Association of Insurance Types and Survival in Acute Promyelocytic Leukemia (APL)

Abstract Introduction Health insurance, or lack thereof, is a significant barrier to health care access in the United States. Patients without insurance or with inadequate coverage are more likely to delay or forego treatment, even with acute illness or significant symptoms, leading to worse health outcomes. We aimed to analyze if insurance types impacted one-month mortality and overall survival (OS) in younger patients with APL. Methods We utilized National Cancer Database to identify patients <65 years who were diagnosed with APL between 2004-2015. We used multiple logistic regression analysis to evaluate the effects of insurance type on the probability of one-month mortality. OS was estimated by the Kaplan-Meier method. A full Cox regression model was used to determine the effects of insurance types on mortality. Results A total of 5380 patients were included. Median age was 44 years (0-64), 50% were female, 93% had Charlson-Deyo comorbidity index (CCI) of 0 or 1, and 58% were treated at academic centers. Insurance types included private (67%), Medicaid or other government insurance (19%), Medicare (7%) or uninsured (6%). Patients with Medicare were older and had increased comorbidities. Lower percent of patients with Medicare (23%) or Medicaid/Other government insurance (21%), compared to those with private insurance (56%) or uninsured patients (63%) were treated at academic centers. One-month mortality was higher for patients with Medicare (16%) or uninsured patients (14%), compared to those with Medicaid/Other government (8%) or private insurance (7%).Patients with Medicare (Odds ratio [OR] 1.69, 95% confidence interval [CI] 1.23-2.32, p=0.001) or uninsured patients (OR 2.23, 95% CI 1.56-3.18, p<0.0001) had worse one-month mortality compared to those with private insurance (Table 1). One-month mortality worsened with increasing comorbidities (OR 2.31 for CCI 1, OR 4.44 for CCI 2, and OR 7.02 for CCI ≥3 compared to patients with CCI of 0, p<0.0001). Female patients and patients traveling <6 miles to the treatment center had lower one-month mortality. Median follow-up for surviving patients was 5.4 years (0.008-13.9). Three-year OS was 89% for private insurance, 81% for Medicaid/Other government insurance, 63% for Medicare, and 80% for uninsured patients (Table 2, Figure 1). Patients with Medicaid/Other government insurance (hazard ratio [HR] 1.39, 95% CI 1.19-1.63 p<0.0001), and Medicare (HR 1.88, 95% CI 1.57-2.24, p<0.0001) were associated with worse OS compared to patients with private insurance (Table 3). Compared to patients ≤18 years of age, the likelihood of death was worse for patients 41-64 years (HR 0.68, 95% CI 1.47-4.90, p=0.001). OS worsened with increasing comorbidities (HR 1.71 for CCI 1, HR 2.33 for CCI 2, and HR 3.48 for CCI ≥3 compared to patients with CCI of 1, p<0.0001). Male gender (p=0.0002) was associated with decreased OS. Conclusion In one of the largest database analyses, we identified insurance status as a significant factor affecting one-month mortality and OS in APL. Our results revealed a higher one-month mortality but similar longer-term OS in uninsured patients compared to patients with private insurance, which may reflect poor access to healthcare necessary for prompt diagnosis and timely initial treatment; similar longer-term OS may reflect a higher proportion of younger patients with less comorbidities in uninsured group. Patients with Medicaid/Other government or Medicare insurance had worse OS compared to private insurance. The reasons for worse OS may be multifactorial including problems with access to quality leukemia care or drug coverage, or the effects of other differences in the patient population including income and in case of Medicare patients, older age and comorbidity burden. Our results raise concern for healthcare disparities based on insurance types and highlight challenges associated with improving OS in patients with Medicaid, Medicare, or no insurance, which comprise a significant proportion of patients with APL. Figure 1 Figure 1. Disclosures Gundabolu: Samus Therapeutics: Research Funding; Pfizer: Research Funding; BioMarin Pharmaceuticals: Consultancy; Blueprint Medicines: Consultancy; Bristol-Myers Squibb Company: Consultancy. Bhatt: Genentech: Consultancy; Abbvie: Consultancy, Research Funding; National Marrow Donor Program: Research Funding; Tolero Pharmaceuticals, Inc: Research Funding; Pfizer: Research Funding; Incyte: Consultancy, Research Funding; Jazz: Research Funding; Abbvie: Consultancy, Research Funding; Partnership for health analytic research, LLC: Consultancy; Servier Pharmaceuticals LLC: Consultancy; Rigel: Consultancy.

