Funni, Shealeigh A.

OBJECTIVE We characterized annual trends of severe hypoglycemic and hyperglycemic crises (diabetic ketoacidosis/hyperglycemic hyperosmolar state) in patients with diabetes and end-stage kidney disease (ESKD). RESEARCH DESIGN AND METHODS This was a nationwide, retrospective study of adults (≥18 years old) with diabetes/ESKD, from the United States Renal Data System registry, between 2013 and 2017. Primary outcome was annual rates of emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises, reported as number of events/1,000 person-years. Event rates and risk factors were adjusted for patient age, sex, race/ethnicity, dialysis modality, comorbidities, treatment regimen, and U.S. region. RESULTS Among 521,789 adults with diabetes/ESKD (median age 65 years [interquartile range 57–73], 56.1% male, and 46% White), overall adjusted rates of hypoglycemic and hyperglycemic crises were 53.64 and 18.24 per 1,000 person-years, respectively. For both hypoglycemia and hyperglycemia crises, respectively, the risks decreased with age and were lowest in older patients (≥75 vs. 18–44 years old: incidence rate ratio 0.35, 95% CI 0.33–0.37, and 0.03, 0.02–0.03), women (1.09, 1.06–1.12, and 1.44, 1.35–1.54), and those with smoking (1.36, 1.28–1.43, and 1.71, 1.53–1.91), substance abuse (1.27, 1.15–1.42, and 1.53, 1.23–1.9), retinopathy (1.10, 1.06–1.15, and 1.36, 1.26–1.47), and insulin therapy (vs. no therapy; 0.60, 0.59–0.63, and 0.44, 0.39–0.48). For hypoglycemia, specifically, additional risk was conferred by Black race (1.11, 1.08–1.15) and amputation history (1.20, 1.13–1.27). CONCLUSIONS In this nationwide study of patients with diabetes/ESKD, hypoglycemic crises were threefold more common than hyperglycemic crises, greatly exceeding national reports in nondialysis patients with chronic kidney disease. Young, Black, and female patients were disproportionately affected.

Objective To describe the epidemiology of paediatric pain-related visits to emergency departments (EDs) across the USA. Design Cross-sectional study. Setting A representative sample of US ED visits using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Participants Paediatric (age ≤18 years) ED visits in the 2017 NHAMCS data set. Data analysis Each visit was coded as pain-related or non-pain-related using the ‘reason for visit’ variable. Weighted proportions were calculated with 95% CIs. Logistic regression was used to compare odds of pain-related visits. Outcome measures Prevalence of pain-related visits among paediatric ED visits. Results There were an estimated 35 million paediatric ED visits in the USA in 2017, 55.6% (CI 53.3% to 57.8%) were pain related, which equates to 19.7 million annual visits. The prevalence of pain-related visits reached more than 50% of visits at age 6–7 and plateaued at relatively high proportions. Children of races other than white or black had lower odds of having a pain-related visit (OR 0.48, CI 0.29 to 0.81) than white children, as did children who were black, though the difference was not statistically significant (OR 0.88, CI 0.73 to 1.06). Relative to children covered by private insurance, children with Medicaid or CHIP (Children’s Health Insurance Program) coverage had lower odds of a pain-related visit (OR 0.75, CI 0.60 to 0.93). Injuries represented 46.5% (CI 42.0% to 51.0%) of pain-related visits. Pain scores were reported in less than 50% of pain-related visits. Conclusion Pain is the reason for visit in 55.6% of paediatric ED visits across the USA. The prevalence of pain-related visits peak before adolescence and it continues relatively high until the age 18. Injury, racial disparities in pain and poor pain score reporting should remain major topics of study in the paediatric population.

