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Background: Lung cancer screening guidelines were introduced in the United States in 2013, with variable implementation. This study evaluated temporal diagnostic trends in non-small cell lung cancer (NSCLC) diagnosis since the introduction of these guidelines., Methods: This retrospective cohort analysis used data from the Veterans Administration Corporate Data Warehouse and the National Cancer Database. We evaluated temporal trends in the distribution of NSCLC stage at the time of diagnosis along with differences based on insurance coverage type, including uninsured, privately insured, Medicare, Medicaid, and Veterans Affairs (VA) coverage, with adjustment for clinically relevant variables., Results: Among 1,450,965 patients diagnosed from 2006 to 2020, the proportion of NSCLC cases diagnosed at stage I increased in all insurance groups by 12.74%, 2%, 0.25%, and 2.57% for the VA, Medicare, private insurance, and Medicaid, respectively. If all insurance systems achieved the unadjusted stage distribution seen in the Veterans Health Administration, an additional 45,684 patients would be diagnosed with stage I NSCLC and 65,933 fewer patients would be diagnosed with stage IV disease., Conclusions: For patients with any form of insurance, there has been an increase in the proportion of early-stage NSCLC (stage I and II) and a corresponding decrease in the proportion of stage III and IV since the introduction of national lung cancer screening guidelines. As the largest integrated single-payer health care system in the United States, the VA dramatically outperforms other insurance types, perhaps attributable to universal coverage and robust lung cancer screening programs., Competing Interests: Disclosures Brendan Heiden reports a relationships with Oncocyte Corporation and Eli Lilly & Company that includes: consulting or advisory and employment. Martin Schoen reports a relationship with Pfizer that includes: speaking and lecture fees. Varun Puri reports a relationship with PrecisCa that includes: speaking and lecture fees. Varun Puri (spouse) reports a relationship with Intuitive Surgical Inc that includes: equity or stocks. The other authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Approximately 3 million Americans served in the armed forces during the Vietnam War. Veterans have a higher incidence rate of lung cancer compared with the general population, which may be related to exposures sustained during service. Agent Orange, one of the tactical herbicides used by the armed forces as a means of destroying crops and clearing vegetation, has been linked to the development of several cancers including non-small cell lung cancer. However, traditional risk models of lung cancer survival and recurrence often do not include such exposures. We aimed to examine the relationship between Agent Orange exposure and overall survival and disease recurrence for surgically treated stage I non-small cell lung cancer., Methods: We performed a retrospective cohort study using a uniquely compiled dataset of US Veterans with pathologic I non-small cell lung cancer. We included adult patients who served in the Vietnam War and underwent surgical resection between 2010 and 2016. Our 2 comparison groups included those with identified Agent Orange exposure and those who were unexposed. We used multivariable Cox proportional hazards and Fine and Gray competing risk analyses to examine overall survival and disease recurrence for patients with pathologic stage I disease, respectively., Results: A total of 3958 Vietnam Veterans with pathologic stage I disease were identified (994 who had Agent Orange exposure and 2964 who were unexposed). Those who had Agent Orange exposure were more likely to be male, to be White, and to live a further distance from their treatment facility (P < .05). Tumor size distribution, grade, and histology were similar between cohorts. Multivariable Cox proportional hazards modeling identified similar overall survival between cohorts (Agent Orange exposure hazard ratio, 0.97; 95% CI, 0.86-1.09). Patients who had Agent Orange exposure had a 19% increased risk of disease recurrence (hazard ratio, 1.19; 95% CI, 1.02-1.40)., Conclusions: Veterans with known Agent Orange exposure who undergo surgical treatment for stage I non-small cell lung cancer have an approximately 20% increased risk of disease recurrence compared with their nonexposed counterparts. Agent Orange exposure should be taken into consideration when determining treatment and surveillance regimens for Veteran patients., (Copyright © 2023. Published by Elsevier Inc.)

