Age-Based Heuristics Bias Treatment of Displaced Femoral Neck Fractures in the Elderly.

Background: Surgeons performing arthroplasty for femoral neck fractures may rely on mental shortcuts (heuristics) when choosing total hip arthroplasty (THA) vs hemiarthroplasty (HA). We sought to quantify the extent to which age-based heuristics drive decision-making. Methods: We identified all Medicare beneficiaries from 2017-2018 with femoral neck fractures who underwent THA or HA. We compared the likelihood of THA vs HA among patients admitted within 4 weeks before vs 4 weeks after their birthday for each age under the hypothesis that these cohorts would be similar except for numerical age. We controlled for race/ethnicity, sex, comorbidities, poverty status, and hospital census region in a multivariable regression that included facility-level cluster effects. We generated predicted/adjusted probabilities for THA vs HA for different age transition points. Results: Thirteen thousand three hundred sixty-six elderly patients were included. One thousand eight hundred sixty-five (14%) received THA and 11,501 (86%) received HA. The likelihood of THA decreased from 50.3% among patients almost 67 to 8% among those ≥85 (P < .001). We found significant decreases in likelihood of THA across age transitions. The largest decrement was at age transition 69 (THA likelihood 28.7% for newly 69 vs 43.3% for almost 69, 33.7% relative change). Female gender, Black race, higher comorbidity burden, and lower socioeconomic status were also associated with a lower likelihood of THA. Conclusions: Our data demonstrate that patient age transitions seem to influence the choice of THA vs HA. Further research is needed to develop data-driven surgical decision aids for this population.

Rehabilitation after brain tumor resection: A national study of postacute care service use through insurance claims data.

OBJECTIVE: To assess postacute rehabilitation service use and length of stay among a national sample of patients with brain tumors after surgery. DESIGN: A retrospective review was conducted of health care claims data of a national sample of patients via The Optum Clinformatics DataMart. SETTING AND PARTICIPANTS: This study included adult individuals (≥18 years of age) who were diagnosed with a brain tumor between 2015 and 2019 and underwent a craniotomy or craniectomy within 180 days of diagnosis. METHODS: Descriptive statistics were used to characterize patients by tumor type. Multivariate models assessed factors associated with discharge setting and length of stay. RESULTS: Of the 10,275 individuals identified, 69% had malignant tumors. Over two thirds of patients were discharged directly home (with or without home health care) and 9.3% and 9.5% were discharged to acute rehabilitation facilities (inpatient rehabilitation facilities [IRF]) and skilled nursing facilities (SNF/ICF), respectively. About 13.5% were discharged to other settings. The average length of stay during the episode of care was 8.6 (SD = 9.6) days. After adjusting for confounders, individuals with benign brain tumors were more likely to be discharged to either IRF or SNF/ICF than return home after acute care stay, as were those with greater comorbidities, older age, fee-for-service and health maintenance organization insurance. Wealthier patients were less likely to be discharged to a SNF/ICF than home, although income was not a factor affecting discharge to an IRF. Patients with benign tumors, the oldest old (80+), those with more comorbidities as well as Black and Hispanic patients had a longer length of stay during the acute hospitalization. CONCLUSIONS: Individuals with brain tumors have deficits amenable to rehabilitation; however, this study finds that service use differs by tumor type and demographic and socioeconomic factors. Further study is needed to identify if there are barriers to access and use of rehabilitation services in this population.

The association of multiple sclerosis, traumatic brain injury, and spinal cord injury to acute and long COVID-19 outcomes.

