Racial and Ethnic Disparities in Patient Restraint in Emergency Departments by Police Transport Status.

Importance: Black patients are more likely than White patients to be restrained during behavioral crises in emergency departments (EDs). Although the perils of policing mental health for Black individuals are recognized, it is unclear whether or to what extent police transport mediates the association between Black race and use of physical restraint in EDs. Objective: To evaluate the degree to which police transport mediates the association between Black race and use of physical restraint in EDs. Design, Setting, and Participants: This retrospective, cross-sectional study used electronic health record data from ED visits by adults (aged ≥18 years) to 3 hospitals in the southeastern US and 10 in the northeastern US between January 1, 2015, and December 31, 2022. Data were analyzed from September 1, 2022, to May 30, 2023. Exposures: Race, ethnicity, and police transport to the hospital. Main Outcomes and Measures: The primary outcome variable was the presence of an order for restraints during an ED visit. Results: A total of 4 263 437 ED visits by 1 257 339 patients (55.5% of visits by female and 44.5% by male patients; 26.1% by patients 65 years or older) were included in the study. Black patients accounted for 27.5% of visits; Hispanic patients, 17.6%; White patients, 50.3%; and other or unknown race or ethnicity, 4.6%. In models adjusted for age, sex, site, previous behavioral or psychiatric history, and visit diagnoses, Black patients were at increased odds of experiencing restraint compared with White patients (adjusted odds ratio [AOR], 1.33 [95% CI, 1.28-1.37]). Within the mediation analysis, Black patients had higher odds of being brought to the hospital by police compared with all other patients (AOR, 1.38 [95% CI, 1.34-1.42]). Patients brought to the ED under police transport had increased odds of experiencing restraint compared with all other modes of transport (AOR, 5.51 [95% CI, 5.21-5.82]). The estimated proportion of use of restraints for Black patients mediated by police transport was 10.70% (95% CI, 9.26%-12.53%). Conclusions and Relevance: In this cross-sectional study of ED visits across 13 hospitals, police transport may have mediated the association between Black race and use of physical restraint. These findings suggest a need to further explore the mechanisms by which transport to emergency care may influence disparate restrictive interventions for patients experiencing behavioral emergencies.

Disparities Associated With Electronic Behavioral Alerts for Safety and Violence Concerns in the Emergency Department.

STUDY OBJECTIVE: Although electronic behavioral alerts are placed as an alert flag in the electronic health record to notify staff of previous behavioral and/or violent incidents in emergency departments (EDs), they have the potential to reinforce negative perceptions of patients and contribute to bias. We provide characterization of ED electronic behavioral alerts using electronic health record data across a large, regional health care system. METHODS: We conducted a retrospective cross-sectional study of adult patients presenting to 10 adult EDs within a Northeastern United States health care system from 2013 to 2022. Electronic behavioral alerts were manually screened for safety concerns and then categorized by the type of concern. In our patient-level analyses, we included patient data at the time of the first ED visit where an electronic behavioral alert was triggered or, if a patient had no electronic behavioral alerts, the earliest visit in the study period. We performed a mixed-effects regression analysis to identify patient-level risk factors associated with safety-related electronic behavioral alert deployment. RESULTS: Of the 2,932,870 ED visits, 6,775 (0.2%) had associated electronic behavioral alerts across 789 unique patients and 1,364 unique electronic behavioral alerts. Of the encounters with electronic behavioral alerts, 5,945 (88%) were adjudicated as having a safety concern involving 653 patients. In our patient-level analysis, the median age for patients with safety-related electronic behavioral alerts was 44 years (interquartile range 33 to 55 years), 66% were men, and 37% were Black. Visits with safety-related electronic behavioral alerts had higher rates of discontinuance of care (7.8% vs 1.5% with no alert; P<.001) as defined by the patient-directed discharge, left-without-being-seen, or elopement-type dispositions. The most common topics in the electronic behavioral alerts were physical (41%) or verbal (36%) incidents with staff or other patients. In the mixed-effects logistic analysis, Black non-Hispanic patients (vs White non-Hispanic patients: adjusted odds ratio 2.60; 95% confidence interval [CI] 2.13 to 3.17), aged younger than 45 (vs aged 45-64 years: adjusted odds ratio 1.41; 95% CI 1.17 to 1.70), male (vs female: adjusted odds ratio 2.09; 95% CI 1.76 to 2.49), and publicly insured patients (Medicaid: adjusted odds ratio 6.18; 95% CI 4.58 to 8.36; Medicare: adjusted odds ratio 5.63; 95% CI 3.96 to 8.00 vs commercial) were associated with a higher risk of a patient having at least 1 safety-related electronic behavioral alert deployment during the study period. CONCLUSION: In our analysis, younger, Black non-Hispanic, publicly insured, and male patients were at a higher risk of having an ED electronic behavioral alert. Although our study is not designed to reflect causality, electronic behavioral alerts may disproportionately affect care delivery and medical decisions for historically marginalized populations presenting to the ED, contribute to structural racism, and perpetuate systemic inequities.

