Impact of Insurance Status on Survival of Patients Diagnosed with Acute Promyelocytic Leukemia in the United States

Abstract Background: Survival among patients diagnosed with acute promyelocytic leukemia (APL) has significantly improved with the use of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). However, the need for immediate diagnosis, access to specialized care and complexity and cost associated with APL management can potentially act as a barrier for disadvantaged patients. Whether socio-economic factors influence the outcomes of patients with APL remains unclear. Methods: We used data from the National Cancer Institute's Surveillance Epidemiology and End Results program (SEER-18) to analyze APL cases diagnosed in patients < 65 years of age between 2007 (year when insurance information became available) and 2015 (most recent year available) to characterize the impact of insurance, marital status, county-level income, county-level educational achievement and residence in rural or urban county on survival. Cases were grouped according to age (< 40 years and ≥ 40 years), and analyzed considering race/ethnicity, gender, and year of diagnosis. Results: A total of 1,787 APL cases (816 < 40 years and 971 ≥ 40 years) were included in the analysis with a median follow up of 35 months (0-107). The median age at diagnosis was 41 years (0-64 years), 52.5% were male, 52.3% non-Hispanic Whites (NHW), 11.8% non-Hispanic Blacks (NHB), 25.9% Hispanics and 9.9% of other race/ethnicity. Marital status was single for 36.9%, married for 54%, divorced for 7.5% and widowed for 1.6%. Among patients <40 years, 64% were insured (other than Medicaid), 29.9% were Medicaid beneficiaries and 6.1% uninsured. Among patients ≥ 40 years figures were 77.1%, 17.6% and 5.3% respectively. For age < 40 years, patients with insurance (other than Medicaid) and Medicaid had improved survival compared to patients without insurance. There was no statistically significant difference between Medicaid and other insurance (Figure). Among patients ≥ 40 years, being insured (other than Medicaid) was associated with higher survival than being Medicaid beneficiary or being uninsured, while patients with Medicaid had better survivals than uninsured patients (Figure). In multivariate analysis of patients < 40, higher risk of death was associated with being male, diagnosis in earlier years and being uninsured while lower risk of death was associated with being single (Table). Other socioeconomic variables did not contribute to the model. For patients ≥ 40 years, mortality was increased for both Medicaid and uninsured patients compared to insured patients (Table). No other demographic or socioeconomic variable contributed to the model. Conclusion: Despite the high cure rate experienced by patients with APL, patients < 65 years without insurance and those ≥ 40 with Medicaid are at significant disadvantage compared to patients with insurance. These findings point to an opportunity to improve survival in APL by addressing access to care. Disclosures Costa: Abbvie: Research Funding; Amgen: Honoraria, Research Funding; Karyopharm: Research Funding; BMS: Research Funding; Celgene: Honoraria, Research Funding; Janssen: Research Funding; Sanofi: Honoraria.

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Temporal Trends in Early Mortality in Acute Promyelocytic Leukemia in the United States

Blood ◽

10.1182/blood-2018-99-114171 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 710-710

Author(s):

Ana C. Xavier ◽

Matthew A. Kutny ◽

Omer Jamy ◽

Luciano J Costa

Keyword(s):

Acute Promyelocytic Leukemia ◽

Rural Areas ◽

Research Funding ◽

Educational Achievement ◽

Temporal Trends ◽

Malignant Neoplasm ◽

The United States ◽

Promyelocytic Leukemia ◽

Early Mortality

Abstract Background: Survival of patients with acute promyelocytic leukemia (APL) has dramatically improved with the use of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). Despite this, due to the complexity of initial management and the high risk of fatal thrombotic and hemorrhagic complications at presentation, early mortality (EM) remains the major contributor for treatment failure. It is less known whether advances in treatment, improvements in supportive measures, urgent access to specialized care and broad availability of ATRA and ATO have reduced EM in the last two decades. Methods: We used data from the National Cancer Institute's Surveillance Epidemiology and End Results program (SEER-13) to determine the rates of EM (death within the first 30 days from diagnosis) and overall survival (OS) in patients with APL. Inclusion criteria was the diagnosis of APL as first malignant neoplasm among patients of all ages between 1992 and 2015. Follow up was updated to the end of 2015. Cases were grouped and analyzed according to age, children, adolescent and young adults (< 40 years) and older adults (≥ 40 years), race/ethnicity, gender, county-level income and educational achievement, and residency in rural or urban county. Trends in EM and OS were analyzed across consecutive 4-year eras. Results: A total of 2,224 APL cases (895 <40 and 1,329 ≥ 40 years) were included in the analysis with median follow up of 41 months (range 0-287 months). Median age of patients was 45, and 1,090 (49%) were male. Most patients were White (1,228; 55.2%), 199 (9%) Black, 785 (35.3%) other ethnicity, and 12 (0.5%) unknown. Three-year OS for APL patients diagnosed in 1992-1995 was 49.2% ± 3.5% vs. 76.4 ± 2.1% for patients diagnosed in 2012-2015 (p < 0.001), Figure 1. Early mortality improved for patients < 40 years (27.4% in 1992-1995 vs. 5.4% in 2012-2015, p < 0.001), but not at the same extent for patients ≥ 40 years (35.2% in 1992-1995 vs. 22.2% in 2012-2015, p = 0.02), Figure 2. Improvements in EM are displayed in Table 1. Importantly, improvements in EM were not seen among patients of residents of rural counties. Conclusion: These findings confirm consistent improvements in EM and OS for APL patients in the US and point to the challenge of further extending these improvements in EM rates to older patients and for those living in rural areas. Disclosures Costa: Celgene: Honoraria, Research Funding; Sanofi: Honoraria; Karyopharm: Research Funding; Janssen: Research Funding; BMS: Research Funding; Abbvie: Research Funding; Amgen: Honoraria, Research Funding.

