
Abstract
PURPOSE Among women with non-metastatic breast cancer, marked disparities in stage at presentation, receipt of guideline-concordant treatment and stage-specific survival have been shown in national cohorts based on race, ethnicity, insurance and language. Little is published on the performance of safety-net hospitals to achieve equitable care. We evaluate differences in treatment and survival by race, ethnicity, language and insurance status among women with non-metastatic invasive breast cancer at a single, urban academic safety-net hospital. METHODS We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2014 at an urban, academic safety-net hospital. Demographic, tumor and treatment characteristics were obtained. Stage at presentation, stage-specific overall survival, and receipt of guideline-concordant surgical and adjuvant therapies were analyzed. Chi-square analysis and ANOVA were used for statistical analysis. Unadjusted survival analysis was conducted by Kaplan-Meier method using log-rank test; adjusted 5 year survival analysis was completed stratified by early and late stage, using flexible parametric survival models incorporating age, race, primary language and insurance status. RESULTS 520 women with stage 1-3 invasive breast cancer were identified. Median age was 58.5 years, 56.1% were non-white, 31.7% were non-English-speaking, 16.4% were Hispanic, and 50.1% were Medicaid/uninsured patients. There were no statistically significant differences in stage at presentation between age group, race, ethnicity, language or insurance. The rate of breast conserving surgery (BCS) among stage 1-2 patients did not vary by race, insurance or language. Among patients indicated for adjuvant therapies, the rates of recommendation and completion of therapy did not vary by race, ethnicity, insurance or language. Unadjusted survival at 5 years was 93.7% for stage 1-2 and 73.5% for stage 3. Adjusting for age, race, insurance status and primary language, overall survival at 5 years was 93.8% (95% CI 86.3-97.2%) for stage 1-2 and 83.4% (95% CI 35.5-96.9%) for stage 3 disease. Independently, for patients with early- and late-stage disease, age, race, language and insurance were not associated with survival at 5-years. CONCLUSION Among patients diagnosed and treated at an academic safety-net hospital, there were no differences in the stage at presentation or receipt of guideline-concordant treatment by race, ethnicity, insurance or language. Overall survival did not vary by race, insurance or language. Additional research is needed to assess how hospitals and healthcare systems mitigate breast cancer disparities.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | | | - Ann Fefferman
- Boston University School of Medicine, Boston, MA, USA
| | - Kelly Kenzik
- Department of Surgery, Boston Medical Center, Boston, MA, USA
| | - Tina Zhang
- Department of Medicine, Boston Medical Center, Boston, MA, USA
| | - F Thurston Drake
- Boston University School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, 820 Harrison Avenue, FGH 5006, Boston, MA, 02118, USA
| | - Teviah E Sachs
- Boston University School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, 820 Harrison Avenue, FGH 5006, Boston, MA, 02118, USA
| | - Ariel E Hirsch
- Boston University School of Medicine, Boston, MA, USA
- Department of Radiation Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Andrea Merrill
- Boston University School of Medicine, Boston, MA, USA
- Section of Surgical Oncology, Boston Medical Center, Boston University, 820 Harrison Avenue, FGH 5006, Boston, MA, 02118, USA
| | - Naomi Y Ko
- Boston University School of Medicine, Boston, MA, USA
- Section of Hematology & Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Michael R Cassidy
- Boston University School of Medicine, Boston, MA, USA.
- Section of Surgical Oncology, Boston Medical Center, Boston University, 820 Harrison Avenue, FGH 5006, Boston, MA, 02118, USA.
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Wu J, Silva JP, Toriola T, Palmer RC, Hernandez F, Compton E, Abel S, Nguyen JD, Dobrowolsky A, Martin MJ, Samakar K. Evaluating the Bariatric Safety Net: Analysis of Socioeconomic Factors and Outcomes at a Bariatric Safety Net Program Compared to an Affiliated Private Center. Obes Surg 2022. [PMID: 36198928 DOI: 10.1007/s11695-022-06307-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Obesity is prevalent among economically disadvantaged and racially underrepresented populations. It has been suggested that socioeconomic factors, race, and lifestyle habits are important factors associated with weight loss and comorbidity remission after bariatric surgery. This study analyzes outcomes of bariatric surgery at a private hospital (PH) versus an affiliated safety-net hospital (SNH). METHODS Retrospective review of laparoscopic sleeve gastrectomies (LSG) performed by the same surgeons at a PH and SNH in a large metropolitan setting. Demographics, socioeconomic status, insurance status, weight metrics, and perioperative outcomes were compared. A postoperative telephone survey was conducted to study dietary and lifestyle differences between cohorts. RESULTS Of the 243 LSG performed, 141 (58%) occurred at PH versus 102 (42%) at SNH. Most patients at SNH were Hispanic, lower socioeconomic status, and had government-sponsored insurance. Based off the results from the postoperative telephone survey, there were no significant differences in dietary and lifestyle habits between both cohorts. Postoperative weight loss outcomes were similar across cohorts. The two groups had similar percent excess weight loss (EWL) at all time points up to 36 months and similar rates of failure to achieve 50% EWL at 12 months. However, patients at PH had greater resolution of diabetes and hypertension after surgery. CONCLUSION Our study demonstrates outcomes after bariatric surgery are similar at a PH and its affiliated SNH. Despite differences in race and socioeconomic factors between the two cohorts, perioperative outcomes, short-term postoperative weight loss, and weight loss failure rates were equivalent between SNH and PH patients.
