Investigating Deferral Rates in Cochlear Implantation: How Often Do Candidates Defer and Why?

OBJECTIVE: Evaluate the rate at which cochlear implant (CI) candidates decline surgery and identify associated factors. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Four hundred ninety-three CI candidates from July 1989 to December 2020 with complete demographic and socioeconomic data. INTERVENTIONS: Diagnostic. MAIN OUTCOME MEASURES: Age, sex, race, marital and employment status, median household income percentile, distance-to-CI-center, and residence in a medically underserved county. RESULTS: Of the 493 CI candidates included, 80 patients (16.2%) declined surgery. Based on chart checking, the most common reason patients did not receive the implant was due to loss of follow-up (38%). African American patients were 73% less likely to undergo implantation compared with White patients (odds ratio [OR], 0.27 [0.11-0.68]; p = 0.005). Asian patients were 95% less likely to undergo implantation (OR, 0.05 [0.009-0.25]; p = 0.0003) compared with White patients. For every 1-year age increase, patients were 4% less likely to undergo implantation (OR, 0.96 [0.94-0.98]; p < 0.0001) and for every 10-year age increase, the patients were 33% less likely. Compared with their single counterparts, married patients were more likely to undergo implantation (OR, 1.87 [1.12-3.15]; p = 0.02). No differences were observed when comparing implanted and nonimplanted CI candidates in sex, employment status, distance-to-CI-center, or median family income percentile. A χ2 test of independence showed no association between receiving CIs and living in medically underserved counties ( χ2 = 2; N = 493; 0.3891; p = 0.53). CONCLUSIONS: Not infrequently, CI candidates decline surgery. Although demographic factors (race, age, and marital status) were associated with the cochlear implantation decision, socioeconomic factors (median family income and residence in a medically underserved community) were not. Perhaps cultural components of a patient's race have a larger impact on whether or not the patients get implanted.

County characteristics associated with refusing breast cancer surgery: Evidence from the Surveillance, Epidemiology, and End Results program.

BACKGROUND: Individuals' communities impact cancer disparities and are intimately related to social determinants of health. Studies show that personal factors affect treatment refusals for a potentially curable cancer, but few studies have investigated whether community-based characteristics affect the receipt of surgery. METHODS: We used Surveillance Epidemiology and End Results Program registries from 2010 to 2015 to examine differences in rates of surgery refusal among non-Hispanic White, non-Hispanic Black, and Hispanic women diagnosed with nonmetastatic breast cancer. The community factor measures were based on county-level factors. Sociodemographic and community differences were analyzed using Pearson's χ2 tests and analysis of variance. Multivariate logistic regression of predictors of surgery refusal and the Cox proportional hazard model of disease-specific mortality were performed. RESULTS: Surgery refusers among non-Hispanic Black and Hispanic all races lived in counties with lower rates of educational attainment, median family and household income, and higher rates of poverty, unemployment, foreign-born, language isolation, urban population, and women more than 40 years old having mammography in last 2 years. Multivariate analysis shows surgery refusal rates increased in counties having a high percentage of urban population and declined in counties with an increased percentage of less than high school level education, unemployment, and median household income. Breast cancer-specific mortality increased significantly with surgery refusal. CONCLUSION: Residence in counties with the lowest socioeconomic status and disproportionately populated by racial and ethnic minorities is associated with surgery refusal. Given the high mortality associated with refusing surgery, culturally sensitive education on the benefits of care may be appropriate.

Disparities in refusal of surgery for gynecologic cancer.

OBJECTIVE: To identify sociodemographic and clinical factors associated with refusal of gynecologic cancer surgery and to estimate its effect on overall survival. METHODS: The National Cancer Database was surveyed for patients with uterine, cervical or ovarian/fallopian tube/primary peritoneal cancer treated between 2004 and 2017. Univariate and multivariate logistic regression were used to assess associations between clinico-demographic variables and refusal of surgery. Overall survival was estimated using the Kaplan-Meier method. Trends in refusal over time were evaluated using joinpoint regression. RESULTS: Of 788,164 women included in our analysis, 5875 (0.75%) patients refused surgery recommended by their treating oncologist. Patients who refused surgery were older at diagnosis (72.4 vs 60.3 years, p < 0.001) and more likely Black (OR 1.77 95% CI 1.62-1.92). Refusal of surgery was associated with uninsured status (OR 2.94 95% CI 2.49-3.46), Medicaid coverage (OR 2.79 95% CI 2.46-3.18), low regional high school graduation (OR 1.18 95% CI 1.05-1.33) and treatment at a community hospital (OR 1.59 95% CI 1.42-1.78). Patients who refused surgery had lower median overall survival (1.0 vs 14.0 years, p < 0.01) and this difference persisted across disease sites. Between 2008 and 2017, there was a significant increase in refusal of surgery annually (annual percent change +1.41%, p < 0.05). CONCLUSIONS: Multiple social determinants of health are independently associated with refusal of surgery for gynecologic cancer. Given that patients who refuse surgery are more likely from vulnerable, underserved populations and have inferior survival, refusal of surgery should be considered a surgical healthcare disparity and tackled as such.

