Association of race, demographic and socioeconomic factors with failure to rescue after hepato-pancreato-biliary surgery in the United States.

BACKGROUND: We aimed to describe the association of patient-related factors such as race, socioeconomic status, and insurance on failure to rescue (FTR) after hepato-pancreato-biliary (HPB) surgeries. METHODS: Using the National Inpatient Sample, we analyzed 98,788 elective HPB surgeries between 2004 and 2017. Major and minor complications were identified using ICD9/10 codes. We evaluated mortality rates and FTR (inpatient mortality after major complications). We used multivariate logistic regression analysis to assess racial, socioeconomic, and demographic factors on FTR, adjusting for covariates. RESULTS: Overall, 43 % of patients (n = 42,256) had pancreatic operations, 36% (n = 35,526) had liver surgery, and 21% (n = 21,006) had biliary interventions. The overall major complication rate was 21% (n = 20,640), of which 8% (n = 1655) suffered FTR. Factors independently associated with increased risk for FTR were male sex, older age, higher Charlson Comorbidity Index, Hispanic ethnicity, Asian or other race, lower income quartile, Medicare insurance, and southern region hospitals. CONCLUSIONS: Medicare insurance, male gender, Hispanic ethnicity, and lower income quartile were associated with increased risk for FTR. Efforts should be made to improve the identification and subsequent treatment of complications for those at high risk of FTR.

Socioeconomic and racial/ethnic disparities in receipt of palliative care among patients with metastatic hepatocellular carcinoma.

BACKGROUND: Patients with metastatic hepatocellular carcinoma (HCC) suffer symptoms of both end-stage liver disease and cancer. Palliative care (PC) enhances the quality of life via symptom control and even improves survival for some cancers. Our study characterized rates of PC utilization among metastatic HCC patients and determined factors associated with PC receipt. METHODS: We conducted a retrospective review of adult National Cancer Database patients diagnosed with metastatic HCC between 2004 and 2016. Chi-square tests were used to analyze two cohorts: those who received PC and those who did not. Logistic regression was performed to assess the impact of clinicodemographic factors on the likelihood of receiving PC. RESULTS: PC utilization was low at just 17%. Later year of diagnosis, insured status, and higher education level were associated with an increased likelihood of receiving PC. Treatment at academic centers or integrated network cancer programs increased the likelihood of receiving PC compared to treatment at a community center (odds ratio [OR] = 1.17, 95% confidence interval [CI] = 1.03-1.33 and OR = 1.25, 95% CI = 1.07-1.45; respectively). Hispanics were significantly less likely to received PC than non-Hispanic Whites (OR = 0.73, 95% CI = 0.64-0.82). CONCLUSIONS: PC utilization among patients with metastatic HCC remains low. Targeted efforts should be enacted to increase the delivery of PC in this group.

Treatment and Survival Disparities of Colon Cancer in the Texas-Mexico Border Population: Cancer Disparities in Border Population.

BACKGROUND: Previous studies have reported healthcare disparities in the Texas-Mexico border population. Our aim was to evaluate treatment utilization and oncologic outcomes of colon cancer patients in this vulnerable population. METHODS: Patients with localized and regional colon cancer (CC) were identified in the Texas Cancer Registry (1995-2016). Clinicopathological data, hospital factors, receipt of optimal treatment, and overall survival (OS) were compared between Texas-Mexico Border (TMB) and the Non-Texas-Mexico Border (NTMB) cohorts. Multivariable analysis was performed to identify risk factors associated with decreased survival. RESULTS: We identified 43,557 patients with localized/regional CC (9% TMB and 91% NTMB). TMB patients were more likely to be Hispanic (73% versus 13%), less likely to have private insurance (13% versus 21%), were more often treated at safety net hospitals (82% versus 22%) and less likely at ACS-CoC accredited hospitals (32% versus 57%). TMB patients were more likely to receive suboptimal treatment (21% versus 16%) and had a lower median OS for localized (8.58 versus 9.58 y) and regional colon cancer (5.75 versus 6.18 y, all P < 0.001). In multivariable analysis, TMB status was not associated with worse OS. Factors associated with worse survival included receipt of suboptimal treatment, Medicare/insured status, and treatment in safety net and non-accredited ACS-CoC hospitals (all P < 0.001) CONCLUSIONS: While TMB CC patients had worse OS, TMB status itself was not found to be a risk factor for decreased survival. This survival disparity is likely associated with higher rate of suboptimal treatment, Medicare/Uninsured status, and decreased access to ACS-CoC accredited hospitals.

One-year mortality in geriatric trauma patients: Improving upon the geriatric trauma outcomes score utilizing the social security death index.

