Disparities in the Use of Preoperative Breast Magnetic Resonance Imaging After Breast Cancer Diagnosis.

PURPOSE: Preoperative magnetic resonance imaging (MRI) after breast cancer diagnosis is increasingly used to improve locoregional staging, particularly among women with dense breasts, extensive ductal carcinoma in situ, and lobular histology. The goals of this study were to (1) assess whether use of preoperative MRI varies by race and insurance type; and (2) determine whether preoperative MRI is associated with downstream surgical management. MATERIALS AND METHODS: We performed a retrospective cohort study of women with stage 0-III breast cancer who were treated with surgical resection within our academic health system (2016-2019). Patients were categorized by race and insurance type. The primary outcome was receipt of preoperative MRI. Secondary outcomes included surgery extent (lumpectomy v mastectomy) and receipt of a second operation. RESULTS: A total of 1,410 women (27% Black, 73% White; 67% private insurance, 26% Medicare, 6% Medicaid) were included. Black patients were significantly less likely to undergo preoperative MRI than White patients (odds ratio [OR], 0.54 [95% CI, 0.38 to 0.76]; P < .001). There was no association between insurance type and preoperative MRI (Medicare v private: OR, 0.77 [95% CI, 0.52 to 1.15]; P = .208; Medicaid v private: OR, 0.67 [95% CI, 0.36 to 1.25]; P = .210). White patients who underwent preoperative MRI were less likely to undergo lumpectomy versus those who did not (OR, 0.53 [95% CI, 0.37 to 0.76]; P < .001). Likelihood of re-excision was lower for Black women who had undergone MRI versus those who had not (OR, 0.43 [95% CI, 0.20 to 0.93]; P = .031). CONCLUSION: Black patients were less likely than White patients to undergo preoperative MRI, yet Black women who underwent MRI were less likely to require re-excision. Standardizing preoperative MRI use may mitigate provider- and system-level biases and promote more equitable care.

Revisiting the Relationship between Tumor Size and Risk in Well-Differentiated Thyroid Cancer.

INTRODUCTION: Large tumor size is associated with poorer outcomes in well-differentiated thyroid cancer (WDTC), yet it remains unclear whether size >4 cm alone confers increased risk, independent of other markers of aggressive disease. The goal of this study was to assess the relationship between tumor size, other high-risk histopathologic features, and survival in WDTC, and to evaluate the significance of 4 cm as a cutoff for management decisions. METHODS: Patients with WDTC were identified from the National Cancer Database (2010-2015) and categorized by tumor size [i.e., small (≤4 cm) or large (>4 cm)] and presence of high-risk histopathologic features (e.g., extrathyroidal extension). First, propensity score matching was used to identify patients who were similar across all other observed characteristics except for small vs. large tumor size, and a multivariable Cox proportional hazards model was used to estimate the relationship between tumor size and survival. Second, we assessed whether the presence of high-risk features demonstrate conditional effects on survival based on the presence of tumor size >4 cm using an interaction term. Finally, additional models assessed the relationship between incremental 1 cm increases in tumor size and survival. Analyses were repeated using a validation cohort from the Surveillance, Epidemiology, and End Results Program (2008-2013). RESULTS: Of 193,133 patients in the primary cohort, 7.9% had tumors >4 cm, and 30% had at least one high-risk feature. After matching, tumor size >4 cm was independently associated with worse survival (HR 1.63, p<0.001). However, tumor size >4 cm and one or more other high-risk features together yielded worse survival than either size >4 cm alone (MMD: 0.70, p<0.001) or other high-risk features alone (MMD: 0.49, p<0.001). When assessed in 1 cm increments, the largest increases in hazard of death occurred at 2 cm and 5 cm, not 4 cm. Results from the validation cohort were largely consistent with our primary findings. CONCLUSIONS: Concomitant high-risk features confer worse survival than large tumor size alone, and a 4 cm cutoff is not associated with the greatest increase in risk. These findings support a more nuanced approach to tumor size in the management of WDTC.

