Poor Access to Mental Healthcare is Associated with Worse Postoperative Outcomes Among Patients with Gastrointestinal Cancer.

BACKGROUND: Mental health has an important role in the care of cancer patients, and access to mental health services may be associated with improved outcomes. Thus, poor access to psychiatric services may contribute to suboptimal cancer treatment. We conducted a geospatial analysis to characterize psychiatrist distribution and assess the impact of mental healthcare shortages with surgical outcomes among patients with gastrointestinal cancer. METHODS: Medicare beneficiaries with mental illness diagnosed with complex gastrointestinal cancers between 2004 and 2016 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare registry. National Provider Identifier-registered psychiatrist locations were mapped and linked to SEER-Medicare records. Regional access to psychiatric services was assessed relative to textbook outcome, a composite assessment of postoperative complications, prolonged length of stay, 90-day readmission and mortality. RESULTS: Among 15,714 patients with mental illness and gastrointestinal cancer, 3937 were classified as having high access to psychiatric services while 3910 had low access. On multivariable logistic regression, areas with low access had higher risk of worse postoperative outcomes. Specifically, individuals residing in areas with low access had increased odds of prolonged length of stay (OR 1.11, 95%CI 1.01-1.22; p = 0.028) and 90-day readmission (OR 1.19, 95%CI 1.08-1.31; p < 0.001), as well as decreased odds of textbook outcome (OR 0.85, 95%CI 0.77-0.93; p < 0.001) and discharge to home (OR 0.89, 95%CI 0.80-0.99; p = 0.028). CONCLUSION: Patients with mental illness and lower access to psychiatric services had worse postoperative outcomes. Policymakers and providers should prioritize incorporating mental health screening and access to psychiatric services to address disparities among patients undergoing gastrointestinal surgery.

Association of Racial and Economic Privilege on Postoperative Outcomes Among Medicare Beneficiaries.

INTRODUCTION: Social determinants of health can play an important role in patient health. Privilege is a right, benefit, advantage, or opportunity that can positively affect all social determinants of health. We sought to assess variations in the prevalence of privilege among patient populations and define the association of privilege on postoperative surgical outcomes. METHODS: Medicare beneficiaries who underwent elective coronary artery bypass grafting, abdominal aortic aneurysm repair, total hip arthroplasty, total knee arthroplasty, colectomy, and lung resection were identified. The Index of Concentration of Extremes (ICE), a validated metric of both social spatial polarization and privilege was calculated and merged with county-level data obtained from the American Community Survey. Textbook outcome (TO) was defined as absence of postoperative complications, extended length of stay, 90-day mortality, and 90-day readmission. Multivariable regression analysis was performed to assess the relationship between ICE and TO. RESULTS: Among 1,885,889 Medicare beneficiaries who met inclusion criteria, 655,980 (34.8%) individuals resided in areas with the highest privilege (i.e., White, high-income homogeneity), whereas 221,314 (11.7%) individuals resided in areas of the lowest privilege (i.e., Black, low-income homogeneity). The overall incidence of TO was 66.2% (n = 1,247,558). On multivariable regression, residence in the most advantaged neighbourhoods was associated with a lower chance of surgical complications (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.88-0.91), a prolonged length of stay (OR 0.81, 95% CI 0.79-82), 90-day readmission (OR 0.94, 95% CI 0.92-0.95), and 90-day mortality (OR 0.71, 95% CI 0.68-0.74) (all P < 0.001). Residence in the most privileged areas was associated with 19% increased odds of achieving TO (OR 1.19, 95% CI 1.18-1.21), as well as a 6% reduction in Medicare expenditures versus individuals in the least privileged counties (OR 0.94, 95% CI 0.94-0.94) (both P < 0.001). CONCLUSIONS: Privilege, based on the ICE joint measure of racial/ethnic and economic spatial concentration, was strongly associated with the likelihood to achieve an "optimal" TO following surgery. As healthcare is a basic human right, privilege should not be associated with disparities in surgical care.