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The Economics of Long-Term Care

The B E Journal of Economic Analysis & Policy ◽

10.1515/bejeap-2012-0063 ◽

2013 ◽

Vol 14 (2) ◽

pp. 343-375 ◽

Cited By ~ 13

Author(s):

Luigi Siciliani

Keyword(s):

Long Term Care ◽

Private Insurance ◽

Care Home ◽

Significant Proportion ◽

Empirical Work ◽

The United States ◽

Ageing Population ◽

Public Insurance ◽

Term Care

Abstract Long-term care expenditure is expected to rise, driven by an ageing population. Given that public long-term care expenditure is high in many OECD countries, governments are increasingly concerned about its future growth. This study focuses on three relevant issues. First, we discuss factors that affect the growth of long-term expenditure and its projections. These include demographics, the balance in provision between informal and formal care, whether higher life expectancy translates into higher disability, the interrelation between health and long-term care, and whether long-term care suffers from Baumol’s disease. Second, given that a significant proportion of long-term care expenditure is nursing- and care-home expenditure, we discuss the role of government regulation aimed at ensuring that individuals receive appropriate quality of care in such institutions. We focus in particular on price regulation, competition, and the non-profit sector; these have been the subject of considerable empirical work (mainly in the United States). Third, we discuss the relative merits of public and private insurance. Countries differ greatly in their approach. Some countries have nearly exclusively public insurance but in others this is small. We consider the conditions under which public insurance can overcome the limitations of a private insurance market.

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Insurance Status Impacts Survival in Burkitt Lymphoma

Blood ◽

10.1182/blood.v130.suppl_1.916.916 ◽

2017 ◽

Vol 130 (Suppl_1) ◽

pp. 916-916

Author(s):

Jordan S. Goldstein ◽

Jeffrey M. Switchenko ◽

Madhusmita Behera ◽

Christopher Flowers ◽

Jean L. Koff

Keyword(s):

United States ◽

Research Funding ◽

Private Insurance ◽

The United States ◽

Insurance Status ◽

Proportional Hazard ◽

Comorbidity Score ◽

Cox Proportional Hazard ◽

Cox Proportional Hazard Models ◽

Insured Patients

Abstract Introduction: Burkitt lymphoma (BL) is an aggressive non-Hodgkin lymphoma with an estimated 1480 new cases diagnosed in the United States in 2016. BL is simultaneously one of the most aggressive lymphomas, with a tumor volume doubling time of just 24 hours, and one of the most curable, with several clinical trials showing 3-year survival rates over 80%. However, recent studies have identified a significant discrepancy between clinical trial and "real-world" survival, implying access to care may play an important role in BL outcomes. A patient's insurance status represents a major factor in the utilization of cancer therapies and outcomes in the United States. Underinsured patients are more likely to be diagnosed at an advanced stage, receive substandard therapy, and have worse outcomes. We examined the effect of insurance status on survival in adults with BL and compared the impact of insurance status on BL outcomes to that seen in plasmablastic lymphoma (PBL), an aggressive lymphoma that has poor outcomes regardless of treatment. Methods: We used data from the National Cancer Database (NCDB), a nationwide, hospital-based cancer registry jointly sponsored by the American Cancer Society and American College of Surgeons that contains 34 million historical records and captures 75% of newly diagnosed cancer cases in the United States. Commission on Cancer (CoC)-accredited facilities report patients' vital status and date of death to the NCDB annually. We included patients > 18 years old diagnosed 2004-2014 with BL or PBL as the primary tumor who received all or part of initial course of treatment at the reporting facility. Patients missing information on insurance status or survival were excluded, as were those who had non-Medicare/Medicaid government insurance (VA, Indian Health Services). Chi-square tests were used to compare sociodemographic and clinical characteristics by insurance status. All analyses were performed for both BL and PBL and stratified on age 65, due to changes in eligibility for Medicare at that age. Kaplan-Meier survival curves were stratified by insurance status, and log-rank tests were performed. Univariate Cox proportional hazard models were generated to describe the unadjusted associations for the covariables, and multivariable Cox proportional hazard models were generated to estimate the hazard ratio (HR) associated with insurance status when adjusted for prognostic factors. Results: We identified 7,073 BL patients and 475 PBL patients in the NCDB who met inclusion criteria. Of the 5235 BL patients < 65 years, 65.0% had private insurance, 17.2% had Medicaid, 7.6% had Medicare, and 10.2% had no insurance. Of the 1838 BL patients ≥ 65 years, 12.9% had private insurance, 1.5% had Medicaid, 85% had Medicare, and 0.65% had no insurance. Uninsured and Medicaid-insured patients were more likely to be Hispanic or black, have lower socioeconomic status (SES), have B symptoms, be HIV-positive, and have a Charlson-Deyo comorbidity score ≥ 2 when compared with privately insured patients. Medicare patients were more likely to be female, have ≥1 comorbidity, and not receive chemotherapy treatment when compared to privately insured patients. BL patients without private insurance had significantly worse overall survival compared to those with private insurance, regardless of age group (adjusted HR age <65: uninsured 1.41 [95% confidence interval 1.2,1.7], Medicaid 1.17 [1,1.4], Medicare 1.5 [1.2,1.8]; adjusted HR age ≥ 65: uninsured 6 [2.1,17.3], Medicare 1.33 [1,1.8]; see Figure). Conversely, Cox regression models demonstrated that PBL patients without private insurance experienced no significant differences in overall survival in either age group. For BL patients age <65, low SES, presence of B symptoms, advanced stage, HIV-positive status, comorbidity score ≥ 2, and lack of treatment were significant, independent predictors of worse outcomes and contributed to the disparities in survival by insurance status. For BL age > 65, B symptoms, comorbidity score ≥ 2, and lack of treatment were significant, independent predictors of worse outcomes. Conclusion: We identified insurance status as an important predictor of clinical outcomes for BL. Our findings suggest that expanding access to care may improve survival disparities in BL, for which curative therapy exists, but not PBL, where more effective therapies are needed to improve outcomes. Disclosures Flowers: Celgene: Consultancy, Research Funding; Bayer: Consultancy; V Foundation: Research Funding; Research to Practice: Research Funding; Infinity: Research Funding; Acerta: Research Funding; National Institutes Of Health: Research Funding; Clinical Care Options: Research Funding; Educational Concepts: Research Funding; Abbvie: Consultancy, Research Funding; Pharmacyclics LLC, an AbbVie Company: Research Funding; OptumRx: Consultancy; Spectrum: Consultancy; Genentech/Roche: Consultancy, Research Funding; National Cancer Institute: Research Funding; Eastern Cooperative Oncology Group: Research Funding; Onyx: Research Funding; Burroughs Welcome Fund: Research Funding; TG Therapeutics: Research Funding; Prime Oncology: Research Funding; Millennium/Takeda: Research Funding; Janssen Pharmaceutical: Research Funding; Seattle Genetics: Consultancy; Gilead: Consultancy.

