ASO Author Reflections: Contemporary Redlining-Direct and Mediating Effects on Healthcare Disparities Among Patients with Gastrointestinal Cancer.

Impact of Contemporary Redlining on Healthcare Disparities Among Patients with Gastrointestinal Cancer: A Mediation Analysis.

BACKGROUND : Historically, housing policies have perpetuated the marginalization and economic disinvestment of redlined neighborhoods. Residential segregation persists nowadays in the form of contemporary redlining, promoting healthcare disparities. The current study sought to assess the effect of redlining on oncological outcomes of patients with gastrointestinal cancer and identify mediators of the association.

METHODS : Patients with colorectal or hepatobiliary cancer were identified from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2007-2019). The contemporary redlining index, a measure of mortgage lending bias, was assessed relative to disease stage at diagnosis, receipt of appropriate treatment, textbook outcome, and mortality. Mediation analysis was used to identify socioeconomic, structural, and clinical mediating factors.

RESULTS : Among 94,988 patients, 32.2% resided in high (n = 23,872) and highest (n = 6,791) redlining census tracts compared with 46.2% in neutral and 21.6% in low redlining tracts. The proportion of Black, Hispanic, and White patients experiencing high and highest redlining was 65.9%, 41.6%, and 27.9%, respectively. Highest redlining was associated with 18.2% higher odds of advanced disease at diagnosis, greater odds of not undergoing surgery for localized disease (adjusted odds ratio [aOR] 1.363, 95% confidence interval [CI] 1.219-1.524) or not receiving chemotherapy for advanced disease (aOR 1.385, 95% CI 1.216-1.577), and 26.7% lower odds of textbook outcome achievement. Mediation analysis for appropriate treatment quantified the proportion of the association driven by socioeconomic status, racial/ethnic minority status, racial/economic segregation, primary care shortage, and housing/transportation.

CONCLUSIONS : Contemporary redlining contributed both directly, and via downstream factors, to disparities in oncological care and outcomes of patients with gastrointestinal cancer.

Trajectory Analysis of Healthcare Use Before and After Gastrointestinal Cancer Surgery.

BACKGROUND : Frailty correlates with worse post-operative outcomes and higher surgical costs, but the long-term impact on healthcare utilization remains ill-defined. We sought to evaluate patterns of healthcare utilization pre- and post-surgery among patients with gastrointestinal cancer and characterize the association with frailty.

STUDY DESIGN : Data on patients who underwent surgical resection for liver, biliary, pancreatic, colon and rectal cancer were obtained from the 2005-2020 SEER-Medicare database. Frailty was assessed using the claims-based frailty index. Group-based trajectory modelling identified clusters of patients with discrete patterns of healthcare utilization. Multivariable regression was performed to predict cluster membership based on preoperative factors, including frailty.

RESULTS : Among 66,684 beneficiaries, four distinct utilization trajectories based on data from 12 months before and after surgery were identified. Following a surge in utilization during the month of surgery, most patients reverted to pre-surgery baseline utilization (low: n=6588, 9.9%; moderate: n=17,627, 26.4%; high: n=29,850, 44.8%). However, a notable trajectory involving 12,619 (18.9%) patients was identified, wherein surgery precipitated a transition from a "low" pre-surgery utilization state to a "high" utilization state post-surgery. Frail patients were more likely to be among those individuals who transitioned to high utilizers (low: 4.2% vs. vs. transition: 12.6% vs. high: 7.5%; p<0.001). On multivariable analysis incorporating preoperative variables, frailty was associated with high group trajectory membership (ref: least and moderate; highest: OR 4.90, 95%CI 4.49-5.35; p<0.001).

CONCLUSIONS : Patients with gastrointestinal cancer demonstrated distinct clusters of healthcare utilization after surgical resection. Preoperative predictive models may help differentiate different health care utilization trajectories to help tailor care for patients in the postoperative period.

Assessing the Impact of a Gastrointestinal Cancer Diagnosis on Mental Health Claims Among Co-Insured Household Family Members.

BACKGROUND : Gastrointestinal (GI) cancer diagnosis can adversely impact the mental health (MH) of a patient's household members, including spouses and children. The objective of the current study was to explore the potential change in MH claims among households following a patient's GI cancer diagnosis.

METHODS : Households of patients with GI cancer diagnosis were identified using the IBM MarketScan Database (2014-2019) and matched with households of patients without cancer. MH-related visits of spouses and children were assessed in the 12 months before and after the index date of diagnosis. Changes were compared between the two cohorts using difference-in-difference (DID) analysis.

RESULTS : Among 40,650 households in the spouses' analysis and 20,014 households in the children's analysis, 25.1% (n=10,210) and 26.8% (n=5,368) were households with GI cancer. Univariable DID analysis demonstrated that households with GI cancer had a greater increase in anxiety-related (spouses:2.2% vs. 0.7%; children:2.0% vs. 1.1%), mental illness-related (spouses:3.2% vs. 1.2%; children:3.0% vs. 1.6%), and overall MH-related visits (spouses:3.3% vs. 1.4%), relative to the control group (all p<0.05). In adjusted DID analysis, spouses, children, and households with GI cancer had 2.1%, 1.6%, and 2.3% absolute risk increase of mental illness-related visits, respectively, compared to non-cancer households (all p<0.05).

