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Background: National guidelines recommend palliative care (PC) alongside life-sustaining treatment for older adults with severe trauma. However, outcomes associated with PC for these patients are not well-defined. Objectives: To determine frequency of inpatient PC process documentation in older adults with severe trauma and test associations with postdischarge health care utilization. Design: Retrospective cohort study using electronic health record data linked to Medicare claims. Setting/Subjects: We included adults ≥66 years old admitted to a large, regional U.S. health care system with severe trauma (2016-2018) using consensus criteria for serious illness in trauma. Measurements: Natural language processing was used to measure documentation of five inpatient PC processes: code status limitations, goals-of-care (GOC) conversations, hospice discussions, PC consultations, and health care proxy designations. Associations between PC processes and postdischarge health care utilization were tested using multivariable regression. Results: Among 1267 admissions, the median age was 82 years (interquartile range [IQR] 75-88), and median injury severity score (0-75, higher is worse) was 16 (IQR 9-21); ≥1 PC process was documented in 81%. Among those surviving hospitalization (87%), one-year mortality was 26%. Documentation of ≥1 PC process was not significantly associated with differences in mean hospital days (16 vs. 19), home days (306 vs. 307), emergency department visits (2.3 vs. 2.2), or intensive care unit days (0.6 vs. 0.9) at one year. PC processes were significantly associated with subsequent hospice enrollment (p < 0.01). Conclusions: PC was not associated with reduced health care utilization in older adults after trauma but was associated with one-year hospice enrollment. GOC conversations, specialty PC, and inpatient hospice discussions had low utilization, highlighting target areas for improvements in care delivery.
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Background: Focal ablative therapy is an alternative treatment option for selected patients with prostate cancer. Despite growing interest, its initial adoption in the United States has been limited, and its real-world utilization remains insufficiently characterized at the national level. With recent expansions in Medicare coverage, we aimed to use national claims data to analyze the utilization patterns and regional variability in ablative therapies across the United States. Methods: We analyzed 100% Medicare claims data to identify patients newly diagnosed with prostate cancer from 2019 to 2023 who underwent ablative therapies, including high-intensity focused ultrasound, cryoablation, and laser ablation. Regional variability was assessed by hospital referral regions, which are designed to capture regional health care markets. We conducted descriptive analyses to examine the uptake of ablative therapies across sociodemographic and clinical variables, including metro, urban, or rural residence (from most to least densely populated areas), United States region, age, race, Medicare/Medicaid eligibility factors, year of diagnosis, and comorbidities. Results: We identified 5462 Medicare beneficiaries newly diagnosed with prostate cancer who underwent ablative therapies from 2019 to 2023, with a median age of 73 years. Most patients were White (84.9%) and had multiple comorbidities (81.1%). Ablative therapies were more commonly performed in metro areas (78.8%) and the South region (39.6%), with utilization rates varying across 306 hospital referral regions from 0% to 6.13% of newly diagnosed prostate cancer cases. Cryotherapy (74.9%) and high-intensity focused ultrasound (24.3%) were the most frequently used ablation techniques. Conclusions: Despite expanded insurance coverage, ablative therapies remain infrequently used for prostate cancer, with substantial regional variations in their adoption. These findings highlight the need for continued data collection and outcomes evaluation to define the optimal use of ablative therapy in prostate cancer care.
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Purpose: Prostate cancer (PCa) mortality disparities are partly driven by unequal access to care. Transportation barriers may limit access to definitive treatment. We studied how driving travel time affects receipt of definitive PCa treatment. Materials and Methods: We conducted a cohort study of men with non-metastatic PCa (2000 - 2015; follow-up through 2018) across the metropolitan area cancer registries of seven US states. Travel burden was estimated using Google Maps isochrones representing driving time thresholds to reach the hospital appended to geomasked residential addresses. Outcomes were "no treatment, " "radical surgery," or "radiotherapy". Covariate-adjusted multinomial logistic regression with interaction terms assessed modification by sociodemographic factors. Results: The study included 132,939 men, of whom 37.0% received no treatment, 41.0% underwent surgery, and 22.0% received radiotherapy. Longer driving time (≥90 min vs <30 min) was associated with higher radical prostatectomy (aOR: 1.07, 95% CI: 1.03, 1.12), but lower radiotherapy (0.72, 95% CI: 0.69 - 0.76). Subgroup analyses revealed higher surgery associated with longer driving times among those in nSES Q1 (aOR: 1.33, 95% CI: 1.21-1.45) vs Q5 (aOR: 0.94, 95% CI: 0.86-1.04), those in low (aOR: 1.16, 95% CI: 1.09-1.24) vs high (aOR: 1.03, 95% CI: 0.98-1.09) population density areas, and those with regional (aOR: 1.30, 95% CI: 1.14-1.48) vs localized (aOR: 1.05, 95% CI: 1.00 -1.09) disease. Longer driving time was mostly associated with lower odds of radiotherapy across sociodemographic subgroups. Conclusions: Higher travel burden was associated with lower radiotherapy receipt, but greater surgery use in deprived and rural patients, which warrants further investigation.