Background: Treatments for multiple myeloma (MM) have evolved over time and improved MM survival. While racial differences in MM treatment and prognosis between non-Hispanic African American (NHAA) and non-Hispanic White (NHW) patients are well-established, it is unclear whether they have persisted after the introduction of novel agents., Methods: Using the Surveillance, Epidemiology, and End Results-Medicare linked database, our study investigated racial difference in the receipt of treatment within 1 year following diagnosis and assessed survival outcomes among Medicare beneficiaries (≥66 years) diagnosed with MM from 2007 to 2017. We applied multivariable Cox proportional hazards models to estimate the association between race and survival and presented hazard ratios (HRs)., Results: Of 2094 NHAA and 11,983 NHW older patients with MM, 59.5% and 64.8% received treatment during the first year, respectively. Discrepancy in the proportion of patients receiving treatment between the two groups increased from 2.9% in 2007 to 2009 to 6.9% in 2014-2017. After controlling for relevant factors, patients who received treatment within the first year had lower mortality than those who did not (HR = 0.90, 95% confidence interval [CI]: 0.86-0.94). NHAA patients had a lower probability to receive treatments during the first year than NHW patients (HR = 0.91, 95% CI: 0.85-0.97) but had lower mortality (HR = 0.94, 95% CI: 0.88-1.00). The lower mortality was only observed among patients who received no treatment (HR = 0.84, 95% CI: 0.77-0.93); NHAA and NHW patients who received treatment had similar survival (p = 0.63)., Conclusions: The increasing racial disparity in treatment utilization over time is concerning. Efforts are needed to eliminate the barriers of receiving treatment., (© 2024 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: We are developing 10 de novo population-level mathematical models in 4 malignancies (multiple myeloma and bladder, gastric, and uterine cancers). Each of these sites has documented disparities in outcome that are believed to be downstream effects of systemic racism., Methods: Ten models are being independently developed as part of the Cancer Intervention and Surveillance Modeling Network incubator program. These models simulate trends in cancer incidence, early diagnosis, treatment, and mortality for the general population and are stratified by racial subgroup. Model inputs are based on large population datasets, clinical trials, and observational studies. Some core parameters are shared, and other parameters are model specific. All models are microsimulation models that use self-reported race to stratify model inputs. They can simulate the distribution of relevant risk factors (eg, smoking, obesity) and insurance status (for multiple myeloma and uterine cancer) in US birth cohorts and population., Discussion: The models aim to refine approaches in prevention, detection, and management of 4 cancers given uncertainties and constraints. They will help explore whether the observed racial disparities are explainable by inequities, assess the effects of existing and potential cancer prevention and control policies on health equity and disparities, and identify policies that balance efficiency and fairness in decreasing cancer mortality., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: Hepatitis C virus (HCV) infection has been associated with increased risk of cardiovascular disease (CVD). It is unclear whether HCV treatment affects risk of CVD among patients infected with HCV. We assessed the incidence and risk of CVD among insured patients with HCV infection and evaluated if HCV treatment was associated with reduced CVD risk., Methods: This retrospective cohort study used MarketScan Commercial and Medicare Supplement databases. Patients newly diagnosed with HCV (vs. patients without HCV) between January 2008 and August 2015 were categorized by treatment (none, insufficient, or minimum effective) based on receipt and duration of anti-HCV treatments. After propensity score matching, time-dependent Cox proportional hazards models were used to compare CVD risk between patients with HCV versus without and between patients with HCV by treatment type and duration., Results: HCV was associated with 13% increased risk of developing CVD overall (adjusted hazard ratio [aHR] 95% CI 1.26-1.35) and with 13% (aHR 1.07-1,18), 9% (aHR 1.03-1.15), and 32% (aHR 1.24-1.40) significantly increased risks of developing coronary artery disease, cerebrovascular disease, and peripheral vascular disease, respectively. Among patients with HCV, compared with no treatment, receipt of minimum effective treatment was associated with 24% decreased risk of CVD, and receipt of insufficient treatment was associated with 14% decreased risk of CVD., Conclusions: Individuals chronically infected with HCV had a higher incidence of CVD. Among patients with HCV, receipt of antiviral treatment for HCV was associated with decreased risk of CVD., (© 2023 John Wiley & Sons Ltd.)

Background: Recent studies have suggested that more frequent postoperative surveillance imaging via computed tomography following lung cancer resection may not improve outcomes. We sought to validate these findings using a uniquely compiled dataset from the Veterans Health Administration, the largest integrated health-care system in the United States., Methods: We performed a retrospective cohort study of veterans with pathologic stage I non-small cell lung cancer receiving surgery (2006-2016). We assessed the relationship between surveillance frequency (chest computed tomography scans within 2 years after surgery) and recurrence-free survival and overall survival., Results: Among 6171 patients, 3047 (49.4%) and 3124 (50.6%) underwent low-frequency (<2 scans per year; every 6-12 months) and high-frequency (≥2 scans per year; every 3-6 months) surveillance, respectively. Factors associated with high-frequency surveillance included being a former smoker (vs current; adjusted odds ratio [aOR] = 1.18, 95% confidence interval [CI] = 1.05 to 1.33), receiving a wedge resection (vs lobectomy; aOR = 1.21, 95% CI = 