Racial Inequities in Police Transport for Patients to the Emergency Department: A Multicenter Analysis.

INTRODUCTION: Police involvement in patient transport to emergency medical care has increased over time, yet studies assessing racial inequities in transport are limited. This study evaluated the relationship between race and police transport to the emergency department for adult patients. METHODS: This cross-sectional study evaluated adult (aged ≥18 years) visits at 13 different emergency departments across two regional hospital systems in the Southeastern and Northeastern U.S. from 2015 to 2022. Data were extracted from electronic health records. This analysis evaluated the association between race and transport by police transport using generalized linear multivariable mixed model with a binary logistic link for presence of police transport. Data were nested by patient and adjusted for site, demographics, and diagnostic visit characteristics. RESULTS: Of 4,291,809 adult emergency department visits, 25,901 (0.6%) involved transport by police. Of the 25,901 visits in police-involved encounters, 10,513 (40.6%) patients were Black, and 9,827 (37.9%) were White. The adjusted model showed that Black patients were at higher odds of transport by police than White patients (AOR=1.64; 95% CI=1.57-1.72). Male sex, younger age (18-35 years), history of behavioral health diagnosis, and emergency department psychiatric or substance use disorders were independently associated with increased odds of police transport. CONCLUSIONS: This analysis revealed racial inequities in police-involved transport to emergency medical care, highlighting an urgent need to evaluate drivers of inequities and the ways in which police transport influences clinical outcomes.

Characterizing Racial Disparities in Emergency Department Pediatric Physical Restraint by Sex and Age.

This cross-sectional study evaluates racial disparities in physical restraint use in US emergency departments.

Trends in U.S. MD-PhD Program Matriculant Diversity by Sex and Race/Ethnicity.

PURPOSE: To examine demographic characteristics of matriculants to U.S. MD-PhD programs by sex and race/ethnicity from academic years (AYs) 2009-2018 and explore the relationships between trends in the percentage of female and underrepresented minority (URM) matriculants to programs with and without Medical Scientist Training Program (MSTP) funding. METHOD: Linear regression and time trend analysis of the absolute percentage of matriculants into all U.S. MD-PhD programs was performed for self-reported sex and race/ethnicity, using Association of American Medical Colleges data for AYs 2009-2018, including an interaction for MSTP funding status (yes/no) and year. Linear regression of the percentage of programs matriculating no female or no URM students between AYs 2009 and 2018 was performed, focusing on programs in the top 3 quartiles by size (i.e., those matriculating 4 or more students per year). RESULTS: Between AYs 2009 and 2018, the percentage of matriculants to all MD-PhD programs who were female (38.0%-46.0%, 1.05%/year, P = .002) or URM (9.8%-16.7%, 0.77%/year, P < .001) increased. The annual percentage gains of URM matriculants were greater at MSTP-funded programs compared with non-MSTP-funded programs (0.50%/year, P = .046). Moreover, among MD-PhD programs in the top 3 quartiles by size, the percentage of programs with no female matriculants decreased by 0.40% per year ( P = .02) from 4.6% in 2009 to 1.6% in 2018, and the percentage of programs with no URM matriculants decreased by 3.41% per year ( P < .001) from 49% in 2009 to 22% in 2018. CONCLUSIONS: A consistent and sustained increase in the percentage of female and URM matriculants to MD-PhD programs from AYs 2009-2018 was observed, but the annual increases in the percentages across groups were small, and the demographics of the MD-PhD workforce still do not reflect the diversity of the U.S. general population.

All clinical stressors are not created equal: Differential task stress in a simulated clinical environment.