Comparison of tumor response and outcomes of patients with hepatocellular carcinoma after multimodal treatment including immune checkpoint inhibitors - a systematic review and meta-analysis.

BACKGROUND: The efficacy of immune checkpoint inhibitors (ICIs) combined with tyrosine kinase inhibitors (TKIs), trans-arterial chemoembolization (TACE), and radiotherapy to treat hepatocellular carcinoma (HCC) has not been well-defined. We performed a meta-analysis to characterize tumor response and survival associated with multimodal treatment of HCC. METHODS: PubMed, Embase, Medline, Scopus, and CINAHL databases were searched (1990-2022). Random-effect meta-analysis was conducted to compare efficacy of treatment modalities. Odds ratios (OR) and standardized mean difference (SMD) were reported. RESULTS: Thirty studies (4170 patients) met inclusion criteria. Triple therapy regimen (ICI + TKI + TACE) had the highest overall disease control rate (DCR) (87%, 95% CI 83-91), while ICI + radiotherapy had the highest objective response rate (ORR) (72%, 95% CI 54%-89%). Triple therapy had a higher DCR than ICI + TACE (OR 4.49, 95% CI 2.09-9.63), ICI + TKI (OR 3.08, 95% CI 1.63-5.82), and TKI + TACE (OR 2.90, 95% CI 1.61-5.20). Triple therapy demonstrated improved overall survival versus ICI + TKI (SMD 0.72, 95% CI 0.37-1.07) and TKI + TACE (SMD 1.13, 95% CI 0.70-1.48) (both p < 0.05). Triple therapy had a greater incidence of adverse events (AEs) compared with ICI + TKI (OR 0.59, 95% CI 0.29-0.91; p = 0.02), but no difference in AEs versus ICI + TACE or TKI + TACE (both p > 0.05). CONCLUSION: The combination of ICIs, TKIs and TACE demonstrated superior tumor response and survival and should be considered for select patients with advanced HCC.

Medicaid expansion and palliative care for advanced-stage liver cancer.

BACKGROUND: Medicaid expansion (ME) has contributed to transforming the United States healthcare system. However, its effect on palliative care of primary liver cancers remains unknown. This study aimed to evaluate the association between ME and the receipt of palliative treatment in advanced-stage liver cancer. METHODS: Patients diagnosed with stage IV hepatocellular carcinoma or intrahepatic cholangiocarcinoma were identified from the National Cancer Database and divided into pre-expansion (2010-2013) and postexpansion (2015-2019) cohorts. Logistic regression identified predictors of palliative treatment. Difference-in-difference (DID) analysis assessed changes in palliative care use between patients living in ME states and patients living in non-ME states. RESULTS: Among 12,516 patients, 4582 (36.6%) were diagnosed before expansion, and 7934 (63.6%) were diagnosed after expansion. Overall, rates of palliative treatment increased after ME (18.1% [pre-expansion] vs 22.3% [postexpansion]; P < .001) and are more pronounced among ME states. Before expansion, only cancer type and education attainment were associated with the receipt of palliative treatment. Conversely, after expansion, race, insurance, location, cancer type, and ME status (odds ratio [OR], 1.23; 95% CI, 1.06-1.44; P = .018) were all associated with palliative care. Interestingly, the odds were higher if treatment involved receipt of pain management (OR, 2.05; 95% CI, 1.23-2.43; P = .006). Adjusted DID analysis confirmed increased rates of palliative treatment among patients living in ME states relative to non-ME states (DID, 4.4%; 95% CI, 1.2-7.7; P = .008); however, racial disparities persist (White, 5.6; 95% CI, 1.4-9.8; P = .009; minority, 2.6; 95% CI, -2.5 to 7.6; P = .333). CONCLUSION: The implementation of ME contributed to increased rates of palliative treatment for patients residing in ME states after expansion. However, racial disparities persist even after ME, resulting in inequitable access to palliative care.