e20077 Background: Small cell lung cancer (SCLC) accounts for about 10% to 15% of lung cancers among women and men. Though heavily associated with smoking, its incidence in women is rapidly increasing despite a decline in cigarette exposure. Given the changing demographics of SCLC and hormonal factors associated with other forms of lung cancer, we studied differences between sexes in SCLC. Methods: Utilizing the National Cancer Database, we identified all incident SCLC cases from 2004 to 2014. Patients were classified as limited stage (LS) or extensive stage (ES). Women were stratified by menopausal status (≥55 years = postmenopausal). Kaplan-Meier method and Cox regression were used for overall survival (OS) and multivariable analysis. Results: 161,978 patients were identified. No significant sociodemographic differences were observed between sexes. The majority of patients were non-Hispanic whites (89.1%), followed by non-Hispanic blacks (7.5%). Men were more likely to be diagnosed with ES disease than women (63% vs. 56%). Both sexes initiated treatment within a similar time frame from diagnosis (chemotherapy, median: 18 days, IQR 8-32). Women had better median OS compared to men in both LS (15.2 vs. 12.7 months, HR: 0.85, 95% CI 0.83-0.86, p < 0.0001) and ES (6.4 vs. 5.7 months, HR: 0.88, 95% CI 0.87-0.90, p < 0.0001). No racial or ethnic disparities in OS were observed, overall and when examined within sex and disease stage groups. Differences between sexes in OS were also observed when comparing patients within the same racial/ethnic group (women having better OS). When divided by menopausal status, postmenopausal women with LS and ES had worse OS than premenopausal women (14.7 vs. 22 months, HR: 1.50, 95% CI 1.44-1.56; 6.1 vs. 9.8 months, HR: 1.41, 95% CI: 1.37-1.46, respectively). We also observed worse OS in older men when divided by age ( < 55 years and ≥55 years). In multivariable analysis, older age, postmenopausal status, and Medicaid as primary insurance were associated with worse OS for both LS and ES. Conclusions: In this large cohort, women with SCLC had better OS compared to men. Post-menopausal women had worse OS compared to pre-menopausal women. Since older men had a similar trend of worse survival compared to younger men, age might exert a more significant influence on survival than hormonal status in SCLC. Further studies with data on sexual hormone levels are necessary to better understand their role in women with SCLC.

BackgroundPrior studies in oncology have shown that a higher annual facility patient volume is associated with reduced mortality. Because classic Hodgkin lymphoma is uncommon but highly curable, this study used the National Cancer Database (2003‐2014) to analyze whether such a relationship exists for this disease.MethodsThe facilities were classified by quartiles, and random intercepts were used to account for clustering of patients within facilities. A Cox regression model was used to determine the volume‐outcome relationship.ResultsThere were 47,633 patients with classic Hodgkin lymphoma treated at 1310 facilities. The first quartile (Q1), which included 58.4% of the facilities, treated 3 or fewer patients per year, whereas the fourth quartile (Q4), which included 5.9% of the facilities, treated more than 9 patients per year. Compared with the patients treated at Q4 facilities, those treated at lower quartile facilities had a higher risk of death (hazard ratio for the third quartile [HR], 1.19; 95% confidence interval [CI], 1.1‐1.29; HR for the second quartile, 1.28; 95% CI, 1.19‐1.38; HR for Q1, 1.29; 95% CI, 1.2‐1.39) after adjustments for all other factors (P < .0001). Compared with facilities treating 10 patients per year, facilities treating 40 patients per year had approximately 27% lower overall mortality rates.ConclusionsPatients with classic Hodgkin lymphoma treated at high‐volume centers had lower overall mortality than those treated at lower volume centers. Because this is a highly curable malignancy, such differences may suggest a benefit from referral to higher volume facilities or the emulation of their care models.

144 Background: Small cell lung cancer (SCLC) is highly responsive to cytotoxic therapy and can be cured in early stages of disease. In this setting, disparities in patient refusal despite provider recommendations are unknown. Methods: All incident limited stage (LS)-SCLC cases from the National Cancer Database were identified from 2004 to 2014. Logistic regression was used to determine factors associated with treatment refusal. Results: 65,664 patients (pts) were identified with LS-SCLC: 44% male, median age 68 years. 3.4% of pts refused radiation and 3.8% refused chemotherapy. The proportion of chemotherapy refusal increased over the study period: 3% in 2004-2006 compared to 5.4% in 2013-2014 [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.55-2.01]; this was not observed for radiation. In multivariate analysis, women were more likely to refuse radiation (OR 1.18, 95% CI 1.06-1.32) and chemotherapy (OR 1.30, 95% CI 1.19-1.43) than men. Women who accepted treatment had higher overall survival compared to those who refused radiation (19.8 vs 5.2 months) or chemotherapy (17.4 vs 3.9 months) (both p < 0.001). Hispanic, Black, and Asian pts were not more likely to refuse treatment than White pts. Older pts were more likely to refuse radiation (OR 1.09 per year, 95% CI 1.08-1.09) and chemotherapy (OR 1.10 per year, 95% CI 1.09-1.11). Charlson comorbidity index (CCI) of 2 was associated with more frequent treatment refusal compared to CCI of 0 (radiation OR 1.96, 95% CI 1.68-2.30; chemotherapy OR 1.54, 95% CI 1.34-1.76). Medicaid as primary insurance predicted a higher risk of refusal compared to private insurance for radiation (OR 2.36, 95% CI 1.81-3.07) and chemotherapy (OR 2.23, 95% CI 1.78-2.80). Treatment at an academic facility predicted a lower risk of radiation refusal (OR 0.71, 95% CI 0.59-0.84) but not chemotherapy refusal. Conclusions: Female sex, comorbidities, and Medicaid insurance were predictors of treatment refusal in LS-SCLC, suggesting that socioeconomic and sex disparities may affect treatment decisions in this life-threatening disease. Further research to identify reasons for refusal via patient and provider interviews can improve care of vulnerable populations with potentially curable cancer.