Discharge against medical advice in Special Care Newborn Unit in Chattogram, Bangladesh: Prevalence, causes and predictors.

INTRODUCTION: Discharge against medical advice (DAMA) is an unexpected event for patients and healthcare personnel. The study aimed to assess the prevalence of DAMA in neonates along with characteristics of neonates who got DAMA and, causes and predictors of DAMA. METHODS AND FINDINGS: This case-control study was carried out in Special Care Newborn Unit (SCANU) at Chittagong Medical College Hospital from July 2017 to December 2017. Clinical and demographic characteristics of neonates with DAMA were compared with that of discharged neonates. The causes of DAMA were identified by a semi-structured questionnaire. Predictors of DAMA were determined using a logistic regression model with a 95% confidence interval. A total of 6167 neonates were admitted and 1588 got DAMA. Most of the DAMA neonates were male (61.3%), term (74.7%), outborn (69.8%), delivered vaginally (65.7%), and had standard weight at admission (54.3%). A significant relationship (p < 0.001) was found between the variables of residence, place of delivery, mode of delivery, gestational age, weight at admission, and day and time of outcome with the type of discharge. False perceptions of wellbeing (28.7%), inadequate facilities for mothers (14.5%), and financial problems (14.1%) were the prevalent causes behind DAMA. Predictors of DAMA were preterm gestation (AOR 1.3, 95% CI 1.07-1.7, p = 0.013), vaginal delivery (AOR 1.56, 95% CI 1.31-1.86, p < 0.001), timing of outcome after office hours (AOR 477.15, 95% CI 236-964.6, p < 0.001), and weekends (AOR 2.55, 95% CI 2.06-3.17, p < 0.001). Neonates suffering from sepsis (AOR 1.4, 95% CI 1.1-1.7, p< 0.001), Respiratory Distress Syndrome (AOR 3.1, 95% CI 1.9-5.2, p< 0.001), prematurity without other complications (AOR 2.1, 95% CI 1.45-3.1, p < 0.001) or who were referred from north-western districts (AOR 1.48, 95% CI 1.13-1.95, p = 0.004) had higher odds for DAMA. CONCLUSIONS: Identification of predictors and reasons behind DAMA may provide opportunities to improve the hospital environment and service related issues so that such vulnerable neonates can complete their treatment. We should ensure better communication with parents, provide provision for mothers' corner, especially for outborn neonates, maintain a standard ratio of neonates and healthcare providers, and adopt specific DAMA policy by the hospital authority.

Medical avoidance among marginalized groups: the impact of the COVID-19 pandemic.

Medical avoidance is common among U.S. adults, and may be emphasized among members of marginalized communities due to discrimination concerns. In the current study, we investigated whether this disparity in avoidance was maintained or exacerbated during the onset of the COVID-19 pandemic. We assessed the likelihood of avoiding medical care due to general-, discrimination-, and COVID-19-related concerns in an online sample (N = 471). As hypothesized, marginalized groups (i.e., non-White race, Latinx/e ethnicity, non-heterosexual sexual orientation, high BMI) endorsed more general- and discrimination-related medical avoidance than majoritized groups. However, marginalized groups were equally likely to seek COVID-19 treatment as majoritized groups. Implications for reducing medical avoidance among marginalized groups are discussed.