1.05 to 1.39), and having follow-up with an oncologist (aOR = 1.58, 95% CI = 1.42 to 1.77), whereas African American race was associated with low-frequency surveillance (vs White race; aOR = 0.64, 95% CI = 0.54 to 0.75). With a median (interquartile range) follow-up of 7.3 (3.4-12.5) years, recurrence was detected in 1360 (22.0%) patients. High-frequency surveillance was not associated with longer recurrence-free survival (adjusted hazard ratio = 0.93, 95% CI = 0.83 to 1.04, P = .22) or overall survival (adjusted hazard ratio = 1.04, 95% CI = 0.96 to 1.12, P = .35)., Conclusions: We found that high-frequency surveillance does not improve outcomes in surgically treated stage I non-small cell lung cancer. Future lung cancer treatment guidelines should consider less frequent surveillance imaging in patients with stage I disease., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Background: Prior studies in the civilian population have reported racial disparities in lung cancer outcomes following surgical treatment, including inferior quality of care and worse survival. It is unclear if racial disparities exist in the Veterans Health Administration (VHA), the largest integrated health care system in the United States., Research Question: Do racial disparities affect early-stage non-small cell lung cancer (NSCLC) outcomes following surgical treatment within the VHA?, Study Design and Methods: This retrospective cohort study was conducted in veterans with clinical stage I NSCLC undergoing surgical treatment in the VHA system. Demographic characteristics, access to care, surgical quality measures, and short- and long-term oncologic outcomes between White and Black veterans were evaluated., Results: From 2006 to 2016, a total of 18,800 veterans with clinical stage I NSCLC were included. The rates of definitive surgical treatment were similar between Black (57.3%) and White (58.1%) veterans (P = .42). The final study cohort included 9,842 patients receiving surgical treatment, of whom 8,356 (84.9%) were White and 1,486 (15.1%) were Black. Black patients were younger and more likely to smoke, although comorbidities were similar between the two groups. Black patients were somewhat less likely to receive adequate lymph node sampling (30.6% vs 33.3%; P = .050); however, other access-to-care metrics and surgical quality measures, including rates of anatomic lobectomy (71.9% vs 69.4%; P = .189) and positive margins (3.2% vs 3.1%; P = .955), were similar between the two groups. Although Black veterans were less likely to experience major postoperative complications, there was no difference in 30-day readmission, 30-day mortality, or disease-free survival between the two groups. Black patients had significantly better risk-adjusted overall survival (hazard ratio, 0.802; 95% CI, 0.729-0.883; P < .001)., Interpretation: Among veterans with NSCLC undergoing surgical treatment through the VHA, Black patients received comparable care with equivalent if not superior outcomes compared with White patients., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Domino liver transplantation (DLT) utilizes a phenotypically normal explant from select recipients as a donor graft in another patient. The procedure is not widely employed and remains restricted to a small number of centers. The purpose of this study was to assess the national profile of DLT in the United States (US) and evaluate current survival outcomes., Methods: The United Network for Organ Sharing (UNOS) database was queried for all liver transplants (LT) between 1996 and 2020. Outcomes of interest were long-term graft and patient survival., Results: Of 181,976 LTs performed nationally during the study period, 185 (0.1%) were DLTs. Amyloidosis and maple syrup urine disease (MSUD) accounted for 83% of dominoed allografts. Out of 210 explants with amyloidosis, 103 (49%) were dominoed into secondary recipients. Only 50 (22%) of all MSUD explants (n = 227) were dominoed. Graft survival was 79%, 73% and 53% at 3-, 5- and 10-years, respectively, for DLT recipients. Overall patient survival was 83%, 76% and 57% at 3-, 5- and 10-years., Conclusion: Despite excellent long-term survival outcomes, DLT allografts comprise a very small percentage of the liver donor pool. A large proportion of potential DLTs may be unconscionably excluded despite shortages in deceased donor organs., (Copyright © 2021. Published by Elsevier Ltd.)

Background & Aims: Colorectal cancer (CRC) incidence has decreased overall in the last several decades, but it has increased among younger adults. Prior studies have characterized this phenomenon in the United States (U.S.) using only a small subset of cases. We describe CRC incidence trends using high-quality data from 92% of the U.S. population, with an emphasis on those younger than 50 years., Methods: We obtained 2001 to 2016 data from the U.S. Cancer Statistics database and analyzed CRC incidence for all age groups, with a focus on individuals diagnosed at ages 20 to 49 years (early-onset CRC). We compared incidence trends stratified by age, as well as by race/ethnicity, sex, region, anatomic site, and stage at diagnosis., Results: We observed 191,659 cases of early-onset and 1,097,765 cases of late-onset CRC during the study period. Overall, CRC incidence increased in every age group from 20 to 54 years. Whites were the only racial group with a consistent increase in incidence across all younger ages, with the steepest rise seen after 2012. Hispanics also experienced smaller increases in incidence in most of the younger age groups. Asians/Pacific Islanders and blacks saw no increase in incidence in any age group in 2016, but blacks continued to have the highest incidence of CRC for every age group. Greater increase in early-onset CRC incidence was observed for males, left-sided tumors, and regional and distant disease., Conclusions: Early-onset CRC incidence increased overall from 2001 to 2016, but the trends were markedly different for whites, blacks, Asians/Pacific Islanders, and Hispanics. These results may inform future research on the risk factors underlying early-onset CRC., (Published by Elsevier Inc.)