Abstract Background Hodgkin lymphoma is a rare hematological malignancy, with 8,500 new cases per year in the United States. Prior studies in oncology have shown that higher patient volume, whether at the treatment facility or provider level, is associated with reduced mortality and improved overall survival (OS). We used a national oncology data set to test our hypothesis that a volume-outcome relationship may also exist in classical Hodgkin lymphoma. Methods Using the National Cancer Data Base (NCDB), we identified patients diagnosed with classical Hodgkin lymphoma between 2003 and 2014. The NCDB is a nationwide oncology outcomes database for ~70% of newly diagnosed cases from more than 1,500 accredited cancer programs in the United States and Puerto Rico. We classified the facilities by quartiles (Q; mean patients with HL treated per year): Q1: < 3.19, Q2: 3.2 to 5.0, Q3: 5.01 to 9.19, and Q4: ≥9.2. Our primary outcome of interest was all-cause mortality. We used random intercepts to account for clustering of patients within facilities and a Cox regression model to determine the volume-outcome relationship, adjusting for demographic (sex, age, race, ethnicity), socioeconomic (income, education, insurance type), geographic (area of residence, treatment facility location, travel distance), and comorbid (Charlson-Deyo score) factors, as well as year of diagnosis. Kaplan-Meier analysis was performed to examine the impact of patient volume (by quartile) on overall survival. Results There were 47,633 patients with classical Hodgkin lymphoma treated at 1,310 facilities. The median age at diagnosis was 40 years, and 54.2% were men. The median annual facility volume was 2.7 patients per year (range, 1 to 42.8). The distribution of facilities according to patient volume was: Q1: 58.4%, Q2: 22.4%, Q3: 13.3%, and Q4: 5.9%. After a median follow-up of 58 months, the highest volume quartile (Q4) had significantly higher 5- and 12-year overall survival rates compared to Q1-Q3 (Table 1). Overall survival by quartile is depicted as a Kaplan-Meier curve (Figure 1). Compared to the patients treated at Q4 facilities, those treated at lower-quartile facilities had a higher risk of death (Q3 hazard ratio [HR], 1.18 [95% CI, 1.10 to 1.27]; Q2 HR, 1.21 [95% CI, 1.13 to 1.30]; Q1 HR, 1.19 [95% CI, 1.11 to 1.28]) after adjustment for the sociodemographic factors discussed in our methods. Multivariable analysis showed that facility volume as a continuous variable was independently associated with all-cause mortality (Figure 2) (P<0.0001). Compared with facilities treating 10 patients per year, facilities treating 20, 30, and 40 patients per year had approximately 10%, 17%, and 23% lower overall mortality rates. Conclusions Patients treated for classical Hodgkin lymphoma at higher-volume facilities had a lower risk of mortality compared with those treated at lower-volume facilities. This adds to the growing body of evidence that a volume-outcomes relationship exists in some of the less common hematologic malignancies. Further research is needed to ascertain whether such differences in survival are related to provider-level or facility-level attributes, and whether patients with Hodgkin lymphoma will benefit from referral to high-volume centers. Disclosures No relevant conflicts of interest to declare.

6581 Background: While AC is recommended for all patients with stage IIA, IIB, and IIIA NSCLC, its use and benefit among the elderly population is unclear. Methods: We identified patients with stage IIA, IIB, or IIIA NSCLC using the National Cancer Database from 2006-2014. Patients were divided into age groups ≤65, 66-70, 71-75, 76-80, > 80 years. Trends in AC use, factors influencing AC administration, and outcomes associated with AC were studied. Results: Out of 27368 patients, 13464 received AC and 13904 did not. 11% had stage IIA disease, 50% had stage IIB disease and 39% had stage IIIA disease. AC use was lower with increasing age (49% age ≤65 vs. 3% age > 80 (P < 0.0001)). Temporal use of chemotherapy for each age group was unchanged from 2006-2014. In multivariate logistic regression analysis, factors predictive of lower AC use were older age, Medicare or Medicaid insurance, academic center, and higher Charlson Comorbidity Index (CCI). Stage IIIA (OR 1.4, 95% CI 1.3-1.6) and Stage IIB (OR 1.3, 95% CI 1.2-1.4) had a higher chance of receiving AC than stage IIA. In a Cox proportional hazard model, younger age, female sex, academic center, private insurance, higher income, lower CCI, West coast center and AC were associated with better outcomes. When stratified by age and stage, AC was still associated with better survival (Table). Conclusions: AC utilization in stages IIA, IIB and IIIA NSCLC remains low, despite its association with improved survival in the elderly. Future clinical trials may be needed focused on elderly patients to establish the best regimen to optimize outcomes. [Table: see text]