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Does An Anthracycline Make a Difference for Follicular Lymphoma (FL) Grade 3? Patterns of Care and Treatment Outcomes of Grade 3 FL From the National LymphoCare Study (NLCS)

Blood ◽

10.1182/blood.v116.21.1768.1768 ◽

2010 ◽

Vol 116 (21) ◽

pp. 1768-1768 ◽

Cited By ~ 1

Author(s):

Christopher R Flowers ◽

Michael Taylor ◽

Michelle Byrtek ◽

Jamie H. Hirata ◽

James Cerhan ◽

...

Keyword(s):

Research Funding ◽

Cox Regression ◽

Combined Modality Therapy ◽

International Prognostic Index ◽

Single Agent ◽

Prognostic Index ◽

The United States ◽

Categorical Variables ◽

Stock Ownership ◽

Grade 3

Abstract Abstract 1768 Background: Although advances in therapy have improved outcomes for patients (pts) with FL, no optimal patient management strategy for pts with FL grade 3 has been identified largely due to debate regarding the benefits of anthracyclines for this subtype. Methods: The NLCS is a multi-center, longitudinal, observational study that collects data on treatment and outcomes for pts with FL diagnosed at 265 community (80%) and academic practices in the United States from 2004–2007. Pts enrolled in NLCS with a diagnosis of FL grade 3 as recorded by the treating physicians were examined to compare patterns of presentation, treatment strategies, and outcomes. No central pathology review was required. Data from pts who received watchful waiting (WW), single agent rituximab (R), R with cyclophosphamide, adriamycin, vincristine, and prednisone (R-CHOP), or R with cyclophosphamide, vincristine, and prednisone (R-CVP) as initial therapy were summarized using median and range for continuous variables and frequencies for categorical variables. Univariate associations between demographic, baseline disease characteristics, treatment setting, and initial treatment strategy, were tested using a standard χ2 test where sample size allowed. Relationship and hazard ratios for progression free survival (PFS) were estimated using Cox regression models adjusted for FL International Prognostic Index (FLIPI). Results: Of 2736 pts enrolled in NLCS, 500 had grade 3 FL. FL grade 3 pts had a median age of 64 years (range 26–97 years), 53% were female, and 67% had stage 3/4 disease. Pts were evenly distributed across FLIPI categories (30% good, 33% intermediate and 37% poor risk). Initial therapies for pts with FL grade 3 were WW (n=48), R alone (n=41), R-CVP (n=30), R-CHOP (n=245), R with another anthracycline (n=26), R with other chemotherapy (n=28), radiation alone (n=14), combined modality therapy (n=26), and regimens without R (n=42). Pts with FL grade 3 who received R-CHOP were younger than those who received R-CVP but similar in other FLIPI factors (Table). Events, defined as death or disease progression, occurred for 58% of patients who watched and waited and 33% of those who received treatment. Treated patients had improved PFS (median not reached [NR] 95% CI 66 months-NR) versus WW (median 29 months; 95% CI 19–43 months). Pts who received R-CHOP had improved PFS compared with WW (hazard ratio [HR] 3.09 95% CI 1.97– 4.86) but not R-CVP (HR 1.06 95% CI 0.52–2.14; Figure) Conclusions: In this large observational dataset of FL grade 3 patients, R-CHOP was the most commonly used first-line regimen. These results suggest that R with chemotherapy provides meaningful PFS benefits over WW for this population. Prospective randomized trials in pathologically identified pts are needed to evaluate the benefit of R-CHOP versus non-anthracycline regimens. Disclosures: Flowers: Millenium: Research Funding; Prescription Solutions: Consultancy; Genentech: Consultancy; Biogen/Idec: Consultancy; Celgene: Consultancy. Taylor:Genentech: Consultancy; Roche: Stock Ownership. Byrtek:Genetech: Consultancy; Roche: Stock Ownership. Hirata:Genentech: Employment; Roche: Stock Ownership. Cerhan:Genentech: Consultancy, Honoraria, Research Funding. Hainsworth:Genentech: Consultancy, Research Funding. Link:Genentech: Consultancy, Research Funding; Biogen Idec: Consultancy, Research Funding; Millennium Pharm: Consultancy, Research Funding; GlaxoSmithKline: Research Funding. Friedberg:Genentech: Consultancy.

