Economic Burden of Inpatient Care for Mitral Regurgitation in Maryland.

BACKGROUND: Mitral regurgitation (MR) is the most common valvular disease in the United States and increases the risk of death and hospitalization. The economic burden of MR in the United States is not known. METHODS AND RESULTS: We analyzed inpatient hospitalization data from the 1 221 173 Maryland residents who had any in-state admissions from October 1, 2015, to September 30, 2019. We assessed the total charges for patients without MR and for patients with MR who underwent medical management, transcatheter mitral valve repair or replacement, or surgical mitral valve repair or replacement. During the study period, 26 076 inpatients had a diagnosis of MR. Compared with patients without MR, these patients had more comorbidities and higher inpatient mortality. Patients with medically managed MR incurred average total charges of $23 575 per year; MR was associated with $10 559 more in charges per year and an incremental 3.1 more inpatient days per year as compared with patients without MR. Both surgical mitral valve repair or replacement and transcatheter mitral valve repair or replacement were associated with higher charges as compared with medical management during the year of intervention ($47 943 for surgical mitral valve repair or replacement and $63 108 for transcatheter mitral valve repair or replacement). Annual charges for both groups were significantly lower as compared with medical management in the second and third years postintervention. CONCLUSIONS: MR is associated with higher mortality and inpatient charges. Patients who undergo surgical or transcatheter intervention incur lower charges compared with medically managed MR patients in the years after the procedure.

The Distressed Communities Index: A Measure of Community-Level Economic Deprivation and Rate of Firearm Injuries in Maryland.

BACKGROUND: This study aimed to investigate the relationship between community-level economic deprivation, as measured by the Distressed Communities Index (DCI) and ED visits on account of firearm injuries (assaults and unintentional). METHODS: A retrospective analysis was conducted using the Maryland State Emergency Department Databases (SEDD) from January 2019 to December 2020 to explore the association between the DCI and ED visits because of firearm injuries (assaults and unintentional). The DCI utilizes 7 variables, based on zip codes, generating 5 levels of socioeconomic distress (prosperous, comfortable, mid-tier, at-risk, and distressed). In a multivariate analysis, we adjusted for age, sex, mental conditions, alcohol addiction, substance abuse, smoking, race/ethnicity, insurance type, and median income. RESULTS: Of the 2725 ED visits for firearm injuries, 84.5% were Black and 88.5% male. The median age was 27 (21-35) years, and the mortality rate was 17.7%. A statistically significant association was found between economic deprivation and ED visits for firearm injuries. Compared to prosperous communities, the odds ratios (ORs) were comfortable (OR = 1.33, 95% CI 1.04-1.71, P = .03), mid-tier (OR = 1.69, 95% CI 1.33-2.15, P < .001), at-risk (OR = 1.53, 95% CI 1.17-1.99, P < .001), and distressed (OR = 2.65, 95% CI 2.11-3.33, P < .001). DISCUSSION: The study highlights the significant association between community-level economic deprivation, as measured by the Distressed Communities Index, and the incidence of firearm injuries in Maryland. The findings underscore the importance of addressing socioeconomic disparities and implementing targeted interventions to reduce firearm-related injuries in economically distressed communities.

A Saliva-Based Serological and Behavioral Analysis of SARS-CoV-2 Antibody Prevalence in Howard County, Maryland.

