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1165 Race and Insurance are Independently Associated With in-Hospital Mortality in Patients With Cholangitis
1166 Are Men and Women Treated Differently With Regard To Hepatocellular Carcinoma? Analysis of an Inpatient Database From Academic Medical Centers at the University Healthsystem Consortium Stephanie Cauble, Ali Abbas, Lydia Bazzano, Sabeen F. Medvedev, Sofia Medvedev, Luis A. Balart, Nathan J. Shores Background and aims: The difference in incidence of hepatocellular carcinoma (HCC) in men versus women has been well documented (2:1 to 8:1). It has also been suggested that females have better natural history of disease compared to men. However, little is known about how treatment for HCC is allocated on a nationwide scale. The aim of this study is to compare treatment of HCC with respect to gender in the United States (US). Methods: This analysis was based on inpatient admission data from the University Health System Consortium (UHC) clinical database, representing 112 academic medical centers in the US and 256 of their affiliated hospitals from 42 states (90% of academic nonprofit US hospitals). Data was extracted for adult patients with a primary discharge diagnosis of HCC, identified by International Classification of Diseases 9th Edition codes. We examined distributions of demographic data, disease factors (metastases, decompensation scores), hospital location, severity of illness indices, comorbidities, insurance status, and treatment options (resection, transplantation, radiofrequency ablation, embolization) across gender using Chi Square tests, t tests and logistic regression analysis. Non-invasive treatment was the treatment control. Results: Over 27,741 patients were included in the multivariate analysis. Compared to men, women were more likely to present with metastases at first admission (OR=1.215, p<0.001), but less likely to have features of liver decompensation (OR=0.77, p<0.001). With regard to treatment options, on a univariate level women received fewer transplants (9% versus 12%, p<0.001). After controlling for the possible confounders, women were as likely to receive transplants and loco regional therapy (p=0.7, p=0.3 respectively), but more likely to receive resection (OR 1.44, p<0.001) compared to men. Higher resection rates did not correlate with race or chronic liver disease type. Conclusions: With regard to HCC, US women are more likely to present with metastatic disease, but with less decompensated liver disease. They more frequently receive invasive treatment, with significantly higher rates of resection across race and diagnoses. US women have lower unadjusted rates of transplant. However, the transplant disparity resolves after controlling for pre-treatment factors.
1. Proximal location defined as proximal to the splenic flexure 2. Advanced adenoma defined as having size ≥1cm, any villous component, high-grade dysplasia, or cancer 1164 Adherence to Programmatic Annual Fecal Occult Blood Test (gFOBt) Versus Screening Colonoscopy in African Americans Compared to Whites With Equal Access and Navigation: Observations From National Colonoscopy Study (NCS) Anjani Jammula, Sidney J. Winawer, Glenn M. Mills, Timothy R. Church, Andrew D. Feld, Martin Fleisher, John I. Allen, Paul A. Jordan, Michael J. O'Brien, Noah D. Kauff, Irene Orlow, Georgia Close, Julie M. Ruckel, Sharon Bayuga-Miller, Georgia Morgan, Deborah Kuk, Frank van Hees, Iris Lansdorp-Vogelaar, Marjolein van Ballegooijen, Ann G. Zauber Background: The incidence and mortality of Colorectal Cancer (CRC) is higher in African Americans (AA) compared to Whites, thought to be largely due to lower adherence to screening in AA. CRC screening guidelines recommend colonoscopy or annual gFOBT as screening options. However, adherence is essential to the effectiveness of either modality. We previously reported equivalent adherence to screening colonoscopy in AA (78%) and Whites (83%) with equal access and navigation. We now present data on adherence to a program of annual gFOBT in AA compared to Whites in the same randomized controlled trial. Methods: The NCS is a randomized controlled trial of Screening Colonoscopy versus a program of annual gFOBT testing with a sensitive slide (Hemoccult SENSA) and gFOBT directed colonoscopy involving 3 clinical centers (University of Minnesota, Minneapolis; Group Health Research Institute, Seattle and Louisiana State University Health Sciences Center, Shreveport (LSUHSC)), a coordinating center (Memorial Sloan-Kettering, New York), and an independent pathology review center (Mallory Institute, Boston). Asymptomatic men and women of ages 40-69 were randomized to colonoscopy arm versus annual programmatic gFOBT. This report is based on the study of the first 3 rounds of gFOBT at LSUHSC, where 50% of the minority population were AA, providing an opportunity to compare AA to Whites from the same population having comparable access. Adherence to gFOBT was defined as completion of 3 out of 3 negative tests or a positive test within the 3 rounds of screening. The rates of diagnostic colonoscopy in those who were gFOBT positive were also assessed. Adjusted relative risks (RR) were derived for adherence with respect to race and CRC screening arm. Results: Of the 1,008 men and women at LSUHSC, 504 were assigned to the Colonoscopy arm among whom 240 were Whites and 246 AA. Another 504 were assigned to the gFOBT arm, among whom 225 were Whites and 259 AA. Adherence rates were comparable in AA and Whites to a screening colonoscopy (78% vs 83%) as well as to a program of annual gFOBT (34% vs 35%) (RR=1.1, 95% CI=0.9-1.2; P=0.3). However, the adherence to a single screening colonoscopy was significantly higher than to the annual programmatic gFOBT in both races (RR=2.3, 95% CI 2.0-2.7, P<0.0001). The adherence rates to diagnostic colonoscopy following a positive gFOBT in AA and Whites were equivalent (88% and 91% respectively). Conclusions: In our randomized controlled trial, adherence to a program of annual gFOBT screening was equivalent in AA and Whites having equal access and navigation. However, adherence to a single screening colonoscopy was higher than to a program of gFOBT for both AA and Whites suggesting that a program of screening colonoscopy would result in greater effectiveness.