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BACKGROUND: Seriously ill older surgical patients with preoperative palliative care needs, such as those with pain, depression, functional dependence, and care partner needs, may benefit from palliative care, but their prevalence, characteristics, and outcomes have not been described. STUDY DESIGN: We used data from the Health and Retirement Survey linked to Medicare claims and included older adults (age 66 years or older) with and without serious illness who underwent major elective surgery between 2007 and 2019. Exposures included serious illness and pain, depression, functional dependence, and care partner needs before operation. Outcomes were 1-year healthcare usage and cost (ie total hospital days, hospital readmission, emergency department visits, and Medicare cost). RESULTS: Among 2,499 older adults undergoing major elective surgery, 63% were seriously ill, and 79% reported pain, depression, functional dependence, or care partner needs. Seriously ill older adults with preoperative palliative care needs experienced a higher rate of total hospital days (incidence rate ratio [IRR] 2.0, 95% CI 1.5 to 2.6), hospital readmission (IRR 2.0, 95% CI 1.6 to 2.4) and emergency department visits (IRR 1.9, 95% CI 1.6 to 2.3). Adjusted 1-year healthcare cost was significantly higher among seriously ill older adults with these palliative care needs compared with those without serious illness (mean [SE] cost $38,187 [2,291] vs $20,129 [1,742]). CONCLUSIONS: Seriously ill older adults undergoing major elective surgery had a high prevalence of palliative care needs, which were associated with increased healthcare usage and cost. These findings highlight the imperative to identify and intervene in older surgical patients who may benefit from palliative care.
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Procedimientos Quirúrgicos Electivos , Costos de la Atención en Salud , Necesidades y Demandas de Servicios de Salud , Cuidados Paliativos , Aceptación de la Atención de Salud , Cuidados Preoperatorios , Humanos , Procedimientos Quirúrgicos Electivos/economía , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Anciano , Femenino , Masculino , Cuidados Paliativos/estadística & datos numéricos , Cuidados Paliativos/economía , Estados Unidos/epidemiología , Anciano de 80 o más Años , Prevalencia , Medicare/economía , Medicare/estadística & datos numéricos , Cuidados Preoperatorios/economía , Cuidados Preoperatorios/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Costos de la Atención en Salud/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/economíaRESUMEN
BACKGROUND: Surgery is common among patients living with dementia, and understanding outcomes may help decision-making. We compared patients' and utilization outcomes after high-risk surgery among patients with and without dementia. METHODS: In this retrospective national cohort study, we compared outcomes of Medicare fee-for-service beneficiaries 66 years or older who underwent high-risk inpatient surgery (i.e., with an inpatient mortality of at least 1%) from January 1, 2017 to September 30, 2018. We examined 90- and 30-day all-cause mortality, major complications, discharge to a higher level of care, intensive end-of-life interventions, and prolonged skilled nursing facility (SNF) stay. We used generalized estimating equations regression modeling and competing risks analysis. RESULTS: Among 19,998,187 beneficiaries, we identified 859,570 who had fee-for-service coverage and were 66 years or older at the time of a high-risk surgery. Of these, 124,822 (14.5%) had a diagnosis of dementia. Female sex accounted for 81,252 (65.1%) of the dementia cohort. Four of five of the most common procedures were related to femur fracture and cardiac surgery in the dementia and non-dementia cohorts. Ninety-day mortality was worse among patients with dementia: 22.8% versus 9.3% (adjusted odds ratio [aOR] 1.82, 95% confidence interval [CI] 1.78-1.85). Patients with dementia were also more likely to have major complications (51.6% vs. 38.5%, aOR 1.19, 95% CI 1.17-1.20), be discharged to a higher level of care (75.1% vs. 41.3%, aOR 1.49, 95% CI 1.44-1.53), and have a prolonged SNF stay (3.7% vs. 1.4%, aOR 1.80, 95% CI 1.69-1.91). Although patients with ADRD were overall less likely to receive intensive interventions during the index admission and at 90 days, they were more likely to receive feeding tubes (aOR 1.22, 95% CI 1.17-1.28). CONCLUSION: Persons living with dementia experience a broad range of worse outcomes after high-risk surgery compared to those without dementia. These data may be used for decision-making.