The objective of the study was to estimate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence in the Howard County, Maryland, general population and demographic subpopulations attributable to natural infection or coronavirus disease 2019 (COVID-19) vaccination and to identify self-reported social behaviors that may affect the likelihood of recent or past SARS-CoV-2 infection. A cross-sectional, saliva-based serological study of 2,880 residents of Howard County, Maryland, was carried out from July through September 2021. Natural SARS-CoV-2 infection prevalence was estimated by inferring infections among individuals according to anti-nucleocapsid immunoglobin G levels and calculating averages weighted by sample proportions of various demographics. Antibody levels between BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) recipients were compared. Antibody decay rate was calculated by fitting exponential decay curves to cross-sectional indirect immunoassay data. Regression analysis was carried out to identify demographic factors, social behaviors, and attitudes that may be linked to an increased likelihood of natural infection. The estimated overall prevalence of natural infection in Howard County, Maryland, was 11.9% (95% confidence interval, 9.2% to 15.1%), compared with 7% reported COVID-19 cases. Antibody prevalence indicating natural infection was highest among Hispanic and non-Hispanic Black participants and lowest among non-Hispanic White and non-Hispanic Asian participants. Participants from census tracts with lower average household income also had higher natural infection rates. After accounting for multiple comparisons and correlations between participants, none of the behavior or attitude factors had significant effects on natural infection. At the same time, recipients of the mRNA-1273 vaccine had higher antibody levels than those of BNT162b2 vaccine recipients. Older study participants had overall lower antibody levels compared with younger study participants. The true prevalence of SARS-CoV-2 infection is higher than the number of reported COVID-19 cases in Howard County, Maryland. A disproportionate impact of infection-induced SARS-CoV-2 positivity was observed across different ethnic/racial subpopulations and incomes, and differences in antibody levels across different demographics were identified. Taken together, this information may inform public health policy to protect vulnerable populations. IMPORTANCE We employed a highly innovative noninvasive multiplex oral fluid SARS-CoV-2 IgG assay to ascertain our seroprevalence estimates. This laboratory-developed test has been applied in NCI's SeroNet consortium, possesses high sensitivity and specificity according to FDA Emergency Use Authorization guidelines, correlates strongly with SARS-CoV-2 neutralizing antibody responses, and is Clinical Laboratory Improvement Amendments-approved by the Johns Hopkins Hospital Department of Pathology. It represents a broadly scalable public health tool to improve understanding of recent and past SARS-CoV-2 exposure and infection without drawing any blood. To our knowledge, this is the first application of a high-performance salivary SARS-CoV-2 IgG assay to estimate population-level seroprevalence, including identifying COVID-19 disparities. We also are the first to report differences in SARS-CoV-2 IgG responses by COVID-19 vaccine manufacturers (BNT162b2 [Pfizer-BioNTech] and mRNA-1273 [Moderna]). Our findings demonstrate remarkable consistency with those of blood-based SARS-CoV-2 IgG assays in terms of differences in the magnitude of SARS-CoV-2 IgG responses between COVID-19 vaccines.

Emergency department utilization and disposition outcomes by pediatric patients with cancer in Maryland and New York from 2013 to 2017.

BACKGROUND: Pediatric patients with cancer commonly seek emergency department (ED) care, yet there is limited evidence on ED utilization patterns and disposition outcomes among these patients. METHODS: Retrospective analysis of the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases for Maryland and New York from 2013 to 2017. We compared ED visits and disposition outcomes for 5.8 million pediatric patients (<18 years old) with and without cancer, and used multivariable regressions to estimate associations between the number of ED visits, hospital (inpatient) admissions through the ED, and ED or inpatient mortality and sociodemographic and clinical factors within the cancer cohort. RESULTS: Pediatric patients with cancer had more ED visits per year on average (2.4 vs. 1.5, p < .001), higher shares of admissions (56.8% vs. 6.6%, p < .001) and mortality (1.2% vs. 0.1%, p < .001) compared to those without cancer. Among patients with cancer, uninsured pediatric patients had fewer ED visits and lower risk of admission to a hospital through the ED compared to those with Medicaid coverage (total visits: incidence rate ratio [IRR]: 0.82, 95% confidence intervals [CI]: 0.75-0.90; admission: IRR: 0.75, 95% CI: 0.65-0.86). Mortality risks were higher for pediatric patients with cancer residing in areas with the lowest median household income, and with no health insurance coverage (IRR: 2.81, 95% CI: 1.21-6.51) compared to Medicaid. CONCLUSIONS: Our findings emphasize the importance of enhancing health insurance coverage policies and social services for pediatric patients with cancer and their families to address clinical and nonclinical needs.