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Silva TS, Singh A, Sinjali K, Gochi A, Allison-Aipa T, Luca F, Plasencia A, Lum S, Solomon N, Molina C. Spanish-Speaking Status: A Protective Factor in Colorectal Cancer Presentation at a Safety-Net Hospital. J Surg Res 2022; 280:404-410. [PMID: 36041340 DOI: 10.1016/j.jss.2022.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 06/16/2022] [Accepted: 06/29/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Lower screening rates and poorer outcomes for colorectal cancer have been associated with Hispanic ethnicity and Spanish-speaking status, respectively. METHODS We reviewed sequential colorectal cancer patients evaluated by the surgical service at a safety-net hospital (SNH) (2016-2019). Insurance type, stage, cancer type, surgery class (elective/urgent), initial surgeon contact setting (outpatient clinic/inpatient consult), operation (resection/diversion), and follow-up were compared by patient-reported primary spoken language. RESULTS Of 157 patients, 85 (54.1%) were men, 91 (58.0%) had colon cancer, 67 (42.7%) primarily spoke Spanish, and late stage (III or IV) presentations occurred in 83 (52.9%) patients. The median age was 58 y, cancer resection was completed in 48 (30.6%) patients, and 51 (32.5%) patients were initially seen as inpatient consults. On univariate analysis, Spanish-speaking status was significantly associated with female sex, Medicaid insurance, being seen as an outpatient consult, and undergoing elective and resection surgery. On multivariable logistic regression, Spanish-speaking patients had higher odds of having Medicaid insurance (AOR 2.28, P = 0.019), receiving a resection (AOR 3.96, P = 0.006), and undergoing an elective surgery (AOR 3.24, P = 0.025). Spanish-speaking patients also had lower odds of undergoing an initial inpatient consult (AOR 0.34, P = 0.046). CONCLUSIONS Spanish-speaking status was associated with a lower likelihood of emergent presentation and need for palliative surgery among SNH colorectal cancer patients. Further research is needed to determine if culturally competent infrastructure in the SNH setting translates into Spanish-speaking status as a potentially protective factor.
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Affiliation(s)
- Trevor S Silva
- Riverside University Health System, Moreno Valley, California
| | - Anika Singh
- Riverside University Health System, Moreno Valley, California
| | - Kiran Sinjali
- University of California Riverside School of Medicine, Riverside, California
| | - Andrea Gochi
- University of California Riverside School of Medicine, Riverside, California
| | - Timothy Allison-Aipa
- Comparative Effectiveness and Clinical Outcomes Research Center (CECORC), Riverside University Health System, Moreno Valley, California
| | - Fabrizio Luca
- Loma Linda University Health, Loma Linda, California
| | - Alexis Plasencia
- Riverside University Health System, Moreno Valley, California; Loma Linda University Health, Loma Linda, California
| | - Sharon Lum
- Riverside University Health System, Moreno Valley, California; University of California Riverside School of Medicine, Riverside, California; Loma Linda University Health, Loma Linda, California
| | | | - Caba Molina
- Riverside University Health System, Moreno Valley, California; University of California Riverside School of Medicine, Riverside, California; Loma Linda University Health, Loma Linda, California.
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Kathuria H, Gunawan A, Spring M, Aijaz S, Cobb V, Fitzgerald C, Wakeman C, Howard J, Clancy M, Foreman AG, Truong V, Wong C, Steiling K, Lasser KE, Bulekova K, Wiener RS. Hospitalization as an opportunity to engage underserved individuals in shared decision-making for lung cancer screening: results from two randomized pilot trials. Cancer Causes Control 2022. [PMID: 35997854 DOI: 10.1007/s10552-022-01620-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 08/09/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE Medicare requires tobacco dependence counseling and shared decision-making (SDM) for lung cancer screening (LCS) reimbursement. We hypothesized that initiating SDM during inpatient tobacco treatment visits would increase LCS among patients with barriers to proactively seeking outpatient preventive care. METHODS We collected baseline assessments and performed two pilot randomized trials at our safety-net hospital. Pilot 1 tested feasibility, acceptability, and preliminary efficacy of a nurse practitioner initiating SDM for LCS during hospitalization (Inpatient SDM). We collected qualitative data on barriers encountered during Pilot 1. Pilot 2 added a community health worker (CHW) to address barriers to LCS completion (Inpatient SDM + CHW-navigation). For both studies, preliminary efficacy was an intention-to-treat analysis of LCS completion at 3 months between intervention and comparator (furnishing of LCS decision aid only) groups. RESULTS Baseline assessments showed that patients preferred in-person LCS discussions versus self-reviewing materials; overall 20% had difficulty understanding written information. In Pilot 1, 4% (2/52) in Inpatient SDM versus 2% (1/48, comparator) completed LCS (p = 0.6), despite 89% (89/100) desiring LCS. Primary care providers noted that competing priorities and patient factors (e.g., social barriers to keeping appointments) prevented the intervention from working as intended. In Pilot 2, 50% (5/10) in Inpatient SDM + CHW-navigation versus 9% (1/11, comparator) completed LCS (p < 0.05). Many patients were ineligible due to recent diagnostic chest CT (Pilot 1: 255/659; Pilot 2: 239/527). CONCLUSIONS Inpatient SDM + CHW-navigation shows promise to improve LCS rates among underserved patients who smoke, but feasibility is limited by recent diagnostic chest CT among inpatients. Implementing CHW-navigation in other clinical settings may facilitate LCS for underserved patients. TRAIL REGISTRATION ClinicalTrials.gov Identifier: NCT03276806 (8 September 2017); NCT03793894 (4 January 2019).
