Changes in Health Insurance Coverage Over Time by Immigration Status Among US Older Adults, 1992-2016.

Importance: Disparities in health insurance coverage by immigration status are well documented; however, there are few data comparing long-term changes in insurance coverage between immigrant and nonimmigrant adults as they age into older adulthood. Objective: To compare longitudinal changes in insurance coverage over 24 years of follow-up between recent immigrant, early immigrant, and nonimmigrant adults in the US. Design, Setting, and Participants: This population-based cohort study used data from the nationally representative Health and Retirement Study. Data were collected biennially from 1992 to 2016. The population included community-dwelling US adults born between 1931 and 1941 and aged 51 to 61 years at baseline. Statistical analysis was performed from February 3, 2017, to January 10, 2020. Exposures: Participants were categorized as nonimmigrants (born in the US), early immigrants (immigrated to the US before the age of 18 years), and recent immigrants (immigrated to the US from the age of 18 years onward). Main Outcomes and Measures: Self-reported data on public, employer, long-term care, and other private insurance were used to define any insurance coverage. Longitudinal changes in insurance coverage were examined over time by immigration status using generalized estimating equations accounting for inverse probability of attrition weights. The association between immigration status and continuous insurance coverage was also evaluated. Results: A total of 9691 participants were included (mean [SD] age, 56.0 [3.2] years; 5111 [52.6%] female). Nonimmigrants composed 90% (n = 8649) of the cohort; early immigrants, 2% (n = 201); and recent immigrants, 8% (n = 841). Insurance coverage increased from 68%, 83%, and 86% of recent immigrant, early immigrant, and nonimmigrant older adults, respectively, in 1992 to 97%, 100%, and 99% in 2016. After accounting for selective attrition, recent immigrants were 15% less likely than nonimmigrants to have any insurance at baseline (risk ratio, 0.85; 95% CI, 0.82-0.88), driven by lower rates of private insurance. However, disparities in insurance decreased incrementally over time and were eliminated, such that insurance coverage rates were similar between groups as participants attained Medicare age eligibility. Furthermore, recent immigrants were less likely than nonimmigrants to be continuously insured (risk ratio, 0.89; 95% CI, 0.85-0.94). Conclusions and Relevance: Among community-dwelling adults who were not age eligible for Medicare, recent immigrants had lower rates of health insurance, but this disparity was eliminated over the 24-year follow-up period because of uptake of public insurance among all participants. Future studies should evaluate policies and health care reforms aimed at reducing disparities among vulnerable populations such as recent immigrants who are not age eligible for Medicare.

Patient Perspectives on Transitions of Surgical Care: Examining the Complexities and Interdependencies of Care.

This study examined a thematic network aimed at identifying experiences that influence patients' outcomes (e.g., patients' satisfaction, anxiety, and discharge readiness) in an effort to improve care transitions and reduce patient burden. We drew upon the Sociology and Complexity Science Toolkit to analyze themes derived from 61 semistructured, longitudinal interviews with 20 patients undergoing either a benign or malignant colorectal resection (three interviews per patient over a 30-day after hospital discharge). Thematic interdependencies illustrate how most outcomes of care are significantly influenced by two cascades identified as patients' medical histories and home circumstances. Patients who reported previous medical or surgical histories also experienced less distress during the discharge process, whereas patients with no prior experiences reported more concerns and greater anxiety. Patient dissatisfactions and challenges were due in large part to the contrasts between hospital and home experiences. Our hybrid approach may inform patient-centered guidelines aimed at improving transitions of care among patients undergoing major surgery.

Variation in Hospital-Specific Rates of Suboptimal Lymphadenectomy and Survival in Colon Cancer: Evidence from the National Cancer Data Base.