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

Blood ◽

10.1182/blood-2018-99-116125 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 321-321 ◽

Cited By ~ 1

Author(s):

Omer Jamy ◽

Ana C. Xavier ◽

Luciano J Costa

Keyword(s):

Marital Status ◽

Acute Promyelocytic Leukemia ◽

Research Funding ◽

The United States ◽

Promyelocytic Leukemia ◽

County Level ◽

Uninsured Patients ◽

Risk Of Death ◽

Race Ethnicity ◽

The Impact

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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Health Insurance in the First 3 Months of Hemodialysis and Early Vascular Access

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.06660518 ◽

2018 ◽

Vol 13 (12) ◽

pp. 1866-1875 ◽

Cited By ~ 6

Author(s):

Eugene Lin ◽

Matthew W. Mell ◽

Wolfgang C. Winkelmayer ◽

Kevin F. Erickson

Keyword(s):

Confidence Interval ◽

Arteriovenous Fistula ◽

Vascular Access ◽

Cox Regression ◽

The United States ◽

National Registry ◽

Hazard Ratio ◽

Uninsured Patients ◽

Arteriovenous Fistulas ◽

Medicare Coverage

Background and objectivesPatients without Medicare who develop ESKD in the United States become Medicare eligible by their fourth dialysis month. Patients without insurance may experience delays in obtaining arteriovenous fistulas or grafts before obtaining Medicare coverage.Design, setting, participants, & measurementsIn this retrospective cohort study, we used a national registry to compare uninsured patients starting in-center hemodialysis with a central venous catheter between 2010 and 2013 with similar patients with Medicare or Medicaid. We evaluated whether insurance status at dialysis start influenced the likelihoods of switching to dialysis through an arteriovenous fistula or graft and hospitalizations involving a vascular access infection. We used multivariable logistic and Cox regression models and transformed odds ratios to relative risks using marginal effects.ResultsPatients with Medicare or Medicaid were more likely to switch to an arteriovenous fistula or graft by their fourth dialysis month versus uninsured patients (Medicare hazard ratio, 1.63; 95% confidence interval, 1.14 to 2.43; Medicaid hazard ratio, 1.23; 95% confidence interval, 1.12 to 1.38). There were no differences in rates of switching to arteriovenous fistulas or grafts after all patients obtained Medicare in their fourth dialysis month (Medicare hazard ratio, 1.17; 95% confidence interval, 0.97 to 1.42; Medicaid hazard ratio, 1.01; 95% confidence interval, 0.96 to 1.06). Patients with Medicare at dialysis start had fewer hospitalizations involving vascular access infection in dialysis months 4–12 (hazard ratio, 0.60; 95% confidence interval, 0.37 to 0.97).ConclusionsInsurance-related disparities in the use of arteriovenous fistulas and grafts persist through the fourth month of dialysis, may not fully correct after all patients obtain Medicare coverage, and may lead to more frequent vascular access infections.

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Racial Disparities in the Utilization of Recommended Supportive Care Among Patients with Multiple Myeloma in the United States

Blood ◽

10.1182/blood-2018-99-119791 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 978-978

Author(s):

Smith Giri ◽

Weiwei Zhu ◽

Rong Wang ◽

Amer M. Zeidan ◽

Nikolai A. Podoltsev ◽

...