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Sociodemographic Profile and Outcomes of Patients with Non-Diffuse Large B-Cell Lymphoma (non-DLBCL) Treated at Minority-Predominant Facilities in the United States

Blood ◽

10.1182/blood-2018-99-119976 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4868-4868

Author(s):

Vivek Kumar ◽

Taimur Sher ◽

Vivek Roy ◽

Prakash Vishnu ◽

Anne M Hazen ◽

...

Keyword(s):

Multivariate Analysis ◽

B Cell Lymphoma ◽

The United States ◽

Racial Minorities ◽

Risk Of Death ◽

Risk Of Mortality ◽

Increased Risk ◽

Race Ethnicity ◽

Facility Level ◽

The Impact

Abstract Background: Racial disparities in outcomes of cancer patients have been reported. Access to comprehensive cancer centers is associated with improved overall survival (OS) but racial/ethnic minorities may have a disparate access to such care. While the impact of treatment facility volume on outcomes has been evaluated, outcomes of centers with minority-predominant patient population have not been studied. We compared demographic profiles, facility level data and OS of patients treated at minority-predominant facilities to facilities that treated predominantly non-Hispanic Whites (NHW) with non-DLBCL. Methods: The National Cancer Database (NCDB) was used to identify all non-DLBCL patients diagnosed between 2004 and 2015. "Minority-treating facilities" were defined as facilities in the top decile by proportion for initial treatment of non-Hispanic African-Americans (NHAA), Hispanics and other races. We performed univariate and multivariate analyses to compare sociodemographic and clinical factors influencing outcomes between minority treating and non-minority treating facilities. A subgroup analysis stratified by race/ethnicity was also conducted to study the effect of treating facilities on the outcome of NHWs and minorities separately. Results: Of 1339 total facilities, 123 (9.1%) qualified as minority treating. Of 207,239 eligible patients in NCDB, 18,719 (9.03%) received treatment at the minority-treating facilities and of these, 11,190 (~60%) belonged to the minority races. Overall, 4.5% (6,988/156,664) NHWs and 30% (11,190/37,639) minorities received treatment at the minority-treating facilities. Several demographic and facility level characteristics were significantly different among the patients treated at minority-treating facilities as compared to non-minority treating facilities. Overall, significantly higher number of patients in minority-treating hospitals had lower income and education, had Medicaid coverage or lack of insurance. The OS of patients in minority treating facilities was significantly worse as compared to non-minority facilities (Figures). On multivariate analysis, patients who received treatment at minority-treating facilities were at 10% (HR=1.10, 95% CI: 1.06-1.14 p<0.001) higher risk of mortality as compared to those treated at the non-minority treating facilities. On multivariate analysis, NHAA (30% increased risk) and 'other races' (9% increased risk) were at significantly higher risk of mortality as compared to the NHW (Table 2). To study the effect of treatment at minority-treating facilities on OS among the patients of same race/ethnicity group, a multivariate analysis was also run separately for NHW and racial minorities. The NHWs who received treatment at minority-treating facilities were at 13% higher risk of death (HR=1.13, 95% CI: 1.08-1.19 p<0.001) as compared to NHWs who were treated at non-minority treating facilities. Similarly, the racial minorities who received treatment at minority treating facilities were at 8% higher risk of death (HR=1.08, 95% CI: 1.03-1.19 p=0.003) as compared to those who received treatment at the nonminority treating facilities. Conclusions:Outcomes of patients who received treatment at minority treating facilities was significantly worse than those at non-minority treating facilities. This was true for NHWs and racial minorities separately as well. Several demographic and facility level characteristics were significantly different in the two groups however OS remained worse after adjusting for them. Causes of poor outcomes at minority-treating facilities must be analyzed to mitigate them and improve outcomes for all. Figure. Figure. Disclosures Ailawadhi: Takeda: Consultancy; Celgene: Consultancy; Amgen: Consultancy; Janssen: Consultancy; Pharmacyclics: Research Funding.

