Sowmya Vasan

State-specific, racial and ethnic heterogeneity in trends of firearm-related fatality rates in the USA from 2000 to 2010

Objectives To document overall, racial, ethnic and intent-specific spatiotemporal trends of firearm-related fatality rates (FRF rates) in the USA. Design Cross-sectional study per year from 2000 to 2010. Setting USA. Participants Aggregate count of all people in the USA from 2000 to 2010. Outcome measures Data from the Web-based Injury Statistics Query and Reporting System from 2000 to 2010 was used to determine annual FRF rates per 100 000 and by states, race, ethnicity and intent. Results The average national 11-year FRF rate was 10.21/100 000, from 3.02 in Hawaii to 18.62 in Louisiana: 60% of states had higher than national rates and 41 states showed no temporal change. The average national FRF rates among African-Americans and Caucasians were 18.51 and 9.05/100 000 and among Hispanics and non-Hispanics were 7.13 and 10.13/100 000; Hispanics had a decreasing change of −0.18, p trend<0.0001. In states with increasing trends (Florida and Massachusetts), Caucasians and non-Hispanics drove the rise; while in states with decreasing trends (California, North Carolina, Arizona, Nevada, New York, Illinois, Maryland), Hispanics and African-Americans drove the fall. The average national FRF rates due to homicides (4.1/100 000) and suicides (5.8/100 000) remained constant, but varied between states. Conclusions Endemic national FRF rates mask a wide variation in time trends between states. FRF rates were twice as high in African-Americans than Caucasians but decreased among Hispanics. Efforts to identify state-specific best practices can contribute to changes in national FRF rates that remain high.

Race and ethnicity, neighborhood poverty and pediatric firearm hospitalizations in the United States

PURPOSE To better understand the effects of race and/or ethnicity and neighborhood poverty on pediatric firearm injuries in the United States, we compared overall and intent-specific firearm hospitalizations (FH) with those of pedestrian motor vehicle crash hospitalizations (PMVH). METHODS We used Nationwide Inpatient Sample data (1998-2011) among 0-15 year-olds in a 1:1 case-case study; 4725 FH and 4725 PMVH matched by age, year, and region. RESULTS Risk of FH versus PMVH was 64% higher among black children, Odds ratio (OR) = 1.64, 95% confidence interval (95% CI) = 1.44-1.87, as compared to white children (P < .0001); this risk did not vary by neighborhood poverty (P interaction = .52). Risk of homicide FH versus PMVH was 842% higher among black (OR = 8.42, 95% CI = 6.27-11.3), 452% higher among Hispanics (OR = 4.52, 95% CI = 3.33-6.13) and 233% higher among other race (OR = 2.33, 95% CI = 1.52-3.59) compared to white children. There was a lower risk for unintentional FH among black OR = 0.73, 95% CI = 0.62-0.87, Hispanics (OR = 0.60, 95% CI = 0.49-0.74), and other (OR = 0.63, 95% CI = 0.47-0.83) compared to whites. These intent-specific risks attributed to race did not vary by neighborhood affluence. CONCLUSIONS Black children were at greater likelihood of FH compared to white children regardless of neighborhood economic status. Minority children had an increased likelihood of intentional FH and a decreased likelihood of unintentional FH as compared to white children irrespective of neighborhood income.

Use and Costs of Disease Monitoring in Women With Metastatic Breast Cancer

PURPOSE The optimal frequency of monitoring patients with metastatic breast cancer (MBC) is unknown; however, data suggest that intensive monitoring does not improve outcomes. We performed a population-based analysis to evaluate patterns and predictors of extreme use of disease-monitoring tests (serum tumor markers [STMs] and radiographic imaging) among women with MBC. METHODS The SEER-Medicare database was used to identify women with MBC diagnosed from 2002 to 2011 who underwent disease monitoring. Billing dates of STMs (carcinoembryonic antigen and/or cancer antigen 15-3/cancer antigen 27.29) and imaging tests (computed tomography and/or positron emission tomography) were recorded; if more than one STM or imaging test were completed on the same day, they were counted once. We defined extreme use as > 12 STM and/or more than four radiographic imaging tests in a 12-month period. Multivariable analysis was used to identify factors associated with extreme use. In extreme users, total health care costs and end-of-life health care utilization were compared with the rest of the study population. RESULTS We identified 2,460 eligible patients. Of these, 924 (37.6%) were extreme users of disease-monitoring tests. Factors significantly associated with extreme use were hormone receptor-negative MBC (odds ratio [OR], 1.63; 95% CI, 1.27 to 2.08), history of a positron emission tomography scan (OR, 2.92; 95% CI, 2.40 to 3.55), and more frequent oncology office visits (OR, 3.14; 95% CI, 2.49 to 3.96). Medical costs per year were 59.2% higher in extreme users. Extreme users were more likely to use emergency department and hospice services at the end of life. CONCLUSION Despite an unknown clinical benefit, approximately one third of elderly women with MBC were extreme users of disease-monitoring tests. Higher use of disease-monitoring tests was associated with higher total health care costs. Efforts to understand the optimal frequency of monitoring are needed to inform clinical practice.