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Hanchate AD, Baker WE, Paasche-Orlow MK, Feldman J. Ambulance diversion and ED destination by race/ethnicity: evaluation of Massachusetts' ambulance diversion ban. BMC Health Serv Res 2022; 22:987. [PMID: 35918721 PMCID: PMC9347077 DOI: 10.1186/s12913-022-08358-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background The impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts’ 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED). Methods We obtained Medicare Fee for Service claims records (2007–2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients (“reference ED”). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients (“safety-net ED”). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states. Results Our study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (− 2.7 percentage point; 95% CI, − 4.5 to − 1.0) and Black (− 4.1 percentage point; 95% CI, − 6.2 to − 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, − 2.3 to − 0.2). Conclusion Massachusetts ambulance diversion ban was associated with a reduction in the proportion of White and Black EMS patients being transported to the most frequent ED destination for White patients, highlighting the role of non-proximity factors in EMS transport destination. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08358-8.
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Affiliation(s)
- Amresh D Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1063, USA. .,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.
| | - William E Baker
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
| | - James Feldman
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
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Lam CM, Qureshi MM, Patel PN, Park JJ, Dang RR, Rubin SJ, Salama AR, Truong MT. Oral cancer patients achieve comparable survival at high safety-net burden hospitals. Am J Otolaryngol 2022; 43:103438. [PMID: 35489110 DOI: 10.1016/j.amjoto.2022.103438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/02/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To evaluate the impact of hospital safety-net burden and social demographics on the overall survival of patients with oral cavity squamous cell carcinoma. MATERIALS AND METHODS We identified 48,176 oral cancer patients diagnosed between the years 2004 to 2015 from the National Cancer Database and categorized treatment facilities as no, low, or high safety-net burden hospitals based on the percentage of uninsured or Medicaid patients treated. Using the Kaplan Meier method and multivariate analysis, we examined the effect of hospital safety-net burden, sociodemographic variables, and clinical factors on overall survival. RESULTS Of the 1269 treatment facilities assessed, the median percentage of uninsured/Medicaid patients treated was 0% at no, 11.6% at low, and 23.5% at high safety-net burden hospitals and median survival was 68.6, 74.8, and 55.0 months, respectively (p < 0.0001). High safety-net burden hospitals treated more non-white populations (15.4%), lower median household income (<$30,000) (23.2%), and advanced stage cancers (AJCC III/IV) (54.6%). Patients treated at low (aHR = 0.97; 95% CI = 0.91-1.04, p = 0.405) and high (aHR = 1.05; 95% CI = 0.98-1.13, p = 0.175) safety-net burden hospitals did not experience worse survival outcomes compared to patients treated at no safety-net burden hospitals. CONCLUSION High safety-net burden hospitals treated more oral cancer patients of lower socioeconomic status and advanced disease. Multivariate analysis showed high safety-net burden hospitals achieved comparable patient survival to lower burden hospitals.
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11
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Tang A, Mooney CM, Mittal A, Dzubnar JM, Knopf KB, Khoury AL. High Compliance With Choosing Wisely Breast Surgical Guidelines at a Safety-Net Hospital. J Surg Res 2021; 272:96-104. [PMID: 34953372 DOI: 10.1016/j.jss.2021.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/22/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Professional organizations recently set guidelines for avoiding surgeries of low utility and overutilization for the Choosing Wisely campaign. These include re-excision for invasive cancer close to margins, double mastectomy in patients with unilateral breast cancer, axillary lymph node dissection in patients with limited nodal disease, and sentinel lymph node biopsy (SLNB) in patients ≥70 years with early-stage breast cancer. Variable adherence to these recommendations led us to evaluate implementation rates of low-value surgical guidelines at a safety-net hospital. METHODS We retrospectively analyzed breast cancer patients who underwent surgery from 2015 to 2020. Each patient was assessed for eligibility for omission of the listed surgeries. Trends were evaluated by cohorts before and after a fellowship-trained breast surgeon joined the faculty in 2018. Outcomes were compared using Fisher's exact test. RESULTS Among 195 patients, none underwent re-excision for close margins of invasive cancer. Only 6.7% of patients (3/45) received contralateral mastectomy and 1.8% of eligible patients (3/169) received axillary lymph node dissection. Overall, 60% of patients ≥ 70 years with stage 1 hormone-positive breast cancer (9/15) received SLNB. There was a downward trend from 71% of eligible patients receiving SLNB in 2015-2018 to 50% in 2019-2020. CONCLUSIONS De-implementation of traditional surgical practices, deemed as low-value care, toward newer guidelines is achievable even at community hospitals serving a low socioeconomic community. By avoiding overtreatment, hospitals can achieve effective resource allocation which allow for social distributive justice among patients with breast cancer and ensure strategic use of scarce health economic resources while preserving patient outcomes.