Impacts of Covid-19 School Closures on School Food Service Revenue: Analysis of Public Local Education Agencies in Maryland.

BACKGROUND: The public health policies and school closures in response to the Covid-19 pandemic have created disruptions in school meal programs. Research is needed to understand the changes in school food service revenue before and during the initial Covid-19-related school shutdowns. METHODS: A longitudinal cohort study examining federal and state reimbursements as well as sales revenues for all public local education agencies (LEAs) in Maryland from school years (SY) 2018-2019 and 2019-2020 was conducted. Monthly changes in federal and state reimbursements for Child Nutrition Programs, including the National School Lunch Program (NSLP), School Breakfast Program (SBP), Summer Food Service Program (SFSP), and Child and Adult Care Food Program (CACFP) were examined. RESULTS: In the SY 2018-2019, the total revenues from federal and state reimbursements for SBP, NSLP, SFSP, and at-risk CACFP were $272.9 million; in comparison, for the SY 2019-2020, the total revenues were $241.8 million (11.4% reduction from SY 2018-2019). On average, the school shutdown (during March to June 2020) was associated with a $450,385 (p-value < .01) reduction in federal and state reimbursements per LEA-month (41% reduction). CONCLUSIONS: The school shutdown during the Covid-19 pandemic was associated with a statistically significant reduction in school food service revenues across Maryland's public LEAs.

Adult Cancer-Related Emergency Department Utilization: An Analysis of Trends and Outcomes From Emergency Departments in Maryland and New York.

PURPOSE: To explore emergency department (ED) visits by adults with cancer and to estimate associations between inpatient admissions through the ED and mortality with sociodemographic and clinical factors within this cohort. METHODS: We conducted a retrospective, pooled, cross-sectional analysis of the Healthcare Cost and Utilization State Emergency Department Databases and State Inpatient Databases for Maryland and New York from January 2013 to December 2017. We examined inpatient admissions through the ED and mortality using frequencies. Among patients with cancer, multivariable regressions were used to estimate sociodemographic and clinical factors associated with inpatient admissions and outpatient ED and inpatient mortality overall. RESULTS: Among 22.7 million adult ED users, 1.3 million (5.7%) had at least one cancer-related diagnosis. ED visit rates per 100,000 population increased annually throughout the study period for patients with cancer and were 9.9% higher in 2017 compared with 2013 (2013: 303.5; 2017: 333.6). Having at least one inpatient admission (68.7% v 20.5%; P < .001) and inpatient or ED mortality (6.5% v 1.0%; P < .001) were higher among ED users with cancer compared with those without. Among patients with cancer, being uninsured (adjusted odds ratio, 0.52; 95% CI, 0.44 to 0.62) compared with having Medicare coverage and non-Hispanic Black (adjusted odds ratio, 0.86; 95% CI, 0.80 to 0.92) compared with non-Hispanic White were associated with decreased odds of inpatient admissions. In contrast, patients with cancer without health insurance, non-Hispanic Black patients, and residents of nonlarge metropolitan areas and of areas with lower household incomes had increased odds of mortality. CONCLUSION: High inpatient admissions through the ED and mortality among adult patients with cancer, coupled with an increase in cancer-related ED visit rates and observed disparities in outcomes, highlight the need to improve access to oncologic services to contain ED use and improve care for patients with cancer.

Comparison of Short-Term Surgical Outcomes of Two Types of Robotic Gastrectomy for Gastric Cancer: Ultrasonic Shears Method Versus the Maryland Bipolar Forceps Method.

