Racial and Ethnic Differences Among Adult Patients Hospitalized for Skin and Soft Tissue Infection: A Cross-Sectional Analysis of 2012-2017 New York State Data.

Skin and soft tissue infections (SSTI) can result in hospitalizations and lead to increased healthcare costs and morbidity. Racial and ethnic disparities in healthcare access, utilization, and outcomes are well-documented. However, limited studies exist on racial and ethnic differences among adult patients hospitalized for SSTI. Our study utilized a large dataset from New York State to investigate such differences. Findings suggest that racial and ethnic minority patients hospitalized for SSTI are younger, primarily covered by Medicaid, and have a higher cost of hospitalization compared to White patients, even after controlling for length of stay and severity of illness. Possible explanations for these disparities include differences in comorbidities and structural vulnerabilities. Further studies are needed to elucidate potential causes of these disparities and their impact on clinical outcomes.

The ocular and periocular involvement of psoriasis.

Ocular manifestations of psoriasis are generally underrepresented in the literature and can often be missed by clinicians. Appreciation of eye involvement in psoriasis is especially important for dermatologists and ophthalmologists who may be closely involved with treating afflicted patients. Depending on the involved site and severity of the condition, signs and symptoms of ocular psoriasis can vary from asymptomatic erythema to debilitating scarring and vision loss. Treatment is critical to prevent disease progression and to improve the quality of life for these patients. We discuss the various clinical manifestations and treatment options for ocular complications in patients with psoriasis, including specific circumstances that should trigger immediate referral to our ophthalmology colleagues.

Impact of a Dedicated Cancer Urgent Care Center on Acute Care Utilization.

PURPOSE: Acute care imposes a significant burden on patients and cancer care costs. We examined whether an advanced practice provider-driven, cancer-specific urgent care center embedded within a large tertiary academic center decreased acute care use among oncology patients on active therapy. MATERIALS AND METHODS: We conducted a quasi-experimental study anchored around the Oncology Extended Care Clinic (OECC) opening date. We evaluated two parallel 4-month periods: a post-OECC period that followed a 5-month run-in phase, and the identical calendar period 1 year earlier. Our primary outcomes included all emergency department (ED) presentations and hospital admissions during the 3-month window following the index provider visit. We used Poisson models to calculate absolute pre-OECC v post-OECC rate differences. RESULTS: Our cohort included 2,095 patients in the pre-OECC period and 2,188 in the post-OECC period. We identified 32.6 ED visits/100 patients and 41.2 hospitalizations/100 patients in the pre-OECC period, versus 28.2 ED visits/100 patients and 26.1 hospitalizations/100 patients post-OECC. After adjusting for age, sex, race and ethnicity, and practice location, we observed a significant decrease of 4.6 ED visits/100 patients during the post-OECC period (95% CI, -8.92/100 to -0.28/100; P = .04) compared with the pre-OECC period. There was no significant association between the OECC opening and hospitalization rate (rate difference: -3.29 admissions/100 patients; 95% CI, -8.24/100 to 1.67/100; P = .19). CONCLUSION: Establishing a cancer-specific urgent care center was significantly associated with a modest decrease in emergency room utilization but not with hospitalization rate. Barriers included clinic capacity, patient awareness, and physician comfort with advanced practice provider autonomy. Optimizing workflow and standardizing clinical pathways can create benchmarks useful for value-based payments.

A Stakeholder-Driven Qualitative Study to Define High Quality End-of-Life Care for Children With Cancer.