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Affiliation(s)
- Annie Tang
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California
| | - Colin M Mooney
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California
| | - Ananya Mittal
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California
| | - Jessica M Dzubnar
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California
| | - Kevin B Knopf
- Department of Medicine, Alameda Health System - Highland Hospital, Oakland, California
| | - Amal L Khoury
- Department of Surgery, University of California San Francisco, East Bay - Highland Hospital, Oakland, California.
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Langston DM, Oslock WM, Paredes AZ, Tamer RM, Heh VK, Santry HP. Hospital Location and Socioeconomic Disadvantage of Emergency General Surgery Patients. J Surg Res 2021; 261:376-84. [PMID: 33493890 DOI: 10.1016/j.jss.2020.12.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 11/01/2020] [Accepted: 12/04/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) patients are more socioeconomically vulnerable than elective counterparts. We hypothesized that a hospital's neighborhood disadvantage is associated with vulnerability of its EGS patients. MATERIALS AND METHODS Area deprivation index (ADI), a neighborhood-level measure of disadvantage, and key characteristics of 724 hospitals in 14 states were linked to patient-level data in State Inpatient Databases. Hospital and EGS patient characteristics were compared across hospital ADI quartiles (least disadvantaged [ADI 1-25] "affluent," minimally disadvantaged [ADI 26-50] "min-da", moderately disadvantaged [ADI 51-75] "mod-da", and most disadvantaged [ADI 76-100] "impoverished") using chi2 tests and multivariable regression. RESULTS Higher disadvantage hospitals are more often nonteaching (affluent = 38.9%, min-da = 53.5%, mod-da = 72.1%, and impoverished = 67.6%), nonaffiliated with medical schools (50%, 72.4%, 81.8%, and 78.8%), and in rural areas (3.3%, 9.2%, 31.2%, and 27.9%). EGS patients at higher disadvantage hospitals are more likely to be older (43.9%, 48.6%, 49.1%, and 46.6%), have >3 comorbidities (17.0%, 19.0%, 18.4%, and 19.3%), live in low-income areas (21.4%, 23.6%, 32.2%, and 42.5%), and experience complications (23.2%, 23.7%, 24.0%, and 25.2%). Rates of uninsurance/underinsurance were highest at affluent and impoverished hospitals (18.0, 16.4%, 17.7%, and 19.2%). Higher disadvantage hospitals serve fewer minorities (32.6%, 21.3%, 20.7%, and 24.0%), except in rural areas (2.9%, 6.7%, 6.5%, and 15.5%). In multivariable analyses, the impoverished hospital ADI quartile did not predict odds of serving as a safety-net or predominantly minority-serving hospital. CONCLUSIONS Hospitals in impoverished areas disproportionately serve underserved EGS patient populations but are less likely to have robust resources for EGS care or train future EGS surgeons. These findings have implications for measures to improve equity in EGS outcomes.
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Arifkhanova A, McCormick Kraus E, Al-Tayyib A, Taub J, Encinias A, McEwen D, Davidson A, Shlay JC. Estimating costs of hospitalizations associated with opioid use disorder or opioid misuse at a large, urban safety-net hospital-Denver, Colorado, 2017. Drug Alcohol Depend 2021; 218:108306. [PMID: 33160792 DOI: 10.1016/j.drugalcdep.2020.108306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The national and state economic burden of the opioid crisis is substantial. This study estimated the number of hospitalizations associated with opioid use disorder (OUD) or opioid misuse (OM) and the cost of those hospitalizations at Denver Health (DH) Medical Center, a large, urban safety-net hospital. METHODS For 2017, direct inpatient medical costs for hospitalizations associated with OUD or OM at DH Medical Center were estimated and categorized by group and insurance type. Data were from the DH electronic health records database that included charge data. Hospitalizations associated with OUD or OM were identified using diagnostic codes and an expanded set of inclusion criteria including diagnostic codes, opioid withdrawal assessments, opioid-related admission notes, and medication prescriptions to treat OUD. Costs were estimated using cost-to-charge ratios specific to DH. RESULTS During 2017, 220 hospitalizations, $9,834,979 in total charges, $3,690,724 in estimated total costs, and $2,115,990 in total reimbursements were identified using diagnostic codes. Using the most expansive set of inclusion criteria, 739 hospitalizations, $35,033,157 in total charges, $13,346,099 in estimated total costs, and $7,020,877 in total reimbursements were identified. Of the 739 hospitalizations, Medicaid covered 546 hospitalizations (74 %), the largest proportion of total reimbursement (65 %), with estimated total costs of $10,135,048 (77 %). CONCLUSIONS Our study identified considerable costs for hospitalizations associated with OUD or OM for DH. Estimating costs for hospitalizations associated with OUD or OM through use of expanded inclusion methodology can guide future program planning to allocate resources efficiently for hospitals such as DH Medical Center.