1167 Getting Polyps off the Street: the Five-Year Experience of a “No-Cost” Screening Colonoscopy Program Jack Braha, Steven Guttmann, Vince Si, Pavel Gozenput, Jonathan A. Erber, Yuriy Tsirlin, Ira E. Mayer, Rabin Rahmani Background: Colorectal cancer (CRC) is the second leading cause of cancer related death in the United States. In 2010, 142,600 patients were diagnosed with CRC and 51,370 died of the disease. CRC is more common in the men than women with an incidence of 61.2 cases per 100,000 vs. 44.8 per 100,000, respectively. Over the last two decades, the incidence of CRC in the United States has declined 2-3% per year and mortality from CRC has also steadily declined, both largely attributed to increased screening for CRC and removal of precursor adenomas. In the United States, adherence to CRC screening guidelines is poor, approximately 50%, and multiple barriers to screening exist. Objectives: In order to overcome financial barriers to screening colonoscopy, Maimonides Medical Center, Brooklyn, New York, in conjunction with the New York City Department of Health & American Cancer Society, initiated a program to provide free screening colonoscopy to all-comers, regardless of ability to pay, within the parameters of current recommended CRC screening guidelines. We report the five-year experience of a “no-cost” CRC screening program. Methods: An IRB approved, retrospective chart review was undertaken to analyze the population of patients that underwent screening colonoscopy from June 2006-June 2011 in the “no-cost” CRC screening program. Demographic data was collected along with findings on colonoscopy and pathology. Results: In the five year period analyzed (figure 1), a total of 643 patients underwent screening colonoscopy in the program. The average age of the patients was 57 years. The incidence of adenomatous polyps in the study population was 29.3%. Seven patients (1.1%) were found to have an early stage adenocarcinoma. Two patients had a carcinoid tumor and one had a ganglioneuroma. Overall, there was no difference in the incidence of adenoma or adenocarcinoma among ethnic groups analyzed (Fisher Exact Test, p=0.45 & p=0.33, respectively). In addition, there was no difference in the incidence of high risk adenomas (proximal lesions, adenoma >1cm, villous features or high grade dysplasia) between genders or ethnic groups (Fisher Exact Test, p=0.79, 0.16, 0.12, respectively). Discussion: In this study, the largest retrospective analysis to date of a “no-cost” colonoscopy program for CRC screening, the incidence of adenomas was 29.3%, higher than the national average. Furthermore, seven (1.1%) early colorectal cancers were found, allowing for curative intent surgical resection. Without this program, many of these patients, without access to
1165 Race and Insurance are Independently Associated With in-Hospital Mortality in Patients With Cholangitis Julia McNabb-Baltar, Quoc-Dien Trinh, Alan N. Barkun Background: Relatively few investigators have focused on the determinants of adverse outcomes in patients presenting with ascending cholangitis. The objective of this study was to examine factors associated with in-hospital mortality, prolonged length of stay (LOS) and increased hospital charges (HC) in patients presenting with acute cholangitis. Methods: Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on patients, 18 years and older, admitted to the emergency department with cholangitis as primary diagnosis (1998-2009). Models were fitted to predict the likelihood of in-hospital
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AGA Abstracts
mortality, prolonged LOS and increased HC. Covariates included race, day of admission, insurance status, socio-economical status and other patient and hospital characteristics. Results: Overall, 50859 patients were identified, of which 2770 (5.5%) died during the admission. Multivariable analyses revealed that relative to Caucasian patients, African American (AA), Hispanic and Asian and Pacific Islander (API) patients admitted with cholangitis were more likely to die (OR=1.63, p<0.001, OR=1.21, p=0.007 and OR=1.26, p=0.009), to experience a prolonged LOS (OR=1.79, p<0.001, OR=1.30, p<0.001, 1.34, p<0.001) and to incur high HC (OR=1.71, p<0.001, OR=1.46, p<0.001, OR=1.60, p<0.001). Moreover, Medicaid and Medicare patients were more likely to die (OR=1.64, p<0.001, OR=1.23, p= 0.001), to experience a prolonged LOS (1.75, p<0.001, OR= 1.24, p<0.001) and to incur high HC (OR=1.22, p=0.002, OR=1.12, p=0.001) compared to privately insured patients. Conclusion: In patients presenting with cholangitis, race and insurance status represent independent predictors of in-hospital mortality and adverse outcomes. Whether these disparities are due to biological predisposition or unequal quality of care require further investigation.