CONTEXT: Among adults with cancer, measures for high quality end-of-life care (EOLC) include avoidance of hospitalizations near end of life. For children with cancer, no measures exist to evaluate or improve EOLC, and adult quality measures may not apply. OBJECTIVE: We engaged key stakeholders to explore EOLC priorities for children with cancer and their families, and to examine relevance of existing adult EOLC quality measures for children with cancer. METHODS: In a multicenter qualitative study, we conducted interviews and focus groups with: adolescents and young adults (AYAs) with advanced cancer, parents of children with advanced cancer, bereaved parents, and interdisciplinary healthcare professionals. We transcribed, coded, and employed thematic analysis to summarize findings. RESULTS: We enrolled 54 stakeholders (25 parents [including 12 bereaved parents], 10 AYAs, and 19 healthcare professionals). Participants uniformly prioritized direct communication with children about preferences and prognosis, interdisciplinary care, symptom management, and honoring family preference for location of death. Many participants valued access to the emergency department or hospital for symptom management or supportive care, which diverges from measures for high quality EOLC in adults. Most wished to avoid mechanical ventilation and cardiopulmonary resuscitation. Notably, participants generally valued hospice; however, few understood hospice care or had utilized its services. CONCLUSION: Childhood cancer stakeholders define high quality EOLC primarily through person-centered measures, characterizing half of existing adult-focused measures as limited in relevance to children. Future research should focus on developing techniques for person-centered quality measurement to capture attributes of greatest importance to children with cancer and their families.

Construction of a Pediatrics Risk Score to Predict High Health Care Costs Among a Community Health Center Cohort.

Risk-stratification strategies are needed for ambulatory pediatric populations. The authors sought to develop age-specific risk scores that predict high health care costs among an urban population. A retrospective cohort study was performed of children ages 1-18 years who received care at Fair Haven Community Health Care (FHCHC), a community health center in New Haven, Connecticut. Cost was estimated from charges in the electronic health record (EHR), which is shared with the only hospital system in the city. Using multivariable logistic regression models, independent predictors of being in the top decile of total charges during the 2017 calendar year were identified, drawing from covariates collected from the EHR prior to 2017. Random forest modeling was used to verify the feature importance of significant covariates and model performance from 2017 cost data were compared to those using 2018 cost data. Regression models were used to construct age-specific nomograms to predict cost. Among 8960 children who received care at FHCHC in the 18 months prior to 2017, covariate frequencies clustered in age groups 1-5 years, 6-11 years, and 12-18 years, so 3 age-specific models were constructed. Prior utilization variables predicted future costs, as did younger children who received specialty care and older children with behavioral health diagnoses. Final models for each age group had C statistics ≥0.68 using both 2017 and 2018 cost data. Prediction models can draw from elements accessible in the EHR to predict cost of ambulatory pediatric patients. Strategies to impact utilization among high-risk children are needed.

Treatment patterns and survival in hepatocellular carcinoma in the United States and Taiwan.

BACKGROUND: Survival in hepatocellular carcinoma (HCC) is lower in the USA than in Taiwan. Little is known about the extent to which differences in stage at diagnosis and treatment contribute to this difference. We examined treatment patterns and survival in HCC and analyzed factors driving the difference. METHODS: Using a uniform methodology, we identified patients aged 66 years and older with newly diagnosed HCC between 2004 and 2011 in the USA and Taiwan. We compared treatment within 6 months after HCC diagnosis and 2-year stage-specific survival between the two countries. RESULTS: Compared with patients in Taiwan (n = 32,987), patients in the USA (n = 7,003) were less likely to be diagnosed as stage IA (4% vs 8%) and II (13% vs 22%), or receive cancer-directed treatments (41% vs 58%; all p < .001). Stage-specific 2-year survival rates were lower in the USA than in Taiwan (stage IA: 57% vs 77%; stage IB: 38% vs 63%; stage II: 40% vs 57%, stage III: 14% vs 18%; stage IV: 4% vs 5%, respectively; all p < .001 except p = .018 for stage IV). Differences in age and sex (combined), stage, and receipt of treatment accounted for 3.8%, 17.0%, and 16.8% of the survival difference, respectively, leaving 62.5% unexplained. CONCLUSIONS: Differential stage at diagnosis and treatment were substantially associated with the survival difference, but approximately two-thirds of the difference remained unexplained. Identifying the main drivers of the difference could help improve HCC survival in the USA.

Utilization, duration, and outcomes of neoadjuvant endocrine therapy in the United States.