BACKGROUND: Little is known about between-hospital differences in the rate of suboptimal lymphadenectomy. This study characterizes variation in hospital-specific rates of suboptimal lymphadenectomy and its effect on overall survival in a national hospital-based registry. METHODS: Stage I-III colon cancer patients were identified from the 2003-2012 National Cancer Data Base. Bayesian multilevel logistic regression models were used to assess the impact of patient- and hospital-level factors on hospital-specific rates of suboptimal lymphadenectomy (<12 lymph nodes), and multilevel Cox models were used to estimate the effect of suboptimal lymphadenectomy at the patient (yes vs. no) and hospital level (quartiles of hospital-specific rates) on overall survival. RESULTS: A total of 360,846 patients across 1345 hospitals in the US met the inclusion criteria, of which 25 % had a suboptimal lymphadenectomy. Wide variation was observed in hospital-specific rates of suboptimal lymphadenectomy (range 0-82 %, median 44 %). Older age, male sex, comorbidity score, no insurance, positive margins, lower tumor grade, lower T and N stage, and sigmoid and left colectomy were associated with higher odds of suboptimal lymphadenectomy. Patients treated at lower-volume and non-academic hospitals had higher odds of suboptimal lymphadenectomy. Patient- and hospital-level factors explained 5 % of the between-hospital variability in suboptimal lymphadenectomy, leaving 95 % unexplained. Higher suboptimal lymphadenectomy rates were associated with worse survival (quartile 4 vs. quartile 1: hazard ratio 1.19, 95 % confidence interval 1.16-1.22). CONCLUSION: Large differences in hospital-specific rates of suboptimal lymphadenectomy were observed, and this variation was associated with survival. Quality improvement initiatives targeting hospital-level adherence to the national standard may improve overall survival among resected colon cancer patients.

Evaluating the Prognostic Role of Elevated Preoperative Carcinoembryonic Antigen Levels in Colon Cancer Patients: Results from the National Cancer Database.

OBJECTIVES: Carcinoembryonic antigen (CEA) is a reliable tumor marker for the management and surveillance of colon cancer. However, limitations in previous studies have made it difficult to elucidate whether CEA should be established as a prognostic indicator. This study examines the association between elevated preoperative CEA levels and overall survival in colon cancer patients using a national population-based registry. METHODS: Stage I-III colon cancer patients were identified from the 2004-2006 National Cancer Database. A multivariable Cox proportional hazards model was used to estimate the association between elevated CEA levels and overall survival after controlling for important patient, hospital, and tumor characteristics. A Monte Carlo Markov Chain was used to impute the large degree of missing CEA data. All models controlled for the propensity score in order to account for selection bias. RESULTS: A total of 137,381 patients met the inclusion criteria. Overall, 34 % of patients had an elevated CEA level and 66 % had a normal CEA level, with a median survival of 70 and 100 months, respectively. Patients with an elevated CEA level had a 62 % increase in the hazard of death (HR 1.62, 95 % CI 1.53-1.74) compared with patients with a normal CEA level. CONCLUSIONS: Preoperative CEA was an independent predictor of overall survival across all stages. The results support recommendations to include CEA levels as another high-risk feature that clinicians can use to counsel patients on adjuvant chemotherapy, especially for stage II patients.

Watch and Wait?--Elevated Pretreatment CEA Is Associated with Decreased Pathological Complete Response in Rectal Cancer.

INTRODUCTION: Between 10 and 30% of rectal cancer patients experience pathological complete response after neoadjuvant treatment. However, physiological factors predicting which patients will experience tumor response are largely unknown. Previous single-institution studies have suggested an association between elevated pretreatment carcinoembryonic antigen and decreased pathological complete response. METHODS: Clinical stage II-III rectal cancer patients undergoing neoadjuvant chemoradiotherapy and surgical resection were selected from the 2006-2011 National Cancer Data Base. Multivariable analysis was used to examine the association between elevated pretreatment carcinoembryonic antigen and pathological complete response, pathological tumor regression, tumor downstaging, and overall survival. RESULTS: Of the 18,113 patients meeting the inclusion criteria, 47% had elevated pretreatment carcinoembryonic antigen and 13% experienced pathological compete response. Elevated pretreatment carcinoembryonic antigen was independently associated with decreased pathological complete response (OR = 0.65, 95% CI = 0.52-0.77, p < 0.001), pathological tumor regression (OR = 0.74, 95% CI = 0.67-0.70, p < 0.001), tumor downstaging (OR = 0.77, 95% CI = 0.63-0.92, p < 0.001), and overall survival (HR = 1.45, 95% CI = 1.34-1.58, p < 0.001). CONCLUSION: Rectal cancer patients with elevated pretreatment carcinoembryonic antigen are less likely to experience pathological complete response, pathological tumor regression, and tumor downstaging after neoadjuvant treatment and experience decreased survival. These patients may not be suitable candidates for an observational "watch-and-wait" strategy. Future prospective studies should investigate the relationships between CEA levels, neoadjuvant treatment response, recurrence, and survival.