Surgeon and Surgical Trainee Experiences After Adverse Patient Events.

Importance: Adverse patient events are inevitable in surgical practice. Objectives: To characterize the impact of adverse patient events on surgeons and trainees, identify coping mechanisms, and assess whether current forms of support are sufficient. Design, Setting, and Participants: In this mixed-methods study, a validated survey instrument was adapted and distributed to surgical trainees from 7 programs, and qualitative interviews were conducted with faculty from 4 surgical departments in an urban academic health system. Main Outcomes and Measures: The personal impact of adverse patient events, current coping mechanisms, and desired forms of support. Results: Of 216 invited trainees, 93 (43.1%) completed the survey (49 [52.7%] male; 60 [64.5%] in third postgraduate year or higher; 23 [24.7%] Asian or Pacific Islander, 6 [6.5%] Black, 51 [54.8%] White, and 8 [8.6%] other race; 13 [14.0%] Hispanic or Latinx ethnicity). Twenty-three of 29 (79.3%) invited faculty completed interviews (13 [56.5%] male; median [IQR] years in practice, 11.0 [7.5-20.0]). Of the trainees, 77 (82.8%) endorsed involvement in at least 1 recent adverse event. Most reported embarrassment (67 of 79 trainees [84.8%]), rumination (64 of 78 trainees [82.1%]), and fear of attempting future procedures (51 of 78 trainees [65.4%]); 28 of 78 trainees (35.9%) had considered quitting. Female trainees and trainees who identified as having a race and/or ethnicity other than non-Hispanic White consistently reported more negative consequences compared with male and White trainees. The most desired form of support was the opportunity to discuss the incident with an attending physician (76 of 78 respondents [97.4%]). Similarly, faculty described feelings of guilt and shame, loss of confidence, and distraction after adverse events. Most described the utility of confiding in peers and senior colleagues, although some expressed unwillingness to reach out. Several suggested designating a departmental point person for event debriefing. Conclusions and Relevance: In this mixed-methods study of the personal impact of adverse events on surgeons and trainees, these events were nearly universally experienced and caused significant distress. Providing formal support mechanisms for both surgical trainees and faculty may decrease stigma and restore confidence, particularly for underrepresented groups.

Racial Disparities and Strategies for Improving Equity in Diagnostic Follow-Up for Abnormal Screening Mammograms.

PURPOSE: Black and White women undergo screening mammography at similar rates, but racial disparities in breast cancer outcomes persist. To assess potential contributors, we investigated delays in follow-up after abnormal imaging by race/ethnicity. METHODS: Women who underwent screening mammography at our urban academic center from January 2015 to February 2018 and received a Breast Imaging Reporting and Data System 0 assessment were included. Kaplan-Meier estimates described distributions of time between diagnostic events from (1) screening to diagnostic imaging and (2) diagnostic imaging to biopsy. Multivariable logistic regression models estimated the associations between race/ethnicity and receipt of follow-up within 15 and 30 days. RESULTS: Two thousand five hundred and fifty-four women were included (48.6% non-Hispanic [NH] Black, 38.2% NH White, 13.1% other/unknown). Median time between screening and diagnostic imaging varied by race/ethnicity (White: 7 days [IQR, 2-14]; Black: 12 days [IQR, 7-23]; other/unknown: 9 days [IQR, 5-21]). There were similar disparities in days between diagnostic imaging and biopsy (White: 12 [IQR, 7-24]; Black: 21 [IQR, 13-37]; other/unknown: 16 [IQR, 9-30]) and between screening and biopsy (White: 20 [IQR, 11-41]; Black: 35 [IQR, 22-63]; other/unknown: 27.5 [IQR, 17-42]). After adjustment, odds of diagnostic imaging follow-up within 15 days of screening were lower for Black versus White women (odds ratio, 0.59 [95% CI, 0.44 to 0.80]; P < .001). CONCLUSION: In this diverse cohort, disparities in timely diagnostic follow-up after abnormal breast screening were observed, with Black women waiting 1.75 times as long as White women to obtain a tissue diagnosis. National guidelines for time to diagnostic follow-up may facilitate more timely breast cancer care and potentially affect outcomes.