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Affiliation(s)
- Aziza Arifkhanova
- Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, GA, USA; Denver Public Health, Denver Health and Hospital Authority, Denver, CO, USA.
| | | | - Alia Al-Tayyib
- Denver Public Health, Denver Health and Hospital Authority, Denver, CO, USA; Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Julie Taub
- Department of Medicine, Denver Health and Hospital Authority, CO, USA; Division of Hospital Medicine, University of Colorado School of Medicine, USA
| | - Annette Encinias
- Behavioral Health Services Department, Denver Health and Hospital Authority, Denver, CO, USA
| | - Dean McEwen
- Denver Public Health, Denver Health and Hospital Authority, Denver, CO, USA
| | - Arthur Davidson
- Denver Public Health, Denver Health and Hospital Authority, Denver, CO, USA; Department of Preventive Medicine and Biometrics, University of Colorado School of Medicine, Aurora, CO, USA; Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Judith C Shlay
- Denver Public Health, Denver Health and Hospital Authority, Denver, CO, USA; Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Gupta A, Cadwell JB, Merchant AM. Social determinants of health and outcomes of ventral hernia repair in a safety-net hospital setting. Hernia 2020; 25:287-293. [PMID: 32361947 DOI: 10.1007/s10029-020-02203-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Lower socioeconomic status has been shown to be predictive of poorer surgical outcomes in ventral hernia repair. Recently, safety-net hospitals have been attempting to address these disparities to improve the care of patients of lower socioeconomic status. METHODS A query of all patients undergoing ventral hernia repair at our institution between 2010 and 2019 was completed (n = 580). Patients not from identifiable New Jersey ZIP-codes were excluded (n = 572). ZIP codes were assigned quartiles based off socioeconomic variables including median household income, percent below poverty line, and high school graduation rate. Patients were then assigned to socioeconomic status quartiles based off their residential ZIP-code. Outcomes of ventral hernia surgery were compared across ZIP-code quartiles. Logistic regression was used to analyze predictors of poor outcomes. RESULTS Patients from lower socioeconomic brackets were more likely to be younger (p < 0.001), female (p = 0.014), black (p < 0.001), and/or Hispanic (p = 0.003). Most notably, outcomes of ventral hernia were not significantly different between patients of different socioeconomic status ZIP-code quartiles. The risk of any post-operative morbidity was higher for longer procedures (p < 0.001) and for hernia repairs being done with other procedures (p < 0.001). Risk of prolonged length of stay and related 30-day readmission was higher with longer procedures (p < 0.001 and p = 0.003, respectively). CONCLUSION We found that outcomes of ventral hernia repair at a safety-net hospital were unaffected by socioeconomic status. This supports the important role that safety-net institutions play in providing quality care to their vulnerable populations. Future studies at other safety-net hospitals should be done to further assess the updated impact of socioeconomic status on ventral hernia outcomes.
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Affiliation(s)
- A Gupta
- Department of Surgery, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Science, 185 South Orange Avenue, MSB G530, Newark, NJ, 07103, USA
| | - J B Cadwell
- Department of Surgery, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Science, 185 South Orange Avenue, MSB G530, Newark, NJ, 07103, USA
| | - A M Merchant
- Department of Surgery, Rutgers New Jersey Medical School, Rutgers Biomedical and Health Science, 185 South Orange Avenue, MSB G530, Newark, NJ, 07103, USA.
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Abstract
Economically vulnerable US patients are at risk for undertreatment of hand-related conditions as well as poorer outcomes. The cost of indigent care can be substantial to both the patients and their communities. Caring for these patients in a system that depends on inconsistent coverage requires a network of safety-net hospitals. To ensure that patients have access to care, the protection of safety-net hospitals should be prioritized when discussing federal and state funding allocation. On an individual scale, surgeons can also make changes in their practices to help find sustainable ways to care for indigent patients.
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Affiliation(s)
- Christina I Brady
- Department of Orthopaedic Surgery, UT Health San Antonio, MC-7774, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - James M Saucedo
- Orthopedics & Sports Medicine, Houston Methodist Hospital, 13802 Centerfield Drive, Suite 300, Houston, TX 77070, USA.