Background: A variety of stressors are encountered while working in the emergency department and are often recreated in simulation-based medical education. We seek to examine the physiologic and stress state response of participants in a simulated clinical environment to commonly encountered stressors. Methods: Emergency medicine (EM) residents participated in a randomized, controlled trial of six simulated patient encounters with one of three stressors, medical difficulty, interpersonal challenge, and technology/equipment failure, randomized into each scenario. Participants wore smart shirts to measure heart rate variability (HRV) at rest and just after the introduced stressor and completed the Short Stress State Questionnaire (SSSQ) before and after each scenario. Results: Twenty-seven EM residents participated in the study. Interpersonal challenge resulted in increased distress as measured by SSSQ compared to the other two stressors (one way ANOVA, F[2,144] = 9.95, p < 0.001). There was no difference in worry or task engagement across stressors. HRV decreased significantly from rest for all stressors (p = 0.0003, p = 0.0112, p = 0.0027 for medical difficulty, interpersonal challenge, and equipment failure, respectively), but there was no statistically significant difference between mean change in HRV across stressors (one way ANOVA, F[2,120] = 0.17, p = 0.8452). Conclusions: Interpersonal challenge stressor was significantly associated with an increase in distress in EM residents during the simulated encounters as compared to the other stressors. While heart rate variability decreased from rest for each stressor as expected following stressor introduction, differing stressors did not produce a differential change.

Design and Implementation of an Agitation Code Response Team in the Emergency Department.

STUDY OBJECTIVE: Agitation, defined as excessive psychomotor activity leading to violent and aggressive behavior, is becoming more prevalent in the emergency department (ED) amidst a strained behavioral health system. Team-based interventions have demonstrated promise in promoting de-escalation, with the hope of minimizing the need for invasive techniques, like physical restraints. This study aimed to evaluate an interprofessional code response team intervention to manage agitation in the ED with the goal of decreasing physical restraint use. METHODS: This quality improvement study occurred over 3 phases, representing stepwise rollout of the intervention: (1) preimplementation (phase I) to establish baseline outcome rates; (2) design and administrative support (phase II) to conduct training and protocol design; and (3) implementation (phase III) of the code response team. An interrupted time-series analysis was used to compare trends between phases to evaluate the primary outcome of physical restraint orders occurring during the study period. RESULTS: Within the 634,578 ED visits over a 5-year period, restraint use significantly declined sequentially over the 3 phases (1.1%, 0.9%, and 0.8%, absolute change -0.3% between phases I and III, 95% confidence interval [CI] -0.4% to 0.3%), which corresponded to a 27.3% proportionate decrease in restraint rates between phases I and III. For the interrupted time-series analysis, there was a significantly decreasing slope in biweekly restraints in phase II compared to phase I (slope, -0.05 restraints per 1,000 ED visits per 2-week period, 95% CI -0.07 to -0.03), which was sustained in an incremental fashion in phase III (slope, -0.05, 95% CI -0.07 to -0.02). CONCLUSION: With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a 5-year period. Results suggest that investment in organizational change, along with interprofessional collaboration during the management of agitated patients in the ED, can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients.

Primary care physician continuity, survival, and end-of-life care intensity.

OBJECTIVE: To examine the associations of primary care physician (PCP) care continuity with cancer-specific survival and end-of-life care intensity. DATA SOURCES: Surveillance, epidemiology, and end results linked to Medicare claims data from 2001 to 2015. STUDY DESIGN: Cox proportional hazards models with mixed effects and hierarchical generalized logistic models were used to examine the associations of PCP care continuity with cancer-specific survival and end-of-life care intensity, respectively. PCP care continuity, defined as having visited the predominant PCP (who saw the patient most frequently before diagnosis) within 6 months of diagnosis. DATA EXTRACTION METHODS: We identified Medicare patients diagnosed at age 66.5-94 years with stage-III or IV poor-prognosis cancer during 2001-2012 and followed them up until 2015. Patients who died within 6 months after diagnosis were excluded. PRINCIPAL FINDINGS: Primary study cohort consisted of 85,467 patients (median survival 22 months), 71.7% of whom had PCP care continuity. Patients with PCP care continuity tended to be older, married, nonblack, non-Hispanic, and to have fewer comorbid conditions (p < 0.001 for all). Patients with PCP care continuity had lower cancer-specific mortality (adjusted hazard ratio: 0.93; 95% confidence interval [CI]: 0.91 to 0.95; p = 0.001) than did those without PCP care continuity. Findings of the 2001-2003 cohorts (nearly all of whom died by 2015) show no associations of overall end-of-life care intensity measures with PCP care continuity (adjusted marginal effects: 0.005; 95% CI: -0.016 to 0.026; p = 0.264). CONCLUSIONS: Among Medicare beneficiaries with advanced poor-prognosis cancer, PCP continuity was associated with modestly improved survival without raising overall aggressive end-of-life care.