Background: The development of cytomegalovirus (CMV) infection after kidney transplant remains a significant cause of posttransplant morbidity, graft loss, and mortality. Despite appropriate antiviral therapy, recipients without previous CMV exposure can currently be allocated a kidney from a donor with previous CMV infection (D+R-) that carries the greatest risk of posttransplant CMV infection and associated complications. Preferential placement of CMV D- organs in negative recipients (R-) has been shown to reduce the risk of viral infection and associated complications., Methods: To assess the long-term survival and economic benefits of allocation policy reforms, a decision-analytic model was constructed to compare receipt of CMV D- with CMV D+ organ in CMV R- recipients using data from transplant registry, Medicare claims, and pharmaceutical costs., Results: For CMV R- patients, receipt of a CMV D- organ was associated with greater average survival (14.3 versus 12.6 y), superior quality-adjusted life years (12.6 versus 9.8), and lower costs ($529 512 versus $542 963). One-way sensitivity analysis demonstrated a survival advantage for patients waiting as long as 30 mo for a CMV D- kidney., Conclusions: Altering national allocation policy to preferentially offer CMV D- organs to CMV R- recipients could improve survival and lower costs after transplant if appropriately implemented., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The lung allocation score (LAS) significantly improved outcomes and wait list mortality in lung transplantation. However, mortality remains high for the sickest wait list candidates despite additional changes to allocation distance. Regulatory considerations of overhauling the current lung allocation system have met significant resistance, and changes would require years to implement. This study evaluates whether a modest change to the current system by prioritization of only high-LAS lung transplant candidates would result in lowered wait list mortality., Methods: The Thoracic Simulated Allocation Model was used to evaluate all lung transplant candidates and donor lungs recovered between July 1, 2009 and June 30, 2011. Current lung allocation rules (initial offer within a 250-nautical mile radius for ABO-identical then compatible offers) were run. Allocation was then changed for only patients with an LAS of50 or higher (high-LAS) to be prioritized within a 500-nautical mile radius with no stratification between ABO-identical and compatible offers. Ten iterations of each model were run. Primary end points were wait list mortality and posttransplant 1-year survival., Results: A total of 6538 wait list candidates and transplant recipients were evaluated per iteration, for a total of 130,760 simulated patients. Compared with current allocation, the adjusted model had a 23.3% decrease in wait list mortality. Posttransplant 1-year survival was minimally affected., Conclusions: Without overhauling the entire system, simple prioritization changes to the allocation system for high-LAS candidates may lead to decreased wait list mortality and increased organ use. Importantly, these changes do not appear to lead to clinically significant changes in posttransplant 1-year survival., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Hydroxychloroquine (HCQ) is an antimalarial drug with immunomodulatory effects used to treat systemic lupus erythematosus (SLE) and scleroderma. The antiviral effects of HCQ have raised attention in the context of the COVID-19 pandemic, although safety is controversial. We examined linkages of national transplant registry data with pharmaceutical claims and Medicare billing claims to study HCQ use among Medicare-insured kidney transplant recipients with SLE or scleroderma (2008-2017; N = 1820). We compared three groups based on immunosuppression regimen 7 months-to-1 year post transplant: (a) tacrolimus (Tac) + mycophenolic acid (MPA) + prednisone (Pred) (referent group, 77.7%); (b) Tac + MPA + Pred + HCQ (16.5%); or (c) other immunosuppression + HCQ (5.7%). Compared to the referent group, recipients treated with other immunosuppression + HCQ had a 2-fold increased risk of abnormal ECG or QT prolongation (18.9% vs. 10.7%; aHR, 1.12 1.96 3.42 , p = .02) and ventricular arrhythmias (15.2% vs. 11.4%; aHR, 1.00 1.81 3.29 , p = .05) in the >1-to-3 years post-transplant. Tac + MPA + Pred + HCQ was associated with increased risk of ventricular arrhythmias (13.5% vs. 11.4%; aHR, 1.02 1.54 2.31 , p = .04) and pancytopenia (35.9% vs. 31.4%; aHR, 1.03 1.31 1.68 , p = .03) compared to triple immunosuppression without HCQ. However, HCQ-containing regimens were not associated with an increased risk of death or graft failure. HCQ may be used safely in selected kidney transplant recipients in addition to their maintenance immunosuppression, although attention to arrhythmias is warranted., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

To investigate the prevalence of obesity-related multimorbidity (co-occurrence of ≥2 obesity-related chronic diseases, ORCDs) and the risk of cardiovascular disease in the presence of multimorbidity in middle-aged adults in the United States. National Health and Nutrition Examination Survey data from 2007 to 2016 were used. Target ORCDs included hypertension (H), diabetes (D), coronary heart disease (C), and stroke (S). Age-standardized prevalence for obesity-related multimorbidity in its combination and permutation was calculated. Risk for cardiovascular disease (C or S) was estimated conditional on demographics, degree of obesity, and presence and duration of pre-existing ORCDs. Analyses were conducted at Washington University in 2019. The analytic sample included 14,243 individuals age 40-79 years, representing a population size of 110,003,550. Age-standardized prevalence for obesity-related multimorbidity was 12.3%. Hypertension was most commonly the first diagnosed ORCD for populations with 2-4 ORCDs, followed by diabetes for populations with 2-3 ORCDs. Compared with no pre-existing hypertension/diabetes/stroke, pre-existing hypertension in combination with diabetes/stroke significantly increased risk of coronary heart disease [H + S (multivariable-adjusted hazard ratio, aHR 27.6, 95% CI 10.9-70.2), D + H + S (aHR 20.3, 95% CI 7.9-52.2)]. Compared with no hypertension/diabetes/coronary heart disease, pre-existing hypertension in combination with diabetes/coronary heart disease significantly increased risk of stroke [C + D + H (aHR 32.6, 95% CI 12.2-87.1), C + H (aHR 25.4, 95% CI 12.1-53.6), D + H (aHR 5.3, 95% CI 2.6-10.8)]. Obesity-related multimorbidity is prevalent and highly associated with cardiovascular disease development. To reduce