Racial Disparities in Invasive ICU Treatments Among Septic Patients: High Resolution Electronic Health Records Analysis from MIMIC-IV

Background: Low-resolution administrative databases can give biased results, whereas high-resolution, time-stamped variables from clinical databases like MIMIC-IV might provide nuanced insights. We evaluated racial-ethnic disparities in life-sustaining ICU-treatments (Invasive Mechanical Ventilation (IMV), Renal Replacement Therapy (RRT), and Vasopressors (VP)) among patients with sepsis. Methods: In this observational retrospective cohort study, patients fulfilling sepsis-3 criteria were categorized by treatment assignment within the first 4 days. The outcomes were treatment allocations. The likelihood of receiving treatment was calculated by race-ethnicity (Racial-ethnic group (REG) or White group (WG)) using 5-fold sub-sampling nested logistic regression and XGBoost. Results: In 23,914 admissions, 82% were White, 42% were women. REG were less likely to receive IMV across all eligibility days (day 1 odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83-0.94, day 4 OR 0.80, 95% CI 0.72 - 0.87). There were no differences in RRT (day 1 OR 1.00, 95% CI 0.96-1.09, day 4 OR 1.00, 95% CI 0.94-1.06). REG were also less likely to be treated with VP at days 1 to 3 (day 1 OR 0.87, 95% CI 0.76-0.94), but not at day 4 (OR 0.95, 95% CI 0.87-1.01). These findings remained robust when relaxing eligibility criteria for treatment allocation. Conclusion: Our findings reveal significant disparities in the use of invasive life-saving ICU treatments among septic patients from racial and ethnic minority backgrounds, particularly with respect to IMV and VP use. These disparities underscore not only the need to address inequality in critical care settings, but also highlight the importance of high-resolution data.

Sex differences in treatment patterns for non-advanced muscle-invasive bladder cancer: a descriptive analysis of 3484 patients of the Netherlands Cancer Registry

PURPOSE

Bladder cancer (BC) is a common malignancy with well-established differences in incidence, clinical manifestation and outcomes between men and women. It is unknown to what extent disparities in outcomes are influenced by differences in treatment approaches. This paper describes treatment patterns among men and women with muscle-invasive BC focusing on curative treatment (radical cystectomy or trimodal therapy).

METHODS

A retrospective population-based cohort study was performed with data from the Netherlands Cancer Registry. All patients newly diagnosed with muscle-invasive, non-advanced BC (MIBC, cT2-4a, N0/X, M0/X) in the years 2018, 2019 and 2020 were identified. Patient and tumor characteristics and initial treatment were compared between men and women with descriptive statistics and multivariable logistic regression analyses.

RESULTS

A total of 3484 patients were diagnosed with non-advanced MIBC in 2018-2020 in the Netherlands, of whom 28% were women. Women had higher T-stage and more often non-urothelial histology. Among all strata of clinical T-stage, women less often received treatment with curative intent (radical cystectomy [RC] or trimodality treatment). Among RC-treated patients, women more often received neoadjuvant treatment (except for cT4a disease). After adjustment for pre-treatment factors, odds ratios were indicative of women having lower probability of receiving curative treatment and RC specifically, and higher probability to receive NAC when treated with RC then men, although not statistically significant.

CONCLUSIONS

Considerable differences in treatment patterns between men and women with MIBC exist. A more considerate role of the patient's sex in treatment decisions could help decrease these differences and might mitigate disparities in outcomes.

Gastrointestinal symptoms and diagnosis preceding ovarian cancer diagnosis: Effects on treatment allocation and potential diagnostic delay

OBJECTIVE

To determine whether gastrointestinal (GI) disorder insurance claims in the year preceding a diagnosis of ovarian cancer (OC) lead to differing treatment allocations. The hypothesis is that GI disorders may be indicative of advanced OC.

