Spaulding, Aaron

Abstract Background: Endocrine therapy (ET) reduces breast cancer (BC) recurrence risk and improves BC outcomes. However, patients (pts) may refuse ET, potentially impacting their outcomes. However, the exact incidence and factors associated with ET refusal are largely unknown. Methods: We conducted a retrospective study of BC pts in the National Cancer Data Base between 2003 and 2017. Demographic, socioeconomic, co-morbidity index and tumor-specific data were compared between BC pts who refused ET versus those who agreed to ET using bivariate and multivariate models. Female pts 18 to 89 years of age with stage I, II, and III were included. Logistic regression was used to determine associations with ET refusal. Results: Among 463,228 pts, the incidence of ET refusal was 5.26% (24, 401). Of these pts, 85% were non-Hispanic White, 7.9% were Non-Hispanic Black, 3.1% non-Hispanic Asian/pacific islander, and 3.6% were Hispanic. A majority (56.9%) had government insurance, and 87.2% were from a metro residential area. Infiltrating ductal carcinoma BC subtype comprised 78% of pts. Most pts were 51-89 years of age (80%), and 20% were 18-50 years of age. On multivariable analysis (Table 1), non-Hispanic black (OR 0.82), non-Hispanic Asian (OR 0.72), and Hispanic (OR 0.84) pts had a reduced odds of refusing ET than non-Hispanic white pts. Pts with government insurance (OR 1.6, p<0.001) and noninsured pts (OR 1.3, p<0.001) had increased odds of refusing ET compared to privately insured pts. Estrogen receptor (ER) -/Progesterone (PR) +, and ER +/PR - had increased odds of refusing therapy (OR 2.9, and 1.1 respectively, p<0.001) than ER +/PR + pts. Patients with positive lymph nodes had reduced odds of refusing ET than those with negative lymph nodes (p<0.001). Additionally, pts with a 2.1-5 cm (OR 0.92) or >5 cm (OR 0.87) tumor size had a reduced odd of refusing ET than those with tumors less than 2 cm (p<0.001). Finally, patients with well-differentiated BC (grade I) had increased odds of refusing ET (OR 1.2, p<0.001) than moderately differentiated (grade II) BC. Conclusions: The incidence of ET therapy refusal is relatively low; however, survival outcomes may be negatively impacted. This is the first study to evaluate specific demographic and disease-specific factors associated with ET refusal, which can inform strategies to improve ET acceptance rate. Table 1.Multivariable Logistic Regression – ET Therapy Acceptance (Referent) vs. Refusal.VariableOR95% CIp-valueAge51 - 89 years18 - 50 years0.940.900.970.001Race/EthnicityWhite Non-HispanicBlack Non-Hispanic0.820.760.88<0.001Pacific Islander Non-Hispanic0.720.660.76<0.001Hispanic0.840.790.87<0.001InsurancePrivateGovernment1.61.521.61<0.001Not insured1.31.181.47<0.001ResidenceMetroUrban0.900.870.87<0.001Rural0.870.780.970.014HistologyInfiltrating ductal carcinomaLobular carcinoma0.840.800.87<0.001Infiltrating duct and lobular carcinoma0.900.850.95<0.001Others1.171.101.24<0.001Positive Nodes01 - 30.620.600.65<0.0014 - 90.610.570.66<0.00110 +0.610.550.68<0.001VariableOR95% CIp-valueER/PR ExpressionER +/PR +ER -/PR +2.92.563.18<0.001ER +/PR -1.11.061.14<0.001Tumor size≤ 2 cm2.1 - 5 cm0.920.880.94<0.001> 5 cm0.870.800.93<0.001GradeIII1.211.181.25<0.001III0.980.951.020.518Charlson-Deyo Score010.940.910.980.00421.070.991.150.071≥31.120.981.280.079 Citation Format: Pooja P Advani, Ricardo Torres Guzman, Francisco Avila Verduzco, Karla Maita, John Garcia, Abdullah Eldaly, Antonio Forte, Aaron Spaulding. Factors associated with endocrine therapy refusal in hormone receptor-positive breast cancer patients [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-14-16.