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Clinical Availability of ATRA for Patients With Suspected Acute Promyelocytic Leukemia: Why Guidelines May Not Be Followed

Journal of the National Comprehensive Cancer Network ◽

10.6004/jnccn.2021.7013 ◽

2021 ◽

Author(s):

Marcus J. Geer ◽

Charles E. Foucar ◽

Sumana Devata ◽

Lydia Benitez ◽

Anthony J. Perissinotti ◽

...

Keyword(s):

United States ◽

Acute Leukemia ◽

Acute Promyelocytic Leukemia ◽

The United States ◽

Promyelocytic Leukemia ◽

Trans Retinoic Acid ◽

All Trans Retinoic Acid ◽

Geographic Regions ◽

The Impact ◽

Regional Referral Center

Background: All-trans retinoic acid (ATRA) serves as the backbone of the management of patients with acute promyelocytic leukemia (APL), with guidelines recommending the initiation of ATRA as soon as APL is suspected. As a regional referral center for patients with acute leukemia, those who are suspected of having APL are often transferred to our facility. However, many referring centers are unable to initiate treatment using ATRA. We conducted an exploratory analysis of the clinical availability of ATRA and the factors limiting access to this critical drug. Patients and Methods: The United States was divided into 6 geographic regions: Northwest, Southwest, Central, Southeast, Northeast, and the Great Lakes. Twenty hospitals were randomly selected from states within each of these regions and were surveyed as to whether they typically treated patients with acute leukemia, the availability of ATRA at their institution, and reported reasons for not stocking ATRA (if not available). Results: Less than one-third of hospitals queried (31%) had ATRA in stock. Neither the size of the hospital nor the hospital’s status as academic versus nonacademic (53% vs 31%; P=.08) influenced ATRA availability. Of the hospitals that referred patients with APL, only 14% (7/49) had ATRA readily available. Hospitals that treated patients with APL were more likely to have ATRA available than referring centers (58% vs 14%; P=.000002). Conclusions: Nearly two-thirds of the hospitals surveyed that cared for patients with acute leukemia do not have ATRA immediately available. Moreover, the vast majority of hospitals that refer patients to other centers do not have ATRA. These findings should spur investigation into the impact of immediate ATRA availability on the morbidity and mortality of patients with APL. A call by hematologists nationwide to their formulary committees is warranted to ensure that this lifesaving medication is available to patients suspected of having APL.

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Insurance Status, Marital Status and Income, but Not Race-Ethnicity Affect Outcomes of Younger Patients Diagnosed with Multiple Myeloma in the US

Blood ◽

10.1182/blood.v126.23.633.633 ◽

2015 ◽

Vol 126 (23) ◽

pp. 633-633

Author(s):

Luciano J Costa ◽

Elizabeth E. Brown

Keyword(s):