the detrimental health impact of multimorbidity, intervention strategies should target preventing increasing multimorbidity and detecting/managing diabetes and hypertension prior to the onset of cardiovascular disease., Competing Interests: Declaration of competing interest The authors report no conflicts of interest. The study sponsors had no role in the study design; collection, analysis, and interpretation of data; writing of the report; or in the decision to submit the paper for publication. The conclusions and opinions presented herein are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health, the Agency for Healthcare Research and Quality, or the Foundation for Barnes Jewish Hospital. Part of this work was presented as a poster at the ObesityWeek annual meeting in Las Vegas, NV, 2019. No financial disclosures were reported by the authors of this paper., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Coronavirus 2019 (COVID-19) is a worldwide pandemic, with many patients requiring prolonged mechanical ventilation. Tracheostomy is not recommended by current guidelines as it is considered a superspreading event owing to aerosolization that unduly risks health care workers., Methods: Patients with severe COVID-19 who were on mechanical ventilation for 5 days or longer were evaluated for percutaneous dilational tracheostomy. We developed a novel percutaneous tracheostomy technique that placed the bronchoscope alongside the endotracheal tube, not inside it. That improved visualization during the procedure and continued standard mechanical ventilation after positioning the inflated endotracheal tube cuff in the distal trachea. This technique offers a significant mitigation for the risk of virus aerosolization during the procedure., Results: From March 10 to April 15, 2020, 270 patients with COVID-19 required invasive mechanical ventilation at New York University Langone Health Manhattan's campus; of those, 98 patients underwent percutaneous dilational tracheostomy. The mean time from intubation to the procedure was 10.6 ± 5 days. Currently, 32 patients (33%) do not require mechanical ventilatory support, 19 (19%) have their tracheostomy tube downsized, and 8 (8%) were decannulated. Forty patients (41%) remain on full ventilator support, and 19 (19%) are weaning from mechanical ventilation. Seven patients (7%) died as a result of respiratory and multiorgan failure. Tracheostomy-related bleeding was the most common complication (5 patients). None of health care providers has had symptoms or tested positive for COVID-19., Conclusions: Our percutaneous tracheostomy technique appears to be safe and effective for COVID-19 patients and safe for health care workers., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Study Objective: Evaluate racial/ethnic variation in hysterectomy surgical route in women likely eligible for minimally invasive hysterectomy., Design: Cross-sectional study., Setting: Multistate including Colorado, Florida, Maryland, New Jersey, and New York., Patients: Women aged ≥18 years without diagnoses of leiomyomas, obesity, or previous abdominopelvic surgery who underwent hysterectomy for benign conditions from the State Inpatient and Ambulatory Surgery Databases, 2010-2014., Interventions: None. Primary exposure is race/ethnicity., Measurements and Main Results: Racial/ethnic variation in annual hysterectomy rates and surgical route. To calculate hysterectomy rates per 100 000 women/year, denominators were adjusted for the proportion of women with previous hysterectomy. A marginal structural log binomial regression model was used to estimate adjusted standardized prevalence ratios (aPRs) for vaginal or laparoscopic vs abdominal hysterectomy, controlling for clustering within hospitals. In addition, hospitals were stratified into quintiles to examine surgical route in hospitals that serve a higher vs lower proportion of African American patients. A total of 133 082 adult women underwent hysterectomy for benign conditions from 2010 to 2014. Annual laparoscopic rates increased more slowly for African Americans (1.6-fold) than for whites (1.8-fold) and Hispanics (1.9-fold). African American and Hispanic women were less likely to undergo vaginal (aPR = 0.93; 95% confidence interval [CI], 0.90-0.96 and aPR = 0.95; 95% CI 0.93-0.97, respectively) and laparoscopic hysterectomy (aPR = 0.90; 95% CI, 0.87-0.94 and aPR = 0.95; 95% CI, 0.92-0.98, respectively) than white women; Asian/Pacific Islander women were less likely to undergo vaginal hysterectomy (aPR = 0.88; 95% CI, 0.81-0.96). Hospitals serving a higher proportion of African American persons performed more abdominal and fewer vaginal procedures across all groups, and more racial/ethnic minority women sought care at those hospitals than white women., Conclusion: African American, Hispanic, and Asian/Pacific Islander women eligible for minimally invasive hysterectomy were more likely than white women to receive abdominal hysterectomy. The proportion of all women undergoing abdominal hysterectomy was highest at hospitals serving higher proportions of African American persons. This difference in treatment type can lead to disparities in outcomes, in part owing to their association with complications., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Purpose: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free cervical cancer screening to low-income women. This study estimated the health benefits gained in terms of life years (LYs) saved and quality-adjusted life years (QALYs) gained if cervical cancer screening by the NBCCEDP increased to reach more eligible women., Methods: Data from Surveillance, Epidemiology, and End Results, NBCCEDP, and Medical Expenditure Panel Surveys were used. LYs saved and QALYs gained/100,000 women were estimated using modeling methods. They were used to predict additional health benefits gained if screening by the NBCCEDP increased from 6.5% up to 10-25% of the eligible women., Results: Overall, per 100,000 women screened by the NBCCEDP, 1,731 LYs were saved and 1,608 QALYs were gained. For white women, 1,926 LYs were saved and 1,780 QALYs were gained/100,000 women screened by the NBCCEDP. For black women, 1,506 LYs were saved and 1,300 QALYs were gained/100,000 women screened. If the proportion of eligible women screened by the NBCCEDP increased to 10-25%, the estimated health benefits would range from 6,626-34,896 LYs saved and 6,153-32,407 QALYs gained., Conclusions: The reported estimates emphasize the value of cervical cancer screening program by extending LE in low-income women. Further, it demonstrates that screening a higher percentage of eligible women in the NBCCEDP may yield more health benefits.