Surgical Management of Metastatic Adrenocortical Carcinoma.

Introduction: Adrenocortical carcinoma (ACC) is a notoriously aggressive cancer with a dismal prognosis, especially for patients with metastatic disease. Metastatic ACC is classically a contraindication to operative management. Here, we evaluate the impact of primary tumor resection and metastasectomy on survival in metastatic ACC. Methods: We performed a retrospective cohort study of patients with metastatic ACC (2010-2019) utilizing the National Cancer Database. The primary outcome was overall survival (OS). Cox proportional hazards models were developed to evaluate the associations between surgical management and survival. Propensity score matching (PSM) was utilized to account for selection bias in receipt of surgery. Results: Of 976 subjects with metastatic ACC, 38% underwent surgical management. Median OS across all patients was 7.6 months. On multivariable Cox proportional hazards regression, primary tumor resection alone (HR: 0.523; p<0.001) and primary resection with metastasectomy (HR: 0.372; p<0.001) were significantly associated with improved OS. Metastasectomy alone had no association with OS (HR: 0.909; p=0.740). Primary resection with metastasectomy was associated with improved OS over resection of the primary tumor alone (HR: 0.636; p=0.018). After PSM, resection of the primary tumor alone remained associated with improved OS (HR 0.593; p<0.001), and metastasectomy alone had no survival benefit (HR 0.709; p=0.196) compared with non-operative management; combined resection was associated with improved OS over primary tumor resection alone (HR 0.575, p=0.008). Conclusion: In metastatic ACC, patients may benefit from primary tumor resection alone or in combination with metastasectomy, however further research is required to facilitate appropriate patient selection.

Belonging in Surgery: A validated instrument and single institutional pilot.

OBJECTIVE: The aim of this study was to develop and validate an instrument to measure Belonging in Surgery among surgical residents. SUMMARY BACKGROUND DATA: Belonging is the essential human need to maintain meaningful relationships and connections to one's community. Increased belongingness is associated with better well-being, job performance and motivation to learn. However, no tools exist to measure belonging among surgical trainees. METHODS: A panel of experts adapted a belonging instrument for use among United States surgery residents. After administration of the 28-item instrument to residents at a single institution, a Cronbach's alpha was calculated to measure internal consistency, and exploratory principal component analyses (PCA) were performed. Multiple iterations of analyses with successively smaller item samples suggested the instrument could be shortened. The expert panel was reconvened to shorten the instrument. Descriptive statistics measured demographic factors associated with Belonging in Surgery. RESULTS: The overall response rate was 52% (114 responses). The Cronbach's alpha among the 28 items was 0.94 (95% CI: 0.93-0.96). The exploratory PCA and subsequent Promax rotation yielded one dominant component with an eigenvalue of 12.84 (70% of the variance). The expert panel narrowed the final instrument to 11 items with an overall Cronbach's alpha of 0.90 (95% CI: 0.86, 0.92). Belonging in Surgery was significantly associated with race (Black and Asian residents scoring lower than White residents), graduating with one's original intern cohort (residents who graduated with their original class scoring higher than those that did not), and inversely correlated with resident stress level. CONCLUSIONS: An instrument to measure Belonging in Surgery was validated among surgical residents. With this instrument, Belonging in Surgery becomes a construct that may be used to investigate surgeon performance and well-being.

Sex differences and racial/ethnic disparities in the presentation and treatment of medullary thyroid cancer.

BACKGROUND: This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC). METHODS: Patients with MTC (2010-2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity. RESULTS: Of 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 â€‹cm were more likely in men (vs. women: OR 2.47, p â€‹< â€‹0.001) and Hispanic patients (vs. White patients: OR 1.52, p â€‹= â€‹0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p â€‹= â€‹0.002; Hispanic: OR 1.44, p â€‹= â€‹0.038) and experienced longer time to surgery (Black: HR 0.66, p â€‹< â€‹0.001; Hispanic: HR 0.71, p â€‹< â€‹0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p â€‹= â€‹0.022). CONCLUSIONS: Male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.