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Demencia , Pacientes Internos , Complicaciones Posoperatorias , Procedimientos Quirúrgicos Operativos , Humanos , Demencia/complicaciones , Demencia/mortalidad , Demencia/epidemiología , Femenino , Masculino , Anciano , Estudios Retrospectivos , Estados Unidos/epidemiología , Anciano de 80 o más Años , Medicare/estadística & datos numéricos , Procedimientos Quirúrgicos Operativos/mortalidad , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Instituciones de Cuidados Especializados de Enfermería/estadística & datos numéricos , Planes de Aranceles por Servicios/estadística & datos numéricos , Mortalidad Hospitalaria , Pacientes Internos/estadística & datos numéricosRESUMEN
Extracorporeal membrane oxygenation (ECMO) is an infrequently utilized, resource intensive life-sustaining therapy used in critically ill children, and frequently those with congenital heart disease. However, reports on the use of ECMO pre-cardiac-surgical intervention as a bridge to an operation are limited. This study evaluated contemporary outcomes in patients supported with ECMO prior to an index cardiac surgical intervention. This is a single center retrospective cohort study from a pediatric quaternary care hospital evaluating demographic and clinical characteristics associated with mortality in a cohort of patients requiring ECMO support as a bridge to an index cardiac surgical intervention. The primary outcome was survival to hospital discharge. Over the 13-year study period there were 37 ECMO runs prior to an index cardiothoracic surgical procedure, representing 6.6% (37/547) of ECMO runs and 0.3% (37/12440) cardiac-surgical admissions in pediatric patients. No clinical covariates were statistically associated with the need for ECMO post a surgical intervention. However, the need for post-operative ECMO was associated with 2.5 times greater risk of mortality with multivariable logistic regression showing the need for post-operative ECMO to be an independent predictor of mortality. Diagnostic category was also important with specific cardiac diagnoses associated with improved survival. The need for ECMO to rescue a clinical decompensation prior to an index cardiac surgical interventions is a rare scenario with diagnosis-specific considerations, the potential for surgical correction of the underlying pathophysiology, and successful immediate post-operative decannulation being key determinants of survival in this population.
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Concerns persist that low-risk prostate cancer in non-Hispanic Black (NHB) men may be more aggressive, with clinicians uncertain if active-surveillance (AS) should be used in this population. Using the SEER Prostate Cancer Specialized Database (2010-2020), we analyzed 106,486 men with low-risk prostate cancer, of whom 16.6% were NHB. AS or watchful waiting (AS/WW) was less frequently used in NHB men compared to non-Hispanic White (NHW) men (32.9% vs 37.5%), NHB men showed consistently lower utilization of AS/WW over the years (aOR = 0.91, 95%CI: 0.86, 0.95), with absolute differences ranging from 3.4% to 8.5%. In multivariable competing risks analysis, 10-year PCSM did not significantly differ by race (SHR = 1.03, 95% CI: 0.66-1.60). These findings suggest AS/WW is a safe option for NHB men and its use may be underutilized in this group despite comparable long-term cancer-specific outcomes.
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Colorectal surgeons have been early adopters of MIS. The objective of this study was to evaluate whether use of minimally invasive surgery (MIS) for colorectal cancers (CRC) has had an impact on use of MIS for hepatic, pancreatic, biliary, and gastric cancer (HPB/gastric) at the hospital level. We hypothesized that there is cross-specialty, hospital-level impact between colorectal and HPB/gastric surgeons in their use of MIS. Using the 2010-2019 National Cancer Database, we identified patients with histologically confirmed cancers who underwent curative-intent surgery. The hospital-level use of MIS for CRC and HPB/gastric cancers was standardized by adjusting hospital and patient covariates. Using these adjusted MIS rates as covariates, the yearly-level odds of receiving MIS for HPB/gastric cancers were estimated using logistic regression models. 87,241 and 134,019 patients (median age 65 years) with HPB/gastric cancers and CRC, respectively, were included. The proportion of hospitals performing more than 50% of their cases via MIS for both groups of cancers increased from 1% in 2010 to 27% in 2019. The proportion of hospitals performing more than 10% of their cases via a robotic approach increased from 1 to 33%. The odds of receiving MIS among patients with HPB/gastric cancers were more strongly associated with the level of MIS use for HPB/gastric cancer in the previous year than with MIS use for CRC. Adoption of MIS for HPB/gastric cancers appears to be influenced to a greater degree by intra-specialty factors rather than by cross-specialty use of MIS for CRC.