BACKGROUND: Geriatric Trauma Outcomes Score (GTOS) predicts in-patient mortality in geriatric trauma patients and has been validated in a prospective multicenter trial and expanded to predict adverse discharge (GTOS II). We hypothesized that these formulations actually underestimate the downstream sequelae of injury and sought to predict longer-term mortality in geriatric trauma patients. METHODS: The Parkland Memorial Hospital Trauma registry was queried for patients 65 years or older from 2001 to 2013. Patients were then matched to the Social Security Death Index. The primary outcome was 1-year mortality. The original GTOS formula (variables of age, Injury Severity Score [ISS], 24-hour transfusion) was tested to predict 1-year mortality using receiver operator curves. Significant variables on univariate analysis were used to build an optimal multivariate model to predict 1-year mortality (GTOS III). RESULTS: There were 3,262 patients who met inclusion. Inpatient mortality was 10.0% (324) and increased each year: 15.8%, 1 year; 17.8%, 2 years; and 22.6%, 5 years. The original GTOS equation had an area under the curve of 0.742 for 1-year mortality. Univariate analysis showed that patients with 1-year mortality had on average increased age (75.7 years vs. 79.5 years), ISS (11.1 vs. 19.1), lower GCS score (14.3 vs. 10.5), more likely to require transfusion within 24 hours (11.5% vs. 31.3%), and adverse discharge (19.5% vs. 78.2%; p < 0.0001 for all). Multivariate logistic regression was used to create the optimal equation to predict 1-year mortality: (GTOSIII = age + [0.806 × ISS] + 5.55 [if transfusion in first 24 hours] + 21.69 [if low GCS] + 34.36 [if adverse discharge]); area under the curve of 0.878. CONCLUSION: Traumatic injury in geriatric patients is associated with high mortality rates at 1 year to 5 years. GTOS III has robust test characteristics to predict death at 1 year and can be used to guide patient centered goals discussions with objective data. LEVEL OF EVIDENCE: Prognostic, level III.

Effect of fragmentation of cancer care on treatment use and survival in hepatocellular carcinoma.

BACKGROUND: Fragmented cancer care (FC), or care received from multiple institutions, increases systemic health care costs and potentiates cancer care disparities. There is a paucity of data on mechanisms contributing to FC and the resulting effect on patient outcomes. This study characterized patient- and hospital-level factors associated with FC, time to treatment (TTT), and overall survival (OS) in patients with hepatocellular carcinoma (HCC). METHODS: Patients newly diagnosed with HCC from 2004 to 2015 and receiving treatment were identified in the Texas Cancer Registry. Patient- and hospital-level factors were compared across 2 cohorts: an FC treatment group and a nonfragmented cancer care (NFC) treatment group. Covariate-adjusted treatment use and OS were compared between the 2 treatment groups. RESULTS: Among 4329 patients with HCC, 1185 (27.4%) received FC, and 3144 (72.6%) received NFC. Compared with NFC patients, FC patients had larger tumors (median size ≥4 cm, 52.6% vs 35.2%; P < .001), and a higher proportion had a regional/metastatic stage (35.9% vs 26.7%; P < .001). Among patients with localized disease, FC was associated with decreased odds of curative therapy (odds ratio, 0.83; 95% confidence interval [CI], 0.7-0.9). FC was associated with worse OS (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24) and increased TTT (HR, 0.76; 95% CI, 0.7-0.8). In the subset of patients with localized-stage HCC who received curative therapy, FC was associated with worse OS (median survival, 67 vs 43 months; HR, 1.2; 95% CI, 1.0-1.4) and increased TTT (HR, 0.74; 95% CI, 0.7-0.8). CONCLUSIONS: FC patients were less likely to undergo curative therapy when they were diagnosed at an early stage. After covariate adjustment, newly diagnosed patients with HCC receiving FC had worse OS and increased TTT.

Factors associated with lymph node assessment in ductal carcinoma in situ: analysis of 1988-2002 seer data.

BACKGROUND: Ductal carcinoma in situ (DCIS) represents 20-30% of mammographically detected breast cancers, but the role of lymph node assessment (LNA) in women with DCIS remains unclear. METHODS: Using the 1988-2002 Surveillance, Epidemiology, and End Results (SEER) Program data, we conducted a case-control study to identify variables associated with (1) LNA in DCIS patients and (2) use of axillary lymph node dissection (ALND) compared with sentinel lymph node biopsy (SLNB). Using separate multivariable logistic regression models, we identified patient and tumor-related factors associated with LNA (1988-2002) and with the method used (recorded only in 1998-2002). We report adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Of 23,502 women with DCIS, 37% underwent mastectomy and 63% underwent breast-conservation therapy (BCT); 6,650 cases (28%) underwent LNA. Women younger than 80 years (aOR 1.47; 95% CI 1.24-1.75) or who had mastectomy (aOR 11.06; 95% CI 10.30-11.90), tumor size greater than 9 mm (aORs ranged from 1.27-1.97 for 10-mm increments from 10 to 50 mm or more) or poorly differentiated grade (aOR 1.33; 95% CI 1.11-1.55) were more likely to have had a LNA. From 1998 to 2002, 10,637 women underwent resection for DCIS (21% mastectomy; 79% BCT); of these, 2,219 (21%) had LNA (73% mastectomy; 27% BCT). Mastectomy patients were 3.52 times more likely to receive ALND (95% CI 2.71-4.57) than SLNB, after controlling for other factors. CONCLUSION: Optimal guidelines for use of LNA in DCIS have not been defined. However, there appeared to be a persistent and excessive utilization of ALND for LNA in women with DCIS (1998-2002).