METHODS

This retrospective study identified patients with newly diagnosed OC from January 2015 to January 2019 in the IBM® MarketScan® US commercial insurance and Medicare databases. Analysis was limited to patients with primary or interval debulking surgery or chemotherapy, with or without GI claims in the year prior to diagnosis, with commercial or Medicare coverage for ≥12 months prior and ≥1 month after the index date. Patients were compared in terms of the odds of treatment with neoadjuvant chemotherapy (NCT) or primary debulking surgery (PDS) (logistic regression analysis). Median treatment-free interval in the subset of patients with antineoplastic treatment was compared (Kaplan-Meier analysis).

RESULTS

Of the 6286 patients, 22% had a diagnosis of ≥1 GI disorder before their OC diagnosis. Of these patients, 39% were diagnosed with a GI disorder between 6 and 12 months before OC diagnosis and 61% were diagnosed <6 months prior. Women with a GI diagnosis were more likely to undergo NCT than PDS (odds ratio [OR], 1.37; P < 0.0001); this remained significant even when controlling for age, region, insurance plan type, and index year (OR, 1.24; P = 0.001).

CONCLUSIONS

In this database, ≈25% of women with OC had a GI claim within the past year and were more likely treated with NCT, an indicator of more advanced disease with a worse prognosis. This suggests that OC should be considered in the differential diagnosis among women with GI complaints, which could alter treatment allocation.

Patient selection for a developmental therapeutics program using whole genome and Transcriptome analysis

Introduction Given the high level of uncertainty surrounding the outcomes of early phase clinical trials, whole genome and transcriptome analysis (WGTA) can be used to optimize patient selection and study assignment. In this retrospective analysis, we reviewed the impact of this approach on one such program. Methods Patients with advanced malignancies underwent fresh tumor biopsies as part of our personalized medicine program (NCT02155621). Tumour molecular data were reviewed for potentially clinically actionable findings and patients were referred to the developmental therapeutics program. Outcomes were reviewed in all patients, including those where trial selection was driven by molecular data (matched) and those where there was no clear molecular rationale (unmatched). Results From January 2014 to January 2018, 28 patients underwent WGTA and enrolled in clinical trials, including 2 patients enrolled in two trials. Fifteen patients were matched to a treatment based on a molecular target. Five patients were matched to a trial based upon single-gene DNA changes, all supported by RNA data. Ten cases were matched on the basis of genome-wide data (n = 4) or RNA gene expression only (n = 6). With a median follow-up of 6.7 months, the median time on treatment was 8.2 weeks. Discussion When compared to single-gene DNA-based data alone, WGTA led to a 3-fold increase in treatment matching. In a setting where there is a high level of uncertainty around both the investigational agents and the biomarkers, more data are needed to fully evaluate the impact of routine use of WGTA.

Treatment allocation of ruptured anterior communicating artery aneurysms: The influence of aneurysm morphology

OBJECTIVES

Since publication of the ISAT study, the majority of neurovascular centers adhere to "coil first" policy for patients with subarachnoid hemorrhage (SAH). However, final allocation in favor of coiling or clipping is based on anatomic features of ruptured intracranial aneurysms with respect to clinical characteristics of SAH. In this study, we analyzed the parameters relevant for treatment allocation of ruptured anterior communicating artery aneurysms (AComAA).

PATIENTS AND METHODS

From our institutional SAH database, all cases with ruptured AComAA, which underwent diagnostic subtraction angiography (DSA) with subsequent treatment allocation, were included. The radiographic features of AComAA were collected from pre-treatment DSA. In addition, demographic, clinical and radiographic parameters of SAH were recorded. The variables selected through univariate analyses were subsequently evaluated using multivariate regression analysis.