PURPOSE: To evaluate if real-world utilization of neoadjuvant endocrine therapy (NET) is associated with similar rates of response and breast conservation surgery (BCS) compared to neoadjuvant chemotherapy (NAC). METHODS: Our population-based assessment used the National Cancer Data Base to identify women diagnosed with stage II-III, hormone receptor (HR)-positive BC who underwent surgery and received endocrine therapy from 2004 to 2014. Women were categorized by receipt of NET, NAC or no neoadjuvant therapy. We used logistic regression to assess differences in outcomes between therapies using inverse propensity score weighting to adjust for potential selection bias. RESULTS: In our sample of 211,986 women, 6584 received NET, 52,310 received NAC, and 153,092 did not receive any neoadjuvant therapy. After adjusting for multiple relevant covariates and cofounders, there was no significant difference between NET and NAC with regard to BCS [odds ratio (OR) 0.91; 95% confidence interval (CI) (0.82-1.01)]; however, women who received NET were significantly less likely to achieve pCR [OR 0.34; 95% CI (0.23-0.51)] or a decrease in T stage [OR 0.39; CI (0.34-0.44)] compared to women treated with NAC. Patients who received NET for ≥ 3 months had higher odds of BCS (OR 1.59; 95% CI 1.46-1.73) and downstaging (OR 1.79; 95% CI 1.63-1.97) compared to patients who did not receive neoadjuvant therapy. CONCLUSIONS: Women who received NET had similar rates of BCS compared to women who received NAC. Those who received NET for longer treatment durations had increased odds of BCS and downstaging compared to women who did not receive neoadjuvant therapy.

Long-Term Outcomes of Sentinel Lymph Node Biopsy for Ductal Carcinoma in Situ.

The use of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is controversial. Using population-cohort data, we examined whether SLNB improves long-term outcomes among patients with DCIS who underwent breast-conserving surgery. We identified 12 776 women aged 67-94 years diagnosed during 2001-2013 with DCIS who underwent breast-conserving surgery from the US Surveillance, Epidemiology, and End Results-Medicare dataset, 1992 (15.6%) of whom underwent SLNB (median follow-up: 69 months). Tests of statistical significance are two-sided. Patients with and without SLNB did not differ statistically significantly regarding treated recurrence (3.9% vs 3.7%; P = .62), ipsilateral invasive occurrence (1.4% vs 1.7%, P = .33), or breast cancer mortality (1.0% vs 0.9%, P = .86). With Mahalanobis-matching and competing-risks survival analyses, SLNB was not statistically significantly associated with treated recurrence, ipsilateral invasive occurrence, or breast cancer mortality (P ≥ .27). Our findings do not support the routine performance of SLNB for older patients with DCIS amenable to breast conservation.

Associations of preoperative breast magnetic resonance imaging with subsequent mastectomy and breast cancer mortality.

PURPOSE: To examine associations between pre-operative magnetic resonance imaging (MRI) use and clinical outcomes among women undergoing breast-conserving surgery (BCS) with or without radiotherapy for early-stage breast cancer. METHODS: We identified women from the Surveillance, Epidemiology, and End Results-Medicare dataset aged 67-94 diagnosed during 2004-2010 with stage I/II breast cancer who received BCS. We compared subsequent mastectomy and breast cancer mortality with versus without pre-operative MRI, using Cox regression and competing risks models. We further stratified by receipt of radiotherapy for subgroup analyses. RESULTS: Our sample consisted of 24,379 beneficiaries, 4691 (19.2%) of whom received pre-operative MRI. Adjusted rates of subsequent mastectomy and breast cancer mortality were not significantly different with and without MRI: 3.2 versus 4.1 per 1000 person-years [adjusted hazard ratio (AHR) 0.92; 95% confidence interval (CI) 0.70-1.19] and 5.3 versus 8.7 per 1000 person-years (AHR 0.89; 95% CI 0.73-1.08), respectively. In subgroup analyses, women receiving BCS plus radiotherapy had similar rates of subsequent mastectomy (AHR 1.17; 95% CI 0.84-1.61) and breast cancer mortality (AHR 1.00; 95% CI 0.80-1.24) with versus without MRI. However, among women receiving BCS alone, MRI use was associated with lower risks of subsequent mastectomy (AHR 0.60; 95% CI 0.37-0.98) and breast cancer mortality (AHR 0.57; 95% CI 0.36-0.92). CONCLUSIONS: Pre-operative MRI was associated with improved outcomes among older women with breast cancer receiving BCS alone, but not among those receiving BCS plus radiotherapy. Further research is needed to identify appropriate settings for which MRI may be helpful.