BACKGROUND: Although persons with disabilities are a high-risk group, little is known about the association between specific disabling conditions and acute or long COVID outcomes. OBJECTIVE: To examine the severity of acute SARS-CoV-2 infection and post-COVID outcomes among people with a preexisting diagnosis of multiple sclerosis (MS), spinal cord injury (SCI), or traumatic brain injury (TBI). METHODS: This was a retrospective cohort study using the TrinetX Research Database, a large representative database of medical records. COVID-19-positive persons with MS, SCI, or TBI (cases) were matched 1:1 on age, gender, race, ethnicity, and comorbidities to COVID-19-positive persons without these diagnoses (controls). The main outcomes assessed were hospitalization for acute COVID-19, length of stay (LOS), the total number of hospitalizations, mortality, and incidence of six prevalent post-COVID sequelae within 6 months following a COVID-19 diagnosis. RESULTS: There were 388,297 laboratory-confirmed COVID-19 cases identified. Of these cases, 2204 individuals had one of the following preexisting diagnoses: 51.3% TBI, 31.4% MS, and 17.3% SCI. People with TBI, MS, and SCI were significantly more likely to be hospitalized for COVID-19 (odds ratio [OR] = 1.22, 95% confidence interval [CI] = 1.03-1.46) than matched controls. There was no difference in LOS, total hospitalizations, or mortality during the 6 months following the initial COVID diagnosis. Multivariable analyses reveal that persons with TBI, MS, and SCI were more likely to experience new weakness (OR = 1.54, 95% CI = 1.19-2.00), mobility difficulties (OR = 1.66, 95% CI = 1.17-2.35), and cognitive dysfunction (OR = 1.79, 95% CI = 1.38-2.33) than controls, even after controlling for the presence of these symptoms prior to their COVID infection and other risk factors. There were no differences in fatigue, pain, or dyspnea. CONCLUSIONS: Having a history of MS, SCI or TBI was not associated with higher mortality risk from COVID-19. However, associations between these diagnoses and postacute COVID-19 symptoms raise concern about widening health outcome disparities for individuals with such potentially disabling conditions following COVID-19 infection.

Hemiarthroplasty Versus Total Hip Arthroplasty for Femoral Neck Fracture in Elderly Patients: Twelve-Month Risk of Revision and Dislocation in an Instrumental Variable Analysis of Medicare Data.

BACKGROUND: There is practice variation in the selection of a total hip arthroplasty (THA) or a hemiarthroplasty (HA) for the treatment of displaced femoral neck fractures in elderly patients. Large data sets are needed to compare the rates of rare complications following these procedures. We sought to examine the relationship between surgery type and secondary hip surgery (revision or conversion arthroplasty) at 12 months following the index arthroplasty, and that between surgery type and dislocation at 12 months, among elderly Medicare beneficiaries who underwent THA or HA for a femoral neck fracture, taking into account the potential for selection bias. METHODS: We performed a population-based, retrospective study of elderly (>65 years of age) Medicare beneficiaries who underwent THA or HA following a femoral neck fracture. Two-stage, instrumental variable regression models were applied to nationally representative Medicare medical claims data from 2017 to 2019. RESULTS: Of the 61,695 elderly patients who met the inclusion criteria, of whom 74.1% were female and 92.2% were non-Hispanic White, 10,268 patients (16.6%) underwent THA and 51,427 (83.4%) underwent HA. The findings from the multivariable, instrumental variable analyses indicated that treatment of displaced femoral neck fractures with THA was associated with a significantly higher risk of dislocation at 12 months compared with treatment with HA (2.9% for the THA group versus 1.9% for the HA group; p = 0.001). There was no significant difference in the likelihood of 12-month revision/conversion between THA and HA. CONCLUSIONS: The use of THA to treat femoral neck fractures in elderly patients is associated with a significantly higher risk of 12-month dislocation, as compared with the use of HA, although the difference may not be clinically important. A low overall rate of dislocation was found in both groups. The risk of revision/conversion at 12 months did not differ between the groups. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Centralization of Initial Care and Improved Survival of Poor Patients With Breast Cancer.

