Regional and racial variations in the utilization of endoscopic retrograde cholangiopancreatography among pancreatic cancer patients in the United States.

BACKGROUND: Pancreatic cancer is projected to become the second leading cause of cancer-related deaths by 2030. Endoscopic retrograde cholangiopancreatography (ERCP) is recommended as first-line therapy for biliary decompression in pancreatic cancer. The aim of our study was to characterize geographic and racial/ethnic disparities in ERCP utilization among patients with pancreatic cancer. METHODS: Retrospective cohort study using the US Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify patients diagnosed with pancreatic cancer from 2003-2013. The primary outcome was receipt of ERCP, with or without stent placement, vs any non-ERCP biliary intervention. RESULTS: Of the 36 619 patients with pancreatic cancer, 37.5% (n = 13 719) underwent an ERCP, percutaneous drainage, or surgical biliary bypass. The most common biliary intervention (82.6%) was ERCP. After adjusting for tumor location and stage, Blacks were significantly less likely to receive ERCP than Whites (aOR 0.84, 95% CI 0.72, 0.97) and more likely to receive percutaneous transhepatic biliary drainage (PTBD) (aOR 1.38, 95% CI 1.14, 1.66). Patients in the Southeast and the West were more likely to receive ERCP than those in the Northeast (Southeast aOR 1.21, 95% CI 1.04, 1.40; West aOR 1.16, 95% CI 1.01, 1.32). CONCLUSION: Racial/ethnic and geographic disparities in access to biliary interventions including ERCP exist for patients with pancreatic cancer in the United States. Our results highlight the need for further research and policies to improve access to appropriate biliary intervention for all patients.

Neighborhood Socioeconomic Disadvantage and Care After Myocardial Infarction in the National Cardiovascular Data Registry.

BACKGROUND: Patients living in disadvantaged neighborhoods are at high risk for adverse outcomes after acute myocardial infarction (MI). Whether residential socioeconomic status (SES) is associated with quality of in-hospital care among patients presenting with MI is unclear. METHODS AND RESULTS: Multivariable logistic regression was used to examine the relationship between SES, quality of care, and in-hospital cardiovascular outcomes among patients with MI from diverse SES neighborhoods from July 2008 to December 2013, at 586 participating hospitals in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines quality improvement program. Patients were categorized according to which SES summary measure group they resided in through linkage with US census block data. Outcomes were in-hospital mortality and major adverse cardiovascular events. Quality of MI care was assessed with the defect-free care measure that delineates the proportion of eligible patients who received all acute and discharge guideline-recommended therapies. Among 390 692 patients, there was a substantially longer median arrival-to-angiography time in lower SES neighborhoods (lowest 8.0 hours, low 5.5 hours, medium 4.8 hours, high 4.5 hours, highest 3.4 hours; P<0.0001), and a higher proportion of ST-segment-elevation myocardial infarction patients treated with fibrinolysis (lowest 23.1%, low 20.2%, medium 18.0%, high 14.2%, highest 5.9%; P<0.0001). However, after adjustment for clinical risk factors, insurance status, and hospital characteristics, socioeconomic disadvantage was not associated with lower rates of guideline-recommended defect-free acute care. Patients presenting from more disadvantaged neighborhoods had a progressively higher independent risk of in-hospital mortality (Pglobal=0.03) and major bleeding (Pglobal<0.001), along with lower quality of discharge care. CONCLUSIONS: In this national registry of MI, patients living in the most disadvantaged neighborhoods received equitable in-hospital care compared with advantaged neighborhoods. However, they experienced substantial delays in receiving angiography. Furthermore, patients living in disadvantaged neighborhoods remain at higher risk of adverse in-hospital outcomes after MI, including mortality. These observations suggest there are further opportunities for improvement in acute and discharge MI care.

Accessibility of family planning services: impact of structural and organizational factors.

OBJECTIVES: This study sought to determine whether selected structural and organizational characteristics of publicly available family planning facilities are associated with greater availability. METHODS: A survey was sent to 726 publicly available family planning facilities in four states. These included local health departments, federally qualified health centers (FQHC), Planned Parenthood sites, hospital outpatient departments, and freestanding women's health centers. Usable responses were obtained from 526 sites for a response rate of 72.5%. Availability variables included the provision of primary care services; the contraceptives offered; professional staffing; scheduling, waiting time, and transportation; and cultural congruence and competency. The structural and organizational variables were state, type of organization, and funding source. RESULTS: Some states were more likely to offer emergency contraception while others were more likely to have weekend hours. FQHCs were most likely to provide primary care and Planned Parenthood sites most likely to offer emergency contraception. Title X funding was associated with increased likelihood of providing emergency contraception and staffing by midlevel practitioners and registered nurses. CONCLUSIONS: This study found that availability varied by structural and organizational variables, many of which are determined by federal and state policies. Revising some of these policies might increase utilization of family planning facilities.