Adrenalectomy approach and outcomes according to surgeon volume.

BACKGROUND: This study assessed the relationship between surgeon volume, operative management, and resource utilization in adrenalectomy. METHODS: Isolated adrenalectomies performed within our health system were identified (2016-2021). High-volume surgeons were defined as those performing ≥6 cases/year. Outcomes included indication for surgery, perioperative outcomes, and costs. RESULTS: Of 476 adrenalectomies, high-volume surgeons (n â€‹= â€‹3) performed 394, while low-volume surgeons (n â€‹= â€‹12) performed 82. High-volume surgeons more frequently operated for pheochromocytoma (19% vs. 16%, p â€‹< â€‹0.001) and less frequently for metastasis (6.4% vs. 23%, p â€‹< â€‹0.001), more frequently used laparoscopy (95% vs. 80%, p â€‹< â€‹0.001), and had lower operative supply costs ($1387 vs. $1,636, p â€‹= â€‹0.037). Additionally, laparoscopic adrenalectomy was associated with shorter length of stay (-3.43 days, p â€‹< â€‹0.001), lower hospitalization costs (-$72,417, p â€‹< â€‹0.001), and increased likelihood of discharge to home (OR 17.03, p â€‹= â€‹0.008). CONCLUSIONS: High-volume surgeons more often resect primary adrenal pathology and utilize laparoscopy. Laparoscopic adrenalectomy is, in turn, associated with decreased healthcare resource utilization.

Defining Optimal Management of Non-metastatic Adrenocortical Carcinoma.

BACKGROUND: Adrenocortical carcinoma (ACC) is an aggressive, deadly malignancy. Resection remains the primary treatment; however, there is conflicting evidence regarding the optimal approach to and extent of surgery and the role of adjuvant therapy. We evaluated the impact of surgical technique and adjuvant therapies on survival in non-metastatic ACC. METHODS: We performed a retrospective cohort study of subjects who underwent surgery for non-metastatic ACC between 2010 and 2019 utilizing the National Cancer Database. The primary outcome was overall survival. Cox proportional hazards models were developed to identify associations between clinical and treatment characteristics and survival. RESULTS: Overall, 1175 subjects were included. Their mean age was 54 ± 15 years, and 62% of patients were female. 67% of procedures were performed via the open approach, 22% involved multi-organ resection, and 26% included lymphadenectomy. Median survival was 77.1 months. Age (hazard ratio [HR] 1.019; p < 0.001), advanced stage (stage III HR 2.421; p < 0.001), laparoscopic approach (HR 1.329; p = 0.010), and positive margins (HR 1.587; p < 0.001) were negatively associated with survival, while extent of resection (HR 1.189; p = 0.140) and lymphadenectomy (HR 1.039; p = 0.759) had no association. Stratified by stage, laparoscopic resection was only associated with worse survival in stage III disease (HR 1.548; p = 0.007). Chemoradiation was only associated with improved survival in patients with positive resection margins (HR 0.475; p = 0.004). CONCLUSION: Tumor biology and surgical margins are the primary determinants of survival in non-metastatic ACC. Surgical extent and lymphadenectomy are not associated with overall survival. In advanced disease, the open approach is associated with improved survival.

The use and costs of same-day surgery versus overnight admission for total thyroidectomy: A multi-state, all-payer analysis.