Risk Factors ◽

Multiple Myeloma ◽

Marital Status ◽

Insurance Status ◽

County Level ◽

Younger Patients ◽

Medicaid Beneficiary ◽

Race Ethnicity ◽

The Impact ◽

Socioeconomic Risk

Abstract Background: Multiple myeloma (MM) affects predominantly older individuals but approximately 38% of patients are under the age of 65. Younger patients have benefitted the most from high dose chemotherapy with autologous hematopoietic cell support and subsequently from the introduction of novel agents. While outcomes have improved, care has become more complex and cost-prohibitive, potentially creating barriers to access for disadvantaged patients. The impact of socio economic factors potentially affecting care, namely insurance status, marital status, income and level of education in the outcomes of younger patients with MM is unknown. Methods: We analyzed MM cases diagnosed in patients < 65 years of age and reported to the Surveillance Epidemiology and End Results (SEER-18) program between 2007 (year when insurance information became available) and 2012 (most recent year available) and characterized the impact of insurance status, marital status, county-level income and county-level education (proportion of adult individuals with bachelor degree) in addition to age, gender, SEER registry and race-ethnicity on survival of MM patients. Risk and corresponding 95% confidence intervals were calculated using multivariable Cox proportional hazard models adjusted for confounders. Results: The analysis included 10,161 patients with a median follow up of survivors of 22 months (IQR 8-41 months). Median age at diagnosis was 57 (IQR 51-61), 43.5% were female, 56.2% non-Hispanic Whites (NHW), 24.9% non-Hispanic Blacks (NHB), 13.0% Hispanics, 5.9% of other race-ethnicity category (REC). Uninsured patients comprised 6%, Medicaid beneficiary 14.7%, and 79.3% had insurance benefits other than Medicaid. Married patients were 62.9%, 20.7% were single, 12.9% divorced or separated and 3.5% widowed. As shown in Table 1, increased risk of death was associated with older age, male gender, residence in the area of certain SEER-18 registries, low county-level income, marital status other than married, being uninsured or being Medicaid beneficiary (Table 1). The presence of increasing number of the 3 following independent socioeconomic risk factors: county-level income in the lower two quartiles, not married and being uninsured or Medicaid beneficiary, was associated with incremental worsening in survival (Figure 1). Patients with 0, 1, 2 and 3 socioeconomic risk factors had four year estimated survival of 71.1% (95% C.I. 68.9-73.3%), 63.2% (95% C.I. 61.2-65.1%) , 53.4% (95% C.I. 50.7-56.1) and 46.5% (95% C.I. 41.6-51.4%) respectively (P<0.001). Of interest, while NHB and Hispanics had worse survival in univariate analysis, REC did not contribute to the multivariate survival model. Conclusions: Insurance status, marital status and county-level income, but not REC and county-level education have a strong influence on the survival of younger patients with MM after adjustment for SEER registry, age and sex. Advances in MM treatment and outcomes disproportionally benefit patients of different socioeconomic backgrounds. Table. Multivariate Analysis Reference HR 95% CI P SEER registry 0.001 Alaska Greater California 0.58 0.14-2.33 0.4 Atlanta Greater California 0.97 0.80-1.17 0.8 Connecticut Greater California 0.81 0.65-1.00 0.05 Detroit Greater California 0.99 0.84-1.18 0.9 Greater Georgia Greater California 0.85 0.72-0.99 0.04 Hawaii Greater California 1.53 1.14-2.05 0.005 Iowa Greater California 1.14 0.92-1.41 0.2 Kentucky Greater California 1.01 0.84-1.22 0.9 Los Angeles Greater California 0.85 0.73-0.99 0.04 Louisiana Greater California 0.96 0.80-1.15 0.9 New Jersey Greater California 0.86 0.74-1.00 0.05 New Mexico Greater California 0.98 0.73-1.31 0.9 Rural Georgia Greater California 2.06 1.15-3.67 0.01 San Francisco-Oakland Greater California 0.90 0.73-1.11 0.3 San Jose-Monterey Greater California 0.89 0.68-1.18 0.4 Seattle Greater California 1.04 0.86-1.26 0.7 Utah Greater California 1.18 0.90-1.54 0.2 Age Per year 1.03 1.02-1.04 <0.001 Female Male 0.85 0.78-0.91 <0.001 Marital status <0.001 Divorced Married 1.24 1.11-1.39 <0.001 Single Married 1.39 1.27-1.53 <0.001 Widow Married 1.43 1.20-1.71 <0.001 Insurance status <0.001 Medicaid Insured 1.76 1.59-1.94 <0.001 Uninsured Insured 1.43 1.23-1.67 <0.001 County-level income <0.001 Quartile 1 Quartile 4 1.27 1.09-1.49 0.002 Quartile 2 Quartile 4 1.19 1.03-1.37 0.02 Quartile 3 Quartile 4 0.97 0.85-1.10 0.6 Figure 1. Figure 1. Disclosures No relevant conflicts of interest to declare.

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Clinical Availability of All-Trans Retinoic Acid (ATRA) for Patients with Suspected Acute Promyelocytic Leukemia – Why National Guidelines May Not be Followed

Blood ◽

10.1182/blood.v124.21.2297.2297 ◽

2014 ◽

Vol 124 (21) ◽

pp. 2297-2297

Author(s):

Nagendra Mogasala ◽

Sumana Devata ◽

Anthony Perissinotti ◽

Dale Bixby

Keyword(s):