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Neoplasias Colorrectales , Procedimientos Quirúrgicos Mínimamente Invasivos , Procedimientos Quirúrgicos Robotizados , Oncología Quirúrgica , Humanos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos/estadística & datos numéricos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Femenino , Anciano , Persona de Mediana Edad , Procedimientos Quirúrgicos Robotizados/estadística & datos numéricos , Procedimientos Quirúrgicos Robotizados/métodos , Oncología Quirúrgica/estadística & datos numéricos , Oncología Quirúrgica/métodos , Neoplasias Gástricas/cirugía , Neoplasias Colorrectales/cirugía , Hospitales/estadística & datos numéricosRESUMEN
Venous thromboembolism (VTE) is a major public health concern. It is often clinically difficult to diagnose and affects up to 900 000 individuals annually in the United States. Delayed or missed VTE diagnosis can impact treatment and increase morbidity and mortality. This retrospective study utilized structured and unstructured electronic health record (EHR) data from a large integrated care network in the northeastern US, focusing on 4678 adult patients presenting with at least one VTE-associated sign or symptom at primary care visits during 2019-2020. Feature selection incorporated expert-guided and data-driven approaches, resulting in a final set of demographic, clinical history, and sign/symptom risk factors. The primary analysis developed seven machine learning models to predict VTE incidence. Secondary analyses included the prediction of timely and delayed VTE diagnoses. All models showed predictive ability with area under the curve (AUC) of 0.83-0.88. The logistic regression model demonstrated robust performance in predicting incident VTE cases, achieving an AUC of 0.88 (95% CI: 0.86-0.90). Multiple risk factors were identified, including cancer history, smoking history, and spinal cord trauma. Variations in the top risk factors between timely and delayed prediction models highlighted how certain patients were more likely to have a delayed or missed diagnosis. This study highlights the potential for data-driven tools to facilitate timely, point-of-care VTE detection by leveraging structured and unstructured EHR data. The prediction model accurately estimated the likelihood of incident VTEs, especially in cases diagnosed late, showing potential to reduce costly diagnostic delays.
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Algoritmos , Registros Electrónicos de Salud , Atención Primaria de Salud , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiología , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto , Anciano , Factores de Riesgo , Aprendizaje Automático , IncidenciaRESUMEN
OBJECTIVES: The use of risk analytics indices alongside clinical factors has potential to assist clinicians in identifying children at high risk for extubation failure (EF). We investigated the association of two physiologic risk analytics indices with EF in children receiving mechanical ventilation (MV) after cardiac surgery: the probability of inadequate oxygen delivery (ID o2 ) and inadequate ventilation of carbon dioxide index (IV co2 ). A secondary aim was to evaluate clinical factors associated with EF. DESIGN: Multicenter retrospective cohort study. SETTING: Eight international pediatric cardiac ICUs. PATIENTS: Children between 1 month and 12 years old receiving MV for greater than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nine hundred twenty-two children were analyzed with 79 (8.6%) having EF (defined as reintubation within 48 hr). In multivariable analysis of clinical variables, preoperative MV (adjusted odds ratio [aOR], 1.78; 95% CI, 1.08-2.96; p = 0.03), receiving inhaled nitric oxide (iNO) at extubation (aOR, 2.22; 95% CI, 1.13-4.35; p = 0.02), and duration of postoperative MV (aOR, 1.03; 95% CI, 1.00-1.06; p = 0.03) were independently associated with EF. Seven hundred ninety-two patients (86%) had pre-extubation ID o2 data, 602 (65%) had pre-extubation IV co2 data, and 600 (65%) had both pre-extubation ID o2 and IV co2 data available. In multivariable analysis including these risk analytics algorithms, patients with either ID o2 greater than or equal to 5 or IV co2 greater than or equal to 50 before extubation had higher odds of EF (aOR, 2.06; 95% CI, 1.08-3.94; p = 0.03). CONCLUSIONS: The addition of risk analytics algorithms evaluating the probability of inadequate systemic oxygen delivery or inadequate ventilation to clinical factors (duration of ventilation or iNO delivery at extubation) is useful in assessing the risk for EF in children recovering from cardiac surgery.