Abstract Background: There is an urgent need to improve clinical trial (CT) enrollment of breast cancer (BC) patients (pts), especially from unrepresented minorities. In this regard, our study aims to better understand the characteristics and factors associated with CT enrollment to inform strategies to enhance CT accrual rates. Method: We included 1,308,767 female pts from the National Cancer Data Base diagnosed from 2010 to 2017 with known ER, PR, and HER2 status. Demographic, socioeconomic, Charlson-Deyo Score (CDS) and BC specific data were compared between CT versus non-CT enrolled pts for initial therapy. Comparisons were assessed by Chi-square test. Logistic regression was utilized to determine associations between characteristics and CT enrollment. Odds ratios (OR) and p-values are reported for each group. Results: A total of 1797 pts (0.14%) were enrolled in CT for initial BC therapy. Focusing on the CT group, majority of pts were non-Hispanic White (W;(78.2%), followed by non-Hispanic black (AA;12.2%); Hispanic (H; 5.6%); and non-Hispanic Asian (A; 4%). Most pts (29.3%) were in 50-59 age quartile. TNBC pts formed 22% of CT pts and non-TNBC were 78%. Most pts were from academic centers (54%), followed by comprehensive community cancer (CCC; 23.5%), community cancer (3.9%) and integrated network cancer (INC; 5.6%) programs. Most had private insurance (70%) versus government insurance (27%) and others (3%). Stage IV pts were only 10% of the CT group while most pts (41%) had Stage II BC. CDS of 0 was noted in 90% pts while 1.3% pts had CDS of 2 or more. Most CT pts traveled < 50 miles from treatment center (88.5%), and only 1.2% CT pts traveled 200 or more miles. Most CT pts resided in areas with highest literacy rate (30%) while 15% were from areas with lowest literacy rate. In multivariable model, non-white pts were less likely than Whites to be enrolled in CT (OR 0.81, p<0.05). The odds of CT enrollment in 40-49, 50-59 and 60-69 age quartiles were 3.5, 2.7 and 2.3 times respectively that of pts 70 years or older (p<0.001). TNBC pts were 1.9 times more likely to be enrolled in CT than non-TNBC pts (p<0.001). Academic center pts were 3 times more likely (p<0.001) while INC program pts were less likely than CCC pts to be enrolled (OR 0.7, p=0.006). Pts with government insurance and other insurance were less likely to enroll in CT (OR 0.74, and 0.55, p <0.001 and p=0.003, respectively) compared to private insurance. The odds of a patient with stage II, III, IV BC enrolling in CT was about 2, 3.5 and 4 times higher than a stage I pt (p -<0.001). Pts with CDS 1 (OR 0.8, p=0.025) or 2 or more (OR 0.5, p=0.002) were less likely than CDS 0 pts to be enrolled. Pts who traveled 50-99 or 100-199 miles from the treatment center conducting CT, were 1.9 (p<0.001) and 1.5 times (p<0.05) more likely to be enrolled while those with > 200 miles were less likely (OR 0.75, p=0.442). The group of pts who belonged to a residential area with the highest literacy rate (<6.3% of no high school diploma) were 1.4 times more likely to accrue in CT (p<0.001) than those with high school diploma rate between 6.3 and 10.8%. Compared to metro areas, pts from rural areas were less likely to be enrolled (OR 0.5, p=0.04) as was a lower median income < $40,227 (OR 0.77, p= 0.016).Conclusion: CT enrollment is poor for initial therapy of BC treatment. We identify several modifiable factors including sociodemographics which are associated with BC pts not getting treated on CT. There are other factors that are non-modifiable, e.g., disease stage but may point to the need for more CT development in these areas. Addressing these disparities would lead to improved CT enrollment and overall advancement in BC management landscape. Citation Format: Pooja P Advani, Aaron Spaulding, Alexander Hochwald, Mizba Baksh, David Hodge, Saranya Chumsri, Shanada Monestime, Sikander Ailawadhi. Clinical trial enrollment for initial therapy of breast cancer: Exploring factors associated with poor accrual and significant disparities [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-11-15.

AbstractStudy RationaleThe swift progression of the COVID‐19 pandemic appeared to facilitate the increase in telehealth utilization. However, it is clear neither how telehealth was offered by providers nor how it was used by patients during this time of unusual and rapid change within the health industry.AimTo investigates the telehealth utilization patterns of Medicare beneficiaries during the height of the COVID‐19 pandemic.Methods and MaterialsA cross‐sectional study design was used to examine the responses of 9686 Medicare beneficiaries to the Centers for Medicare and Medicaid Services (CMS) Medicare Current Beneficiary Survey, Fall 2020 COVID‐19 Supplement. Multiple logistic regression analyses were conducted to examine the relationship between telehealth offering and beneficiaries' sociodemographic variables.ResultsOver half (58%) of primary care providers provided telehealth services, while only 26%–28% of specialists did. Less than 8% of Medicare beneficiaries reported that they were unable to obtain care because of COVID‐19.ConclusionsThis research found that changes in Medicare policy, associated with CMS' declaration of telehealth waivers during the Public Health Emergency (PHE), likely increased the proliferation and utilization of telehealth services during the COVID‐19 pandemic, providing important access to care for certain populations. With the impending conclusion of the PHE, policymakers must 1) ascertain which elements of the new telehealth landscape will be retained, 2) modernize the regulatory, accreditation and reimbursement framework to maintain pace with care model innovation and 3) address disparities in access to broadband connectivity with a particular focus on rural and underserved communities.