Background: More people who have personally consented to organ donation via first person authorization (FPA) registration before death become organ donors than those not personally consenting. The majority of registrations occur at state-specific department of motor vehicle (DMV) and licensing offices, where people register their vehicles and obtain driver's licenses., Methods: One organ procurement organization (OPO) ran 3 DMV offices and implemented an intervention: a donor-centric approach, including employee education, office decoration with donation materials, and customer experience improvements. Data about registry enrollment was collected before and during the 4-year OPO licensing office contract. A linear mixed model and interrupted time series analyses were performed to evaluate whether the intervention improved rates of registration., Results: Preintervention registry enrollment rates per month were 10%-50%. Having the offices run by an OPO was associated with more enrollments independent of the increasing trend of enrollment (P < 0.001). Also, the DMV office with the lowest preimplementation registration rates had an immediate increase in enrollments after the intervention leading to higher registration rates (P < 0.001)., Conclusions: A donor-centric OPO-managed DMV experience increases FPA registration, especially at offices with low initial registration rates. However, even at the office with the highest percentage of FPA registrations, rates were only 65% at intervention conclusion. The transplant community should consider other opportunities for FPA registration.

Background: The effect of metformin use on survival among patients with pancreatic ductal adenocarcinoma (PDAC) is controversial. Furthermore, there are no data on African American patients. To address these, we analyzed data from the United States Veterans Health Administration (VHA)., Methods: A population-based retrospective cohort study evaluating overall survival among 3,811 patients with PDAC with preexisting diabetes mellitus, diagnosed with PDAC within the VHA between 1998 and 2013. We calculated HRs and 95% confidence intervals (CI) using multivariable adjusted time-varying Cox proportional hazards regression to control for immortal time bias and confounders., Results: Metformin use was not associated with overall survival in the complete analyses (HR = 1.05; 95% CI, 0.92-1.14; P = 0.28). However, among patients who were metformin naïve at the time of PDAC diagnosis ( N = 1,158), metformin use was associated with improved overall survival in non-Hispanic white patients (HR = 0.78; 95% CI, 0.61-0.99; P = 0.04), but not African American patients (HR = 1.20; 95% CI, 0.75-1.93; P = 0.45). The survival benefit among non-Hispanic whites was limited to patients with metastatic disease (HR = 0.67; 95% CI, 0.44-1.01; P = 0.06). Among African American patients with metastatic disease, HR was 1.30 (95% CI, 0.77-2.53; P = 0.28). There was a suggestion of heterogeneity by race in patients with metastatic disease ( P heterogeneity = 0.05)., Conclusions: We observed no associations between metformin use and survival in patients with PDAC, but there appears to be a survival benefit among non-Hispanic white patients who were metformin naïve at the time of PDAC diagnosis., Impact: If confirmed in other studies, our findings suggest that metformin as an adjunctive treatment for PDAC may not improve survival among African American patients., (©2019 American Association for Cancer Research.)

Background: Since the Model for End-stage Liver Disease (MELD) allocation system was implemented, the proportion of simultaneous liver-kidney transplantation (SLKT) has increased significantly. However, whether racial/ethnic disparities exist in access to SLKT and post-SLKT survival remains understudied., Methods: A retrospective cohort of patients aged ≥18 years with renal dysfunction on the liver transplant (LT) waiting list was obtained from Organ Procurement and Transplantation Network. Renal dysfunction was defined as estimated glomerular filtration rate <60 mL/min/1.73 m at listing for LT. Multilevel time-to-competing-events regression adjusting for center effect was used to examine the likelihood of receiving SLKT. Inverse probability of treatment weighted survival analyses were used to analyze posttransplant mortality outcomes., Results: For patients with renal dysfunction at listing for LT, not listed for simultaneous kidney transplant, non-Hispanic black (NHB) and Hispanic patients were more likely to receive SLKT than non-Hispanic white (NHW) patients (NHB: multivariable-adjusted hazard ratio [aHR] 2.57; 95% confidence interval [CI], 1.42-4.65; Hispanic: aHR, 2.03; 95% CI, 1.14-3.60). For post-SLKT outcomes, compared to NHW patients, NHB patients had a lower mortality risk before 24 months (aHR, 0.80; 95% CI, 0.65-0.97) but had a higher mortality risk (aHR, 2.00; 95% CI, 1.59-2.55) afterward; in contrast, Hispanic patients had a lower overall mortality risk than NHW patients (aHR, 0.61; 95% CI, 0.51-0.74)., Conclusions: In the MELD era, racial/ethnic differences exist in access and survival of SLKT for patients with renal dysfunction at listing for LT. Future studies are warranted to examine whether these differences remain in the post-SLK allocation policy era.