Retinoic Acid ◽

Great Lakes ◽

Acute Promyelocytic Leukemia ◽

The United States ◽

Promyelocytic Leukemia ◽

National Guidelines ◽

Trans Retinoic Acid ◽

All Trans Retinoic Acid ◽

Geographical Regions ◽

The Impact

Abstract Background: All-Trans Retinoic Acid (ATRA, Tretinoin, Vesinoid, Teva Pharmaceuticals Industries, North Wales, PA) serves as a uniform backbone in the care and management of patients with acute promyelocytic leukemia (APL). While first investigated as a salvage therapy for patients with relapsed or refractory disease, current National Comprehensive Cancer Network (NCCN) and European LeukemiaNet (ELN) guidelines call for its early use in patients suspected of having APL even prior to the genetic confirmation of the disease. Because ATRA can significantly mitigate disseminated intravascular coagulopathy (DIC), one of the early complications of APL, the NCCN and ELN guidelines support the prescription of ATRA as soon as there is a clinical suspicion of the diagnosis. As a regional referral center for the care of patients with advanced myeloid malignancies, we receive numerous requests for the transfer of care for patients suspected of having APL. Yet many of the referring centers have not instituted treatment with ATRA, typically due to a lack of access to the medication in the referring hospital’s formulary. Therefore, we conducted an exploratory analysis of the clinical availability of ATRA for patients with a suspected diagnosis of APL and also to explore the potential hurdles limiting the availability of this drug. Methods: We divided the United States into six geographical regions: Northwest, Southwest, Central, Southeast, Northeast, and the Great Lakes. A state from each of these regions was selected (Washington, Arizona, Missouri, Georgia, Massachusetts, and Michigan). To select the 120 hospitals, an online hospital directory – American Hospital Directory (ahd.com) was utilized. We went to each state’s specific hospital list page and assigned a number to all hospitals with a bed capacity of greater than 100. We then entered these numbers into a random number generator and selected the first 20 hospitals to be generated (excluding repeats). We then asked the following set of questions to the inpatient pharmacist of the hospital: 1. Does your hospital treat Acute Leukemia or do they refer to other hospitals; 2. Do you have All Trans Retinoic Acid (oral) – 10 mg tablets on the formulary or available in stock as a non-formulary request; 3. If no, why not. Results: Based upon the responses we received, ATRA was available in less than half of the hospitals queried (46%) (Table 1). There were no identifiable differences in the percentages based upon hospital size (inpatient beds) or academic versus non-academic status of the hospital. Interestingly, of the hospitals that refer to other institutions for the care of their leukemia patients, only 19% (8/43) had ATRA on their formulary or available in stock as a non-formulary request that could act as a bridge prior to the transfer. The analysis identified three common barriers to the availability of ATRA in these hospitals including: a) that it has not been recently requested by a physician and therefore was not available, b) the inpatient pharmacist had never heard of the drug, and c) that the hospital relied on associated hospitals or cancer centers to provide the drug to the patient. Table 1 Clinical Availability of All-Trans Retinoic Acid in Participating Hospitals Region State Percentage of Hospitals Possessing ATRA Northwest Washington 65% Southwest Arizona 45% Midwest Missouri 35% Great Lakes Michigan 58% Southeast Georgia 35% Northeast Massachusetts 40% Conclusion: While national guidelines support the rapid introduction of ATRA as soon as there is a morphologic consideration for APL, the majority of hospitals caring for these patients can not rapidly institute therapy due to a lack of availability of the medication. Moreover, only 19% (8/43) of hospitals that we studied that refer patients to tertiary care centers can provide ATRA as a bridge prior to their transfer. While much has been written about the early 30-day mortality seen in patients with APL, we can not specifically comment on the impact of these findings on the rates of mortality of APL patients treated in hospitals without ready access to ATRA versus those with the medication available on formulary. However, we propose that these findings should spur an investigation of this possibility together with a call by hematologists nationwide to their formulary committees to ensure that this lifesaving medication is available to patients in as timely a manner as possible. Disclosures Off Label Use: All Trans Retinoic Acid (ATRA) is indicated for the use in patients with acute promyelocytic leukemia (APL) who are refractory to, or who have relapsed from, anthracycline chemotherapy, or for whom anthracycline based chemotherapy is contraindicated. We will be discussing the availability of ATRA for the use in patients with newly diagnosed APL..

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Nonbiological Factors Affecting Outcomes in Adolescent and Young Adults with Lymphoma

Blood ◽

10.1182/blood-2018-99-115724 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4857-4857

Author(s):

Ana C. Xavier ◽

Luciano J Costa

Keyword(s):