1. Proximal location defined as proximal to the splenic flexure 2. Advanced adenoma defined as having size ≥1cm, any villous component, high-grade dysplasia, or cancer 1164 Adherence to Programmatic Annual Fecal Occult Blood Test (gFOBt) Versus Screening Colonoscopy in African Americans Compared to Whites With Equal Access and Navigation: Observations From National Colonoscopy Study (NCS) Anjani Jammula, Sidney J. Winawer, Glenn M. Mills, Timothy R. Church, Andrew D. Feld, Martin Fleisher, John I. Allen, Paul A. Jordan, Michael J. O'Brien, Noah D. Kauff, Irene Orlow, Georgia Close, Julie M. Ruckel, Sharon Bayuga-Miller, Georgia Morgan, Deborah Kuk, Frank van Hees, Iris Lansdorp-Vogelaar, Marjolein van Ballegooijen, Ann G. Zauber Background: The incidence and mortality of Colorectal Cancer (CRC) is higher in African Americans (AA) compared to Whites, thought to be largely due to lower adherence to screening in AA. CRC screening guidelines recommend colonoscopy or annual gFOBT as screening options. However, adherence is essential to the effectiveness of either modality. We previously reported equivalent adherence to screening colonoscopy in AA (78%) and Whites (83%) with equal access and navigation. We now present data on adherence to a program of annual gFOBT in AA compared to Whites in the same randomized controlled trial. Methods: The NCS is a randomized controlled trial of Screening Colonoscopy versus a program of annual gFOBT testing with a sensitive slide (Hemoccult SENSA) and gFOBT directed colonoscopy involving 3 clinical centers (University of Minnesota, Minneapolis; Group Health Research Institute, Seattle and Louisiana State University Health Sciences Center, Shreveport (LSUHSC)), a coordinating center (Memorial Sloan-Kettering, New York), and an independent pathology review center (Mallory Institute, Boston). Asymptomatic men and women of ages 40-69 were randomized to colonoscopy arm versus annual programmatic gFOBT. This report is based on the study of the first 3 rounds of gFOBT at LSUHSC, where 50% of the minority population were AA, providing an opportunity to compare AA to Whites from the same population having comparable access. Adherence to gFOBT was defined as completion of 3 out of 3 negative tests or a positive test within the 3 rounds of screening. The rates of diagnostic colonoscopy in those who were gFOBT positive were also assessed. Adjusted relative risks (RR) were derived for adherence with respect to race and CRC screening arm. Results: Of the 1,008 men and women at LSUHSC, 504 were assigned to the Colonoscopy arm among whom 240 were Whites and 246 AA. Another 504 were assigned to the gFOBT arm, among whom 225 were Whites and 259 AA. Adherence rates were comparable in AA and Whites to a screening colonoscopy (78% vs 83%) as well as to a program of annual gFOBT (34% vs 35%) (RR=1.1, 95% CI=0.9-1.2; P=0.3). However, the adherence to a single screening colonoscopy was significantly higher than to the annual programmatic gFOBT in both races (RR=2.3, 95% CI 2.0-2.7, P<0.0001). The adherence rates to diagnostic colonoscopy following a positive gFOBT in AA and Whites were equivalent (88% and 91% respectively). Conclusions: In our randomized controlled trial, adherence to a program of annual gFOBT screening was equivalent in AA and Whites having equal access and navigation. However, adherence to a single screening colonoscopy was higher than to a program of gFOBT for both AA and Whites suggesting that a program of screening colonoscopy would result in greater effectiveness.