BACKGROUND: This study investigated the impact and short-term surgical outcomes of two different main energy devices for robotic gastrectomy for gastric cancer. The outcomes of robotic gastrectomy with ultrasonic shears and those of robotic gastrectomy with conventional forceps were compared. METHODS: We retrospectively evaluated 171 patients who underwent robotic distal gastrectomy or total gastrectomy for gastric cancer. We classified patients into the ultrasonic shears (US) and Maryland bipolar (MB) forceps groups according to the main energy device used for robotic gastrectomy. RESULTS: We extracted 58 patients from the US group and 58 patients from the MB forceps groups using propensity score matching. The total console time (310 min [interquartile range (IQR), 253-369 min] and 332 min, [IQR, 294-429 min]; p = 0.022) and the console time to gastrectomy (222 min [IQR, 177-266 min] and 247 min [IQR, 208-321 min]; p = 0.004) were significantly shorter in the US group than in the MB forceps group. Less blood loss occurred in the US group than in the MB forceps group (20 mL [IQR, 10-40 mL] and 30 mL [IQR, 16-80 mL]; p = 0.014). The postoperative complication rate and postoperative hospital stay length were similar between groups. A multivariate multiple linear regression analysis demonstrated that the use of an ultrasonically activated device was one an independent factor that reduced the operative time of robotic gastrectomy. CONCLUSION: Using ultrasonic shears as the main energy device may contribute to better surgical outcomes after robotic gastrectomy for gastric cancer.

PREVALENCE OF MULTIPLE REPTILIAN PATHOGENS IN THE OROPHARYNGEAL MUCOSA, CLOACAL MUCOSA, AND BLOOD OF DIAMONDBACK TERRAPIN (MALACLEMYS TERRAPIN) POPULATIONS FROM MARYLAND AND GEORGIA, USA.

The diamondback terrapin (Malaclemys terrapin) is a coastal turtle with a range from Massachusetts to Texas and is the only exclusively brackish water turtle in North America. Two populations of wild terrapins from Maryland (n=55) and Georgia (n=7) were examined and tested for potential reptile pathogens. Whole blood and a mucosal (combined oropharyngeal and cloacal) swab from each animal were evaluated by quantitative PCR for 15 potential pathogens including frog virus 3, box turtle Mycoplasmopsis, Mycoplasma agassizii, Mycoplasma testudineum, Salmonella Enteritidis, Salmonella Typhimurium, Borrelia burgdorferi, Anaplasma phagocytophilum, tortoise intranuclear coccidia, testudinid alphaherpesvirus 2, terrapene herpesvirus 1, and terrapene adenovirus. Swabs were positive for a DNA segment 100% homologous to M. testudineum in both populations, with Maryland animals 87% (48 of 55) positive and Georgia animals 86% (6 of 7) positive. Although Mycoplasmopsis spp. are important respiratory pathogens for members of the order Testudines, none of the animals in the study showed any sign of upper respiratory disease. Our data suggest that M. testudineum may survive in non-Testudinidae turtles without causing clinical sigs of disease and suggesting appropriate precautions should be taken in facilities that house multiple species of turtles simultaneously.

Area-level deprivation and adverse childhood experiences among high school students in Maryland.

BACKGROUND: Nearly one-half of Americans have been exposed to at least one adverse childhood experience (ACE) before turning 18, contributing to a broad array of problems spanning physical health, mental and behavioral health, and psychosocial functioning. METHODS: This was a cross-sectional, survey research study, using 2018 data from a state adolescent health surveillance system, i.e., Maryland Youth Risk Behavior Survey/Youth Tobacco Survey. The population-based sample of Maryland high school students (n = 41,091) is representative at the state and county levels. The outcome variables included five binary measures of ACEs (i.e., food insecurity, parental substance use/gambling, parental mental illness, family member in jail/prison, and caregiver verbal abuse), and number of ACEs. The main exposure variable, area-level socioeconomic disadvantage, was assessed at the county level using a continuous measure of the area deprivation index (ADI). Additional covariates included: rural county status, age, race/ethnicity, sex, and sexual or gender minority (SGM) status. We used mixed-effect multivariate logistic regression to estimate the odds of ACEs in association with socioeconomic deprivation. Models were adjusted for all covariates. RESULTS: County-level ADI was associated with 3 of the 5 ACES [i.e., food insecurity (OR = 1.10, 95% CI: 1.07-1.13), parental substance use/gambling (OR = 1.05, 95% CI: 1.02-1.07), and incarceration of a family member (OR = 1.14, 95% CI: 1.09-1.19)]; and with having at least one ACE (i.e., OR = 1.08, 95% CI: 1.05-1.10). Odds of reporting at least one ACE were higher among girls, older adolescents (i.e., aged 16 and ≥ 17 relative to those aged ≤ 14 years), and among SGM, Black, and Latinx students (all ORs > 1.20). CONCLUSIONS: ACEs greatly increase risk for adolescent risk behaviors. We observed an increased likelihood of adversity among youth in more deprived counties and among Black, Latinx, or SGM youth, suggesting that social and structural factors play a role in determining the adversity that youth face. Therefore, efforts to address structural factors (e.g., food access, family financial support, imprisonment as a sanction for criminal behavior) could be a critical strategy for primary prevention of ACEs and promoting adolescent health.