Young Adults ◽

Multivariate Analysis ◽

Research Funding ◽

Cell Lymphoma ◽

Insurance Status ◽

Advanced Stage ◽

Uninsured Patients ◽

Risk Of Death ◽

Adolescent And Young Adults ◽

The Impact

Abstract Background: Lymphoma is one of the most common cancers in adolescent and young adults (AYA). Although histology, stage, age, and gender are known to affect outcome, little is known about nonbiological factors (NBF) that may affect access to care on survival. Objectives: To determine the impact of NBF in the survival of AYA with classical Hodgkin lymphoma (cHL) or non-Hodgkin lymphoma (NHL), including diffuse large B-cell lymphoma (DLBCL), Burkitt lymphoma (BL), lymphoblastic lymphoma (LL), and anaplastic large cell lymphoma (ALCL). Design/Methods: The impact of NBF (insurance status, median household income, and educational achievement in the county of residence) along with biological factors (histology, stage, gender, age, and race/ethnicity) on survival of AYA lymphoma patients was analyzed using a SEER-18 (Surveillance, Epidemiology, and End Results) cohort diagnosed between 2007 and 2014. Results: There were 8,173 cases of cHL and 4,973 cases of NHL with a median follow-up of 44 months and 32 months, respectively. Five-year overall survival (OS) for AYA patients with localized cHL according to insurance status was 98% vs. 91% vs. 92% for insured, Medicaid, and uninsured patients, respectively (P < 0.001). The 5-year OS for advanced stage cHL was 91.5% vs. 85% vs. 85% for insured, Medicaid, and uninsured patients, respectively (P < 0.001). In multivariate analysis, the increase risk of death was associated with Medicaid (HR 2.23, 95% C.I. 1.76-2.81), and uninsured (HR 1.88, 95% C.I. 1.38-2.55), after adjustment for age, gender, histology and stage (P<0.001). Five-year OS for AYA patients with localized NHL according to insurance status was 90% vs. 76.5% vs. 84.5% for insured, Medicaid, and uninsured patients, respectively (P < 0.001). The 5-year OS for advanced stage NHL was 76% vs. 57%, and 62% for insured, Medicaid, and uninsured patients, respectively (P < 0.001). In multivariate analysis, the increased risk of death in AYA NHL was associated with Medicaid (HR 1.95, 95% CI 1.67-2.27), and uninsured (HR 1.48, 95% CI 1.18-1.84) (P<0.001) and county level of income in the second (HR 1.33, 95% C.I. 1.07-2.64), third (HR 1.54, 95% C.I. 1.25-1.90), and forth (HR 1.57, 95% C.I. 1.27-1.93) (P< 0.001) lower quartiles (P<0.001), after adjustment for age, gender, histology, and stage. Conclusion: Lack of insurance or Medicaid insured status and lower income are associated with increased mortality in AYA lymphomas, indicating an opportunity to increase outcomes by addressing NBF. Disclosures Costa: Karyopharm: Research Funding; Amgen: Honoraria, Research Funding; Janssen: Research Funding; Celgene: Honoraria, Research Funding; Abbvie: Research Funding; Sanofi: Honoraria; BMS: Research Funding.

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The Impact of Marital and Socioeconomic Status on Outcomes of Patients with Acute Promyelocytic Leukemia

Blood ◽

10.1182/blood.v124.21.1282.1282 ◽

2014 ◽

Vol 124 (21) ◽

pp. 1282-1282

Author(s):

Scott F Huntington ◽

Nirav N. Shah ◽

Andrew Epstein ◽

Alison W. Loren

Keyword(s):

Socioeconomic Status ◽

Marital Status ◽

Hematological Malignancies ◽

Cox Regression ◽

Promyelocytic Leukemia ◽

County Level ◽

Patient Factors ◽

Term Survival ◽

The Impact

Abstract Background: Marital status, social support, and socioeconomic status (SES) have been long identified as factors that have a role in outcomes in patient care and health. In patients with solid malignancies, both marital status and socioeconomic status influence the timing and stage of disease presentation. In such malignancies, late presentations are often consistent with incurable metastatic disease. In contrast, patients with hematological malignancies are often considered to have curable disease independent of their stage or timing of presentation. Given this discrepancy, we set out to determine the impact of marital status and SES on outcomes in patients with highly curable hematological malignancies such as acute promyelocytic leukemia (APML). Methods: We used the Surveillance, Epidemiology, and End Results (SEER) program to identify patients diagnosed with APML between 1999 and 2010. Linkage of SEER to Area Health Resources Files (AHRF) allowed county-level evaluation of socioeconomic factors. The association of individual patient factors on both 30-day mortality and long-term survival were analyzed to evaluate for differing influence on early-versus-delayed APML mortality. Results: A total of 2,635 individuals had baseline and follow-up information available for multivariable logistic regression and Cox regression analysis. The models included a standardized socioeconomic status (SES) index along with measures of county-level uninsurance rates and urban-rural stratification. In addition to increased early mortality with rising age, the likelihood of death during the first 30 days was higher in men (OR 1.22, 95% CI 1.01-1.44; p = 0.04). Marital status was not a significant predictor of death at 30 days, but there was a 2% increase in the odds of early death with every 1% increase of county-level uninsurance (p = 0.02). Conversely, gender and census-level uninsurance rates did not predict survival beyond the first 30 days, however, marriage and SES index above the median were associated with improved long-term survival (OR 0.70, 95% CI 0.57-0.81; OR 0.64, 95% CI 0.46 – 0.84 respectively, p ≤ 0.001). Conclusion: The impact of marital status, gender, and socioeconomic factors on clinical outcomes of patients with newly diagnosed APML appears to differ between the early acute and late clinical settings. Male sex and uninsurance rates were associated with early APML mortality and may suggest delay in seeking acute medical care. Marital and SES status appear to have greater influence on late survival of patients with APML and may be related to improvements in long-term medical adherence. Overall, our analysis suggests marital status, insurance coverage, and SES factors affect the outcomes of patients with APML, a highly curable malignancy. Future studies investigating the impact of social support on outcomes of other highly curable hematological malignancies may allow identification of important patient factors that affect clinical course. Table 1: 30-day mortality, multivariable logistic regression Variable Unadjusted OR (95% CI) Adjusted OR (95% CI) p Age at diagnosis (years) 1.03 (1.02-1.04) 1..03 (1.02-1.04) <0.001 Gender (M:F) 1.20 (1.01-1.44) 1.22 (1.01-1.47) 0.04 Marriage (Y:N) 1.08 (0.91-1.31) 0.84 (0.69-1.02) 0.08 Race (white:non-white) 1.24 (0.98-1.57) 1.12 (0.88-1.43) 0.36 SES index (50%+) 0.88 (0.70-1.13) 0.97 (0.74-1.26) 0.80 Rural vs. Urban 1.24 (0.80-1.92) 1.21 (0.76-1.93) 0.43 % uninsured 1.01 (0.99-1.03) 1.02 (1.00-1.04) 0.02 Table 2: Long-term overall survival, Cox regression Variable Unadjusted HR (95% CI) Adjusted HR (95% CI) p Age at diagnosis (years) 1.04 (1.03-1.05) 1.04 (1.03-1.05) <0.001 Gender (M:F) 0.99 (0.82-1.21) 1.04 (0.85-1.27) 0.68 Marriage (Y:N) 0.97 (0.80-1.19) 0.70 (0.57-0.85) <0.001 Race (white:non-white) 0.90 (0.71-1.14) 0.81 (0.63-1.03) 0.09 SES index (50%+) 0.68 (0.53-0.87) 0.64 (0.50-0.84) 0.001 Rural vs. Urban 0.99 (0.58-1.69) 0.82 (0.47-1.41) 0.47 % uninsured 0.99 (0.97-1.01) 0.99 (0.97-1.01) 0.41 Disclosures No relevant conflicts of interest to declare.