ReCAP: Serum Tumor Marker Use in Patients With Advanced Solid Tumors

PURPOSE There is substantial variability in the frequency of serum tumor marker testing in patients with advanced solid tumors. We performed a retrospective analysis to evaluate the frequency of serum tumor marker use. METHODS Patients with a diagnosis of advanced cancer with outpatient visits between July 1, 2013, and June 30, 2014, at a single center were included. Tumor and stage were determined by International Classification of Diseases, Ninth Revision codes and confirmed with tumor registry and medical record review. For each patient, we recorded the dates of each of the following tumor markers: a-fetoprotein, CA-125, CA 15-3, CA 19-9, CA 27-29, and carcinoembryonic antigen. We evaluated the number of tests per patient over 12 months and the maximum number of tests per patient per month. RESULTS We included 928 patients in the analysis. The mean number of any individual test per patient was seven tests, and the maximum number was 35 tests; the mean number of total tests per patient was 12 tests, and the maximum number was 70 tests; 16.3% of patients had more than 12 individual tests per year. In a 1-month span, 34.3% of patients had more than one individual test. CA 19-9 and carcinoembryonic antigen were the most commonly overused tests. CONCLUSION We found a high rate of serum tumor marker testing use in patients with advanced solid tumors. Given the increasing costs of cancer care, efforts should be made to determine the benefit of serum tumor markers in the follow-up care of patients with advanced solid tumors.

The role of interpersonal conflict as a determinant of firearm-related homicide-suicides at different ages

Although firearm-related homicide–suicides and firearm-related suicides are tragic and catastrophic events, there is increasing evidence that the two events have different precipitants and that understanding these precipitants may help prevention efforts. We aimed to assess the role of interpersonal conflict (IPC) and recent crises in firearm-related homicide–suicides as compared with firearm-related suicides alone. We also assessed whether these differences were consistent across young and old perpetrators. Using an unmatched case-control study, we compared firearm-related homicide–suicides andsuicides alone from 2003 to 2011 in the National Violent Death Registry data to assess the risk associated with IPC and crisis. Survival analysis was performed to compare time-to-incident of homicide–suicide versus suicide only. We derived odds ratios (ORs) and 95% confidence intervals (95%CI) due to IPC and recent crisis from mixed logistic regression models. Stratified analysis by age on the effect of IPC and recent crisis, and type of incident was also performed. After adjusting for relevant covariates, homicide–suicides were more likely than suicide alone following IPC (OR = 20.6, 95%CI = [16.6, 25.7]) and recent crisis (OR = 14.5, 95%CI = [12.4, 16.9]). The risk of firearm homicide–suicide compared with suicide associated with IPC was twice greater among those >30 years compared with those ≤30 years (p-interaction = .033), and no differential by age associated with recent crisis (p-interaction = .64). IPC and recent crisis are risk factors for committing homicide–suicides compared with suicides alone, with the risk doubly greater among older than younger perpetrators.

Assessment of Electronic Alert to Reduce Overuse of Granulocyte Colony-Stimulating Factor in Patients Hospitalized for Febrile Neutropenia

This study evaluates the efficacy of an alert in the electronic health record to reduce overuse of granulocyte colony-stimulating factor in older patients hospitalized with febrile neutropenia.

Factors and Costs Associated With Delay in Treatment Initiation and Prolonged Length of Stay With Inpatient EPOCH Chemotherapy in Patients With Hematologic Malignancies

ABSTRACT Reducing delays related to inpatient chemotherapy may reduce healthcare costs. Using a national database, we identified patients with lymphoma/leukemia with ≥1 etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone (EPOCH) chemotherapy claim and evaluated chemotherapy initiation delay (ID), >1 day from admission. Standard tests/procedures prior to initiation were evaluated. Among 4453 inpatient cycles, 19.7% had ID, odds ratio 2.28 (95% confidence interval: 1.83–2.85) with cycle 1 compared to cycle 2, and mean costs were higher in patients with ID than without ID (p < .0001). Prior to cycle 1, patients were more likely to undergo routine diagnostic procedures compared to subsequent cycles. Efforts to perform routine procedures prior to admission may reduce hospital length of stay and costs.

Understanding efficiency of chemotherapy delivery for planned chemotherapy admission at Columbia University Medical Center.

206 Background: Delays in administration of planned in-patient chemotherapy can lead to prolonged length of stay (LOS), resulting in increased cost and risk of nosocomial infections and other complications. METHODS We conducted a retrospective analysis of cancer patients admitted to Columbia University Medical Center, a tertiary care center, for planned chemotherapy from January 1, 2014 through December 31, 2014. Eligible patients were identified as cancer patients (via ICD9 codes) who were admitted directly to the inpatient hematology/oncology service with intravenous chemotherapy orders submitted within 24 hours of the admission. Patients were excluded if they received oral, non-formulary, intrathecal, or high dose methotrexate therapy. For each admission, the duration of time from admission to infusion start time was recorded. We evaluated patients who were admitted to the Intensive care unit (ICU) separately. Chart review and provider interviews were conducted on a subset of patients. RESULTS Over 12 months, 314 unique hospital admissions involving 162 patients were included in the analysis. The median time from admission to chemotherapy infusion start was 15.8 hours (mean 31.5, IQR 3.1-41.0 hours). Of the 314 unique admissions, 299 (95.2%) did not require ICU involvement during their hospitalization. Of these patients, median admission to chemotherapy infusion start time was 15.5 hours (mean 29.9, IQR 2.9-38.9 hours). Chart review and provider interview were conducted for 22 patient admissions. In this subset, median time from admission to chemotherapy start was 13.6 hours. Top reasons for delays were: order modifications for lab abnormalities, lack of chemotherapy consent, and delay in chemotherapy delivery to inpatient units. CONCLUSIONS In cancer patients admitted for planned chemotherapy we found a significant delay between hospital admission and infusion start time. Inefficiencies in this process are likely multifactorial on the patient, provider, and systems level, however our data suggests that they may be modifiable. Interventions devoted to reducing the time may decrease LOS, reduce cost, improve patient satisfaction, and reduce risk of complications.