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Extubación Traqueal , Procedimientos Quirúrgicos Cardíacos , Cardiopatías Congénitas , Respiración Artificial , Humanos , Estudios Retrospectivos , Extubación Traqueal/estadística & datos numéricos , Extubación Traqueal/efectos adversos , Masculino , Femenino , Lactante , Preescolar , Niño , Medición de Riesgo/métodos , Cardiopatías Congénitas/cirugía , Unidades de Cuidado Intensivo Pediátrico , Factores de Riesgo , Recién Nacido , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Potential rural-urban differences in prostate cancer care are understudied, particularly regarding the utilization of advanced diagnostic tests. Herein we examined variations in Positron Emission Tomography (PET) utilization for prostate cancer care, including diagnosis, staging and treatment planning, across residential regions in the United States. METHODS: Patients newly diagnosed with prostate cancer between 2019 and 2021 and post-diagnostic PETs were identified using full Medicare claims data. PET use was assessed in all newly diagnosed patients, though indications vary by risk. Patients' counties were categorized as metro, urban, or rural, from most to least urbanized. Regional PET utilization was further examined at the level of hospital referral regions. A multivariable logistic regression model was performed to assess the impact of rurality on PET imaging. A secondary analysis included an interaction term for race to explore the effect of residence on PET imaging by racial group. RESULTS: Overall, 495 865 patients were included in the analysis: 393 861 (79.4%) lived in metro, 56 698 (11.4%) in urban and 39 707 (8.0%) in rural counties. Patients in metro counties underwent PET imaging more often (8.4%) than patients in urban (7.3%) or rural counties (7.2%), p < 0.0001. At a level of hospital referral region, PET utilization rates ranged from 2.2 to 20.8%. PET imaging was more commonly performed in White compared to Black or Hispanic patients. Rural patients were less likely to undergo PET imaging compared to metro patients (odds ratio [OR] 0.87, 95% Confidence interval [CI]: 0.82-0.92 p < 0.0001). Rural Black (OR 0.69, 95%CI 0.57-0.83, p < 0.0001) and rural White patients (OR 0.89, 95%CI 0.83-0.94 p < 0.0001) were less likely to obtain PET imaging compared to their metro counterparts, p-interaction < 0.0001. CONCLUSION: Rural patients were less likely to undergo PET imaging than metro patients. The effect of rurality was most pronounced among Black patients. Our findings underscore the need for strategies to support equitable use of PET imaging.
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Tomografía de Emisión de Positrones , Neoplasias de la Próstata , Humanos , Masculino , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/patología , Estados Unidos , Medicare/estadística & datos numéricos , Anciano , Tomografía de Emisión de Positrones/estadística & datos numéricos , Población Rural/estadística & datos numéricos , Población Urbana/estadística & datos numéricos , Estudios de Cohortes , Anciano de 80 o más AñosRESUMEN
OBJECTIVE: To determine associations between documented palliative care processes and changes in post-discharge healthcare utilization among a cohort of seriously ill older adults after common major elective surgeries. SUMMARY BACKGROUND DATA: National guidelines recommend palliative care processes for patients with serious illness undergoing major surgery. However, outcomes associated with palliative care delivery to elective surgical patients are understudied. METHODS: We conducted a retrospective, multicenter study using Natural Language Processing to identify electronic health record documentation of five palliative care processes in a cohort of older adults with serious illness who underwent one of five major elective surgeries in a large regional health system between 2016-2018. The processes included: (1) Goals of care conversation, (2) Code status limitation, (3) Palliative care consultation, (4) Hospice assessment, and (5) Surrogate decision-maker designation. We used Medicare claims to assess healthcare utilization one-year post-discharge. RESULTS: Among 1,082 patients, 54.1% had a documented surrogate decision-maker, 4.3% had code status limitations, 2.6% had goals of care conversations, and<2.0% had assessment for hospice or palliative care consultations. In adjusted analysis, patients with documented surrogate decision-maker had no significant changes in hospital days, days at home, or ED visits in the year following surgery. Patients who had documented code status limitations alone spent significantly fewer days at home than those who did not (314.9 vs. 338.6, P=0.004). CONCLUSIONS: Inpatient palliative care processes such as surrogate decision maker-designation are not associated with changes in one-year healthcare utilization after elective surgery.
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BACKGROUND: Personalized therapeutic approaches for localized prostate cancer have evolved significantly, with tissue-based biomarker tests supplementing traditional risk stratification tools. However, national testing patterns and geographic variability remain limited a decade after coverage implementation. We aimed to assess current nationwide utilization and urban-rural differences in tissue-based biomarker testing. METHODS: Using full Medicare claims data, we retrospectively identified patients with newly diagnosed prostate cancer and tissue-based biomarker testing claims from 2019 to 2023. Patients' county of residence was categorized as metro, urban, or rural. Regional testing rates were further assessed across hospital referral regions. A multivariable logistic regression model was performed to assess the effect of residence on test receipt. RESULTS: Our final cohort included 749 202 patients, of whom 79.5% lived in metro, 11.4% in urban and 8.00% in rural counties. Overall, 86 908 (11.6%) patients underwent tissue-based biomarker tests. Hospital referral region-level testing rates ranged from 2.4% to 42.7%. Rural patients were 18% less likely to undergo testing compared to metro patients (odds ratio [OR] 0.82, 95% CI = 0.73 to 0.91). Independently, the odds of undergoing testing were lower among Black (OR 0.82, 95% CI = 0.77 to 0.88) and Hispanic patients (OR 0.80, 95% CI = 0.73 to 0.88) compared to White patients. CONCLUSION: This study reveals high geographic variability in tissue-based biomarker testing for prostate cancer. Further, Black and Hispanic patients were less likely to receive testing. Our findings highlight regional practice variation in the use of advanced, not routinely recommended tests and underscore the need to minimize disparities in diagnostic access.