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Coffield E, Thirunavukkarasu S, Ho E, Munnangi S, Angus LDG. Disparities in length of stay for hip fracture treatment between patients treated in safety-net and non- safety-net hospitals. BMC Health Serv Res 2020; 20:100. [PMID: 32041586 PMCID: PMC7011469 DOI: 10.1186/s12913-020-4896-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/08/2020] [Indexed: 12/31/2022] Open
Abstract
Background Length of hospital stay (LOS) for hip fracture treatments is associated with mortality. In addition to patient demographic and clinical factors, hospital and payer type may also influence LOS, and thus mortality, among hip fracture patients; accordingly, outcome disparities between groups may arise from where patients are treated and from their health insurance type. The purpose of this study was to examine if where hip fracture patients are treated and how they pay for their care is associated with outcome disparities between patient groups. Specifically, we examined whether LOS differed between patients treated at safety-net and non-safety-net hospitals and whether LOS was associated with patients’ insurance type within each hospital category. Methods A sample of 48,948 hip fracture patients was extracted from New York State’s Statewide Planning and Research Cooperative System (SPARCS), 2014–2016. Using means comparison and X2 tests, differences between safety-net and non-safety-net hospitals on LOS and patient characteristics were examined. Relationships between LOS and hospital category (safety-net or non-safety-net) and LOS and insurance type were further evaluated through negative binomial regression models. Results LOS was statistically (p ≤ 0.001) longer in safety-net hospitals (7.37 days) relative to non-safety-net hospitals (6.34 days). Treatment in a safety-net hospital was associated with a LOS that was 11.7% (p = 0.003) longer than in a non-safety-net hospital. Having Medicaid was associated with a longer LOS relative to having commercial health insurance. Conclusion Where hip fracture patients are treated is associated with LOS and may influence outcome disparities between groups. Future research should examine whether outcome differences between safety-net and non-safety-net hospitals are associated with resource availability and hospital payer mix.
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Affiliation(s)
- Edward Coffield
- Department of Health Professions, Hofstra University, 262 Swim Center, 220 Hofstra University, Hempstead, NY, 11549-2200, USA.
| | - Saeyoan Thirunavukkarasu
- Department of Data Analytics, Alliance for Positive Change, 64 West 35th Street, New York, NY, 10001, USA
| | - Emily Ho
- Department of Surgery, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
| | - Swapna Munnangi
- Department of Surgery, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
| | - L D George Angus
- Department of Surgery, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
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Asokan S, Sridhar P, Qureshi MM, Bhatt M, Truong MT, Suzuki K, Mak KS, Litle VR. Presentation, Treatment, and Outcomes of Vulnerable Populations With Esophageal Cancer Treated at a Safety-Net Hospital. Semin Thorac Cardiovasc Surg 2019; 32:347-354. [PMID: 31866573 DOI: 10.1053/j.semtcvs.2019.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/14/2019] [Indexed: 02/08/2023]
Abstract
Social determinants of health have been associated with poor outcomes in esophageal cancer. Primary language and immigration status have not been examined in relation to esophageal cancer outcomes. This study aims to investigate the impact of these variables on stage of presentation, treatment, and outcomes of esophageal cancer patients at an urban safety-net hospital. Clinical data of patients with esophageal cancer at our institution between 2003 and 2018 were reviewed. Demographic, tumor, and treatment characteristics were obtained. Outcomes included median overall survival, stage-specific survival, and utilization of surgical and perioperative therapy. Statistical analysis was conducted using Chi-square test, Fisher's exact tests, Kaplan-Meier method, and logistic regression. There were 266 patients; 77% were male. Mean age was 63.9 years, 23.7% were immigrants, 33.5% were uninsured/Medicaid, and 16.2% were non-English speaking. Adenocarcinoma was diagnosed in 55.3% and squamous cell in 41.0%. More patients of non-Hispanic received esophagectomies when compared to those of Hispanic origin (64% vs 25%, P = 0.012). Immigrants were less likely to undergo esophagectomy compared to US-born patients (42% vs 76%, P = 0.001). Patients with adenocarcinoma were more likely than squamous cell carcinoma patients to undergo esophagectomy (odds ratio = 4.40, 95% confidence interval 1.61-12.01, P = 0.004). More commercially/privately insured patients (75%) received perioperative therapy compared to Medicaid/uninsured (54%) and Medicare (49%) patients (P = 0.030). There was no association between demographic factors and the utilization of perioperative chemoradiation for patients with operable disease. Approximately 23% of patients with operable disease were too frail or declined to undergo surgical intervention. In this small single-center study, race and primary language were not associated with median survival for patients treated for esophageal cancer. US-born patients experienced higher surgical utilization and privately insured patients were more likely to receive perioperative therapy. Many patients with operable cancer were too frail to undergo a curative surgery. Studies should expand on the relationships between social determinants of health and nonclinical services on delivery of care and survival of vulnerable populations with esophageal cancer.