PURPOSE: Poor women with breast cancer have worse survival than others, and are more likely to undergo surgery in low-volume facilities. We leveraged a natural experiment to study the effectiveness of a policy intervention undertaken by New York (NY) state in 2009 that precluded payment for breast cancer surgery for NY Medicaid beneficiaries treated in facilities performing fewer than 30 breast cancer surgeries annually. METHODS: We identified 37,822 women with stage I-III breast cancer during 2004-2008 or 2010-2013 and linked them to NY hospital discharge data. A multivariable difference-in-differences approach compared mortality of Medicaid insured patients with that of commercially or otherwise insured patients unaffected by the policy. RESULTS: Women treated during the postpolicy years had slightly lower 5-year overall mortality than those treated prepolicy; the survival gain was significantly larger for Medicaid patients (P = .018). Women enrolled in Medicaid had a greater reduction than others in breast cancer-specific mortality (P = .005), but no greater reduction in other causes of death (P = .50). Adjusted breast cancer mortality among women covered by Medicaid declined from 6.6% to 4.5% postpolicy, while breast cancer mortality among other women fell from 3.9% to 3.8%. A similar effect was not observed among New Jersey Medicaid patients with breast cancer treated during the same years. CONCLUSION: A statewide centralization policy discouraging initial care for breast cancer in low-volume facilities was associated with better survival for the Medicaid population targeted. Given these impressive results and those from prior research, other policymakers should consider adopting comparable policies to improve breast cancer outcomes.[Media: see text].

Prevalence of Race/Ethnicity Reporting in Light Chain (AL) Amyloidosis Clinical Research in the USA.

Little is known about racial differences in the incidence of light chain (AL) amyloidosis despite the well-documented racial disparities in the epidemiology of other plasma cell disorders. The goal of this study was to examine the extent to which published clinical research in AL amyloidosis report information on patients' race. Clinical research publications in AL amyloidosis between January 1, 2010, and December 31, 2020, from the USA were identified. In addition to the reporting of race, study design, funding, cohort size, year of publication, impact factor of publication journal, and first author degree were abstracted. Among papers reporting race, we also assessed whether ethnicity was reported separately. A PubMed search yielded 2,770 papers of which 220 met the pre-specified criteria for analysis. Of those, 37 (16.5%) reported race. Single institution publications, those with physicians as first authors, and those published in journals with impact factor 6 or higher were less likely to report race. On multivariate analysis, only single institution studies were negatively associated with race reporting. Of the 37 papers reporting race, none defined it in methods, 16% stated how race was identified, and 19% discussed its significance. Ethnicity was reported in 6 studies. Our results indicate that race/ethnicity is underreported in USA. AL amyloidosis clinical literature leads to a challenge for identifying potential racial/ethnic disparities. Standards for collecting and reporting racial/ethnic demographics are needed. Clear and consistent reporting of race and ethnicity of clinical populations is a necessary first step in identifying disparities and promoting equitable care.

Medication delivery factors and adjuvant endocrine therapy adherence in breast cancer.

PURPOSE: Over 50% of breast cancer patients prescribed a 5-year course of daily oral adjuvant endocrine therapy (ET) are nonadherent. We investigated the role of costs and cancer medication delivery mode and other medication delivery factors on adherence. METHODS: We conducted a retrospective cohort study of commercially insured and Medicare advantage patients with newly diagnosed breast cancer in 2007-2015 who initiated ET. We examined the association between 12-month ET adherence (proportion of days covered by fills ≥ 0.80) and ET copayments, 90-day prescription refill use, mail order pharmacy use, number of pharmacies, and synchronization of medications. We used regression models to estimate nonadherence risk ratios adjusted for demographics (age, income, race, urbanicity), comorbidities, total medications, primary cancer treatments, and generic AI availability. Sensitivity analyses were conducted using alternative specifications for independent variables. RESULTS: Mail order users had higher adherence in both commercial and Medicare-insured cohorts. Commercially insured patients who used mail order were more likely to be adherent if they had low copayments (< $5) and 90-day prescription refills. For commercially insured patients who used local pharmacies, use of one pharmacy and better synchronized refills were also associated with adherence. Among Medicare patients who used mail order pharmacies, only low copayments were associated with adherence, while among Medicare patients using local pharmacies both low copayments and 90-day prescriptions were associated with ET adherence. CONCLUSION: Out-of-pocket costs, medication delivery mode, and other pharmacy-related medication delivery factors are associated with adherence to breast cancer ET. Future work should investigate whether interventions aimed at streamlining medication delivery could improve adherence for breast cancer patients.