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Biomarcadores de Tumor , Disparidades en Atención de Salud , Medicare , Neoplasias de la Próstata , Humanos , Masculino , Neoplasias de la Próstata/diagnóstico , Neoplasias de la Próstata/patología , Estados Unidos , Medicare/estadística & datos numéricos , Anciano , Estudios Retrospectivos , Biomarcadores de Tumor/análisis , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/etnología , Población Rural/estadística & datos numéricos , Población Urbana/estadística & datos numéricos , Anciano de 80 o más Años , Negro o Afroamericano/estadística & datos numéricos , BlancoRESUMEN
BACKGROUND: In recent years, there has been considerable interest in addressing racial disparities in prostate cancer (PCa) care including risk-adapted screening. This study examined trends in metastatic PCa incidence by race and placed them in context of changes in PSA screening recommendations. METHODS: We analyzed metastatic PCa incidence trends by race (using Surveillance Epidemiology and End Results data, 2005-2021) and PSA screening trends (using Behavioral Risk Factors Surveillance Survey data, 2012-2020). We fitted a generalized linear model with an interaction term for race and year of diagnosis and calculated annual incidence rate ratios (metastatic disease) and odds ratios (screening) for Non-Hispanic Black (NHB) vs. Non-Hispanic White (NHW) men. RESULTS: From 2005 to 2021, the age-adjusted metastatic PCa incidence (per 100,000) increased from 16.4 to 22.3 in NHB men, and from 6.2 to 10.8 in NHW men. While the incidence increased in both groups, the NHB vs. NHW incidence rate ratio declined from 2.6 (95%CI: 2.4, 2.9) in 2005 to 2.1 (95%CI:2.0,2.2) in 2021 (p < .0001), indicating a narrowing racial gap. From 2012 to 2020, PSA screening declined in both groups. NHB men initially had higher rates (OR:1.34, 95%CI: 1.21, 1.49, p < 0.0001) but experienced a steeper decline, resulting in no significant difference by 2020 (OR: 1.04, 95% CI: 0.91, 1.19, p = 0.59). CONCLUSIONS: The racial gap in metastatic PCa narrowed over the study period, while overall incidence increased. Higher screening rates among Black men in the early 2010s may explain the narrowing gap. The subsequent more rapid decline among Black men raises concerns about resurgence of racial disparities in the coming years.
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Disparidades en Atención de Salud , Neoplasias de la Próstata , Anciano , Humanos , Masculino , Persona de Mediana Edad , Negro o Afroamericano/estadística & datos numéricos , Detección Precoz del Cáncer , Disparidades en Atención de Salud/etnología , Incidencia , Metástasis de la Neoplasia , Antígeno Prostático Específico/sangre , Neoplasias de la Próstata/epidemiología , Neoplasias de la Próstata/etnología , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/diagnóstico , Programa de VERF , Estados Unidos/epidemiología , Blanco/estadística & datos numéricosRESUMEN
PURPOSE: The National Comprehensive Cancer Network (NCCN) recommends germline genetic testing for individuals at risk for hereditary ovarian cancer. We sought to determine the proportion and characteristics of individuals meeting testing criteria in a multicenter biobank who were appropriately offered testing. METHODS: In this retrospective cohort study, we identified Mass General Brigham Biobank participants meeting genetic testing criteria per NCCN guidelines. Logistic regression was used to analyze sociodemographic factors associated with which participants were offered testing, completed testing, and had a family history that matched their self-report documented in the electronic medical record. RESULTS: Most eligible participants (909/1441, 63.1%) were not offered genetic testing. Participants who were Black or Hispanic had a lower likelihood of being offered testing. Compared with self-report, 988 (68.6%) participants had a family history of ovarian cancer documented in their electronic medical record. Older age, Hispanic ethnicity, and public insurance use were associated with decreased likelihoods of accurate family history documentation. Correct documentation was associated with an increased likelihood of being offered testing. CONCLUSION: The majority of participants in this study did not receive NCCN-compliant care. Germline genetic testing for hereditary ovarian cancer screening is underutilized and access to this testing is currently inequitable.