Medical Students' Demographic Characteristics and Their Perceptions of Faculty Role Modeling of Respect for Diversity.

Importance: Faculty role modeling is critical to medical students' professional development to provide culturally adept, patient-centered care. However, little is known about students' perceptions of faculty role modeling of respect for diversity. Objective: To examine whether variation exists in medical students' perceptions of faculty role modeling of respect for diversity by student demographic characteristics. Design, Setting, and Participants: This cross-sectional study analyzed data from the Association of American Medical Colleges' 2016 and 2017 Medical School Graduation Questionnaire, which was administered to graduating students at 140 accredited allopathic US medical schools. Data were analyzed from January 1 to November 1, 2020. Main Outcomes and Measures: Students' perceptions of faculty role modeling of respect for diversity by the independent variables sex, race/ethnicity, sexual orientation, and age. Multivariable logistic regression was used to examine the extent to which student-reported perceptions of faculty respect for diversity varied by demographic characteristics, and logistic regression models were sequentially adjusted first for demographic characteristics and then for marital status and financial variables. Results: Of 30 651 students who completed the survey, the final study sample consisted of 28 778 respondents, representing 75.4% of the 38 160 total US medical school graduates in 2016 and 2017. Of the respondents, 14 804 (51.4%) were male participants and 1506 (5.2%) identified as lesbian, gay, or bisexual (LGB); a total of 11 926 respondents (41.4%) were 26 years or younger. A total of 17 159 respondents (59.6%) identified as White, 5958 (20.7%) as Asian, 1469 (5.1%) as Black/African American, 2431 (8.4%) as Hispanic/Latinx, and 87 (0.3%) as American Indian/Alaska Native/Native Hawaiian/Pacific Islander individuals. Overall, 5101 students (17.7%) reported perceiving that faculty showed a lack of respect for diversity. Of those who identified as Black/African American students, 540 (36.8%) reported perceiving a lack of faculty respect for diversity compared with 2468 White students (14.4%), with an OR of perceived lack of respect of 3.24 (95% CI, 2.86-3.66) after adjusting for other demographic characteristics and covariates. American Indian/Alaska Native/Native Hawaiian/Pacific Islander (OR, 1.73; 95% CI, 1.03-2.92), Asian (OR, 1.62; 95% CI, 1.49-1.75), or Hispanic/Latinx (OR, 1.43; 95% CI, 1.26-1.75) students also had greater odds of perceiving a lack of faculty respect for diversity compared with White students. Female students had greater odds compared with male students (OR, 1.17; 95% CI, 1.10-1.25), and students who identified as LGB (OR, 1.96; 95% CI, 1.74-2.22) or unknown sexual orientation (OR, 1.79; 95% CI, 1.29-2.47) had greater odds compared with heterosexual students. Students aged 33 years or older had greater odds of reporting a perceived lack of respect compared with students aged 26 years or younger (OR, 1.81; 95% CI, 1.58-2.08). Conclusions and Relevance: In this cross-sectional study, female students, students belonging to racial/ethnic minority groups, and LGB students disproportionately reported perceiving a lack of respect for diversity among faculty, which has important implications for patient care, the learning environment, and the well-being of medical trainees.

Association Between Sexual Orientation, Mistreatment, and Burnout Among US Medical Students.