Testing satisfaction of basic psychological needs as a mediator of the relationship between socioeconomic status and physical and mental health.

This research applied self-determination theory to examine the degree to which satisfaction of basic psychological needs for autonomy, relatedness, and competence explained the association between socioeconomic status and physical and mental health outcomes, while controlling for age, exercise, and smoking status. This was a survey research study with 513 full-time employees in professions representative of a hierarchal organization. The results of the structural equation model verify that psychological need satisfaction mediates the inverse association between socioeconomic status and physical and mental health. Self-determination theory contributes to understanding the psychosocial roots of the uneven distribution of health across the socioeconomic gradient.

Significant Variation in Blood Transfusion Practice Persists following Upper GI Cancer Resection.

PURPOSE: Perioperative blood transfusions are costly and linked to adverse clinical outcomes. We investigated the factors associated with variation in blood transfusion utilization following upper gastrointestinal cancer resection and its association with infectious complications. METHODS: The Statewide Planning and Research Cooperative System was queried for elective esophagectomy, gastrectomy, and pancreatectomy for malignancy in NY State from 2001 to 2013. Bivariate and hierarchical logistic regression analyses were performed to assess the factors associated with receiving a perioperative allogeneic red blood cell transfusion. Additional multivariable analysis examined the relationship between transfusion and infectious complications. RESULTS: Among 14,875 patients who underwent upper GI cancer resection, 32 % of patients received a perioperative blood transfusion. After controlling for patient, surgeon, and hospital-level factors, significant variation in transfusion rates was present across both surgeons (p < 0.0001) and hospitals (p < 0.0001). Receipt of a blood transfusion was also independently associated with wound infection (OR = 1.68, 95% CI = 1.47 and 1.91), pneumonia (OR = 1.98, 95% CI = 1.74 and 2.26), and sepsis (OR = 2.49, 95% CI = 2.11 and 2.94). CONCLUSION: Significant variation in perioperative blood transfusion utilization is present at both the surgeon and hospital level. These findings are unexplained by patient-level factors and other known hospital characteristics, suggesting that variation is due to provider preferences and/or lack of standardized transfusion protocols. Implementing institutional transfusion guidelines is necessary to limit unwarranted variation and reduce infectious complication rates.

Opportunity lost: Adjuvant chemotherapy in patients with stage III colon cancer remains underused.

INTRODUCTION: There is strong evidence supporting the efficacy of adjuvant chemotherapy for patients with pathologic, stage III colon cancer. This study examines differences in adherence to evidence-based adjuvant chemotherapy guidelines for pathologic, stage III colon cancer cases across hospital and patient subgroups. METHODS: Patients with stage III colon cancer were identified from the 2003 to 2011 National Cancer Data Base (NCDB). A logistic regression model was used to estimate the odds of receipt of adjuvant chemotherapy across varying hospital and patient characteristics. A multivariable Cox proportional hazards model was used to estimate the association between receipt of adjuvant chemotherapy and 5-year survival. Risk adjusted observed/expected (O/E) outcome ratios were calculated for each hospital to compare hospital-specific quality of care during the study period. RESULTS: A total of 124,008 patients met the inclusion criteria. Adjuvant chemotherapy was not administered to 34%. The rates of adjuvant chemotherapy have shown little improvement over time (63% in 2003 vs 66% in 2011). The Cox model indicates that patients receiving adjuvant chemotherapy had better survival (hazard ratio = 0.48, 95% confidence interval 0.47-0.49). Analysis of risk adjusted O/E ratios indicated no consistent pattern as to which hospitals were performing optimally or subopitmally over time. CONCLUSION: There has been no meaningful improvement in receipt of chemotherapy in patients with stage III colon cancer. The fact that chemotherapy is not being considered or offered to more than 20% of patients with node-positive colon cancer suggests that there are substantial process failures across many institutions and regions in the United States.