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Pruebas Genéticas , Adhesión a Directriz , Disparidades en Atención de Salud , Neoplasias Ováricas , Adulto , Anciano , Femenino , Humanos , Persona de Mediana Edad , Predisposición Genética a la Enfermedad , Pruebas Genéticas/normas , Pruebas Genéticas/métodos , Mutación de Línea Germinal , Hispánicos o Latinos , Neoplasias Ováricas/genética , Neoplasias Ováricas/diagnóstico , Neoplasias Ováricas/epidemiología , Estudios Retrospectivos , Blanco , Negro o AfroamericanoRESUMEN
CONTEXT: In response to the opioid crisis, federal guidelines were implemented, including the Veterans Health Administration's (VA) Opioid Safety Initiative in 2013. The impact of policies on patients near the end of life is unknown. OBJECTIVES: Examine temporal trends in opioid prescribing, pain, and opioid overdoses among Veterans near the end of life. METHODS: Retrospective, time series analysis of VA decedents between October 2009 and September 2018 whose next-of-kin participated in VA's Bereaved Family Survey (BFS). Using multivariate regression to adjust for sociodemographic and clinical covariates, we examined temporal trends in outpatient opioid prescribing, uncontrolled pain based on BFS report, and opioid overdose-related hospitalizations, in the last month of life, overall and by clinical diagnosis (cancer versus non-cancer). RESULTS: Among 79,409 decedents, mean daily outpatient opioid dose in morphine milligram equivalents in the last month of life decreased from 4.6 mg in 2010 to 2.1 mg in 2018 (adjusted change -0.20 mg/year; P < .001). Opioid overdose-related hospitalization decreased from 0.8% in 2010 to 0.1% in 2018 (adjusted percentage point [PP] change -0.06 PP/year; P < .001). Among the 63,965 Veterans with pain data, the percentage with frequent uncontrolled pain increased from 48.8% in 2010 to 52.2% in 2018 (adjusted PP change +1.37 PP/y; P < .001). Patterns were similar among patients with cancer versus non-cancer conditions. CONCLUSIONS: Over a time period during which opioid safety initiatives were implemented, opioid prescribing near the end of life decreased, accompanied by decreases in opioid-related hospitalizations but increases in pain. These findings suggest that important tradeoffs may exist between reducing opioid-related serious adverse events and undertreating patient pain in the last month of life. Opioid prescribing guidelines could consider incorporating prognosis into recommendations.
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Analgésicos Opioides , Manejo del Dolor , Dolor , Cuidado Terminal , Veteranos , Humanos , Analgésicos Opioides/uso terapéutico , Analgésicos Opioides/efectos adversos , Masculino , Cuidado Terminal/tendencias , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Estados Unidos , Anciano , Dolor/tratamiento farmacológico , Pautas de la Práctica en Medicina/tendencias , Hospitalización , Manejo del Dolor/tendencias , United States Department of Veterans Affairs , Sobredosis de Opiáceos/epidemiología , AdultoRESUMEN
BACKGROUND: Cholecystectomy is considered the definitive treatment option for cholecystitis, but the effect of different treatment options among people living with dementia (PLWD) has not been elucidated. This study compares outcomes following cholecystectomy, cholecystostomy tube, and medical management of cholecystitis among this high-risk group. METHODS: We conducted a retrospective analysis of Medicare claims data 1/1/2016 to 12/31/2020. The cohort comprised Medicare PLWD aged 66+ admitted to acute care facilities with a new primary diagnosis of cholecystitis. We used inverse propensity weighting regression to adjust for confounding by indication. We compared outcomes during index admission, readmissions, and mortality. RESULTS: Eight thousand and seven hundred and seventy four individuals met inclusion criteria; 7% open cholecystectomy, 49% minimally invasive (MIS) cholecystectomy, 13% cholecystostomy tube, 31% managed medically. After adjustment, PLWD undergoing open or MIS cholecystectomy had a greater risk of intensive interventions (Open OR 3.3, p < 0.001; MIS OR 1.3, p = 0.02) and surgical complications (Open OR 10.6, p < 0.001; MIS OR 3.3, p < 0.001) during the index admission, but a lower risk of readmission (Open HR 0.9, p = 0.009; MIS HR 0.9, p < 0.001) and lower mortality (Open HR 0.6, p < 0.001; MIS 0.6, p < 0.001) compared with PLWD managed medically. PLWD managed with cholecystostomy tube had no difference in intensive interventions or surgical complications during the index admission, but a higher risk of readmission (HR 1.1, p = 0.01), cholecystectomy during readmission (HR 1.8, p < 0.001) and no difference in mortality compared to those managed medically. CONCLUSIONS: Over half of PLWD experiencing acute cholecystitis received definitive surgical treatment during the index admission. Open and MIS cholecystectomy were associated with worse outcomes during the index admission, but reduced mortality and readmissions in the 2 years following index admission. Cholecystostomy tube was associated with a greater likelihood of readmission and subsequent cholecystectomy, and no difference in mortality. These findings should be interpreted within the context of administrative data, which has the potential for selection bias and unmeasured confounding.