1167 Getting Polyps off the Street: the Five-Year Experience of a “No-Cost” Screening Colonoscopy Program Jack Braha, Steven Guttmann, Vince Si, Pavel Gozenput, Jonathan A. Erber, Yuriy Tsirlin, Ira E. Mayer, Rabin Rahmani Background: Colorectal cancer (CRC) is the second leading cause of cancer related death in the United States. In 2010, 142,600 patients were diagnosed with CRC and 51,370 died of the disease. CRC is more common in the men than women with an incidence of 61.2 cases per 100,000 vs. 44.8 per 100,000, respectively. Over the last two decades, the incidence of CRC in the United States has declined 2-3% per year and mortality from CRC has also steadily declined, both largely attributed to increased screening for CRC and removal of precursor adenomas. In the United States, adherence to CRC screening guidelines is poor, approximately 50%, and multiple barriers to screening exist. Objectives: In order to overcome financial barriers to screening colonoscopy, Maimonides Medical Center, Brooklyn, New York, in conjunction with the New York City Department of Health & American Cancer Society, initiated a program to provide free screening colonoscopy to all-comers, regardless of ability to pay, within the parameters of current recommended CRC screening guidelines. We report the five-year experience of a “no-cost” CRC screening program. Methods: An IRB approved, retrospective chart review was undertaken to analyze the population of patients that underwent screening colonoscopy from June 2006-June 2011 in the “no-cost” CRC screening program. Demographic data was collected along with findings on colonoscopy and pathology. Results: In the five year period analyzed (figure 1), a total of 643 patients underwent screening colonoscopy in the program. The average age of the patients was 57 years. The incidence of adenomatous polyps in the study population was 29.3%. Seven patients (1.1%) were found to have an early stage adenocarcinoma. Two patients had a carcinoid tumor and one had a ganglioneuroma. Overall, there was no difference in the incidence of adenoma or adenocarcinoma among ethnic groups analyzed (Fisher Exact Test, p=0.45 & p=0.33, respectively). In addition, there was no difference in the incidence of high risk adenomas (proximal lesions, adenoma >1cm, villous features or high grade dysplasia) between genders or ethnic groups (Fisher Exact Test, p=0.79, 0.16, 0.12, respectively). Discussion: In this study, the largest retrospective analysis to date of a “no-cost” colonoscopy program for CRC screening, the incidence of adenomas was 29.3%, higher than the national average. Furthermore, seven (1.1%) early colorectal cancers were found, allowing for curative intent surgical resection. Without this program, many of these patients, without access to
1165 Race and Insurance are Independently Associated With in-Hospital Mortality in Patients With Cholangitis Julia McNabb-Baltar, Quoc-Dien Trinh, Alan N. Barkun Background: Relatively few investigators have focused on the determinants of adverse outcomes in patients presenting with ascending cholangitis. The objective of this study was to examine factors associated with in-hospital mortality, prolonged length of stay (LOS) and increased hospital charges (HC) in patients presenting with acute cholangitis. Methods: Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we focused on patients, 18 years and older, admitted to the emergency department with cholangitis as primary diagnosis (1998-2009). Models were fitted to predict the likelihood of in-hospital
S-213
AGA Abstracts
AGA Abstracts
mortality, prolonged LOS and increased HC. Covariates included race, day of admission, insurance status, socio-economical status and other patient and hospital characteristics. Results: Overall, 50859 patients were identified, of which 2770 (5.5%) died during the admission. Multivariable analyses revealed that relative to Caucasian patients, African American (AA), Hispanic and Asian and Pacific Islander (API) patients admitted with cholangitis were more likely to die (OR=1.63, p<0.001, OR=1.21, p=0.007 and OR=1.26, p=0.009), to experience a prolonged LOS (OR=1.79, p<0.001, OR=1.30, p<0.001, 1.34, p<0.001) and to incur high HC (OR=1.71, p<0.001, OR=1.46, p<0.001, OR=1.60, p<0.001). Moreover, Medicaid and Medicare patients were more likely to die (OR=1.64, p<0.001, OR=1.23, p= 0.001), to experience a prolonged LOS (1.75, p<0.001, OR= 1.24, p<0.001) and to incur high HC (OR=1.22, p=0.002, OR=1.12, p=0.001) compared to privately insured patients. Conclusion: In patients presenting with cholangitis, race and insurance status represent independent predictors of in-hospital mortality and adverse outcomes. Whether these disparities are due to biological predisposition or unequal quality of care require further investigation.