Abstract Aims To determine if there is an association between better County Health Rankings and the increased odds of a hospital gaining Magnet designation in subsequent years (2014–2019) compared with counties with lower rankings. Background The Magnet hospital model is recognized to have a great effect on nurses, patients and organizational outcomes. Although Magnet hospital designation is a well‐established structural marker for nursing excellence, the effect of County Health Rankings and subsequent hospital achievement of Magnet status is unknown. Design A descriptive, cross‐sectional quantitative approach was adopted for this study. Methods Data were derived from 2010 to 2019 U.S. County Health Rankings, American Hospital Association, and American Nursing Credentialing Center databases. Logistic regression models were utilized to determine associations between county rankings for health behaviours, clinical care, social and economic factors, physical environment and counties with a new Magnet hospital after 2014. Results Counties with the worst rankings for clinical care and socio‐economic status had reduced odds of obtaining a Magnet hospital designation compared with best‐ranking counties. While middle‐ranking counties for the physical environment ranking had increased odds of having Magnet designation compared with best‐ranking counties. Additionally, having an increased percent of government non‐federal hospital or a higher percentage of critical access hospitals in the county reduced the odds of having a Magnet‐designated facility after 2014. Conclusion The findings underscore the important associations between Magnet‐designated facilities’ location and the health of its surrounding counties. This study is the first to examine the relationship between County Health Rankings and a hospital's likelihood of obtaining Magnet status and points to the need for future research to explore outcomes of care previously identified as improved in Magnet‐designated hospitals. Implications Recognizing the benefits of Magnet facilities, it is important for health care leaders and policy makers to seek opportunities to promote centres of excellence in higher need communities through policy and financial intervention.

Background: Tranexamic acid (TXA) is considered safe and efficacious for elective total joint arthroplasty. However, evidence of TXA’s safety in high-risk patients with hip fracture requiring nonelective arthroplasty has been lacking. This study aimed to assess whether TXA administration to high-risk patients with a hip fracture requiring arthroplasty increased the risk of thrombotic complications or mortality. Methods: All patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) for displaced femoral neck fractures between 2011 and 2019 at 4 sites within 1 hospital system were retrospectively identified. Patients were grouped by risk (high-risk or low-risk) and TXA treatment (with or without TXA). Propensity scores were used for risk adjustment in comparisons between surgery with and without TXA for only the high-risk group (n = 1,066) and the entire population (n = 2,166). Differences in the occurrence of postoperative mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, and stroke within 90 days of hip arthroplasty were evaluated. Results: TXA administration was not associated with an increased risk of thrombotic complications or mortality within 90 days in either high-risk or all-patient groups. Specifically, among 1,066 matched high-risk patients who did not or did receive TXA, there were no significant differences in mortality (14.82% and 10.00%; p = 0.295), deep venous thrombosis (3.56% and 3.04%; p = 0.440), pulmonary embolism (2.44% and 1.96%; p = 0.374), myocardial infarction (3.38% and 2.14%; p = 0.704), or stroke (4.32% and 5.71%; p = 0.225). Conclusions: In our review of 1,066 propensity-matched high-risk patients undergoing hip arthroplasty for displaced femoral neck fractures, we found that TXA administration (compared with no TXA administration) was not associated with an increased risk of mortality, deep venous thrombosis, pulmonary embolism, myocardial infarction, or stroke. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: It is standard of care and an accreditation requirement to screen for and address distress and psychosocial needs in patients with cancer. This study assessed the availability of mental health (MH) and chemical dependency (CD) services at US cancer centers. Methods: The 2017–2018 American Hospital Association (AHA) survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases were used to assess availability of services and associations with hospital-level and health services area (HSA)–level characteristics. Results: Of 1,144 cancer centers surveyed, 85.4% offered MH services and 45.5% offered CD services; only 44.1% provided both. Factors associated with increased adjusted odds of offering MH services were teaching status (odds ratio [OR], 1.76; 95% CI, 1.18–2.62), being a member of a hospital system (OR, 2.00; 95% CI, 1.31–3.07), and having more beds (OR, 1.04 per 10-bed increase; 95% CI, 1.02–1.05). Higher population estimate (OR, 0.98; 95% CI, 0.97–0.99), higher percentage uninsured (OR, 0.90; 95% CI, 0.86–0.95), and higher Mental Health Professional Shortage Area level in the HSA (OR, 0.99; 95% CI, 0.98–1.00) were associated with decreased odds of offering MH services. Government-run (OR, 2.85; 95% CI, 1.30–6.22) and nonprofit centers (OR, 3.48; 95% CI, 1.78–6.79) showed increased odds of offering CD services compared with for-profit centers. Those that were members of hospital systems (OR, 1.61; 95% CI, 1.14–2.29) and had more beds (OR, 1.02; 95% CI, 1.01–1.03) also showed increased odds of offering these services. A higher percentage of uninsured patients in the HSA (OR, 0.92; 95% CI, 0.88–0.97) was associated with decreased odds of offering CD services. Conclusions: Patients’ ability to pay, membership in a hospital system, and organization size may be drivers of decisions to co-locate services within cancer centers. Larger organizations may be better able to financially support offering these services despite poor reimbursement rates. Innovations in specialty payment models highlight opportunities to drive transformation in delivering MH and CD services for high-need patients with cancer.

