Understanding Disparities in Receipt of Complex Gastrointestinal Cancer Surgery at a Small Geographic Scale.

OBJECTIVE: To define neighborhood-level disparities in the receipt of complex cancer surgery. BACKGROUND: Little is known about the geographic variation of receipt of surgery among patients with complex gastrointestinal (GI) cancers, especially at a small geographic scale. METHODS: This study included individuals diagnosed with 5 invasive, nonmetastatic, complex GI cancers (esophagus, stomach, pancreas, bile ducts, liver) from the Ohio Cancer Incidence Surveillance System during 2009 and 2018. To preserve patient privacy, we combined US census tracts into the smallest geographic areas that included a minimum number of surgery cases (n=11) using the Max-p-regions method and called these new areas "MaxTracts." Age-adjusted surgery rates were calculated for MaxTracts, and the Hot Spot analysis identified clusters of high and low surgery rates. US Census and CDC PLACES were used to compare neighborhood characteristics between the high- and low-surgery clusters. RESULTS: This study included 33,091 individuals with complex GI cancers located in 1006 MaxTracts throughout Ohio. The proportion in each MaxTract receiving surgery ranged from 20.7% to 92.3% with a median (interquartile range) of 48.9% (42.4-56.3). Low-surgery clusters were mostly in urban cores and the Appalachian region, whereas high-surgery clusters were mostly in suburbs. Low-surgery clusters differed from high-surgery clusters in several ways, including higher rates of poverty (23% vs. 12%), fewer married households (40% vs. 50%), and more tobacco use (25% vs. 19%; all P <0.01). CONCLUSIONS: This improved understanding of neighborhood-level variation in receipt of potentially curative surgery will guide future outreach and community-based interventions to reduce treatment disparities. Similar methods can be used to target other treatment phases and other cancers.

Geographic Variation and Risk Factor Association of Early Versus Late Onset Colorectal Cancer.

The proportion of patients diagnosed with colorectal cancer (CRC) at age < 50 (early-onset CRC, or EOCRC) has steadily increased over the past three decades relative to the proportion of patients diagnosed at age ≥ 50 (late-onset CRC, or LOCRC), despite the reduction in CRC incidence overall. An important gap in the literature is whether EOCRC shares the same community-level risk factors as LOCRC. Thus, we sought to (1) identify disparities in the incidence rates of EOCRC and LOCRC using geospatial analysis and (2) compare the importance of community-level risk factors (racial/ethnic, health status, behavioral, clinical care, physical environmental, and socioeconomic status risk factors) in the prediction of EOCRC and LOCRC incidence rates using a random forest machine learning approach. The incidence data came from the Surveillance, Epidemiology, and End Results program (years 2000-2019). The geospatial analysis revealed large geographic variations in EOCRC and LOCRC incidence rates. For example, some regions had relatively low LOCRC and high EOCRC rates (e.g., Georgia and eastern Texas) while others had relatively high LOCRC and low EOCRC rates (e.g., Iowa and New Jersey). The random forest analysis revealed that the importance of community-level risk factors most predictive of EOCRC versus LOCRC incidence rates differed meaningfully. For example, diabetes prevalence was the most important risk factor in predicting EOCRC incidence rate, but it was a less important risk factor of LOCRC incidence rate; physical inactivity was the most important risk factor in predicting LOCRC incidence rate, but it was the fourth most important predictor for EOCRC incidence rate. Thus, our community-level analysis demonstrates the geographic variation in EOCRC burden and the distinctive set of risk factors most predictive of EOCRC.

What Critical Ethical Values Guide Strategic Planning Processes in Health Care Organizations?

This case explores a fictitious hospital's use of co-creation to make a decision about redesign of inpatient units as a first step in incorporating stakeholder input into creation of governing policies. We apply a "procedural fairness" framework to reveal that conditions required for an ethical decision about space redesign were not met by using clinician and patient focus groups to obtain stakeholder input. In this article, we identify epistemic injustices resulting from this process that could undermine confidence in leadership decisions. Suggestions are offered for incorporating stakeholder input going forward that address prior shortcomings. The result should be conditions that are perceived as procedurally fair and decisions that engender confidence in institutional leadership.

Suicide in Jail: A Ten-Year Retrospective Study.

Suicide in jails, like all death in custody, may involve complicated investigation. Allegations of mistreatment and/or abuse may be raised and these possibilities need to be addressed. Apart from these investigative concerns, the occurrence of suicides in such a controlled environment raises additional questions about potential preventative measures. Between 2004 and 2014, there were ten deaths of incarcerated individuals in Cuyahoga County (metropolitan Cleveland) Ohio. Most (80%) were white and all were male. Similar to previous reviews, the majority of decedents hanged themselves (90%), with one case of asphyxiation by airway obstruction with a foreign body. Psychiatric disorders were noted in six of ten decedents while seven of ten had a history of substance abuse including alcoholism. Overall, nine of ten had at least one of these disorders. All suicide deaths occurred within one year of incarceration, which may reflect the absence of a long-term prison fatality in our county. It is noteworthy that 70% of deaths occurred within the first month of incarceration with four of ten events occurring in less than a day including two deaths in less than 30 minutes. Positive toxicology for abused substances was noted in 75% (three) of the four individuals who died in less than a day and only in one other suicide, which occurred on the second day of incarceration. Our data suggest that suicide in jail is predominantly a male phenomenon, with early incarceration being a particularly vulnerable period. The presence of another inmate in the same cell as the decedent was not seen to have an independent deterrent effect. Intoxication, particularly in individuals with a history of substance abuse and/or alcoholism, should raise concern for potential self-harm in recently jailed individuals. Possible interventions suggested by this study might include closer direct surveillance in the early incarceration period, earlier access to mental health services as well as design modifications in holding cells with possible dedicated short-term holding areas where self-harm risks are minimized and surveillance can be optimized.