The effectiveness of bariatric surgery has been well-studied. However, complications after bariatric surgery have been understudied. This review assesses <30-d major complications associated with bariatric procedures, including anastomotic leak, myocardial infarction and pulmonary embolism. This review included 71 studies conducted in the USA between 2003 and 2014 and 107,874 patients undergoing either gastric bypass, adjustable gastric banding or sleeve gastrectomy, with mean age of 44 years and pre-surgery body mass index of 46.5 kg m -2 . Less than 30-d anastomotic leak rate was 1.15%; myocardial infarction rate was 0.37%; pulmonary embolism rate was 1.17%. Among all patients, mortality rate following anastomotic leak, myocardial infarction and pulmonary embolism was 0.12%, 0.37% and 0.18%, respectively. Among surgical procedures, <30-d after surgery, sleeve gastrectomy (1.21% [95% confidence interval, 0.23-2.19%]) had higher anastomotic leak rate than gastric bypass (1.14% [95% confidence interval, 0.84-1.43%]); gastric bypass had higher rates of myocardial infarction and pulmonary embolism than adjustable gastric banding or sleeve gastrectomy. During the review, we found that the quality of complication reporting is lower than the reporting of other outcomes. In summary, <30-d rates of the three major complications after either one of the procedures range from 0% to 1.55%. Mortality following these complications ranges from 0% to 0.64%. Future studies reporting complications after bariatric surgery should improve their reporting quality., (© 2017 World Obesity Federation.)

This study aims to quantify the aggregate potential life-years (LYs) saved and healthcare cost-savings if the Healthy People 2020 objective were met to reduce invasive colorectal cancer (CRC) incidence by 15%. We identified patients (n=886,380) diagnosed with invasive CRC between 2001 and 2011 from a nationally representative cancer dataset. We stratified these patients by sex, race/ethnicity, and age. Using these data and data from the 2001-2011 U.S. life tables, we estimated a survival function for each CRC group and the corresponding reference group and computed per-person LYs saved. We estimated per-person annual healthcare cost-savings using the 2008-2012 Medical Expenditure Panel Survey. We calculated aggregate LYs saved and cost-savings by multiplying the reduced number of CRC patients by the per-person LYs saved and lifetime healthcare cost-savings, respectively. We estimated an aggregate of 84,569 and 64,924 LYs saved for men and women, respectively, accounting for healthcare cost-savings of $329.3 and $294.2 million (in 2013$), respectively. Per person, we estimated 6.3 potential LYs saved related to those who developed CRC for both men and women, and healthcare cost-savings of $24,000 for men and $28,000 for women. Non-Hispanic whites and those aged 60-64 had the highest aggregate potential LYs saved and cost-savings. Achieving the HP2020 objective of reducing invasive CRC incidence by 15% by year 2020 would potentially save nearly 150,000 life-years and $624 million on healthcare costs., (Copyright © 2017. Published by Elsevier Inc.)

Background: Multiple myeloma (MM) is one of the most common hematologic malignancies in the United States and is consistently preceded by monoclonal gammopathy of undetermined significance (MGUS). This study investigates the role of obesity in the progression of MGUS to MM., Methods: A retrospective identified cohort of patients in the US Veterans Health Administration database diagnosed with MGUS between October 1, 1999, and December 31, 2009, was followed through August 6, 2013. Patient-level clinical data were reviewed to verify MM diagnosis, if any. Survival analyses utilizing interval-censored data were used to investigate the risk of progression of MGUS to MM. Statistical tests were two-sided., Results: The analytic cohort consisted of 7878 MGUS patients with a median follow-up of 68 months. Within the cohort, 39.8% were overweight and 33.8% were obese; 64.1% were of white race. During follow-up, 329 MGUS patients (4.2%) progressed to MM: 72 (3.5%) normal-weight patients (median follow-up = 61.9 months), 144 (4.6%) overweight patients (median follow-up = 69.1 months), and 113 (4.3%) obese patients (median follow-up = 70.6 months). In the multivariable analysis, overweight (hazard ratio [HR] = 1.55, 95% confidence interval [CI] = 1.16 to 2.06) and obesity (HR = 1.98, 95% CI = 1.47 to 2.68) were associated with an increased risk of transformation of MGUS to MM. Moreover, black race was associated with a higher risk of MM (HR = 1.98, 95% CI = 1.55 to 2.54)., Conclusions: Obesity and black race are risk factors for transformation of MGUS to MM. Future clinical trials should examine whether weight loss is a way to prevent the progression to MM in MGUS patients., (© The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Objective: This study analyzed the lifetime health care expenditures and life years lost associated with diabetes in the U.S., Research Design and Methods: Data from the National Health Interview Survey (NHIS), the Medical Expenditure Panel Survey from 1997 to 2000, and the NHIS Linked Mortality Public-use Files with a mortality follow-up to 2006 were used to estimate age-, race-, sex-, and BMI-specific risk of diabetes, mortality, and annual health care expenditures for both patients with diabetes and those without diabetes. A Markov model populated by the risk and cost estimates was used to compute life years and total lifetime health care expenditures by age, race, sex, and BMI classifications for patients with diabetes and without diabetes., Results: Predicted life expectancy for patients with diabetes and without diabetes demonstrated an inverted U shape across most BMI classifications, with highest life expectancy being for the overweight. Lifetime health care expenditures were higher for whites than blacks and for females than males. Using U.S. adults aged 50 years as an example, we found that diabetic white females with a BMI >40 kg/m(2) had 17.9 remaining life years and lifetime health expenditures of $185,609, whereas diabetic white females with normal weight had 22.2 remaining life years and lifetime health expenditures of $183,704., Conclusions: Our results show that diabetes is associated with large decreases in life expectancy and large increases in lifetime health care expenditures. In addition to decreasing life expectancy by 3.3 to 18.7 years, diabetes increased lifetime health care expenditures by $8,946 to $159,380 depending on age-race-sex-BMI classification groups., (© 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Purpose: We investigated racial disparities in healthy behaviors and cancer screening in a large sample from the US population., Methods: This analysis used the data from 2005 National Health Interview Survey and included women at age ≥ 40 years who completed the cancer questionnaires (2,427,075 breast cancer survivors and 57,978,043 women without cancer). Self-reported information on cancer history, healthy behaviors (body mass index, smoking, alcohol use, physical activity, fruit/vegetable consumption, sunscreen use) was collected. We compared distributions of each factor among Caucasian, African American, and Hispanic women with and without breast cancer history., Results: Caucasian breast cancer survivors as compared to their cancer-free counterparts were less likely to be current smokers (8.3 vs. 16.9 %, p < 0.001) and to have regular mammograms (51.5 vs. 36.9 %, p < 0.05). Differences in associations between cancer survivors and respondents without cancer among African American and Hispanic women did not reach statistical significance., Conclusions: Certain breast cancer survivor groups can benefit from tailored preventive services that would address concerns related to selected healthy behaviors and screening practices. However, most of the differences are suggestive and do not differ by race.