Postoperative Radiation Therapy Refusal in Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVES/HYPOTHESIS: Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a distinct clinical entity with good prognosis, unique demographics, and a trend toward treatment deintensification. Patients with this disease may opt out of recommended postoperative radiation therapy (PORT) for a variety of reasons. The aim of this paper was to examine factors that predict patient refusal of recommended PORT in HPV-associated OPSCC, and the association of refusal with overall survival. STUDY DESIGN: Retrospective population-based cohort study of patients in the National Cancer Database. METHODS: We conducted a retrospective cohort study of patients in the National Cancer Database diagnosed with OPSCC between January 2010 and December 2015. We primarily assessed overall survival and the odds of refusing PORT based on demographic, socioeconomic, and clinical factors. Analysis was conducted using multivariable logistic regression and multivariable Cox proportional hazards model. RESULTS: A total of 4229 patients were included in the final analysis, with 156 (3.7%) patients opting out of recommended PORT. On multivariable analysis, patient refusal of PORT was independently associated with a variety of socioeconomic factors such as race, insurance status, comorbidity, treatment at a single facility, and margin status. Lastly, PORT refusal was associated with significantly lower overall survival compared to receipt of recommended PORT (hazard ratio 1.69, confidence interval 1.02-2.82). CONCLUSIONS: Patient refusal of recommended PORT in HPV-associated OPSCC is rare and associated with variety of disease and socioeconomic factors. PORT refusal may decrease overall survival in this population. Our findings may help clinicians when counseling patients and identifying those who may be more likely to opt out of recommended adjuvant therapy. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:339-348, 2022.

Perfil de caries de la infancia temprana / Profile of early childhood caries

La Caries de la Infancia Temprana (CIT) se ha descrito como una patología de origen multifactorial en niños hasta los 71 meses de edad. Se considera como Ca-ries de la Infancia Temprana Severa (CITS) cuando a los 3 años el índice ceod es ≥ 4; a los 4 años, ≥ 5, y a los 5 años ≥ 6. La rehabilitación de las lesiones provo-cadas por esta patología puede ser compleja debido a la calidad y cantidad de estructura remanente y a la edad de los pacientes afectados. Objetivos: Estimar la frecuencia de CIT y CITS en niños menores a 72 me-ses que concurrieron para su atención, e identificar el tipo de práctica realizada, y la adhesión al trata-miento. Métodos: Diseño retrospectivo observacional sobre las historias clínicas de pacientes menores a 72 meses asistidos por los cursantes de la Especiali-zación en Odontopediatría, entre febrero 2021 y julio 2022. Resultados: La muestra quedó constituida por 101 niños, de 46+13,5 meses. El 91% presentó CITS. La totalidad de los pacientes mantuvieron lactancia nocturna prolongada después del año, siendo en el 72,3% a libre demanda durante el sueño, en un perío-do de 23+6 meses. Se registró un total de 1010 lesio-nes de caries. El 29,3% de los pacientes abandonaron el tratamiento. Conclusiones: La mayor parte de los niños presentaron Caries de la Infancia Temprana Severa, con altos valores de patología y lactancia noc-turna prolongada a libre demanda después del año Los tratamientos recomendados en estos casos son muy prolongados y requieren de prácticas invasivas, complejas y de alto costo, lo que provoca el abandono del tratamiento (AU)

Early childhood caries (ECC) is defined as a multifactorial disease in children 71 months of age or younger. When the dmft index is ≥4 (age 3), ≥5 (age 4), or ≥6 (age 5) it is referred to as Severe early childhood caries (SECC). Management of ECC is complex due to the quality and quantity of remaining structure of teeth at an early age. Objectives: To estimate the frequency of ECC and SECC in children < 72 months of age undergoing comprehensive treatment, to identify the type of treatment provided and treatment compliance. Methods: Retrospective observational design on dental records of patients under 72 months of age treated by Pediatric Dentistry Specialty Program students between February 2021 and July 2022. Results: The sample included 101 children, mean age 46+13.5 months, 91% of patients with SECC. All patients were fed nightly for over 1 year, 72.3% of whom were fed nightly on demand over a period of 23±6 months. A total of 1010 caries lesions were detected. 29.3% of children discontinued treatment. Conclusions: Most of the children presented severe early childhood caries with high values of pathology and prolonged nocturnal breastfeeding on demand after one year. The recommended treatments in these cases are very long and require invasive, complex and expensive practices, which causes abandonment of the treatment (AU)

Hepatitis C diagnosis and treatment in people who use drugs: mind the gap in the linkage to care.