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910. A Comprehensive, One Year, Hospital-Wide Snapshot of All Serious Infectious Complications in People Who Inject Drugs

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1098 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S489-S490

Author(s):

John T Henderson ◽

Evelyn Villacorta Cari ◽

Nicole Leedy ◽

Alice Thornton ◽

Donna R Burgess ◽

...

Keyword(s):

Multivariable Analysis ◽

Vertebral Osteomyelitis ◽

The United States ◽

Infectious Complications ◽

Data Set ◽

Cumulative Impact ◽

Mortality And Morbidity ◽

Icu Admission ◽

Risk Of Death ◽

The Impact

Abstract Background There has been a dramatic rise in IV drug use (IVDU) and its associated mortality and morbidity, however, the scope of this effect has not been described. Kentucky is at the epicenter of this epidemic and is an ideal place to better understand the health complications of IVDU in order to improve outcomes. Methods All adult in-patient admissions to University of Kentucky hospitals in 2018 with an Infectious Diseases (ID) consult and an ICD 9/10 code associated with IVDU underwent thorough retrospective chart review. Demographic, descriptive, and outcome data were collected and analyzed by standard statistical analysis. Results 390 patients (467 visits) met study criteria. The top illicit substances used were methamphetamine (37.2%), heroin (38.2%), and cocaine (10.3%). While only 4.1% of tested patients were HIV+, 74.2% were HCV antibody positive. Endocarditis (41.1%), vertebral osteomyelitis (20.8%), bacteremia without endocarditis (14.1%), abscess (12.4%), and septic arthritis (10.4%) were the most common infectious complications. The in-patient death rate was 3.0%, and 32.2% of patients were readmitted within the study period. The average length of stay was 26 days. In multivariable analysis, infectious endocarditis was associated with a statistically significant increase in risk of death, ICU admission, and hospital readmission. Although not statistically significant, trends toward mortality and ICU admission were identified for patients with prior endocarditis and methadone was correlated with decreased risk of readmission and ICU stay. FIGURE 1: Reported Substances Used FIGURE 2: Comorbidities FIGURE 3: Types of Severe Infectious Complications Conclusion We report on a novel, comprehensive perspective on the serious infectious complications of IVDU in an attempt to measure its cumulative impact in an unbiased way. This preliminary analysis of a much larger dataset (2008-2019) reveals some sobering statistics about the impact of IVDU in the United States. While it confirms the well accepted mortality and morbidity associated with infective endocarditis and bacteremia, there is a significant unrecognized impact of other infectious etiologies. Additional analysis of this data set will be aimed at identifying key predictive factors in poor outcomes in hopes of mitigating them. Disclosures All Authors: No reported disclosures

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Survival in elderly glioblastoma patients treated with bevacizumab-based regimens in the United States

Neuro-Oncology Practice ◽

10.1093/nop/npy001 ◽

2018 ◽

Vol 5 (4) ◽

pp. 251-261 ◽

Cited By ~ 2

Author(s):

Jessica Davies ◽

Irmarie Reyes-Rivera ◽

Thirupathi Pattipaka ◽

Stephen Skirboll ◽

Beatrice Ugiliweneza ◽

...