RESULTS

Of 300 SAH patients in the final analysis, the majority of the cases underwent endovascular coiling (n = 221, 73.7%). The following aneurysm features were associated with treatment modality in the univariate analysis: maximal sack size (p = 0.034), perpendicular height (p = 0.007), aspect ratio (p < 0.001) and sack/neck-ratio (p = 0.001). Accordingly, the following cutoffs for these variables were defined upon the receiver operating characteristics curves: 5 mm for sack size, 6 mm for perpendicular height, 1.6 for aspect ratio and sack/neck-ratio. In the multivariate analysis, aspect ratio of 1.6 was the only independent predictor of treatment allocation (p = 0.005; aOR = 2.57; 95% CI 1.33-4.96), which remained significant (p = 0.003; aOR = 2.77; 95% CI 1.41-5.45) after adjusting for patients' age, WFNS & Fisher grades, as well as intracerebral hematoma volume.

CONCLUSION

Although not-routinely assessed during initial allocation treatment, our retrospective analysis proved that aspect ratio is a reliable predictor of treatment allocation of ruptured AComAA. Except for large space-occupying ICH commonly obligating the microsurgical treatment, other clinical and radiographic characteristics of SAH do not seem to be of clinical relevance for the selection of treatment modality.

The Shiny Balancer - software and imbalance criteria for optimally balanced treatment allocation in small RCTs and cRCTs

Background

In randomised controlled trials with only few randomisation units, treatment allocation may be challenging if balanced distributions of many covariates or baseline outcome measures are desired across all treatment groups. Both traditional approaches, stratified randomisation and allocation by minimisation, have their own limitations. A third method for achieving balance consists of randomly choosing from a preselected list of sufficiently balanced allocations. As with minimisation, this method requires that heterogeneity between treatment groups is measured by specified imbalance metrics. Although certain imbalance measures are more commonly used than others, to the author's knowledge there is no generally accepted “gold standard”, neither for categorical and even less so for continuous variables.

Methods

An intuitive and easily accessible web-based software tool was developed which allows for balancing multiple variables of different types and using various imbalance metrics. Different metrics were compared in a simulation study.

Results

Using simulated data, it could be shown that for categorical variables, χ²-based imbalance measures seem to be viable alternatives to the established “quadratic imbalance” metric. For continuous variables, using the area between the empirical cumulative distribution functions or the largest difference in the three pairs of quartiles is recommended to measure imbalance. Another imbalance metric suggested in the literature for continuous variables, the (symmetrised) Kullback-Leibler divergence, should be used with caution.

Conclusion

The Shiny Balancer offers the possibility to visually explore the balancing properties of several well established or newly suggested imbalance metrics, and its use is particularly advocated in clinical studies with few randomisation units, as it is typically the case in cluster randomised trials.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0551-5) contains supplementary material, which is available to authorized users.

Optimal treatment allocations in space and time for on-line control of an emerging infectious disease

A key component in controlling the spread of an epidemic is deciding where, when and to whom to apply an intervention. We develop a framework for using data to inform these decisions in realtime. We formalize a treatment allocation strategy as a sequence of functions, one per treatment period, that map up-to-date information on the spread of an infectious disease to a subset of locations where treatment should be allocated. An optimal allocation strategy optimizes some cumulative outcome, e.g. the number of uninfected locations, the geographic footprint of the disease or the cost of the epidemic. Estimation of an optimal allocation strategy for an emerging infectious disease is challenging because spatial proximity induces interference between locations, the number of possible allocations is exponential in the number of locations, and because disease dynamics and intervention effectiveness are unknown at out-break. We derive a Bayesian on-line estimator of the optimal allocation strategy that combines simulation-optimization with Thompson sampling. The estimator proposed performs favourably in simulation experiments. This work is motivated by and illustrated using data on the spread of white nose syndrome, which is a highly fatal infectious disease devastating bat populations in North America.

The Short Treatment Allocation Tool for Eating Disorders: current practices in assigning patients to level of care

OBJECTIVE

The Short Treatment Allocation Tool for Eating Disorders (STATED) is a new evidence-based algorithm developed to match patients to the most clinically appropriate and cost-effective level of care (Geller et al., 2016). The objective of this research was to examine the extent to which current practices are in alignment with STATED recommendations.