Psychological and Cognitive Functioning Among Patients Receiving Outpatient Rehabilitation for Post-COVID Sequelae: An Observational Study.

OBJECTIVES: To describe the characteristics of individuals receiving outpatient rehabilitation for post-acute sequelae of SARS-CoV-2 infection (PASC). Further, to examine factors associated with variation in their psychological and cognitive functioning and health-related quality of life. DESIGN: Observational study. SETTING: Outpatient COVID-19 recovery clinic at a large, tertiary, urban health system in the US. PARTICIPANTS: COVID-19 survivors with persistent sequelae (N=324). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Multivariable logistic and linear regression models were used to examine factors associated with COVID survivors' experience of severe anxiety, severe depression, post-traumatic stress disorder (PTSD), cognitive impairment, and self-reported health-related quality of life. RESULTS: About 38% of survivors seeking care for their persistent COVID symptoms suffered from severe anxiety, 31.8% from severe depression, 43% experiencing moderate to severe PTSD symptomology, and 17.5% had cognitive impairment. Their health-related quality of life was substantially lower than that of the general population (-26%) and of persons with other chronic conditions. Poor and African American/Black individuals experienced worse psychological and cognitive sequelae after COVID19 infection, even after controlling for age, sex, initial severity of the acute infection, and time since diagnosis. CONCLUSIONS: Evidence of consistent disparities in outcomes by the patients' race and socioeconomic status, even among those with access to post-acute COVID rehabilitation care, are concerning and have significant implications for PASC policy and program development.

Association Between COVID-19 and Delirium Development in the General Medical Units at an Academic Medical Center.

INTRODUCTION: Evidence suggests that inpatients who develop delirium experience worse outcomes. Although there is reason to believe that COVID-positive patients may be at a higher risk for developing delirium, little is known about the association between COVID-19 and delirium among hospitalized patients outside the intensive care unit (ICU). This study aimed to examine (1) the independent association between COVID-19 infection and the development of delirium among all non-ICU patients and (2) the risk factors associated with developing delirium among patients admitted with COVID-19, with a special focus on presenting symptoms. METHODS: Using electronic health record (EHR) data of adults admitted to any general medical unit at a large academic medical center from July 2020 through February 2021, we used a cross-sectional multivariable logistic regression to estimate the associations, while adjusting for patients' sociodemographic, clinical characteristics, delirium-free length of stay, as well as time fixed effects. RESULTS: Multivariable regression estimates applied to 20 509 patients hospitalized during the study period indicate that COVID-19-positive patients had 72% higher relative risk (odds ratio 1.72; 95% CI, 1.31 - 2.26; P < 0.001) of developing delirium than the COVID-19-negative patients. However, among the subset of patients admitted with COVID-19, having any COVID-19-specific symptoms was not associated with elevated odds of developing delirium compared to those who were asymptomatic, after controlling for potential confounders. CONCLUSIONS: COVID-19 positivity was associated with higher odds of developing delirium among patients during their non-ICU hospitalization. These findings may be helpful in targeting the use of delirium prevention strategies among non-ICU patients.

Race, ethnicity, and utilization of outpatient rehabilitation for treatment of post COVID-19 condition.