Keyword(s):

Elderly Patients ◽

Lower Risk ◽

Karnofsky Performance Status ◽

The United States ◽

Cox Proportional Hazards Model ◽

Sensitivity Analyses ◽

Primary Analysis ◽

Risk Of Death ◽

Initial Surgery ◽

The Impact

AbstractBackgroundThe efficacy of bevacizumab (BEV) in elderly patients with glioblastoma remains unclear. We evaluated the effect of BEV on survival in this patient population using the Survival, Epidemiology, and End Results (SEER)-Medicare database.MethodsThis retrospective, cohort study analyzed SEER-Medicare data for patients (aged ≥66 years) diagnosed with glioblastoma from 2006 to 2011. Two cohorts were constructed: one comprised patients who had received BEV (BEV cohort); the other comprised patients who had received any anticancer treatment other than BEV (NBEV cohort). The primary analysis used a multivariate Cox proportional hazards model to compare overall survival in the BEV and NBEV cohorts with initiation of BEV as a time-dependent variable, adjusting for potential confounders (age, gender, Charlson comorbidity index, region, race, radiotherapy after initial surgery, and diagnosis of coronary artery disease). Sensitivity analyses were conducted using landmark survival, propensity score modeling, and the impact of poor Karnofsky Performance Status.ResultsWe identified 2603 patients (BEV, n = 597; NBEV, n = 2006). In the BEV cohort, most patients were Caucasian males and were younger with fewer comorbidities and more initial resections. In the primary analysis, the BEV cohort showed a lower risk of death compared with the NBEV cohort (hazard ratio, 0.80; 95% confidence interval, 0.72–0.89; P < .01). The survival benefit of BEV appeared independent of the number of temozolomide cycles or frontline treatment with radiotherapy and temozolomide.ConclusionBEV exposure was associated with a lower risk of death, providing evidence that there might be a potential benefit of BEV in elderly patients with glioblastoma.

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Abstract MP35: The American Heart Association’s Life’s Simple 7 and Mortality by Race and Sex in the U.S.: the REasons for Geographic And Racial Differences in Stroke (REGARDS) Cohort

Circulation ◽

10.1161/circ.129.suppl_1.mp35 ◽

2014 ◽

Vol 129 (suppl_1) ◽

Author(s):

Mary Cushman ◽

Suzanne E Judd ◽

Virginia J Howard ◽

Neil A Zakai ◽

Brett Kissela ◽

...

Keyword(s):

Racial Differences ◽

Mortality Risk ◽

Lower Risk ◽

Population Sample ◽

White Men ◽

The United States ◽

Risk Of Death ◽

Life’S Simple 7 ◽

Life's Simple 7 ◽

The Impact

Background: The Life’s Simple 7 (LSS) metric is being used by AHA to track the cardiovascular health of the United States population and move toward a 2020 impact goal for improvement. Levels of LSS are associated with mortality risk but there are limited data on whether this association differs by race or sex. Hypothesis: There will be sex and race differences in the association of LSS with mortality in the REGARDS cohort study. Methods: We studied 29,692 REGARDS participants; a population sample of black and white men and women aged 45-98 from across the US, enrolled in 2003-7. Extensive baseline risk factor data were measured in participants’ homes. The 7 LSS components (blood pressure, cholesterol, glucose, body-mass index, smoking, physical activity, diet) were each scored in AHA-defined categories of poor (0 points), intermediate (1 point) and ideal (2 points), and were summed to yield scores ranging from poor for all (0) to ideal for all (14). With 6.4 years follow up there were 3709 deaths. Results: The LSS score was normally distributed with mean (SD) of 7.9 (2.0) in whites and 6.9 (2.0) in blacks. The age, region, income and education adjusted hazard ratio (HR) of death for a 1-unit worse LSS score, stratified by race and sex, are shown in the table. Race and sex interactions were tested individually in separate models. While better scores for LSS were strongly associated with lower mortality, associations differed by race and sex, being weaker in blacks than whites and in men than women. Conclusion: There were large associations of LSS with mortality risk in the REGARDS national sample; 1 point difference in score, corresponding to movement from poor to intermediate or intermediate to ideal for 1 of the 7 factors, was associated with a 16% lower risk of death in white women, 14% lower risk in white men or black women, but only an 11% lower risk in black men. Observed differences in the association of LSS with mortality by race and sex should be considered in efforts to gauge the impact of LSS interventions on health disparities.

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