Keyword(s):

Multiple Myeloma ◽

Supportive Care ◽

Influenza Vaccination ◽

Racial Disparities ◽

Research Funding ◽

The United States ◽

Antiviral Prophylaxis ◽

Medicare Beneficiaries ◽

Comorbidity Burden ◽

Provider Volume

Abstract Introduction: Patients with Multiple Myeloma (MM) are living longer due to therapeutic advancements. With improving MM outcomes, supportive care measures focused on optimizing quality of life and minimizing treatment-related toxicities have become more relevant. Patients with MM report high rates of bone pain, skeletal-related events and infections for which bisphosphonates, influenza vaccination, and antiviral prophylaxis have been recommended. The extent to which these supportive care measures are used during routine clinical practice and the factors predicting utilization remain unknown. Methods: We selected older adults (age >65 years) diagnosed with MM between 2008-13 from the Surveillance Epidemiology and End Results-Medicare linked database. We excluded patients diagnosed at autopsy or by death certificate, those without continuous Medicare Parts A and B coverage from 12 months prior to diagnosis through death or end of study (12/31/2014). Additionally, we required continuous Part D claims from 12 months prior to diagnosis to 2 years after diagnosis. We required patients to receive anti-myeloma therapy and survive the first full flu season after diagnosis. Outcomes of interest included proportion of patients receiving guideline concordant supportive care therapy defined as 1) bisphosphonate therapy (zoledronic acid or pamidronic acid) within first 12 months after diagnosis, 2) influenza vaccination in the first flu season after diagnosis, and 3) receipt of antivirals (acyclovir, valacyclovir) among patients receiving bortezomib therapy. We estimated a multivariable logistic regression model for each outcome to evaluate potential predictors of supportive care use including patient characteristics (age, gender, race/ethnicity, comorbidity, disability status, diagnosis of CKD, socio-economic status, year of diagnosis), provider volume/experience (number of MM patients treated during a 12 month look back), and facility type (hospital outpatient vs community). Results: A total of 1,569 Medicare beneficiaries met our eligibility criteria. The median age was 74 years with 47% male and 73% non-Hispanic whites. Only 66% of Medicare beneficiaries on active MM therapy received bisphosphonates within 1 year of diagnosis. 53% of patients received influenza vaccination in the first flu season following diagnosis, and 44% received antiviral prophylaxis while receiving bortezomib therapy. Sensitivity analysis with and without pre-existing chronic kidney disease showed that 48% and 72% received bisphosphonates respectively. In the multivariate analysis, predictors of bisphosphonate non-usage included increasing age, (odds ratio [OR] for 85+ years 0.37; 95% confidence interval [CI] 0.23-0.58 compared to 66-69 years), non-Hispanic black and Hispanic ethnicity (OR 0.51; 95% CI 0.34-0.76 and OR 0.56; 95% CI 0.35-0.91 respectively compared to whites), and higher comorbidity index (for Elixhauser index of 3+ OR 0.41, 95% CI 0.29-0.57 compared to 0). Significant predictors of flu shot non-usage included non-Hispanic black ethnicity (OR 0.49; 95% CI 0.34-0.70 compared to whites), living in West (OR 0.53; 95% CI 0.38-0.75 compared to Midwest), having Medicaid dual coverage (OR 0.66; 95% CI 0.49-0.89) and lower comorbidity burden (For Elixhauser index of 3+ OR 1.44; 95% CI 1.07-1.93 compared to 0). Meanwhile, predictors of antiviral prophylaxis non usage included earlier years of diagnosis (global P<0.01, with increasing OR for more recent years), and higher comorbidity burden (For Elixhauser index of 3+ OR 0.40; 95% CI 0.24-0.67 compared to 0). Conclusion: We found significant under-utilization of supportive care measures focused at bone health and infection prevention among elderly adults with MM in the US. Similar to prior work evaluating utilization of novel MM therapies and transplantation, we found significant racial disparities in receipt of MM supportive care. Future studies should seek to identify reasons for such under-utilization of supportive care during MM therapy so that appropriate interventions may be implemented. Disclosures Zeidan: Agios: Consultancy; Celgene: Consultancy; Novartis: Consultancy; Incyte: Employment; Gilead: Consultancy; Ariad: Consultancy, Speakers Bureau; Abbvie: Consultancy; Pfizer: Consultancy. Podoltsev:Sunesis Pharmaceuticals: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees; Boehringer Ingelheim: Research Funding; Astex Pharmaceuticals: Research Funding; Astellas Pharma: Research Funding; LAM Therapeutics: Research Funding; Celgene: Research Funding; Pfizer: Research Funding; Genentech: Research Funding; Daiichi Snakyo: Research Funding; Celator: Research Funding. Gore:Celgene: Consultancy, Research Funding. Ma:Celgene: Consultancy, Research Funding; Incyte: Consultancy. Davidoff:Celgene: Research Funding. Huntington:Celgene: Consultancy; Bayer: Consultancy; Janssen: Consultancy.

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Endoscopic versus nonendoscopic surgery for resection of pituitary adenomas: a national database study

Journal of Neurosurgery ◽

10.3171/2020.1.jns193062 ◽

2020 ◽

pp. 1-9 ◽

Cited By ~ 2

Author(s):

Khodayar Goshtasbi ◽

Brandon M. Lehrich ◽

Mehdi Abouzari ◽

Arash Abiri ◽

Jack Birkenbeuel ◽

...