BACKGROUND: Outpatient thyroidectomy is increasingly favored, given evidence of safety and convenience for selected patients. However, the prevalence of same-day discharge is unclear. We aimed to evaluate temporal trends, hospital characteristics, and costs associated with same-day discharge after total thyroidectomy in an all-payer, multi-state cohort. METHODS: We included patients aged ≥18 years who underwent a total thyroidectomy (2013-2019) using Healthcare Cost and Utilization Project data. Admission type was defined as same-day, overnight, or inpatient based on length of stay. Same-day patients were propensity-score matched 1:1 with overnight patients. Hospital characteristics and costs were compared in the matched cohort. RESULTS: Among 86,187 patients who underwent total thyroidectomy, 16,743 (19.4%) cases were same-day, 59,778 (69.4%) were overnight, and 9,666 (11.2%) were inpatient. The proportion of patients who underwent same-day thyroidectomy increased from 14.8% to 20.8% over the study period (P < .001), whereas overnight admissions decreased from 72.9% to 68.8% (P < .001). In total, 9,571 same-day patients were matched to 9,571 overnight patients. Same-day patients had higher odds of treatment at a certified cancer center (odds ratio 1.77; 95% confidence interval 1.65-1.90), Accreditation Council for Graduate Medical Education-accredited teaching hospital (odds ratio 1.72; 95% confidence interval 1.61-1.85), and high-volume hospital (odds ratio 1.53; 95% confidence interval 1.42-1.65). Pairwise cost differences showed median savings of $974 (interquartile range -1,610 to 3,491) for same-day relative to overnight admission (P < .001). CONCLUSION: Although over two-thirds of patients are admitted overnight, same-day total thyroidectomy is increasingly performed. Same-day thyroidectomy may be a lower-cost option for selected patients, particularly in specialty centers with experience in thyroidectomy.

Development of a risk-prediction model for primary aldosteronism in veterans with hypertension.

BACKGROUND: Rates of screening for primary aldosteronism in patients who meet the criteria are exceedingly low (1%-3%). To help clinicians prioritize screening in patients most likely to benefit, we developed a risk-prediction model. METHODS: Using national Veterans Health Administration data, we identified patients who met the criteria for primary aldosteronism screening between 2000 and 2019. We performed multivariable logistic regression to identify characteristics associated with positive primary aldosteronism testing before generating a risk-scoring system based on the coefficients (0< ß < 0.5 = 1 pt, 0.5 ≤ ß < 1 = 2 pts, 1 ≤ ß < 1.5 = 3 pts) and then tested the system performance using an internal validation cohort. RESULTS: We identified 502,190 patients who met primary aldosteronism screening criteria, of whom 1.6% were screened and 15% tested positive. Based on the regression model, we generated a risk-scoring system based on a total of 9 possible points in which age under 50, absence of smoking history, and resistant hypertension each scored 1 point; elevated serum sodium 2 points; and hypokalemia 3 points. Rates of positive screening increased with risk score, with 5.6% to 6.7% of those scoring 0 points testing positive; 7.9% to 9.0% 1 point; 8.6% to 10% 2 points; 13% to 14% 3 points; 21% 4 points; 22% to 38% 5 points; 27% to 38% 6 points; 42% to 49% 7 points; and 50% to 51% ≥8 points. CONCLUSION: In hypertensive patients who meet the criteria for primary aldosteronism screening, rates of positive screening range from 5.6% to 51%. Use of our risk-predication model incorporating these factors can identify patients most likely to benefit from testing.

Assessing the Frequency of Deferrable Thyroid Nodule Biopsies to De-escalate Low-Value Care.

OBJECTIVE: Thyroid nodules are common, yet fewer than 1 in 10 harbors malignancy. When present, thyroid cancer is typically indolent with excellent survival. Therefore, patients who are not candidates for thyroid cancer treatment due to comorbid disease may not require further thyroid nodule evaluation. The goal of this study was to determine the rate of deferrable thyroid nodule biopsies in patients with limited life expectancy. METHODS: We identified patients who underwent thyroid fine needle aspiration (FNA) between 2015 and 2018 at our institution. The primary outcome was the number of deferrable FNAs, defined as FNAs performed in patients who died within 2 years after biopsy. Secondary outcomes included cytologic Bethesda score, procedure costs, and final diagnosis on surgical pathology. Multivariable logistic and Cox proportional hazards regressions were used to evaluate factors associated with FNA in patients with limited life expectancy. RESULTS: A total of 2565 FNAs were performed. Most patients were female (79%), and 37 (1.5%) patients died within 2 years. Nonthyroid specialists were significantly more likely to order deferrable FNAs (odds ratio 4.13, P < .001). Of the patients who died within 2 years, most (78%) had a concomitant diagnosis of nonthyroid cancer, and 4 went on to have thyroid surgery (Bethesda scores: 3, 4, 4, and 6). Spending associated with deferrable FNAs and subsequent surgery totaled over $98 000. CONCLUSIONS: Overall, the rate of deferrable thyroid nodule biopsies was low. However, there is an opportunity to reduce low-value biopsies in patients with a concurrent nonthyroid cancer by partnering with oncology providers.