Factors Associated With Cancer Disparities Among Low-, Medium-, and High-Income US Counties.

Background: There are concerns about the degree to which county income level might underlie the stark disparities in cancer death rates among US counties; at the same time, there is uncertainty about the factors that may mediate the disparities. Objectives: To assess county-level cancer death rates and to identify possible mediators of the association between county-level median incomes and cancer death rates. Design, Setting, and Participants: Cross-sectional study using death records from the National Center for Health Statistics in 2014, with data collected and analyzed between October 1, 2016, and July 31, 2017. All US counties and county equivalents were included. Exposures: County-level median household income. Main Outcomes and Measures: County-level age-standardized cancer death rate. Results: In 3135 counties, median incomes ranged from $22 126 to $121 250 per year. Low-income counties (median income, $33 445) vs high-income counties (median income, $55 780) had higher proportions of residents who were non-Hispanic black, lived in rural areas, or reported poor or fair health. The mean (SD) cancer death rate was 185.9 (24.4) per 100 000 person-years in high-income counties, compared with 204.9 (26.3) and 229.7 (32.9) per 100 000 person-years in medium- and low-income counties, respectively. In mediation models, health risk behaviors (smoking, obesity, and physical inactivity); clinical care factors (unaffordable care and low-quality care); health environments (food insecurity); and health policies (state smoke-free laws and Medicaid payment rates) in aggregate accounted for more than 80% of the income-related disparity. The strongest possible mediators were food insecurity (explaining 19.1% [95% CI, 12.5%-26.5%] of the association between county incomes and cancer deaths), low-quality care (17.9%; 95% CI, 14.0%-21.8%), smoking (12.7%; 95% CI, 9.4%-15.6%), and physical inactivity (12.2%; 95% CI, 9.4%-15.6%). Conclusions and Relevance: There are wide gaps in cancer death rates between low-, medium-, and high-income counties. Future studies are needed to assess whether targeting the possible mediators might ameliorate the substantial socioeconomic cancer disparities.

Tick-borne disease preventive practices and perceptions in an endemic area.

Lyme disease is the most commonly reported vector-borne illness in the United States. Since the institution of Nationally Notifiable surveillance efforts for Lyme disease in the United States in 1991, there has been a consistent increase in the number of reported cases. Thus, the need for targeted prevention strategies is underscored. The purpose of this study was to investigate knowledge about tick-borne diseases as well as beliefs and practices related to a variety of personal tick-borne disease prevention methods among individuals in southwestern Connecticut, a Lyme disease-endemic area. Between June and September 2014, an anonymous questionnaire was administered to 275 participants through a point-of-contact convenience sample obtained at community events in southwestern Connecticut. The questionnaire assessed individuals' general knowledge about tick-borne diseases, performance of four selected tick-borne disease prevention methods, and perceived effectiveness and burdensomeness of those four behaviors. Some 80% of participants were female; median age was 55 years (IQR 45-64 years); 30% reported having been treated for a tick-borne illness and 50% reported a family member having been treated for a tick-borne illness. Overall, participants' knowledge of tick-borne diseases was poor; the average knowledge score was only 57% (SD 22.6%). The reported frequency of performing preventive behaviors was variable. The most commonly reported behavior was performing a tick check (68%); use of tick repellent was the least commonly reported behavior (38%). Those who were more knowledgeable about Lyme disease were more likely to perform tick checks but knowledge score was not significantly associated with any of the other three behaviors studied. Respondents largely believed preventive behaviors to be effective at reducing the risk of tick-borne diseases. Belief that a prevention behavior is effective was highly correlated with performing that behavior but perceived burdensomeness does not appear to influence behavior performance. The reasons for differential uptake of preventive behaviors remains unknown; further study of barriers to performance of personal preventive behaviors is needed to better target public health interventions.