Importance: Medical trainee burnout is associated with poor quality care and attrition. Medical students in sexual minority groups report fear of discrimination and increased mistreatment, but the association between sexual orientation, burnout, and mistreatment is unknown. Objective: To evaluate whether medical student burnout differs by sexual orientation and whether this association is mediated by experiences of mistreatment. Design, Setting, and Participants: This cross-sectional study surveyed US medical students graduating from Association of American Medical Colleges (AAMC)-accredited US allopathic medical schools who responded to the AAMC graduation questionnaire in 2016 and 2017. Statistical analyses were performed from March 15, 2019, to July 2, 2020, and from November 20 to December 9, 2020. Main Outcomes and Measures: Burnout was measured using the Oldenburg Burnout Inventory for Medical Students, and sexual orientation was categorized as either heterosexual or lesbian, gay, or bisexual (LGB). Logistic regression models were constructed to evaluate the association between sexual orientation and experiencing burnout (defined as being in the top quartile of exhaustion and disengagement burnout dimensions) and to test the mediating association of mistreatment. Results: From 2016 to 2017, 30 651 students completed the AAMC Graduation Questionnaire, and 26 123 responses were analyzed. Most respondents were younger than 30 years (82.9%) and White (60.3%). A total of 13 470 respondents (51.6%) were male, and 5.4% identified as LGB. Compared with heterosexual students, a greater proportion of LGB students reported experiencing mistreatment in all categories, including humiliation (27.0% LGB students vs 20.7% heterosexual students; P < .001), mistreatment not specific to identity (17.0% vs 10.3%; P < .001), and mistreatment specific to gender (27.3% vs 17.9%; P < .001), race/ethnicity (11.9% vs 8.6%; P < .001), and sexual orientation (23.3% vs 1.0%; P < .001). Being LGB was associated with increased odds of burnout (adjusted odds ratio, 1.63 [95% CI, 1.41-1.89]); this association persisted but was attenuated after adjusting for mistreatment (odds ratio, 1.36 [95% CI, 1.16-1.60]). The odds of burnout increased in a dose-response manner with mistreatment intensity. Lesbian, gay, or bisexual students reporting higher mistreatment specific to sexual orientation had and 8-fold higher predicted probability of burnout compared with heterosexual students (19.8% [95% CI, 8.3%-31.4%] vs 2.3% [95% CI, 0.2%-4.5%]; P < .001). Mediation analysis showed that mistreatment accounts for 31% of the total association of LGB sexual orientation with overall burnout (P < .001). Conclusions and Relevance: This study suggests that LGB medical students are more likely than their heterosexual peers to experience burnout, an association that is partly mediated by mistreatment. Further work is needed to ensure that medical schools offer safe and inclusive learning environments for LGB medical students.

Did quality of life for older cancer survivors improve with the turn of the century in the United States?

OBJECTIVES: Although survival after a cancer diagnosis has improved considerably over the past 20 years, little is known about trends in health-related quality-of-life (HRQOL) for older prostate, breast, and lung cancer survivors. METHODS: Using a population-based registry with longitudinal patient reported outcomes (the National Cancer Institute Surveillance, Epidemiology and End Results database linked to Medicare Health Outcomes Survey), we analyzed Medicare Advantage patients diagnosed with cancer during 1998-2011, who completed surveys regarding HRQOL through 2013. 'Early Era' patients were treated during 1998-2003; 'Late Era' patients were treated during 2006-2011. After propensity score matching, post-diagnosis changes in health utility (HU), Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were calculated and compared between the two eras. RESULT: We identified 208 older patients with prostate, 276 with breast and 76 with lung cancer who were treated in the 'Early Era' and matched to equal numbers in the 'Late Era'. Mean age of patients in early and late era was 72 and 73 years, respectively. The mean post-diagnosis decline in health utility for patients treated in the 'Late Era' was not significantly different from the 'Early Era' for any cancer (Prostate [early vs. late]: -0.06 vs. -0.03, p = .09; Breast: -0.03 vs. -0.04, p = .65; Lung: -0.07 vs. -0.07, p = .95); nor for Physical Component Summary or Mental Component Summary scores. CONCLUSION: Older patients treated for prostate, breast or lung cancer in the later era reported similar outcomes of changes in HRQOL compared to earlier era patients.

Disparities in Mental and Behavioral Health Treatment for Children and Youth in Immigrant Families.

BACKGROUND AND OBJECTIVE: Children and youth in immigrant families (CIF)-children and youth with at least 1 foreign-born parent-face unique psychosocial stressors. Yet little is known about access to mental and behavioral health (MBH) services for CIF. Among US CIF and non-CIF with MBH problems, we assessed access to MBH treatment. METHODS: We used the National Survey of Children's Health-2016, a nationally representative survey of predominantly English- or Spanish-speaking US parents. The sample included 2- to 17-year-olds whose parent reported at least 1 MBH problem. The primary outcome was prior-year receipt of MBH treatment (counseling, medication, or both). RESULTS: Of 50,212 survey respondents, 7164 reported a current MBH problem (809 CIF and 6355 non-CIF). The majority of CIF were Hispanic/Latinx (56% CIF vs 13% non-CIF, P < .001). CIF were less likely than non-CIF to have an Attention Deficit Hyperactivity Disorder (ADHD) diagnosis (35% vs 59%, P < .001) and less likely to have received MBH medication and/or counseling (61% vs 71%, P = .02). This difference was pronounced for receiving medication (32% vs 50%, P < .001). When controlling for multiple covariates, differences in any MBH treatment were no longer statistically significant (adjusted odds ratios 0.76, 95% confidence interval 0.52-1.11), while the odds of receipt of medication remained significantly lower for CIF (adjusted odds ratios 0.61, 95% confidence interval 0.42-0.88). CONCLUSIONS: Among children and youth with at least 1 parent-reported MBH problem, CIF, compared with non-CIF, were less likely to receive MBH treatment, specifically medication. This may be explained, in part, by differences in the proportion of CIF and non-CIF diagnosed with ADHD.

Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation.

Importance: Previous studies have shown that medical student mistreatment is common. However, few data exist to date describing how the prevalence of medical student mistreatment varies by student sex, race/ethnicity, and sexual orientation. Objective: To examine the association between mistreatment and medical student sex, race/ethnicity, and sexual orientation. Design, Setting, and Participants: This cohort study analyzed data from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The questionnaire annually surveys graduating students at all 140 accredited allopathic US medical schools. Participants were graduates from allopathic US medical schools in 2016 and 2017. Data were analyzed between April 1 and December 31, 2019. Main Outcomes and Measures: Prevalence of self-reported medical student mistreatment by sex, race/ethnicity, and sexual orientation. Results: A total of 27 504 unique student surveys were analyzed, representing 72.1% of graduating US medical students in 2016 and 2017. The sample included the following: 13 351 female respondents (48.5%), 16 521 white (60.1%), 5641 Asian (20.5%), 2433 underrepresented minority (URM) (8.8%), and 2376 multiracial respondents (8.6%); and 25 763 heterosexual (93.7%) and 1463 lesbian, gay, or bisexual (LGB) respondents (5.3%). At least 1 episode of mistreatment was reported by a greater proportion of female students compared with male students (40.9% vs 25.2%, P < .001); Asian, URM, and multiracial students compared with white students (31.9%, 38.0%, 32.9%, and 24.0%, respectively; P < .001); and LGB students compared with heterosexual students (43.5% vs 23.6%, P < .001). A higher percentage of female students compared with male students reported discrimination based on gender (28.2% vs 9.4%, P < .001); a greater proportion of Asian, URM, and multiracial students compared with white students reported discrimination based on race/ethnicity (15.7%, 23.3%, 11.8%, and 3.8%, respectively; P < .001), and LGB students reported a higher prevalence of discrimination based on sexual orientation than heterosexual students (23.1% vs 1.0%, P < .001). Moreover, higher proportions of female (17.8% vs 7.0%), URM, Asian, and multiracial (4.9% white, 10.7% Asian, 16.3% URM, and 11.3% multiracial), and LGB (16.4% vs 3.6%) students reported 2 or more types of mistreatment compared with their male, white, and heterosexual counterparts (P < .001). Conclusions and Relevance: Female, URM, Asian, multiracial, and LGB students seem to bear a disproportionate burden of the mistreatment reported in medical schools. It appears that addressing the disparate mistreatment reported will be an important step to promote diversity, equity, and inclusion in medical education.

Comparative effectiveness of surgery and radiosurgery for stage I non-small cell lung cancer.

BACKGROUND: Although surgery is the standard treatment for early-stage non-small cell lung cancer (NSCLC), stereotactic body radiotherapy (SBRT) has been disseminated as an alternative therapy. The comparative mortalities and toxicities of these treatments for patients of different life expectancies are unknown. METHODS: The Surveillance, Epidemiology, and End Results-Medicare linked database was used to identify patients who were 67 years old or older and underwent SBRT or surgery for stage I NSCLC from 2007 to 2009. Matched patients were stratified into short life expectancies (<5 years) and long life expectancies (≥5 years). Mortality and complication rates were compared with Poisson regression. RESULTS: Overall, 367 SBRT patients and 711 surgery patients were matched. Acute toxicity (0-1 month) was lower from SBRT versus surgery (7.9% vs 54.9%, P < .001). At 24 months after treatment, there was no difference (69.7% vs 73.9%, P = .31). The incidence rate ratio (IRR) for toxicity from SBRT versus surgery was 0.74 (95% confidence interval [CI], 0.64-0.87). Overall mortality was lower with SBRT versus surgery at 3 months (2.2% vs 6.1%, P = .005), but by 24 months, overall mortality was higher with SBRT (40.1% vs 22.3%, P < .001). For patients with short life expectancies, there was no difference in lung cancer mortality (IRR, 1.01; 95% CI, 0.40-2.56). However, for patients with long life expectancies, there was greater overall mortality (IRR, 1.49; 95% CI, 1.11-2.01) as well as a trend toward greater lung cancer mortality (IRR, 1.63; 95% CI, 0.95-2.79) with SBRT versus surgery. CONCLUSIONS: SBRT was associated with lower immediate mortality and toxicity in comparison with surgery. However, for patients with long life expectancies, there appears to be a relative benefit from surgery versus SBRT.