Introduction: The relationship between obesity and breast cancer has been extensively investigated. However, how obesity and breast cancer interplay to affect mortality and life expectancy of women in the United States has not been well studied., Methods: We used data from the National Health Interview Survey, 1997-2000. Our sample included nonsmoking, nonpregnant women who reported a body mass index of at least 18.5 kg/m(2) and no cancer other than breast cancer at the time of the survey. A survival model with Gamma frailty and Gompertz baseline was used to estimate relative risks of total mortality and project life years lost associated with breast cancer by obesity status and age., Results: Breast cancer increased risk of mortality depending on degree of obesity and decreased life years by 1 to 12 years depending on race, age, and obesity status. Relative risks for death increased with degree of obesity. Obese women under age 50 across all racial groups were predicted to lose the most life years; racial groups other than whites and blacks lost the most life years (11.9 y), followed by whites (9.8 y) and blacks (9.2 y)., Conclusion: The number of life years lost associated with breast cancer was more marked for more obese than for less obese women and for women under age 50 and women aged 70 or older than for women aged 50 through 69. Public health initiatives should put more emphasis on the prevention and control of obesity for these target populations.

Security control of Electronic Medical Record (EMR) is a mechanism used to manage electronic medical records files and protect sensitive medical records document from information leakage. Researches proposed the Role-Based Access Control(RBAC). However, with the increasing scale of medical institutions, the access control behavior is difficult to have a detailed declaration among roles in RBAC. Furthermore, with the stringent specifications such as the U.S. HIPAA and Canada PIPEDA etc., patients are encouraged to have the right in regulating the access control of his EMR. In response to these problems, we propose an EMR digital rights management system, which is a RBAC-based extension to a matrix organization of medical institutions, known as RBAC-Matrix. With the aim of authorizing the EMR among roles in the organization, RBAC-Matrix also allow patients to be involved in defining access rights of his records. RBAC-Matrix authorizes access control declaration among matrix organizations of medical institutions by using XrML file in association with each EMR. It processes XrML rights declaration file-based authorization of behavior in the two-stage design, called master & servant stage, thus makes the associated EMR to be better protected. RBAC-Matrix will also make medical record file and its associated XrML declaration to two different EMRA(EMR Authorization)roles, namely, the medical records Document Creator (DC) and the medical records Document Right Setting (DRS). Access right setting, determined by the DRS, is cosigned by the patient, thus make the declaration of rights and the use of EMR to comply with HIPAA specifications.

Purpose: Obesity increases the risk of death from many malignancies, including non-Hodgkin's lymphoma (NHL). In diffuse large B-cell lymphoma (DLBCL), the most common form of NHL, the association between body mass index (BMI) at diagnosis and survival is unclear., Patients and Methods: We evaluated the association between BMI at diagnosis and overall survival in a retrospective cohort of 2,534 United States veterans diagnosed with DLBCL between October 1, 1998 and December 31, 2008. Cox modeling was used to control for patient- and disease-related prognostic variables., Results: Mean age at diagnosis was 68 years (range, 20 to 100 years); 64% of patients were overweight (BMI, 25 to < 30) or obese (BMI, ≥ 30). Obese patients were significantly younger, had significantly fewer B symptoms, and trended toward lower-stage disease, compared with other BMI groups. Cox analysis showed reduced mortality in overweight and obese patients (overweight: hazard ratio [HR], 0.73; 95% CI, 0.65 to 0.83; obese: HR, 0.68; 95% CI, 0.58 to 0.80), compared with normal-weight patients (BMI, 18.5 to < 25). Treatment during the rituximab era reduced the risk of death without affecting the association between BMI and survival. Disease-related weight loss occurred in 29% of patients with weight data 1 year before diagnosis. Cox analysis based on BMI 1 year before diagnosis continued to demonstrate reduced risk of death in overweight and obese patients., Conclusion: Being overweight or obese at the time of DLBCL diagnosis is associated with improved overall survival. Understanding the mechanisms responsible for this association will require further study.