Keyword(s):

Tumor Size ◽

Household Income ◽

Pituitary Adenomas ◽

Private Insurance ◽

Large Population ◽

Treatment Center ◽

National Database ◽

Insurance Status ◽

Treatment Site ◽

Comorbidity Burden

OBJECTIVEFor symptomatic nonsecreting pituitary adenomas (PAs), resection remains a critical option for treatment. In this study, the authors used a large-population national database to compare endoscopic surgery (ES) to nonendoscopic surgery (NES) for the surgical management of PA.METHODSThe National Cancer Database was queried for all patients diagnosed with histologically confirmed PA who underwent resection between 2010 and 2016 in which the surgical approach was specified. Due to database limitations, microsurgery and craniotomy were both categorized as NES.RESULTSOf 30,488 identified patients, 16,373 (53.7%) underwent ES and 14,115 (46.3%) underwent NES. There was a significant increase in the use of ES over time (OR 1.16, p < 0.01). Furthermore, there was a significant temporal increase in ES approach for tumors ≥ 2 cm (OR 1.17, p < 0.01). Compared to NES, patients who underwent ES were younger (p = 0.01), were treated at academic centers (p < 0.01), lived a greater distance from their treatment site (p < 0.01), had smaller tumors (p < 0.01), had greater medical comorbidity burden (p = 0.04), had private insurance (p < 0.01), and had a higher household income (p < 0.01). After propensity score matching to control for age, tumor size, Charlson/Deyo score, and type of treatment center, patients who underwent ES had a shorter length of hospital stay (LOS) (3.9 ± 4.9 days vs 4.3 ± 5.4 days, p < 0.01), although rates of gross-total resection (GTR; p = 0.34), adjuvant radiotherapy (p = 0.41), and 90-day mortality (p = 0.45) were similar. On multivariate logistic regression, African American race (OR 0.85, p < 0.01) and tumor size ≥ 2 cm (OR 0.89, p = 0.01) were negative predictors of receiving ES, whereas diagnosis in more recent years (OR 1.16, p < 0.01), greater Charlson/Deyo score (OR 1.10, p = 0.01), receiving treatment at an academic institution (OR 1.67, p < 0.01) or at a treatment site ≥ 20 miles away (OR 1.17, p < 0.01), having private insurance (OR 1.09, p = 0.01), and having a higher household income (OR 1.11, p = 0.01) were predictive of receiving ES. Compared to the ES cohort, patients who started with ES and converted to NES (n = 293) had a higher ratio of nonwhite race (p < 0.01), uninsured insurance status (p < 0.01), longer LOS (p < 0.01), and higher rates of GTR (p = 0.04).CONCLUSIONSThere is an increasing trend toward ES for PA resection including its use for larger tumors. Although ES may result in shorter LOS compared to NES, rates of GTR, need for adjuvant therapy, and short-term mortality may be similar. Factors such as tumor size, insurance status, facility type, income, race, and existing comorbidities may predict receiving ES.

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Sixty-day unplanned readmissions after robot-assisted versus open-radical prostatectomy.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.6_suppl.244 ◽

2021 ◽

Vol 39 (6_suppl) ◽

pp. 244-244

Author(s):

Prasanth Lingamaneni ◽

Binav Baral ◽

Krishna Rekha Moturi ◽

Trilok Shrivastava ◽

Omnia Darweesh ◽

...

Keyword(s):