Stereotactic body radiation therapy versus intensity-modulated radiation therapy for prostate cancer: comparison of toxicity.

PURPOSE: Stereotactic body radiation therapy (SBRT) is a technically demanding prostate cancer treatment that may be less expensive than intensity-modulated radiation therapy (IMRT). Because SBRT may deliver a greater biologic dose of radiation than IMRT, toxicity could be increased. Studies comparing treatment cost to the Medicare program and toxicity are needed. METHODS: We performed a retrospective study by using a national sample of Medicare beneficiaries age ≥ 66 years who received SBRT or IMRT as primary treatment for prostate cancer from 2008 to 2011. Each SBRT patient was matched to two IMRT patients with similar follow-up (6, 12, or 24 months). We calculated the cost of radiation therapy treatment to the Medicare program and toxicity as measured by Medicare claims; we used a random effects model to compare genitourinary (GU), GI, and other toxicity between matched patients. RESULTS: The study sample consisted of 1,335 SBRT patients matched to 2,670 IMRT patients. The mean treatment cost was $13,645 for SBRT versus $21,023 for IMRT. In the 6 months after treatment initiation, 15.6% of SBRT versus 12.6% of IMRT patients experienced GU toxicity (odds ratio [OR], 1.29; 95% CI, 1.05 to 1.53; P = .009). At 24 months after treatment initiation, 43.9% of SBRT versus 36.3% of IMRT patients had GU toxicity (OR, 1.38; 95% CI, 1.12 to 1.63; P = .001). The increase in GU toxicity was due to claims indicative of urethritis, urinary incontinence, and/or obstruction. CONCLUSION: Although SBRT was associated with lower treatment costs, there appears to be a greater rate of GU toxicity for patients undergoing SBRT compared with IMRT, and prospective correlation with randomized trials is needed.

A new approach to understanding racial disparities in prostate cancer treatment.

OBJECTIVE: Previous studies addressing racial disparities in treatment for early-stage prostate cancer have focused on the etiology of undertreatment of black men. Our objective was to determine whether racial disparities are attributable to undertreatment, overtreatment, or both. METHODS: Using the SEER-Medicare dataset, we identified men 67­84 years-old diagnosed with localized prostate cancer from 1998 to 2007. We stratified men into clinical benefit groups using tumor aggressiveness and life expectancy. Low-benefit was defined as low-risk tumors and life expectancy <10 years; high-benefit as moderate-risk tumors and life expectancy ≥10 years; all others were intermediate-benefit. Logistic regression modeled the association between race and treatment (radical prostatectomy or radiotherapy) across benefit groups. RESULTS: Of 68,817 men (9.8% black and 90.2% white), 56.2% of black and 66.3% of white men received treatment (adjusted odds ratio (OR)=0.65; 95% CI, 0.62­0.69). The percent of low-, intermediate-, and high-benefit men who received treatment was 56.7%, 68.4%, and 79.6%, respectively (P=<0.001). In the low-benefit group, 51.9% of black vs. 57.2% of white patients received treatment (OR=0.74; 95% CI, 0.67­0.81) compared to 57.2% vs. 69.6% in the intermediate-benefit group (OR=0.64; 95% CI, 0.59­0.70). Racial disparity was largest in the high-benefit group (64.2% of black vs. 81.4% of white patients received treatment; OR=0.57; 95% CI, 0.48­0.68). The interaction between race and clinical benefit was significant (P<0.001). CONCLUSION: Racial disparities were largest among men most likely to benefit from treatment. However, a substantial proportion of both black and white men with a low clinical benefit received treatment, indicating a high level of overtreatment.