Center Variation in Use of Preoperative Dual Antiplatelet Therapy and Platelet Function Testing at the Time of Coronary Artery Bypass Grafting in Maryland.

BACKGROUND: Patients presenting with acute coronary syndrome are administered a P2Y 12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice. METHODS: We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared. RESULTS: There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% ( P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients. CONCLUSIONS: There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks.

Progress in Cancer Control in Maryland: 1985-2015.

PURPOSE: Maryland historically had a high cancer burden, which prompted the implementation of aggressive cancer control strategies. We examined the status of cancer in Maryland and work under the current and previous editions of the MD Comprehensive Cancer Control Plan. METHODS: We examined the prevalence of cancer mortality, cancer incidence, and cancer-related behaviors in Maryland and the United States from 1985 to 2015 using publicly available data in the US Cancer Control PLANET, CDC WONDER, and Behavioral Risk Factor Surveillance System portals. We estimated the average annual cancer deaths avoided by triangulation. RESULTS: In 1983-1987, Maryland had the highest age-adjusted cancer mortality rate of all 50 states, second only to Washington, District of Columbia. Today (2011-2015), Maryland's age-adjusted cancer mortality rate ranks 31st. Overall cancer mortality rates have declined 1.9% annually from 1990 to 2015, avoiding nearly 60 000 deaths over 3 decades. While the prevalence of healthy cancer-related behaviors in Maryland was qualitatively similar or higher than that of the United States in 2015, Maryland's 5-year (2011-2015) cancer incidence rate was significantly greater than that of the United States. CONCLUSIONS: Maryland's 30-year cancer mortality declines have outpaced other states. However, a reduction in mortality while incidence rates remain high indicates a need for enhanced focus on primary prevention.

Mortality in Outpatients with Bronchopulmonary Dysplasia.

OBJECTIVES: To study the demographic and clinical characteristics of preterm infants with bronchopulmonary dysplasia (BPD) to identify the factors most strongly predictive of outpatient mortality, with the goal of identifying those individuals at greatest risk. STUDY DESIGN: Demographic and clinical characteristics were retrospectively reviewed for 862 subjects recruited from an outpatient BPD clinic. Characteristics of the deceased and living participants were compared using nonparametric analysis. Regression analysis was performed to identify factors associated with mortality. RESULTS: Of the 862 subjects, 13 (1.5%) died during follow-up, for an overall mortality rate of approximately 15.1 deaths per 1000 subjects. Two patients died in the postneonatal period (annual mortality incidence, 369.9 per 100 000), 9 died between age 1 and 4 years (annual mortality incidence, 310.2 per 100 000), and 2 died between age of 5 and 14 years (annual mortality incidence, 71.4 per 100 000). After adjusting for gestational age and BPD severity, mortality was found to be associated with the amount of supplemental oxygen required at discharge from the neonatal intensive care unit (adjusted hazard ratio [aHR], 4.10; P = .001), presence of a gastrostomy tube (aHR, 8.13; P = .012), and presence of a cerebrospinal fluid (CSF) shunt (aHR, 4.31; P = .021). CONCLUSIONS: The incidence of mortality among preterm infants with BPD is substantially higher than that seen in the general population. The need for greater amounts of home supplemental oxygen and the presence of a gastrostomy tube or CSF shunt were associated with an increased risk of postdischarge mortality. Future studies should focus on clarifying risk factors for the development of severe disease to allow for early identification and treatment of those at highest risk.