Prostate Cancer ◽

United States ◽

Radical Prostatectomy ◽

Private Insurance ◽

The United States ◽

Categorical Variables ◽

Continuous Variables ◽

Robot Assisted ◽

Post Procedure ◽

Comorbidity Burden

244 Background: Options for clinically localized prostate cancer include radical prostatectomy, radiation therapy and active surveillance. Robot-assisted radical prostatectomy (RARP) is increasingly being used, and now accounts for the majority of radical prostatectomies performed in the United States. The aim of our study was to evaluate differences in the patient population undergoing open versus robot-assisted prostatectomy, and to compare 60-day readmissions after index hospitalization for radical prostatectomy. Methods: We utilized the Nationwide Readmission database (NRD) to obtain data on patients with prostate cancer admitted in 2016 and 2017 for radical prostatectomy in the United States. We used T-test to compare means of continuous variables and chi-square test to compare proportions of categorical variables. Multivariable logistic regression was used evaluate risk factors for 60-day unplanned readmissions. Results: A total of 115,551 patients met the inclusion criteria, of which 80.1% underwent RARP. Patients undergoing RARP were slightly older (64.8 vs 63.1 years, p < 0.0001), more likely to have private insurance (51.7% vs 44.3%, p < 0.0001) and undergo surgery at a teaching hospital (83% vs 74.6%, p < 0.0001). Importantly, open prostatectomy (OP) patients had higher rates of co-morbidities, including, hypertension, diabetes mellitus, chronic kidney disease, obstructive lung disease, heart failure, coronary artery disease and malnutrition (p < 0.01 for these co-morbidities). Hospital stay was longer in those who underwent OP (3.1 vs 1.7 days, p < 0.0001), and they were more likely to be discharged to nursing facility (3.0% vs 0.4%, p < 0.0001) or with home health care (10.9% vs 4.8%, p < 0.0001). Hospitalization charges were higher in the RARP population ($60k vs 57k, p = 0.04). Inpatient mortality was low in both groups (0.3% for OP and ~0% for RARP, p < 0.001). 60-day readmission rate was higher in those who underwent OP (9.3% vs 5.0%, p > 0.0001). Overall, the three leading causes for readmission included sepsis (10.6%), post-procedure infection (8.4%) and venous thromboembolism (VTE, 8.3%). Even after adjustment for age and comorbidities, those who underwent OP had higher risk of all-cause readmission (aOR 1.39, 95% CI 1.25-1.53, p < 0.001) and readmissions for sepsis (aOR 1.36, 95% CI 1.02-1.81, p = 0.03) and post-procedure infection (aOR 1.38, 95% CI 1.06-1.81, p = 0.02). Risk of readmission for VTE was similar in both groups. Conclusions: Nationwide, there are differences in demographics and comorbid illness burden in prostate cancer patients selected for open and robot-assisted radical prostatectomy. Better short-term outcomes in the RARP cohort may be partially attributed to lower comorbidity burden in this group. However, despite adjustment for comorbidities, higher risk for all-cause readmissions and readmissions for infectious complications persisted in the OP group.

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Use of Preemptive Treatment for Immune Thrombotic Thrombocytopenic Purpura: A Matched Survival Analysis

Blood ◽

10.1182/blood-2021-149984 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 2084-2084

Author(s):

Aaron Boothby ◽

Michael Evans ◽

Radhika Gangaraju ◽

Camila Masias ◽

Aric D. Parnes ◽

...

Keyword(s):

African American ◽

Board Of Directors ◽

Thrombotic Thrombocytopenic Purpura ◽

Research Funding ◽

The United States ◽

Treatment Center ◽

Clinical Relapse ◽

Advisory Committees ◽

Thrombocytopenic Purpura ◽

Preemptive Treatment

Abstract Background: Immune Thrombotic thrombocytopenic purpura (iTTP) is a relapsing disorder, resulting from depletion of ADAMTS13. With the goal of preventing clinical relapse there has been considerable interest in ADAMTS13 monitoring and preemptive treatment. Indeed, preemptive treatment with rituximab has shown significant promise and is now included in the 2020 International Society on Thrombosis and Haemostasis (ISTH) treatment guidelines. Evaluation of long-term outcomes of ADAMTS13 based preemptive treatment have generally relied on limited numbers of historical controls which did not incorporate matching for known risk factors for relapse such as race, number of prior episodes, and immunosuppression. Our study aims to leverage the data in the United States Thrombotic Microangiopathy (USTMA) iTTP registry to compare the clinical relapse-free survival (RFS) intervals between iTTP patients treated preemptively based on ADAMTS13 level and those treated only for clinical relapse base on clinical and laboratory manifestations of iTTP. Methods: We carried out a retrospective study utilizing the multi-center cohort of patients with iTTP from the USTMA Consortium (spanning 1985-2019 and containing 780 participant records). We selected for patients with relapsing disease treated either preemptively based on ADAMTS13 level or for clinical relapse. Each preemptively treated episode was matched to up to five clinically relapsed episodes using covariate balancing propensity score nearest-neighbor matching by age, gender, race, prior relapse status, acute treatment, treatment center, and calendar year, with exact matching required for treatment center and prior relapse status. Time from prior episode to relapse was compared between preemptively treated episodes and matched controls using a Cox proportional hazards model weighted by the matching weights, including subclasses as a cluster, and using cluster-robust standard errors. Results: We identified 1068 episodes of iTTP. Of these. Thirteen participants accounting for a total of seventeen preemptive treatment episodes were included in the data set however, we included only the thirteen first uses of preemptive treatment to avoid selection bias. These were matched with 59 episodes treated for clinical relapse. Over 70% of the included participants in both groups were identified as black/African American. Distribution of immunosuppressive medications used in clinically relapsed cases were not significantly different than those used in preemptive treatment, and corticosteroids were the most frequently used. Demographic and treatment data before and after matching are included in Table 1. There was no significant difference in RFS between the groups, hazard ratio 0.63 (95% confidence interval 0.26-1.54), p=0.31. Conclusion: To our knowledge this is the first study to use matching controls to obtain a causal estimate of the effect of ADAMTS13 monitoring based preemptive treatment on RFS in iTTP. In contrast to previous work, we did not observe a significant increase in RFS in the preemptively treated group. It is possible that the limited number of preemptively treated episodes herein did not provide sufficient power to detect a difference. However, given the significant effect size that has been proposed, based on prior work, we suspect other factors may have also influenced this finding. Previous analysis of the USTMA iTTP registry has shown a higher incidence of relapse in African American participants. While the precise reason for this finding is not yet clear, it is worth considering that there may also be differential response to preemptive treatment. Our study highlights the importance of continued efforts to determine the generalizability and efficacy of ADAMTS13 monitoring based preemptive treatment in iTTP. Figure 1 Figure 1. Disclosures Gangaraju: Alexion: Consultancy; Sanofi Genzyme: Consultancy. Masias: Sanofi: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Membership on an entity's Board of Directors or advisory committees. Parnes: Sigilon: Membership on an entity's Board of Directors or advisory committees; Genentech: Membership on an entity's Board of Directors or advisory committees; Shire/Takeda: Membership on an entity's Board of Directors or advisory committees, Research Funding; I-mAb: Consultancy; Sunovion: Consultancy; Genentech/Hoffman LaRoche: Research Funding; UniQure: Membership on an entity's Board of Directors or advisory committees; Aspa: Consultancy. Mazepa: Answering TTP Foundation: Research Funding; Sanofi Aventis: Other. OffLabel Disclosure: Rituximab, an anti CD20 monoclonal antibody will be discussed in relation to treatment of thrombotic thrombocytopenic purpura.