OBJECTIVE: The objective of this study is to identify a simplified rapid screening and linkage-to-care model for HCV among PWUD. PATIENTS AND METHODS: The study stems from a collaborative project bringing together two local Italian Centers for Drug Addiction and the Hepatology-Infectious Diseases Department of Lazzaro Spallanzani. A research physician analyzed the available medical records seeking to identify HCV and HIV infected patients in care in the addiction centers. Between March 2018 and January 2020 subjects were selected from among a cohort of 720 PWUD in the two Centers' care. The study comprises three steps: first, screening for HCVAb; second, the linkage to care; third, clinical assessment to treatment. The research physician recruited patients for the first two steps directly in their local addiction center. The third step was conducted in the Spallanzani. The characteristics of those subjects who adhered to the three-step study program were then compared to those of the non-adhering PWUD. RESULTS: 194 were known HCVAb positive patients. Of the 505 PWUD in the care of the two Centers eligible for screening, 364 were enrolled in the study. 144 resulted HCVAb positive. 269 were tested for HCVRNA. 101 underwent a full assessment. 96 patients started antiviral therapy with DAA. Patients who refused first step screening were older patients and mainly heroin users; in the second step, almost all the HIV/HCV co-infected patients agreed to a viremia test; in the third step all the HIV/HCV co-infected patients refused HCV treatment. CONCLUSIONS: The study suggests an on-site specialist approach conducted directly in the addiction centers themselves starting from screening; it can bring the goal of HCV PWUD microelimination closer.

Assessment of Communication Strategies for Mitigating COVID-19 Vaccine-Specific Hesitancy in Canada.

Importance: Ensuring widespread uptake of available COVID-19 vaccinations, each with different safety and efficacy profiles, is essential to combating the unfolding pandemic. Objective: To test communication interventions that may encourage the uptake of less-preferred vaccines. Design, Setting, and Participants: This online survey was conducted from March 24 to 30, 2021, using a nonprobability convenience sample of Canadian citizens aged 18 years or older, with quota sampling to match 2016 Canadian Census benchmarks on age, gender, region, and language. Respondents completed a 2-by-2-by-2 factorial experiment with random assignment of brand (AstraZeneca or Johnson & Johnson), information about the vaccine's effectiveness against symptomatic infection (yes or no), and information about the vaccine's effectiveness at preventing death from COVID-19 (yes or no) before being asked about their willingness to receive their assigned vaccine and their beliefs about its effectiveness. Exposures: Respondents were randomly assigned a vaccine brand (AstraZeneca or Johnson & Johnson) and information about the vaccine's effectiveness against symptomatic COVID-19 infection (yes or no) and at preventing death from COVID-19 (yes or no). Main Outcomes and Measures: Respondents' self-reported likelihood of taking their assigned vaccine if offered (response categories: very likely, somewhat likely, not very likely, or not at all likely, scaled 0-1) and their beliefs about their assigned vaccine's effectiveness (response categories: very effective, somewhat effective, not very effective, or not at all effective, scaled 0-1) were measured. Results: A total of 2556 Canadian adults responded to the survey (median [IQR] age, 50 [34-63] years; 1339 women [52%]). The self-reported likelihood of taking an assigned AstraZeneca or Johnson & Johnson vaccine was higher for respondents given information about their assigned vaccine's effectiveness at preventing death from COVID-19 (b, 0.04; 95% CI, 0.01 to 0.06) and lower among those given information about its overall effectiveness at preventing symptomatic transmission (b, -0.03; 95% CI, -0.05 to 0.00), compared with those who were not given the information. Perceived effectiveness was also higher among those given information about their assigned vaccine's effectiveness at preventing death from COVID-19 (b, 0.03; 95% CI, 0.01 to 0.05) and lower among those given information about their assigned vaccine's overall efficacy at preventing symptomatic infection (b, -0.05; 95% CI, -0.08 to -0.03), compared with those who were not given this information. The interaction between these treatments was neither substantively nor statistically significant. Conclusions and Relevance: These findings suggest that providing information on the effectiveness of less-preferred vaccines at preventing death from COVID-19 is associated with more confidence in their effectiveness and less vaccine-specific hesitancy. These results can inform public health communication strategies to reduce hesitancy toward specific COVID-19 vaccines.

Factors Associated With Voluntary Refusal of Emergency Medical System Transport for Emergency Care in Detroit During the Early Phase of the COVID-19 Pandemic.