The actual, long-term cost of intentional injury care among a cohort of Maryland Medicaid recipients.

BACKGROUND: Intentional injury (both self-harm and interpersonal) is a major cause of morbidity and mortality, yet there are little data on the per-person cost of caring for these patients. Extant data focus on hospital charges related to the initial admission but does not include actual dollars spent or follow-up outpatient care. The Affordable Care Act has made Medicaid the primary payor of intentional injury care (39%) in the United States and the ideal source of cost data for these patients. We sought to determine the total and per-person long-term cost (initial event and following 24 months) of intentional injury among Maryland Medicaid recipients. METHODS: Retrospective cohort study of Maryland Medicaid claims was performed. Recipients who submitted claims after receiving an intentional injury, as defined by the International Classification of Diseases, Tenth Revision, between October 2015 and October 2017, were included in this study. Subjects were followed for 24 months (last participant enrolled October 2017 and followed to October 2019). Our primary outcome was the dollars paid by Medicaid. We examined subgroups of patients who harmed themselves and those who received repeated intentional injury. RESULTS: Maryland Medicaid paid $11,757,083 for the care of 12,172 recipients of intentional injuries between 2015 and 2019. The per-person, 2-year health care cost of an intentional injury was a median of $183 (SD, $5,284). These costs were highly skewed: min, $2.56; Q1 = 117.60, median, $182.80; Q3 = $480.82; and max, $332,394.20. The top 5% (≥95% percentile) required $3,000 (SD, $6,973) during the initial event and $8,403 (SD, $22,024) per served month thereafter, or 55% of the overall costs in this study. CONCLUSION: The long-term, per-person cost of intentional injury can be high. Private insurers were not included and may experience different costs in other states. LEVEL OF EVIDENCE: Economic and Value Based Evaluations; level III.

Racial/Ethnic Inequities in Adverse Childhood Experiences and Selected Health-Related Behaviors and Problems Among Maryland Adolescents.

We examined racial/ethnic inequities in the prevalence of adverse childhood experiences (ACEs) and examined the association between ACEs and selected health-related behaviors and problems. Data for this cross-sectional study come from the 2018 Maryland Youth Risk Behavior Survey/Youth Tobacco Survey, a statewide survey of high school students (n = 40,188). ACEs included caregiver verbal abuse and household food insecurity, substance use or gambling, mental illness, and involvement with the criminal justice system. We estimated the prevalence of ACEs overall and by race/ethnicity, and then used multiple logistic regression to determine associations between ACEs and emotional/behavioral problems, adjusting for race/ethnicity. Outcome variables included emotional distress, poor school performance, suicidal ideation, fighting, alcohol use, and marijuana use. More than one fifth of students reported each individual ACE. Differences in the prevalence of ACEs by race/ethnicity were statistically significant (p < .001). More than one fourth (25.8%) reported one of the five ACEs, 15.1% reported two, and 15.4% reported three or more. For each ACE, reporting having experienced it (vs. not) was associated with a >30% higher prevalence for each of the outcome variables. Among students who reported three or more ACEs (relative to none), the odds of emotional distress and suicidal ideation were more than 8 times greater. Among Maryland adolescents, ACEs are common, are inequitably distributed by race/ethnicity, and are strongly linked to behavioral health. Findings suggest the need to monitor ACEs as a routine component of adolescent health surveillance and to refocus assessment and intervention toward "upstream" factors that shape adolescent health.

Racial disparities in mortality outcomes among women diagnosed with breast cancer in Maryland: Impact of cardiovascular disease and clinical characteristics.