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Disparity in utilization of multiagent therapy for acute promyelocytic leukemia (APL): A large National Cancer Database (NCDB) analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.6587 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 6587-6587

Author(s):

Prajwal Dhakal ◽

Elizabeth Lyden ◽

Krishna Gundabolu ◽

Amer Methqal Zeidan ◽

Kah Poh Loh ◽

...

Keyword(s):

Clinical Trials ◽

Real World ◽

Private Insurance ◽

Multiple Logistic Regression Analysis ◽

Single Agent ◽

High Rate ◽

Cancer Center ◽

Uninsured Patients ◽

Single Agent Therapy ◽

To Receive

6587 Background: Clinical trials have demonstrated a high rate of cure in APL with the use of multiagent therapy; however, overall survival in real world practice is significantly lower than that in the trials (Blood 2020; 136 (s 1): 13-14). We performed a large NCDB analysis to determine the appropriateness of treatment as a possible explanation for worse survival outside of the clinical trials. Methods: We included a total of 7190 APL cases reported to NCDB between 2004-2015. Multiple logistic regression analysis was used to evaluate the effect of covariates on probability of multiagent therapy use. Results: Only 64% of total patients received multiagent therapy; 29% received singe agent therapy and 4% received unknown therapy. 3% (n = 207) did not receive any treatment for reasons including early death (n = 8), patient refusal (n = 15), perceived contraindication (n = 12) and unknown reasons (n = 182). Compared to patients > 60 years, younger patients aged 0-18 years (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.8-5.5, p < 0.001), 19-40 years (HR 1.6, 95% CI 1.03-2.54, p = 0.03) and 41-60 years (HR 1.6, 95% CI 1.3-1.9, p < 0.001) were more likely to receive multiagent chemotherapy. Patients with Medicaid were more likely to receive multiagent therapy compared to those with private insurance (HR 1.2, 95% CI 1.01-1.42, p = 0.04), possibly because patients with Medicaid are younger. The likelihood of receiving multiagent therapy decreased in uninsured patients (HR 0.6, 95% CI 0.5-0.8, p < 0.001). Compared to academic cancer centers, patients treated at community cancer center (HR 0.5, 95% CI 0.3-0.7, p = 0.001), comprehensive community cancer center (HR 0.7, 95% CI 0.6-0.8, p < 0.001)) and integrated network cancer center (HR 0.8, 95% CI 0.6-0-0.9, p = 0.01) were less likely to be treated with multiagent therapy. Lower comorbidity index increased the likelihood of receiving multiagent therapy. The likelihood of receiving multiagent therapy was not influenced by sex, race, annual income, distance traveled to treatment facility and high school education. Conclusions: To our knowledge, this is the first large scale analysis of utilization of multiagent therapy in APL in real world practice. In our study, 3% of patients did not receive treatment, a much smaller proportion of patients compared to acute myeloid leukemia, where a quarter to a third of patients do not receive any chemotherapy (Blood Adv; 2018 (2): 1277–1282). However, 29% of APL patients received suboptimal treatment with single agent therapy. The use of single agent therapy was higher in older adults and those with greater comorbidity. About half of the patients were treated outside of academic centers, which was associated with a higher probability of receiving single agent therapy. Uninsured patients were more likely to receive single agent therapy. Our findings highlight disparity based on insurance and health system factors.

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