Importance: Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown. Objective: To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths. Design, Setting, and Participants: A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression. Exposures: A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions. Main Outcomes and Measures: Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability. Results: A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir). Conclusions and Relevance: In this cohort study, EMS transport refusals increased with the COVID-19 outbreak's peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.

A Retrospective Investigation of Neuraxial Anesthesia Rates for Elective Cesarean Delivery Before and During the SARS-CoV-2 Pandemic.

BACKGROUND: Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries. OBJECTIVES: To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic. METHODS: We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications. RESULTS: We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001). CONCLUSIONS: We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition.

[The reasons for refusal and abandonment of treatment in the emergency surgery at the University Hospital Center of Bouake, Ivory Coast]. / Les raisons du refus et abandon de soins aux urgences chirurgicales du Centre Hospitalier et Universitaire de Bouaké, Côte d'Ivoire.

The refusal and abandonment of treatment is a behavior frequently observed in our daily practice. The purpose of this study was to describe the epidemiology and to identify the reasons for refusals and abandonment of treatment. We conducted a prospective study in the emergency surgery at the University Hospital Center of Bouake from 1st January 2018 to 31st December 2018. It involved all patients admitted with traumatic lesions who had refused or abandoned treatment. Data from 106 cases (16%) of refusal and abandonment of treatment out of 662 cases admitted with limb traumas were examined over this period. The average age of patients was 37 years. The study enrolled 77 men (72.6%). Tertiary sector workers accounted for 56.6% (n= 60) of cases. Lesions were dominated by closed fractures (82.1%; n= 87) and pelvic limbs were the most achieved (78.3%; n=83). Treatment was based on surgery (n=85; 80.2% ) and orthopaedic treatment (n=21; 19.8%). The cost of orthopedic treatment was estimated at 26 500 CFA francs (40 euros) while at 250 000 FCFA (380 euros) for surgical treatment. These costs varied as a function of implant prescribed and its location. Refusal of tratment was expressed by patients (n=30; 28.3%) and by parents (n=76; 71.7%). Reported reasons were dominated by financial problems (n=62; 58.5%), trust in traditional medicine (n=42; 39.6%), religious belief (n=2; 1.9%). The average time of refusal was 22 hours. Eighty eight point seven percent (n=94) of patients signed discharge while 11.3% (n=12) escaped. Refusal of care is a recurrent theme in our context and is due to inadequate health care management of people with limited financial resources.

Treatment abandonment and refusal among children with central nervous system tumors in Jordan.

BACKGROUND: Treatment abandonment and refusal are reported to contribute significantly to poor survival of children with cancer in low- and middle-income countries. We aimed to assess this phenomenon among children diagnosed with central nervous system (CNS) tumors in Jordan. METHODS: We retrospectively reviewed the medical charts of children <18 years diagnosed with CNS tumors (2010-2020). Patients who abandoned or refused part of treatment were reviewed for their clinical characteristics, social circumstances, and possible reasons. We excluded patients referred for second opinion, radiotherapy only, or who traveled abroad for treatment. RESULTS: Four hundred seventy-three Jordanian children were identified; 12 families (2.5%) abandoned treatment, and 15 refused part of therapy (3%). Most patients were females (67%) and most had good or moderate performance status (89%). Most families (93%) lived within 2 hours from King Hussein Cancer Center. Most parents were university graduates (71%) and all fathers were employed, while 71% of mothers were housewives. The most common reasons to abandon or refuse therapy were treatment intensity in view of poor tumor outcome or bad quality of life, conflicting recommendations from other health care providers, "personal beliefs" against chemotherapy, and preference to use alternative medicine. CONCLUSIONS: Treatment abandonment and refusal in Jordanian children with CNS tumors is low. Universal cancer insurance, high level of education in the country, centralized cancer care in one institution, and the twinning program likely contributed to our low incidence. Improving knowledge on CNS tumors and better community rehabilitation and supportive services may help further decrease the abandonment and treatment refusal rate.

Factors Associated With Treatment Refusal and Impact of Treatment Refusal on Survival of Patients With Small Cell Lung Cancer.