BACKGROUND: Although racial disparities in breast cancer (BC) mortality have been well documented in the United States, little is known about the impact of coexisting cardiovascular disease (CVD) and other clinical factors on Black-White survival disparities after the diagnosis of BC. This study examined the associations of race, CVD, and clinical factors at diagnosis with the hazard of BC and CVD-related mortality among patients with BC identified from the Maryland Cancer Registry. METHODS: A total of 36,088 women (25,181 Whites and 10,907 Blacks) diagnosed with incident invasive BC between 2007 and 2017 were included. Subdistribution hazard ratios (sdHRs) for CVD-related and BC mortality were estimated with Fine and Gray regression models, which accounted for the influence of competing events. RESULTS: After a median follow-up of 5.8 years, 8019 deaths occurred; 3896 were BC deaths, and 1167 deaths were CVD-related. Black women had a higher hazard of BC mortality (sdHR, 1.66; 95% confidence interval [CI], 1.55-1.77) and CVD mortality (sdHR, 1.33; 95% CI, 1.17-1.51) in comparison with White women. Associations with CVD mortality were significantly stronger among Black women aged 50 to 59 years (sdHR, 2.86; 95% CI, 1.84-4.44; P for interaction < .001). Among Black women with CVD, the hazard of BC death was 41% higher in comparison with White women. By treatment, a significant association with CVD mortality was observed only among Black women undergoing surgery and radiation (sdHR, 1.61; 95% CI, 1.22-2.13). CONCLUSIONS: Clinicians should consider the impact of younger age, preexisting CVD, and BC treatments among Black patients. Early identification of those at risk for worse survival may improve surveillance and outcomes.

Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health-academic collaborative: an evaluation of a quality improvement intervention.

To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention using four quarters of preintervention and six quarters of postintervention National Healthcare Safety Network data for SPARC hospitals (April 2017 to March 2020) and 10 quarters for control hospitals (October 2017 to March 2020). Mixed-effects negative binomial models were used to assess changes over time. Process evaluation using hospital intervention implementation plans, assessments and interviews with staff at eight SPARC hospitals. Maryland, USA. All Maryland acute care hospitals; 12 intervention and 36 control hospitals. Participation in SPARC, a public health-academic collaborative made available to Maryland hospitals, with staggered enrolment between June 2018 and August 2019. Hospitals with higher C. difficile rates were recruited via email and phone. SPARC included assessments, feedback reports and ongoing technical assistance. Primary outcomes were C. difficile incidence rate measured as the quarterly number of C. difficile infections per 10 000 patient-days (outcome measure) and SPARC intervention hospitals' experiences participating in the collaborative (process measures). SPARC invited 13 hospitals to participate in the intervention, with 92% (n=12) participating. The 36 hospitals that did not participate served as control hospitals. SPARC hospitals were associated with 45% greater C. difficile reduction as compared with control hospitals (incidence rate ratio=0.55, 95% CI 0.35 to 0.88, p=0.012). Key SPARC activities, including access to trusted external experts, technical assistance, multidisciplinary collaboration, an accountability structure, peer-to-peer learning opportunities and educational resources, were associated with hospitals reporting positive experiences with SPARC. SPARC intervention hospitals experienced 45% greater reduction in C. difficile rates than control hospitals. A public health-academic collaborative might help reduce C. difficile and other hospital-acquired infections in individual hospitals and at state or regional levels.

Racialized Economic Segregation and Breast Cancer Mortality among Women in Maryland.