INTRODUCTION: Outpatient rehabilitation is recommended in the treatment of post coronavirus disease 2019 (COVID-19) condition. Although racial and ethnic disparities in the incidence and severity of COVID-19 have been well documented, little is known about the use of outpatient rehabilitation among patients with post COVID-19 condition. OBJECTIVE: To examine factors associated with outpatient rehabilitation use following COVID-19 and to ascertain whether differential incidence of sequelae explain variation in post COVID-19 rehabilitation utilization by race and ethnicity. DESIGN: Case-control study. SETTING: Community. PARTICIPANTS: U.S. adults with COVID-19 during 2020 in the TriNetX database. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Receipt of outpatient rehabilitation services within 6 months of COVID-19 diagnosis and incidence of post COVID-19 condition symptoms (weakness, fatigue, pain, cognitive impairment, mobility difficulties, and dyspnea). RESULTS: From 406,630 laboratory-confirmed COVID-19 cases, we identified 8724 individuals who received outpatient rehabilitation and matched 28,719 controls. Of rehabilitation users, 43.3% were 40 years old or younger, 54.8% were female, 58.2% were White, 17.9% were African American/Black, 2.1% were Asian, 13.0% were Hispanic, 39.2% had no comorbidities, and 40.3% had been hospitalized for COVID-19. Dyspnea (20.4%), fatigue (12.4%), and weakness (8.2%) were the most frequently identified symptoms. Although there were no racial differences in the incidence of the six post COVID-19 condition symptoms considered, African American/Black individuals were significantly less likely than their White counterparts to receive outpatient rehabilitation (odds ratio [OR] = 0.89; 95% confidence interval [CI]: 0.84-0.96; p = .003). Hispanic individuals had higher outpatient rehabilitation utilization (OR = 1.22; 95% CI: 1.11-1.33; p < .001) and a significantly higher incidence of post COVID-19 fatigue. CONCLUSIONS: In this large nationally representative study, African American/Black race was associated with lower utilization of outpatient rehabilitation services despite a similar incidence of post COVID-19 condition symptoms. Further research is needed to better understand access barriers to rehabilitation services for post COVID-19 condition recovery care and address racial inequalities in receipt of care.

The Effect of CMS's Comprehensive Care for Joint Replacement Bundled Payment Model on Trajectories of Post-acute Rehabilitation Care After Total Hip Arthroplasty.

OBJECTIVE: To evaluate the effect of the Comprehensive Care for Joint Replacement (CJR) policy on the 90-day trajectory of post-acute care after a total hip arthroplasty (THA). DESIGN: Multivariable difference-in-difference models applied to Medicare beneficiaries undergoing a THA prior to (2014-2015) and post-CJR implementation (2017) in areas subjected to or exempt from the policy. SETTING: Hospitals in standard metropolitan statistical areas. PARTICIPANTS: 357,844 elderly Medicare patients nationwide undergoing THA (N=357,844). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Escalation in care to institutionalization (ie, admission to an inpatient rehabilitation or skilled nursing facility during 90-days postdischarge for those initially discharged to the community and return to the community at the end of the episode of care among those initially discharged to an institutional setting). RESULTS: Of the 357,844 elderly Medicare patients nationwide undergoing THA during the study period, 47.6% were discharged directly to the community and 52.4% received post-acute care in an institution. Patients discharged to an institution post-policy in a CJR area were about 10% less likely to return to the community (odds ratio=0.91; 95% confidence interval, 0.84-0.98; P=.02) at the end of the 90-day episode of care than those treated in policy-exempt areas. Despite the large magnitude, estimates of escalation in care among patients treated in bundling areas post-CJR implementation were not statistically significant. CONCLUSIONS: Our findings support further exploration of unanticipated effects of mandatory bundled payment policies on outcomes, as well as further examination of outcomes among policy-relevant subgroups of patients undergoing hip replacement in the United States.

The Impact of Femoral Component Cementation on Fracture and Mortality Risk in Elective Total Hip Arthroplasty: Analysis from a National Medicare Sample.