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Affiliation(s)
- Sainath Asokan
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Praveen Sridhar
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Muhammad M Qureshi
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Maunil Bhatt
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Minh Tam Truong
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kei Suzuki
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kimberley S Mak
- Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Virginia R Litle
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
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DiGiorgio AM, Mummaneni PV, Fisher JL, Podet AG, Crutcher CL, Virk MS, Fang Z, Wilson JD, Tender GC, Culicchia F. Change in Policy Allowing Overlapping Surgery Decreases Length of Stay in an Academic, Safety-Net Hospital. Oper Neurosurg (Hagerstown) 2019; 17:543-548. [PMID: 30919890 DOI: 10.1093/ons/opz009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 01/30/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The practice of surgeons running overlapping operating rooms has recently come under scrutiny. OBJECTIVE To examine the impact of hospital policy allowing overlapping rooms in the case of patients admitted to a tertiary care, safety-net hospital for urgent neurosurgical procedures. METHODS The neurosurgery service at the hospital being studied transitioned from routinely allowing 1 room per day (period 1) to overlapping rooms (period 2), with the second room being staffed by the same attending surgeon. Patients undergoing neurosurgical intervention in each period were retrospectively compared. Demographics, indication, case type, complications, outcomes, and total charges were tracked. RESULTS There were 59 urgent cases in period 1 and 63 in period 2. In the case of these patients, the length of stay was significantly decreased in period 2 (13.09 d vs 19.52; P = .006). The time from admission to surgery (wait time) was also significantly decreased in period 2 (5.12 d vs 7.00; P = .04). Total charges also trended towards less in period 2 (${\$}$150 942 vs ${\$}$200 075; P = .05). Surgical complications were no different between the groups (16.9% vs 14.3%; P = .59), but medical complications were significantly decreased in period 2 (14.3% vs 30.5%; P = .009). Significantly more patients were discharged to home in period 2 (69.8% vs 42.4%; P = .003). CONCLUSION As a matter of policy, allowing overlapping rooms significantly reduces the length of stay in the case of a vulnerable population in need of urgent surgery at a single safety-net academic institution. This may be due to a reduction in medical complications in these patients.
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Affiliation(s)
- Anthony M DiGiorgio
- Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Jonathan L Fisher
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana.,Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, Texas
| | - Adam G Podet
- Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Clifford L Crutcher
- Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Michael S Virk
- Department of Neurological Surgery, University of California, San Francisco, California.,Department of Neurological Surgery, Weill Cornell Medicine - New York Presbyterian, New York
| | - Zhide Fang
- Department of Biostatistics, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Jason D Wilson
- Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Gabriel C Tender
- Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Frank Culicchia
- Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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Satyananda V, Ozao-Choy J, Dauphine C, Chen KT. Effect of the Affordable Care Act on breast cancer presentation at a safety net hospital. Am J Surg 2019; 217:764-766. [PMID: 30683317 DOI: 10.1016/j.amjsurg.2019.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/06/2018] [Accepted: 01/12/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The Affordable Care Act (ACA) mandated the expansion of Medicaid in order to increase access to health care services. We examined the effect of the ACA on breast cancer screening and diagnosis at a Los Angeles safety net hospital. METHODS We performed a retrospective review of breast cancer patients treated at our institution. We compared two cohorts: patients diagnosed with breast cancer in the years 2011-2012 (pre-ACA) vs. 2015-2016 (post-ACA). RESULTS There were no differences in number of screening mammograms performed, age at diagnosis, mammography-detected cancers, or clinical stage at diagnosis. There was a significant decrease in the number of patients who reported as self-pay (34% vs. 6%, p < 0.0001). CONCLUSION In the 2-year period following ACA implementation, there was limited impact on breast cancer presentation at a safety-net hospital. Long-term follow-up across different healthcare systems is necessary to fully evaluate the global impact of the ACA on breast cancer care.
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Affiliation(s)
- Vikas Satyananda
- Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA
| | - Junko Ozao-Choy
- Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA
| | - Christine Dauphine
- Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA
| | - Kathryn T Chen
- Division of Surgical Oncology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, 90502, USA.
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20
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Tran AN, Sachdev R, Fricker ZP, Leber M, Zahorian T, Shah B, Nunes DP, Long MT. Intensive Pharmacy Care Improves Outcomes of Hepatitis C Treatment in a Vulnerable Patient Population at a Safety-Net Hospital. Dig Dis Sci 2018; 63:3241-9. [PMID: 30078116 DOI: 10.1007/s10620-018-5231-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 07/30/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment of hepatitis C virus (HCV) with direct-acting antiviral (DAA) regimens has resulted in high rates of sustained virologic response (SVR). Treatment of vulnerable populations may be improved by incorporating an on-site intensive specialty pharmacy (ON-ISP). AIMS To describe outcomes of HCV treatment at a safety-net hospital and proportion of subjects achieving SVR for those using the ON-ISP compared to an off-site pharmacy (OFF-SP). METHODS A retrospective cohort study of 219 subjects treated for HCV with DAA at Boston Medical Center was conducted. Subject characteristics, virologic response, and pharmacy services used were recorded. We used multivariable logistic regression to test the association between ON-ISP and SVR after adjusting for covariates. RESULTS SVR occurred in 71% of subjects by intention-to-treat (73% among ON-ISP users vs 57% among OFF-SP users) and 95% completing treatment per-protocol (96% among ON-ISP users vs 87% among OFF-SP users). Adjustment for age, sex, ethnicity, insurance, fibrosis, prior treatment, and MELD revealed an increased likelihood of SVR among users of ON-ISP: OR 6.0 (95% CI 1.18-31.0). No significant difference in treatment delay or adverse events was seen among users of either pharmacy type. CONCLUSIONS HCV treatment with DAA was well tolerated, but the rate of SVR was low (71%) compared to trials. This was due to loss to follow-up, as the per-protocol rate of SVR was much higher (95%). Use of ON-ISP was associated with an increase in SVR and may be valuable for improving care for vulnerable populations.