BACKGROUND: With fewer than 7% of patients with small cell lung cancer (SCLC) surviving 5 years after diagnosis, the receipt of recommended treatment is of utmost importance for patient survival. Nevertheless, treatment refusal by patients with SCLC has not been studied well. Our study examined factors associated with treatment refusal and the effect of refusal on patient survival. METHODS: From the National Cancer Database, we analyzed data of 107,988 patients with SCLC diagnosed between 2003 and 2012. Treatment refusals were analyzed separately for chemoradiotherapy among patients with limited stage disease (LS-SCLC) and chemotherapy among those with extensive stage disease (ES-SCLC). We used logistic regression to investigate factors associated with treatment refusal. We estimated survival probability using the Kaplan-Meier method and compared survival of those who received and refused treatment using Cox proportional hazards regression analysis. RESULTS: The refusal rates of chemoradiotherapy among patients with LS-SCLC and chemotherapy among those with ES-SCLC were 1.34% and 4.70%, respectively. From 2003 to 2012, trends show an increase of refusals, especially among the patients with ES-SCLC who were recommended chemotherapy. Multivariable analyses showed that in both SCLC groups, older age at diagnosis (>70 years), female gender, uninsured status, and presence of comorbidities were associated with treatment refusals. Patients with LS-SCLC who refused chemoradiotherapy had a higher risk of mortality than those who received treatment (HR, 4.96; 95% CI, 4.45-5.53); the median survival of those who refused treatment was 3 months vs 18 months for those who received it (P < .001). Similarly, patients with ES-SCLC who refused chemotherapy had a higher risk of mortality than those who received treatment (HR, 3.69; 95% CI, 3.48-3.92); the median survival was 1 month vs 7 months, respectively (P < .001). CONCLUSIONS: Treatment refusal among patients with SCLC was associated with worse survival. Strategies to increase patient acceptance of the recommended treatment need to be studied further.

United States' Performance on Emergency Department Throughput, 2006 to 2016.

STUDY OBJECTIVE: Studies of early data found that US emergency departments (EDs) were characterized by prolonged patient waiting, long visit times, frequent and prolonged boarding (ie, patients kept waiting in ED hallways or other space outside the ED on admission to the hospital), and patients leaving without receiving or completing treatment. We sought to assess recent trends in ED throughput nationally. METHODS: This was a retrospective cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2006 to 2016. We used survey-weighted generalized linear models to assess changes over time. The primary outcome variables were the number of visits, wait time to consult a physician, length of visit (time from arrival to leaving for home or hospital ward), boarding time, the proportion of patients leaving without being seen, the proportion treated within recommended waiting times, and the proportion dispositioned within 4, 6, and 8 hours. RESULTS: Between 2006 and 2016, the number of ED visits increased from 119.2 million to 145.6 million. During this period, annual median wait time decreased from 31 minutes (interquartile range 14 to 67) to 17 minutes (interquartile range 6 to 45). The proportion of patients who left without being seen declined from 2.0% (95% confidence interval [CI] 1.7% to 2.4%) to 1.1% (95% CI 0.8% to 1.4%). The proportion treated by a qualified practitioner within recommended waiting times increased from 75.5% (95% CI 72.7% to 78.3%) to 80.8% (95% CI 77.2% to 84.4%). Overall, there was no statistically significant change in median length of visit. However, over time, decreased proportions of the sickest patients were discharged within 4, 6, and 8 hours, whereas increased proportions of low-acuity patients were discharged within 4 hours. The distribution of patient boarding time remained fairly unchanged from 2009 to 2015, with a median of approximately 75 minutes. CONCLUSION: Overall, there was improvement in ED timeliness from 2006 to 2016. However, we observed a decrease in the proportion of the sickest patients discharged within 8 hours of arrival, although this may be due to increased ancillary testing or specially consultation over time.

Emergency Department Patients Who Leave Before Treatment Is Complete.

INTRODUCTION: Emergency department (ED) patients who leave before treatment is complete (LBTC) represent medicolegal risk and lost revenue. We sought to examine LBTC return visits characteristics and potential revenue effects for a large healthcare system. METHODS: This retrospective, multicenter study examined all encounters from January 1-December 31, 2019 at 18 EDs. The LBTC patients were divided into left without being seen (LWBS), defined as leaving prior to completed medical screening exam (MSE), and left subsequent to being seen (LSBS), defined as leaving after MSE was complete but before disposition. We recorded 30-day returns by facility type including median return hours, admission rate, and return to index ED. Expected realization rate and potential charges were calculated for each patient visit. RESULTS: During the study period 626,548 ED visits occurred; 20,158 (3.2%) LBTC index encounters occurred, and 6745 (33.5%) returned within 30 days. The majority (41.7%) returned in <24 hours with 76.1% returning in 10 days and 66.4% returning to index ED. Median return time was 43.3 hours, and 23.2% were admitted. Urban community EDs had the highest 30-day return rate (37.8%, 95% confidence interval, 36.41-39.1). Patients categorized as LSBS had longer median return hours (66.0) and higher admission rates (29.8%) than the LWBS cohort. There was a net potential realization rate of $9.5 million to the healthcare system. CONCLUSION: In our system, LSBS patients had longer return times and higher admission rates than LWBS patients. There was significant potential financial impact for the system. Further studies should examine how healthcare systems can reduce risk and financial impacts of LBTC patients.