An acute care surgeon's dilemma: Operative vs. non-operative management of emergency general surgery conditions in patients with recent colorectal cancer treatment.

BACKGROUND: This comparative effectiveness study examined outcomes of operative vs. non-operative management for emergency general surgery (EGS) conditions in patients with recent cancer treatment (RT). METHODS: Medicare beneficiaries with a history of colorectal cancer hospitalized for an EGS condition (2016-2018) were identified. RT was defined as chemotherapy/radiation within 3 months prior to admission. Instrumental variable analysis assessed the impact of management on mortality and readmissions among survivors (30d, 60d, and 90d), for patients in whom there was clinical equipoise regarding optimal management strategy. RESULTS: Of 26,097 patients, 13% had undergone RT. In both the RT and non-RT groups, the optimal management strategy was uncertain in 14%. Operative management conferred increased risk of mortality but not readmission in patients with RT compared to those without (90d mortality:+43%, p â€‹= â€‹0.03; 90d readmission:+7.1%, p â€‹= â€‹0.776). CONCLUSIONS: In patients with RT for whom there is clinical equipoise regarding EGS management, operative intervention increases risk of mortality.

Identifying and Addressing Barriers to Screening Mammography in a Medically Underserved Community.

RATIONALE AND OBJECTIVES: Breast cancer mortality is 40% higher for Black women compared to White women. This study seeks to assess knowledge of breast cancer screening recommendations and identify barriers to risk assessment and mammographic screening among a medically underserved, low-income, predominantly Black community in West Philadelphia. MATERIALS AND METHODS: During a free mobile mammography screening event, women were offered surveys to assess perceptions of and barriers to breast cancer risk assessment and screening. Among those who subsequently underwent mobile screening, health insurance and time to additional diagnostic imaging and biopsy, when relevant, were retrospectively collected. RESULTS: 233 women completed surveys (mean age 54 ± 13 years). Ninety-three percent of respondents identified as Black. The most frequently cited barrier to screening mammography was cost and/or lack of insurance coverage (30%). Women under 50 reported more barriers to screening compared to older women. Among those recalled from screening and recommended to undergo biopsy, there was a trend toward longer delays between screening and biopsy among those without a PCP (median 45 days, IQR 25-53) compared to those with a PCP (median 24 days, IQR 16-29) (p = 0.072). CONCLUSION: In a study of a medically underserved community of primarily Black patients, barriers to breast cancer risk assessment, screening, and diagnosis were identified by self-report and by documented care delays. While free mobile mammography initiatives that bring medical professionals into communities can help mitigate barriers to screening, strategies for navigation and coordination of follow-up are critical to promote timely diagnostic resolution for all patients.

Together We Go Farther: Improving Access to Cancer Screening Through a Multidisciplinary, One-Stop-Shop Approach.

RATIONALE AND OBJECTIVES: Despite significant scientific advances in cancer treatment in recent decades, Black Americans still face marked inequities in cancer screening, diagnosis, and treatment. Redressing these persistent inequities will require innovative strategies for community engagement. Radiologists, as experts in cancer screening and diagnosis for multiple malignancies, including breast, lung, and colon, are ideally suited to lead and implement community-based strategies to address local cancer disparities. MATERIALS AND METHODS: Through an established academic-community partnership in West Philadelphia built over the course of multiple prior community healthcare events, the authors piloted a novel radiology-led multidisciplinary approach to improve access to cancer screening for the predominantly Black, medically-underserved residents. Using a "one-stop-shop" framework to provide a comprehensive suite of screening and ancillary services in the heart of the community, the authors sought to remove as many impediments to screening as possible. RESULTS: Approximately 350 participants attended the health fair, and a total of 232 screening tests or assessments were completed. Data from this event suggest that this inclusive approach, as well as the use of a health fair "passport" to incentivize engagement, can successfully improve access to screening and follow-up in an underserved community. CONCLUSION: This "one-stop-shop" community approach can be replicated by radiology-led teams in other settings as a high-value, scalable opportunity to reduce disparities in access to cancer screening.