BACKGROUND: Our objective was to determine the association between racialized economic segregation and the hazard of breast cancer mortality in Maryland. METHODS: Among 35,066 women (24,540 White; 10,526 Black) diagnosed with incident invasive breast cancer in Maryland during 2007 to 2017, exposure to racialized economic segregation was measured at the census tract level using Index of Concentration at the Extremes metrics. HRs and 95% confidence intervals (CI) were estimated using Cox proportional hazards regression for the association between racialized economic segregation and the hazard of breast cancer mortality, accounting for clustering at the census tract level. Models were adjusted for age and stratified by race, median age (<60 years, ≥60 years), and clinical characteristics. RESULTS: Overall, the hazard of breast cancer mortality was 1.84 times as high (95% CI, 1.64-2.06) for the least privileged quintile of racialized economic segregation compared with the most privileged quintile. This association differed significantly (P interaction< 0.05) by race and age, with 1.20 (95% CI, 0.90-1.60) times the hazard of breast cancer mortality for Black women versus 1.66 (95% CI, 1.41-1.95) times the hazard for White women, and with greater hazards for younger women (HR, 2.17; 95% CI, 1.83-2.57) than older women (HR, 1.62; 95% CI, 1.40-1.88). CONCLUSIONS: Our results suggest that breast cancer survival disparities exist in Maryland among women residing in the least privileged census tracts with lower income households and higher proportions of Black residents. IMPACT: Our findings provide new insights into the breast cancer mortality disparities observed among women in Maryland.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

Predictors of cancer screening among Black and White Maryland Medicaid enrollees with serious mental illness.

BACKGROUND: Cancer is the second leading cause of death for people with serious mental illness (SMI), such as schizophrenia and bipolar disorder. People with SMI receive cancer screenings at lower rates than the general population. AIMS: We sought to identify factors associated with cancer screening in a publicly insured population with SMI and stratified by race, a factor itself linked with differential rates of cancer screening. MATERIALS AND METHODS: We used Maryland Medicaid administrative claims data (2010-2018) to examine screening rates for cervical cancer (N = 40,622), breast cancer (N = 9818), colorectal cancer (N = 19,306), and prostate cancer (N = 4887) among eligible Black and white enrollees with SMI. We examined individual-level socio-demographic and clinical factors, including co-occurring substance use disorder, medical comorbidities, psychiatric diagnosis, obstetric-gynecologic and primary care utilization, as well as county-level characteristics, including metropolitan status, mean household income, and primary care workforce capacity. Generalized estimating equations with a logit link were used to examine the characteristics associated with cancer screening. RESULTS: Compared with white enrollees, Black enrollees were more likely to receive screening for cervical cancer (AOR: 1.18; 95% CI: 1.15-1.22), breast cancer (AOR: 1.27; 95% CI: 1.19-1.36), and colorectal cancer (AOR: 1.07; 95% CI: 1.02-1.13), while similar rates were observed for prostate cancer screening (AOR: 1.06; 95% CI: 0.96-1.18). Primary care utilization and longer Medicaid enrollment were positively associated with cancer screening while co-occurring substance use disorder was negatively associated with cancer screening. CONCLUSION: Improving cancer screening rates among populations with SMI should focus on facilitating continuous insurance coverage and access to primary care.

The Impact of the COVID-19 Pandemic on Elective Inpatient Surgical Admissions: Evidence From Maryland.

BACKGROUND: The COVID-19 pandemic led to large-scale cancellation and deferral of elective surgeries. We quantified volume declines, and subsequent recoveries, across all hospitals in Maryland. MATERIALS AND METHODS: Data on elective inpatient surgical volumes were assembled from the Maryland Health Service Cost Review Commission for years 2019-2020. The data covered all hospitals in the state. We compared the volume of elective inpatient surgeries in the second (Q2) and fourth quarters (Q4) of 2020 to those same quarters in 2019. Analysis was stratified by patient, hospital, and service characteristics. RESULTS: Surgical volumes were 55.8% lower in 2020 Q2 than in 2019 Q2. Differences were largest for orthopedic surgeries (74.3% decline), those on Medicare (61.4%), and in urban hospitals (57.3%). By 2020 Q4, volumes for most service lines were within 15% of volumes in 2019 Q4. Orthopedic surgery remained most affected (44.5% below levels in 2019 Q4) and Plastic Surgery (21.9% lower). CONCLUSIONS: COVID-19 led to large volume declines across hospitals in Maryland followed by a partial recovery. We observed large variability, particularly across service lines. These results can help contextualize case-specific experiences and inform research studying potential health effects of these delays and cancellations.