COVID-19 Vaccine Hesitancy in Canada: Content Analysis of Tweets Using the Theoretical Domains Framework.

BACKGROUND: With the approval of two COVID-19 vaccines in Canada, many people feel a sense of relief, as hope is on the horizon. However, only about 75% of people in Canada plan to receive one of the vaccines. OBJECTIVE: The purpose of this study is to determine the reasons why people in Canada feel hesitant toward receiving a COVID-19 vaccine. METHODS: We screened 3915 tweets from public Twitter profiles in Canada by using the search words "vaccine" and "COVID." The tweets that met the inclusion criteria (ie, those about COVID-19 vaccine hesitancy) were coded via content analysis. Codes were then organized into themes and interpreted by using the Theoretical Domains Framework. RESULTS: Overall, 605 tweets were identified as those about COVID-19 vaccine hesitancy. Vaccine hesitancy stemmed from the following themes: concerns over safety, suspicion about political or economic forces driving the COVID-19 pandemic or vaccine development, a lack of knowledge about the vaccine, antivaccine or confusing messages from authority figures, and a lack of legal liability from vaccine companies. This study also examined mistrust toward the medical industry not due to hesitancy, but due to the legacy of communities marginalized by health care institutions. These themes were categorized into the following five Theoretical Domains Framework constructs: knowledge, beliefs about consequences, environmental context and resources, social influence, and emotion. CONCLUSIONS: With the World Health Organization stating that one of the worst threats to global health is vaccine hesitancy, it is important to have a comprehensive understanding of the reasons behind this reluctance. By using a behavioral science framework, this study adds to the emerging knowledge about vaccine hesitancy in relation to COVID-19 vaccines by analyzing public discourse in tweets in real time. Health care leaders and clinicians may use this knowledge to develop public health interventions that are responsive to the concerns of people who are hesitant to receive vaccines.

Refusal of cancer-directed surgery in male breast cancer.

ABSTRACT: It has been reported that some male breast cancer patients may refuse the recommended surgery, but the incidence rate in the United States is not clear. The purpose of this study was to identify the incidence, trends, risk factors, and eventual survival outcomes associated with the rejection of such cancer-directed surgery.We collected data on 5860 patients with male breast cancer (MBC) from the Surveillance, Epidemiology, and End Results database, including 50 patients refusing surgery as recommended. Kaplan-Meier survival analysis and Cox proportional hazard regression were used to identify the effects of refusing surgery on cancer-specific survival (CSS) and overall survival (OS). The association between acceptance or rejection of surgery and mortality were estimated by nested Cox proportional hazards regression models with adjustment for age, race, clinical characteristics, and radiation.Of the 5860 patients identified, 50 (0.9%) refused surgery. Old age (≥65: hazard ratio [HR]: 3.056, 95% confidence interval [CI]: 1.738-5.374, P < .0001), higher AJCC stage (III: HR: 3.283, 95% CI: 2.134-5.050, P < .0001, IV: HR: 14.237, 95% CI: 8.367-24.226, P < .0001), progesterone receptor status (negative: HR: 1.633, 95% CI: 1.007-2.648, P = .047) were considered risk factors. Compared with the surgery group, the refusal group was associated with a poorer prognosis in both OS and CSS (χ2 = 94.81, P < .001, χ2 = 140.4, P < .001). Moreover, significant differences were also observed in OS and CSS among 1:3 matched groups (P = .0002, P < .001).Compared with the patients undergoing surgery, the patients who refused the cancer-directed surgery had poor prognosis in the total survival period, particularly in stage II and III. The survival benefit for undergoing surgery remained even after adjustment, which indicates the importance of surgical treatment before an advanced stage for male breast cancer patients.