Disparities in Presentation, Treatment, and Survival in Anaplastic Thyroid Cancer.

BACKGROUND: Disparities have been previously described in the presentation, management, and outcomes of other thyroid cancer subtypes; however, it is unclear whether such disparities exist in anaplastic thyroid cancer (ATC). METHODS: We identified patients with ATC from the National Cancer Database (2004-2020). The primary outcomes were receipt of surgery, chemotherapy, and radiation. The secondary outcome was 1-year survival. Multivariable logistic and Cox proportional hazards regressions were used to assess the associations between sex, race/ethnicity, and the outcomes. RESULTS: Among 5359 patients included, 58% were female, and 80% were non-Hispanic white. Median tumor size was larger in males than females (6.5 vs. 6.0 cm; p < 0.001) and in patients with minority race/ethnicity than in white patients (6.5 vs. 6.0 cm; p < 0.001). After controlling for tumor size and metastatic disease, female patients were more likely to undergo surgical resection (odds ratio [OR]: 1.20; p = 0.016) but less likely to undergo chemotherapy (OR: 0.72; p < 0.001) and radiation (OR: 0.76; p < 0.001) compared with males. Additionally, patients from minority racial/ethnic backgrounds were less likely to undergo chemotherapy (OR: 0.69; p < 0.001) and radiation (OR: 0.71; p < 0.001) than white patients. Overall, unadjusted, 1-year survival was 23%, with differences in treatment receipt accounting for small but significant differences in survival between groups. CONCLUSIONS: There are disparities in the presentation and treatment of ATC by sex and race/ethnicity that likely reflect differences in access to care as well as patient and provider preferences. While survival is similarly poor across groups, the changing landscape of treatments for ATC warrants efforts to address the potential for exacerbation of disparities.

Time to Transfer as a Quality Improvement Imperative: Implications of a Hub-and-Spoke Health System Model on the Timing of Emergency Procedures.

BACKGROUND: In the increasingly prevalent hub-and-spoke health system model, specialized services are centralized at a hub hospital, while spoke hospitals offer more limited services and transfer patients to the hub as needed. In one urban, academic health system, a community hospital without procedural capabilities was recently incorporated as a spoke. The goal of this study was to assess the timeliness of emergent procedures for patients presenting to the spoke hospital under this model. METHODS: The authors performed a retrospective cohort study of patients transferred from the spoke hospital to the hub hospital for emergency procedures after the health system restructuring (April 2021-October 2022). The primary outcome was the proportion of patients who arrived within their goal transfer time. Secondary outcomes were time from transfer request to procedure start and whether procedure start occurred within guideline-recommended treatment time frames for ST-elevation myocardial infarction (STEMI), necrotizing soft tissue infection (NSTI), and acute limb ischemia (ALI). RESULTS: A total of 335 patients were transferred for emergency procedural intervention during the study period, most commonly for interventional cardiology (23.9%), endoscopy or colonoscopy (11.0%), or bone or soft tissue debridement (10.7%). Overall, 65.7% of patients were transferred within the goal time. 23.5% of patients with STEMI met goal door-to-balloon time, and more patients with NSTI (55.6%) and ALI (100%) underwent intervention within the guideline-recommended time frame. CONCLUSION: A hub-and-spoke health system model can provide access to specialized procedures in a high-volume, resource-rich setting. However, ongoing performance improvement is required to ensure that patients with emergency conditions receive timely intervention.