EXECUTIVE SUMMARY Medicare’s Hospital Valued-Based Purchasing (HVBP) program measures hospitals’ total performance score (TPS); its measurement strategies have changed regularly since its rollout in 2013. Because the program influences care delivery, it is important to examine how the policy has changed hospitals’ behavior and how it may inform future policies. The purpose of this study was to assess the relationship between hospitals’ performance on TPS annually from 2013 to 2018 and organizational characteristics. Using the HVBP TPS from 2013 to 2018 and associated hospital characteristics—hospital size, teaching hospital status, system membership, ownership type, urban/rural location, average percentages of patients from Medicare and Medicaid, operating margins, percentages of inpatient revenue as a proportion of total revenue, and case mix index—we conducted a retrospective cohort study of all U.S. hospitals participating in the HVBP program. Regression and panel analyses found that organizations that were expected to have robust and rigid resources were unable to score in the superior category consistently. In addition, organizations were unable to consistently perform positively over time because of changes in the HVBP program measurement and the required organizational responses. Policymakers should consider the ability of organizations to respond to changes to the HVBP program. Likewise, healthcare managers, particularly those in larger organizations, should seek to remove bureaucracy or allow for greater resource slack to meet these changes.

Importance: Social media is widely used by various segments of society. Its role as a tool of communication by the Public Health Departments in the U.S. remains unknown. Objective: To determine the impact of the COVID-19 pandemic on social media following of the Public Health Departments of the 50 States of the U.S. Design, Setting, and Participants: Data were collected by visiting the Public Health Department web page for each social media platform. State-level demographics were collected from the U.S. Census Bureau. The Center for Disease Control and Prevention was utilized to collect information regarding the Governance of each State’s Public Health Department. Health rankings were collected from “America’s Health Rankings” 2019 Annual report from the United Health Foundation. The U.S. News and World Report Education Rankings were utilized to provide information regarding the public education of each State. Exposure: Data were pulled on 3 separate dates: first on March 5th (baseline and pre-national emergency declaration (NED) for COVID-19), March 18th (week following NED), and March 25th (2 weeks after NED). In addition, a variable identifying the total change across platforms was also created. All data were collected at the State level. Main Outcome: Overall, the social media following of the state Public Health Departments was very low. There was a significant increase in the public interest in following the Public Health Departments during the early phase of the COVID-19 pandemic. Results: With the declaration of National Emergency, there was a 150% increase in overall public following of the State Public Health Departments in the U.S. The increase was most noted in the Midwest and South regions of the U.S. The overall following in the pandemic “hotspots,” such as New York, California, and Florida, was significantly lower. Interesting correlations were noted between various demographic variables, health, and education ranking of the States and the social media following of their Health Departments. Conclusion and Relevance: Social media following of Public Health Departments across all States of the U.S. was very low. Though, the social media following significantly increased during the early course of the COVID-19 pandemic, but it still remains low. Significant opportunity exists for Public Health Departments to improve social media use to engage the public better.

Abstract Background This study aimed to identify socioeconomic predictors of permanent stoma in rectal cancer treatment and examine its association with length of stay at the treatment facility.MethodsRectal cancer patients were identified from the Agency for Health Care Administration Florida Hospital Inpatient Discharge Dataset. Multivariate regression models were utilized to identify demographic, and socioeconomic factors associated with receiving a permanent stoma as well as the associated length of stay of these patients.ResultsOf 2,630 rectal cancer patients who underwent surgery for rectal cancer, 21% had a permanent stoma. The odds of receiving permanent stoma increased with higher Elixhauser score, metastatic disease, residing in Southwest Florida, and having Medicaid insurance or no insurance/self-payers (p<0.05). Patients with a permanent stoma had a significantly extended stay after surgery (p<0.001). ConclusionsPatients with a permanent stoma following cancer resection were more likely to have open surgery, had more comorbidities, and had a longer length of stay. Additionally, the payer type significantly affected the length of stay and odds of receiving a permanent stoma.