METHOD

Participants were 179 healthcare professionals providing care for youth and/or adults with eating disorders. They completed an online survey and rated the extent to which three patient dimensions (medical stability, symptom severity, and readiness) were used in assigning patients to each of five levels of care.

RESULTS

The majority of analyses testing a priori hypotheses based on the STATED were statistically significant (all p's < .001), in the direction of STATED recommendations. However, a strict coding scheme evaluating the extent to which ratings were fully consistent with the STATED showed inconsistency rates ranging from 17 to 55% across the five levels of care, with the greatest inconsistencies involving the use of readiness information, and the lowest involving the use of medical stability information.

DISCUSSION

Although practices were generally aligned with the STATED recommendations, readiness information was used least consistently in assigning patients to level of care.

Role of curative treatment in patients with intermediate-stage hepatocellular carcinoma

PURPOSE

To retrospectively evaluate the role of curative treatment in patients with intermediate-stage hepatocellular carcinomas (HCCs), and to identify the subgroup having benefit from curative treatment.

METHODS

From April 2000 to December 2014, 100 patients with intermediate-stage HCCs underwent either curative treatment (hepatectomy: n = 23, radiofrequency ablation (RFA); n = 29, both: n = 4) or transarterial chemoembolization (TACE): n = 44) as initial treatments for HCCs. Overall survival, influence of treatment allocation on prognosis, and factors affecting treatment allocation were evaluated.

RESULTS

The 5-year survival rate was 59.2% [95% confidence interval (CI) 51.6-66.8%] in the curative group, and 25.1% (95% CI 11.5-38.7%) in the TACE group. Treatment allocation was the only significant prognostic factor (p = 0.014, hazard ratio: 0.382, 95% CI 0.177-0.821). The curative group consisted of more patients with Child-Pugh A (p = 0.0016) than the TACE group, a tumor number of 3 or fewer (p < 0.0001), a unilobar tumor location (p = 0.02), within 4 of 7 cm criterion (p = 0.001), and within up-to-7 criterion (p = 0.04). Child-Pugh A, within the 4 of 7 cm criterion, and a unilobar tumor location were significantly linked with treatment allocation in multivariate analysis.

CONCLUSIONS

Curative treatment can prolong survival in selected patients with intermediate-stage HCCs.

Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols

Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.

The effects of age on treatment and outcomes in women with stages IB1-IIB cervical cancer

OBJECTIVE

Age may affect the treatment choice and subsequent outcome in elderly patients with cervical cancer. Given the potential for cure with either surgery or chemoradiation in early stage disease, we aimed to determine whether a patient's age influenced treatment received and the ensuing outcome.

MATERIALS AND METHODS

We identified 303 patients with stages IB1-IIB cervical carcinoma treated at our institution between 2000 and 2010, who were divided into two groups based on age at time of diagnosis: < 65 and ≥ 65 years. Adjusted odd ratios were calculated to determine variables associated with treatment received. Single and multivariate Cox proportional hazards modeling were used to estimate hazard ratios (HRs) for variables associated with disease-specific survival.

RESULTS

Patients were more commonly <65 years at diagnosis (83% versus 17% ≥ 65 years). There was no difference between the two groups in terms of tumor histology, stage at presentation, and grade. Women ≥ 65 years of age were less likely to receive primary surgical management (p=0.03). Age did not influence disease-specific or all-cause mortality. However, women over 65 years who underwent primary surgery were at significantly increased risk of all-cause mortality compared to younger women (HR 6.53, 95% CI: 2.57-16.6).

CONCLUSIONS

Age appears to influence treatment received by patients with stages IB1-IIB cervical cancer. Although there was no difference in cancer-specific mortality stratified by type of treatment received, surgery was associated with a 6.5-fold increased risk of all-cause mortality among women 65 years or over.