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21
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Burton BN, Labastide AS, Meineke MN, Schmidt UH, Gabriel RA. Cardiorespiratory morbidity and mortality of opioid overdose during admission to safety-net hospitals. J Clin Anesth 2018; 54:66-71. [PMID: 30408618 DOI: 10.1016/j.jclinane.2018.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/11/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Safety-net hospitals disproportionately care for high-risk patients. Prior work has shown safety-net hospitals to have inferior postoperative outcomes with higher cost and worse patient ratings. We aim to examine the association of hospital safety-net burden with morbidity and mortality in patients with opioid overdose hospital admission. DESIGN Retrospective cross-sectional analysis using the National Inpatient Sample registry from 2010 to 2014. SETTING Multi-institutional. PATIENTS We included 547, 399 patients admitted to a United States hospital with an International Classification of Disease, Ninth Revision, code of opioid overdose. To study the association of hospital safety-net burden on mortality and morbidity, we calculated hospital safety-net burden defined as the percent of Medicaid or uninsured among all admitted patients. Hospitals were categorized into one of three categories: low burden hospitals, medium burden hospitals, and high burden hospitals (i.e., safety-net hospitals). We performed a mixed effects multivariable logistic regression analysis to assess the association of hospital safety-net burden with short-term inpatient outcomes. INTERVENTION None. MEASUREMENTS The primary outcomes were inpatient mortality and morbidity. MAIN RESULTS Compared to MBHs and LBHs, HBHs had a greater proportion of minority patients (i.e., Black, Hispanic, and Native American) and patients with median household income in the lowest quartile (p < 0.001). Among prescription opioid overdose admissions, the odds of inpatient mortality and pulmonary and cardiac morbidity were also not significantly higher between HBHs versus LBHs (p > 0.05). CONCLUSIONS Safety-net hospital disproportionately care for vulnerable populations, however the odds of poor outcomes were no different in opioid overdose. Safety-net hospitals should have equal access to the funding and resources that allows them to deliver the same standard of care as their counterparts.
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Affiliation(s)
- Brittany N Burton
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Angele S Labastide
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Minhthy N Meineke
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Ulrich H Schmidt
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, San Diego, CA, USA.
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Dhar VK, Hoehn RS, Kim Y, Xia BT, Jung AD, Hanseman DJ, Ahmad SA, Shah SA. Equivalent Treatment and Survival after Resection of Pancreatic Cancer at Safety-Net Hospitals. J Gastrointest Surg 2018; 22:98-106. [PMID: 28849353 DOI: 10.1007/s11605-017-3549-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/15/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes. METHODS The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival. RESULTS Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63). CONCLUSION For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.
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Yek C, de la Flor C, Marshall J, Zoellner C, Thompson G, Quirk L, Mayorga C, Turner BJ, Singal AG, Jain MK. Effectiveness of direct-acting antiviral therapy for hepatitis C in difficult-to-treat patients in a safety-net health system: a retrospective cohort study. BMC Med 2017; 15:204. [PMID: 29151365 PMCID: PMC5694912 DOI: 10.1186/s12916-017-0969-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 10/31/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Direct-acting antivirals (DAAs) have revolutionized chronic hepatitis C (HCV) treatment, but real-world effectiveness among vulnerable populations, including uninsured patients, is lacking. This study was conducted to characterize the effectiveness of DAAs in a socioeconomically disadvantaged and underinsured patient cohort. METHODS This retrospective observational study included all patients undergoing HCV treatment with DAA-based therapy between April 2014 and June 2016 at a large urban safety-net health system (Parkland Health and Hospital System, Dallas, TX, USA). The primary outcome was sustained virologic response (SVR), with secondary outcomes including treatment discontinuation, treatment relapse, and loss to follow-up. RESULTS DAA-based therapy was initiated in 512 patients. The cohort was socioeconomically disadvantaged (56% uninsured and 13% Medicaid), with high historic rates of alcohol (41%) and substance (50%) use, and mental health disorders (38%). SVR was achieved in 90% of patients (n = 459); 26 patients (5%) were lost to follow-up. SVR was significantly lower in patients with decompensated cirrhosis (82% SVR; OR 0.37, 95% CI 0.16-0.85) but did not differ by insurance status (P = 0.98) or alcohol/substance use (P = 0.34). Reasons for treatment failure included loss to follow-up (n = 26, 5%), viral relapse (n = 16, 3%), non-treatment-related death (n = 7, 1%), and treatment discontinuation (n = 4, 1%). Of patients with viral relapse, 6 reported non-compliance and have not been retreated, 5 have been retreated and achieved SVR, 4 have undergone resistance testing but not yet initiated retreatment, and 1 was lost to follow-up. CONCLUSIONS Effective outcomes with DAA-based therapy can be achieved in difficult-to-treat underinsured populations followed in resource-constrained safety-net health systems.
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Affiliation(s)
- Christina Yek
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Carolina de la Flor
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John Marshall
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Lisa Quirk
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Christian Mayorga
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Barbara J Turner
- University of Texas Health Science Center, San Antonio, Texas, USA
| | - Amit G Singal
- Parkland Health and Hospital System, Dallas, Texas, USA.,University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mamta K Jain
- Parkland Health and Hospital System, Dallas, Texas, USA. .,University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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