BACKGROUND: Complications following elective total hip arthroplasty (THA) are rare but potentially devastating. The impact of femoral component cementation on the risk of periprosthetic femoral fractures and early perioperative death has not been studied in a nationally representative population in the United States. METHODS: Elective primary THAs performed with or without cement among elderly patients were identified from Medicare claims from 2017 to 2018. We performed separate nested case-control analyses matched 1:2 on age, sex, race/ethnicity, comorbidities, payment model, census division of facility, and exposure time and compared fixation mode between (1) groups with and without 90-day periprosthetic femoral fracture and (2) groups with and without 30-day mortality. RESULTS: A total of 118,675 THAs were included. The 90-day periprosthetic femoral fracture rate was 2.0%, and the 30-day mortality rate was 0.18%. Cases were successfully matched. The risk of periprosthetic femoral fracture was significantly lower among female patients with cement fixation compared with matched controls with cementless fixation (OR = 0.83; 95% CI, 0.69 to 1.00; p = 0.05); this finding was not evident among male patients (p = 0.94). In contrast, the 30-day mortality risk was higher among male patients with cement fixation compared with matched controls with cementless fixation (OR = 2.09; 95% CI, 1.12 to 3.87; p = 0.02). The association between cement usage and mortality among female patients almost reached significance (OR = 1.74; 95% CI, 0.98 to 3.11; p = 0.06). CONCLUSIONS: In elderly patients managed with THA, cemented stems were associated with lower rates of periprosthetic femoral fracture among female patients but not male patients. The association between cemented stems and higher rates of 30-day mortality was significant for male patients and almost reached significance for female patients, although the absolute rates of mortality were very low. For surgeons who can competently perform THA with cement, our data support the use of a cemented stem to avoid periprosthetic femoral fracture in elderly female patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Inpatient Rehabilitation Outcomes After Severe COVID-19 Infections: A Retrospective Cohort Study.

OBJECTIVE: The aim of the study was to describe the characteristics and functional outcomes of patients undergoing acute inpatient rehabilitation after hospitalization for COVID-19. DESIGN: Using a retrospective chart review, patients were identified who were admitted to inpatient rehabilitation after COVID-19. Patient information collected included sociodemographic characteristics, comorbidities, length of stay, discharge disposition, self-care, mobility, and cognitive functioning. These patients were compared with patients (controls) without COVID-19 with similar impairment codes treated at the same facility before the COVID-19 pandemic. RESULTS: There were 43 patients who were admitted to the inpatient rehabilitation hospital after COVID-19 infection and 247 controls. Patients who had COVID-19 were significantly more likely to be African American and to have been admitted to a long-term acute care hospital. They also had a longer length of rehabilitation stay. The groups did not differ by age, sex, or insurance. Functionally, although presenting with significantly worse mobility, self-care, and motor scores, the patients previously infected with COVID-19 had similar functional outcomes at time of discharge to the control group. CONCLUSIONS: Although patients with a history of COVID-19 had worse function at time of admission to acute rehabilitation, inpatient rehabilitation significantly improved their function to comparable levels as patients who did not have COVID-19. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Identify how characteristics of patients with COVID-19 admitted to acute rehabilitation differ from those with similar admission codes but without COVID-19; (2) Describe changes in functional measures at admission and discharge of COVID-19 patients compared with patients without COVID-19; and (3) Recognize how inpatient rehabilitation may help reduce inequities in outcomes after severe COVID-19 infection. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

SARS-CoV-2 and Wisconsin Nursing Homes: Temporal Dynamics During the COVID-19 Pandemic.

OBJECTIVES: Evidence suggests that quality, location, and staffing levels may be associated with COVID-19 incidence in nursing homes. However, it is unknown if these relationships remain constant over time. We describe incidence rates of COVID-19 across Wisconsin nursing homes while examining factors associated with their trajectory during 5 months of the pandemic. DESIGN: Retrospective cohort study. SETTING/PARTICIPANTS: Wisconsin nursing homes. METHODS: Publicly available data from June 1, 2020, to October 31, 2020, were obtained. These included facility size, staffing, 5-star Medicare rating score, and components. Nursing home characteristics were compared using Pearson chi-square and Kruskal-Wallis tests. Multiple linear regressions were used to evaluate the effect of rurality on COVID-19. RESULTS: There were a total of 2459 COVID-19 cases across 246 Wisconsin nursing homes. Number of beds (P < .001), average count of residents per day (P < .001), and governmental ownership (P = .014) were associated with a higher number of COVID-19 cases. Temporal analysis showed that the highest incidence rates of COVID-19 were observed in October 2020 (30.33 cases per 10,000 nursing home occupied-bed days, respectively). Urban nursing homes experienced higher incidence rates until September 2020; then incidence rates among rural nursing homes surged. In the first half of the study period, nursing homes with lower-quality scores (1-3 stars) had higher COVID-19 incidence rates. However, since August 2020, incidence was highest among nursing homes with higher-quality scores (4 or 5 stars). Multivariate analysis indicated that over time rural location was associated with increased incidence of COVID-19 (ß = 0.05, P = .03). CONCLUSIONS AND IMPLICATIONS: Higher COVID-19 incidence rates were first observed in large, urban nursing homes with low-quality rating. By October 2020, the disease had spread to rural and smaller nursing homes and those with higher-quality ratings, suggesting that community transmission of SARS-CoV-2 may have propelled its spread.

