Disparate outcomes in nonsmall cell lung cancer by immigration status.

OBJECTIVE: The purpose of this study was to evaluate overall survival (OS) outcomes by race, stratified by country of origin in patients diagnosed with NSCLC in California. METHODS: We performed a retrospective analysis of nonsmall cell lung cancer (NSCLC) patients diagnosed between 2000 and 2012. Race/ethnicity was defined as White (W), Black (B), Hispanic (H), and Asian (A) and stratified by country of origin (US vs. non-US [NUS]) creating the following patient cohorts: W-US, W-NUS, B-US, B-NUS, H-US, H-NUS, A-US, and A-NUS. Three multivariate models were created: model 1 adjusted for age, gender, stage, year of diagnosis and histology; model 2 included model 1 plus treatment modalities; and model 3 included model 2 with the addition of socioeconomic status, marital status, and insurance. RESULTS: A total of 68,232 patients were included. Median OS from highest to lowest were: A-NUS (15 months), W-NUS (14 months), A-US (13 months), B-NUS (13 months), H-US (11 months), W-US (11 months), H-NUS (10 months), and B-US (10 months) (p < 0.001). In model 1, B-US had worse OS, whereas A-US, W-NUS, B-NUS, H-NUS, and A-NUS had better OS when compared to W-US. In model 2 after adjusting for receipt of treatment, there was no difference in OS for B-US when compared to W-US. After adjusting for all variables (model 3), all race/ethnicity profiles had better OS when compared to W-US; B-NUS patients had similar OS to W-US. CONCLUSION: Foreign-born patients with NSCLC have decreased risk of mortality when compared to native-born patients in California after accounting for treatments received and socioeconomic differences.

Clinical pathways improve hospital resource use in endocrine surgery.

BACKGROUND: Clinical pathways are increasingly adopted to streamline care after elective surgery. Here, we describe novel clinical pathways developed for endocrine operations (ie, unilateral thyroid lobectomy, total thyroidectomy, parathyroidectomy) and evaluate their effects on economic end points at a major academic hospital. STUDY DESIGN: Length of stay (LOS), hospital charges, and hospital costs for 681 patients undergoing elective endocrine surgery during a 30-month period were compared between patients managed with or without a specific pathway. Hospital costs were subcategorized by cost center. The analysis arms were conducted concurrently to control for institutional effects and end points were adjusted for demographic factors and comorbidity. RESULTS: Clinical pathways were observed to significantly reduce LOS, charges, and costs for endocrine procedures. LOS was reduced for thyroid lobectomy (nonpathway 1.6 days versus pathway 1.0; p < 0.001), total thyroidectomy (2.8 versus 1.1; p < 0.0001), and parathyroidectomy (1.6 versus 1.1; p < 0.001). Nonpathway patients were 6.2 times more likely to be admitted to the intensive care unit than pathway patients (p < 0.05). Clinical pathways reduced total charges from $21,941 to $17,313 for all cases (21% reduction; p < 0.0001), with 47% of savings attributable to reduced LOS. Significant improvements were observed for laboratory use (73% reduction; p < 0.0001) and nonroutine medication administration (73% reduction; p < 0.0001). The readmission rate within 72 hours of discharge was not significantly lower in the pathway group. CONCLUSIONS: Implementation of clinical pathways improves efficiency of care after elective endocrine surgery without adversely affecting safety or quality. Because these system measures optimize resource use, they represent an important component of high-volume subspecialty surgical services.