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Colecistectomía , Colecistitis , Colecistostomía , Demencia , Humanos , Masculino , Femenino , Estudios Retrospectivos , Anciano , Colecistectomía/métodos , Colecistectomía/estadística & datos numéricos , Demencia/complicaciones , Medicare/estadística & datos numéricos , Estados Unidos/epidemiología , Anciano de 80 o más Años , Colecistitis/cirugía , Colecistitis/terapia , Colecistitis/mortalidad , Colecistitis/complicaciones , Readmisión del Paciente/estadística & datos numéricos , Colecistostomía/estadística & datos numéricos , Colecistostomía/métodos , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiologíaRESUMEN
OBJECTIVES: Extubation failure (EF) in neonates recovering from congenital cardiac surgery is associated with morbidity and mortality. Adding continuous physiologic monitoring data and risk analytics algorithms to clinical factors has the potential to assist clinicians in identifying those neonates at high risk for EF. We aimed to evaluate the association of two physiologic risk analytics algorithms evaluating the probability of inadequate delivery of oxygen index (ID o2 ) and inadequate ventilation of carbon dioxide index (IV co2 ) with EF in neonates receiving mechanical ventilation (MV) after cardiac surgery. A secondary aim was to evaluate the clinical factors associated with EF. DESIGN: Multicenter retrospective cohort study. SETTING: Eight international pediatric cardiac ICUs. PATIENTS: Neonates (age < 1 mo at the time of surgery) receiving MV for longer than 48 hours following cardiac surgery between January 1, 2017, and December 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data from 736 neonates were analyzed with 102 (13.9%) having EF (defined as reintubation within 48 hr of extubation). In multivariable analysis (odds ratio [OR] and 95% CI), preoperative respiratory support (OR, 1.72 [95% CI, 1.11-2.67]) was associated with greater odds of EF. In all, 611 neonates had pre-extubation ID o2 data and 478 neonates had both pre-extubation ID o2 and IV co2 data. In multivariable analysis of patients with both pre-extubation ID o2 and IV co2 data, single ventricle anatomy (OR, 2.50 [95% CI, 1.27-4.92]) and high ID o2 (≥ 25) or high IV co2 (≥ 50) in the 2 hours preceding extubation (OR, 1.77 [95% CI, 1.01-3.12]) were associated with greater odds of EF. CONCLUSIONS: In this 2017-2020 cohort, EF is high in post-cardiac surgery neonates receiving at least 48 hours of MV. The ID o2 and IV co2 algorithms may be useful in assessing risk of EF in such neonates.
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Extubación Traqueal , Procedimientos Quirúrgicos Cardíacos , Cardiopatías Congénitas , Respiración Artificial , Humanos , Estudios Retrospectivos , Recién Nacido , Extubación Traqueal/estadística & datos numéricos , Extubación Traqueal/efectos adversos , Masculino , Femenino , Cardiopatías Congénitas/cirugía , Algoritmos , Factores de Riesgo , Unidades de Cuidado Intensivo Pediátrico , Insuficiencia del TratamientoRESUMEN
Background: Many older adults with trauma have pre-existing serious illness like dementia, frailty, and organ insufficiency and are candidates for palliative care to improve outcomes and reduce downstream healthcare utilization. We hypothesize that baseline pain, depressive symptoms, and unpaid caregiving needs are associated with increased healthcare utilization in the year after trauma admission in seriously ill older adults. Methods: Using the Health and Retirement Study (2008-2018) linked to Medicare claims, we identified adults aged ≥66 years admitted for trauma. We assessed pre-admission pain (none/mild vs moderate/severe), depressive symptoms (no-Center for Epidemiologic Studies Depression Scale (CES-D) <3 vs yes-CES-D ≥3) and unpaid caregiving needs (none vs any); and hospital characteristics: trauma center designation and palliative care service. The χ2 tests were used for categorical variables, and t-tests were used for continuous variables. Associations of pain, depressive symptoms, unpaid caregiving needs with healthcare utilization were tested with negative binomial and Poisson regression models. Results: Among 1693 older adults with serious illness, a third (35.7%) were older than 85 years, two-thirds were female (67.5%), and almost all were White (88.7%). Before trauma, 36.4% reported moderate/severe pain, 40.2% reported depressive symptoms (CES-D >3), and 34.9% reported any amount of hours/week of unpaid caregiving needs. Adjusted analyses demonstrated that compared with those without depressive symptoms, seriously ill older adults with depressive symptoms were less likely to be alive (incidence rate ratio (IRR) 0.61, 95% CI 0.41 to 0.91), had more emergency room visits (IRR 1.62, 95% CI 1.15 to 2.27), and more hospital visits (IRR 1.48, 95% CI 1.08 to 2.03) in the year after admission. Adjusted analyses of association of pain and caregiving with healthcare utilization were not significant. Conclusions: Seriously ill older trauma patients with depressive symptoms have increased healthcare utilization in the year after discharge. Palliative care interventions may improve patient outcomes and reduce postdischarge healthcare utilization. Level of evidence: III.