Disparities in utilization of outpatient surgical care among children.

BACKGROUND: The purpose of this study was to quantify disparities in the utilization of outpatient pediatric surgical care and to examine the extent to which neighborhood-level socioeconomic disadvantage is associated with access to care among children. METHODS: Clinic "no-shows" were examined among children scheduled from 2017 to 2019 at seven pediatric surgery clinics associated with a tertiary care children's hospital. The association between Area Deprivation Index, a neighborhood-level measure of socioeconomic disadvantage, and other patient factors with clinic no-shows was examined using multivariable logistic regression models. Difficulties in accessing postoperative care in particular were explored in a subgroup analysis of postoperative (within 90 days) clinic visits after appendectomy or inguinal/umbilical hernia repairs. RESULTS: Among 10,162 patients, 16% had at least 1 no-show for a clinic appointment. Area Deprivation Index (most deprived decile adjusted odds ratio 3.17, 95% confidence interval 2.20-4.58, P < .001), Black race (adjusted odds ratio 3.30, 95% confidence interval 2.70-4.00, P < .001), and public insurance (adjusted odds ratio 2.75, 95% confidence interval 2.38-3.31, P < .001) were associated with having at least 1 no-show. Similar associations were identified among 2,399 children scheduled for postoperative clinic visits after undergoing appendectomy or inguinal/umbilical hernia repair, among whom 20% were a no-show. CONCLUSION: Race, insurance type, and neighborhood-level socioeconomic disadvantage are associated with disparities in utilization of outpatient pediatric surgical care. Challenges accessing routine outpatient care among disadvantaged children may be one mechanism through which disparate outcomes result among children requiring surgical care.

An adapted two-step floating catchment area method accounting for urban-rural differences in spatial access to pharmacies.

OBJECTIVE: To adapt the two-step floating catchment area approach to account for urban-rural differences in pharmacy access in the United States. METHODS: The urban-rural two-step floating catchment area method was described mathematically. To calculate urban-rural-two-step floating catchment area measure, census tracts and pharmacies within the study area (Southeastern Wisconsin) were classified as urban, suburban or rural, and then different catchment area sizes (2, 5 and 15 miles) were applied, based on the Centers for Medicare & Medicaid Services (CMS)' criteria for Medicare Part D service access within urban, suburban and rural areas. The urban-rural-two-step floating catchment area measures were compared to traditional two-step floating catchment area measures computed using three fixed catchment area sizes (2, 5, and 15 miles) by visually examining their spatial distributions. Associations between the four pharmacy accessibility measures and selected socio-demographics are calculated using Spearman's rank-order correlation and further compared. KEY FINDINGS: The urban-rural two-step floating catchment area measure outperforms all the fixed catchment size measures and has the strongest Spearman correlations with the selected census variables. It also reduces the number of census tracts characterized as 'no access' when compared to the original measures. The spatial distribution of urban-rural two-step floating catchment area pharmacy access exhibits a more granular variation across the study area. CONCLUSIONS: The results support our hypothesis that spatial access to pharmacies should account for urbanicity/rurality patterns within a region.

Guideline-concordant treatment predicts survival: a National Cancer Database validation study of novel composite locoregional and systemic treatment scores among women with early stage breast cancer.

BACKGROUND: The aim of this large nationwide study was to validate two novel composite treatment scores that address guideline-concordant locoregional and systemic breast cancer care. We examined the relationship between these two scores and their association with survival. METHODS: Women with Stage I-III unilateral breast cancer were identified within the National Cancer Database. For each woman, a locoregional and a systemic treatment score (0, 1, 2) was assigned based on receipt of guideline-concordant care. Multivariable Cox regression models evaluated the association between the scores and survival. RESULTS: 623,756 women were treated at 1,221 different American College of Surgeons Commission on Cancer (CoC) facilities. Overall, 86% had a locoregional treatment score of 2 (most guideline-concordant), 75% had a systemic treatment score of 2, and 72% had both scores of 2. Median follow-up was 4.5 years. Compared to women with a locoregional treatment score of 2, those with a score of 1 or 0 had a 1.7-fold and 2.0-fold adjusted greater risk of death. Compared to women with a systemic treatment score of 2, those with a score of 1 or 0 had a 1.5-fold and 2.1-fold adjusted greater risk of death. Risk-adjusted 5-year overall survival was 91.6% when both scores were 2 compared to 73.4% when both scores were 0. CONCLUSIONS: In this large national study of CoC facilities, two composite scores capturing guideline-concordant breast cancer care had independent and combined robust effects on survival. These clinically constructed novel scores are promising tools for health services research and quality-of-care studies.

Transmission Dynamics of Clostridioides difficile in 2 High-Acuity Hospital Units.

BACKGROUND: The key epidemiological drivers of Clostridioides difficile transmission are not well understood. We estimated epidemiological parameters to characterize variation in C. difficile transmission, while accounting for the imperfect nature of surveillance tests. METHODS: We conducted a retrospective analysis of C. difficile surveillance tests for patients admitted to a bone marrow transplant (BMT) unit or a solid tumor unit (STU) in a 565-bed tertiary hospital. We constructed a transmission model for estimating key parameters, including admission prevalence, transmission rate, and duration of colonization to understand the potential variation in C. difficile dynamics between these 2 units. RESULTS: A combined 2425 patients had 5491 admissions into 1 of the 2 units. A total of 3559 surveillance tests were collected from 1394 patients, with 11% of the surveillance tests being positive for C. difficile. We estimate that the transmission rate in the BMT unit was nearly 3-fold higher at 0.29 acquisitions per percentage colonized per 1000 days, compared to our estimate in the STU (0.10). Our model suggests that 20% of individuals admitted into either the STU or BMT unit were colonized with C. difficile at the time of admission. In contrast, the percentage of surveillance tests that were positive within 1 day of admission to either unit for C. difficile was 13.4%, with 15.4% in the STU and 11.6% in the BMT unit. CONCLUSIONS: Although prevalence was similar between the units, there were important differences in the rates of transmission and clearance. Influential factors may include antimicrobial exposure or other patient-care factors.

SARS-CoV-2 Cycle Thresholds, Poverty, Race, and Clinical Outcomes.

BACKGROUND: Poverty and high viral load are associated with worse outcomes among COVID-19 patients. METHODS: We included patients admitted to Froedtert Health between March 16 and June 1, 2020. SARS-CoV-2 viral load was proxied by cycle-threshold values. To measure poverty, we used Medicaid or uninsured status and residence in socially disadvantaged areas. We assessed the association between viral load and length of stay and discharge disposition, while controlling for demographics and confounders. RESULTS: Higher viral load was associated with longer length of stay (coefficient -0.02; 95% CI, -0.04 to 0.01; P = 0.006) and higher likelihood of death (coefficient -0.11; 95% CI, -0.17 to -0.06; P < 0.001). Poverty, residence in disadvantaged areas, and race were not. DISCUSSION: This study confirms a relationship of viral load with in-hospital death, even after controlling for race and poverty.