CONCLUSION : In this cohort study of privately-insured households, co-insured spouses and children of patients diagnosed with GI cancer presented a higher risk of having MH-related claims than households not experiencing cancer diagnosis. Interventions should focus on the importance of counseling and psychological support in the aftermath of a loved one's cancer diagnosis.

Pancreas and biliary ablation devices.

Variation in Physician Spending and its Association with Postoperative Outcomes among Patients undergoing Surgery for Gastrointestinal Cancer.

BACKGROUND : There is significant variation in inpatient expenditures among physicians and hospitals. We sought to characterize the association of variation in physician spending with short-term outcomes among patients undergoing surgery for pancreatic ductal adenocarcinoma (PDAC) and colorectal cancer (CRC).

METHODS : Patients who underwent surgery for PDAC and CRC from 2010-2020 were identified using the Surveillance, Epidemiology, and End Result (SEER)-Medicare-linked database. The cohort was divided into quartiles based on adjusted physician spending and multivariable models were utilized to assess the association of physician spending with patient outcomes.

RESULTS : Among 27,596 Medicare beneficiaries, around 92.8% (n=25,615) and 7.2% (n=1,981) underwent surgery for CRC and PDAC, respectively. Around 79.9% of the variation in spending was due to patient-level factors, 13.3% was due to hospital characteristics, and 6.8% was due to surgeon-level variables. On multivariable analysis, there was no significant association between physician spending and 30-day readmission (With complications: Q1 referent; Q4 OR 1.10 95%CI 0.86-1.41 [p=0.123], Without complications: Q1 referent; Q3 Stage IV OR 0.97 95%CI 0.68-1.40 [p=0.882]) and 30-day mortality (Without Complications: Q1 referent; Q2 Stage I OR1.17 95% CI 0.45-3.01 [p=0.804]). However, an increase in physician spending was associated with higher 30-day mortality among patients with complications (Q1 referent; Q4 OR 2.28 95%CI 1.72-3.03[p<0.001]).

CONCLUSION : There is more variation in healthcare spending across hospitals than across individual physicians. Our results demonstrated no consistent association between variation in physician spending and patient outcomes. Wasteful spending can be reduced through targeted interventions aimed at reducing variations at the physician and hospital levels.

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the diagnosis and management of solid pancreatic masses: summary and recommendations.

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the diagnosis and management of pancreatic masses. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses needle selection (fine-needle biopsy [FNB] needle vs FNA needle), needle caliber (22-gauge vs 25-gauge needles), FNB needle type (novel or contemporary [fork-tip and Franseen] vs alternative FNB needle designs), and sample processing (rapid on-site evaluation [ROSE] vs no ROSE). In addition, this guideline addresses stent selection (self-expandable metal stent [SEMS] vs plastic stent), SEMS type (covered [cSEMS] vs uncovered [uSEMS]), and pain management (celiac plexus neurolysis [CPN] vs medical analgesic therapy). In patients with solid pancreatic masses undergoing EUS-guided tissue acquisition (EUS-TA), the ASGE recommends FNB needles over FNA needles. With regard to needle caliber, the ASGE suggests 22-gauge over 25-gauge needles. When an FNB needle is used, the ASGE recommends using either a fork-tip or a Franseen needle over alternative FNB needle designs. After a sample has been obtained, the ASGE suggests against the routine use of ROSE in patients undergoing an initial EUS-TA of a solid pancreatic mass. In patients with distal malignant biliary obstruction undergoing drainage with ERCP, the ASGE suggests using SEMSs over plastic stents. In patients with proven malignancy undergoing SEMS placement, the ASGE suggests using cSEMSs over uSEMSs. If malignancy has not been histopathologically confirmed, the ASGE recommends against the use of uSEMSs. Finally, in patients with unresectable pancreatic cancer and abdominal pain, the ASGE suggests the use of CPN as an adjunct for the treatment of abdominal pain. This document outlines the process, analyses, and decision approaches used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

Upping the Ante in the Treatment of Gastrointestinal Cancer.

Upper gastrointestinal cancers: Trends and determinants of location of death.

BACKGROUND : Patients diagnosed with upper gastrointestinal cancers often require extensive end-of-life care. We sought to investigate social determinants of health associated with disparities in the location of death among patients who died of upper gastrointestinal cancers.

METHODS : Patients who died between 2003 and 2020 from esophageal cancer, gastric cancer, hepatobiliary cancer, and pancreatic cancer were identified using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Social determinants of health were assessed using the Social Vulnerability Index. Patients were categorized on the basis of location of death: inpatient hospital, home, nursing home, hospice, and outpatient medical facility/emergency department. Multivariable regression and mediation analyses defined the association of patient race as well as social determinants of health with location of death.

RESULTS : Among 815,780 decedents (esophageal cancer: 15.3%; gastric cancer: 3.6%; hepatobiliary cancer: 36.6%; pancreatic cancer: 54.5%), most were male (60.8%), aged 55-74 years (52.3%), and White (89.1%). Most decedents died at home (55.7%), followed by inpatient hospital (24.8%), hospice (9.0%), nursing home (8.1%), and outpatient medical facility/emergency department (2.5%). During the study period, location of death shifted notably from inpatient hospital (36.8% to 21.3%) to home (45.8% to 56.3%). Residents of high Social Vulnerability Index areas were more likely to die at inpatient hospital compared with home (31.8% vs 24.3%) (P < .001). Black race (reference: White; odds ratio; 0.41, 95% confidence interval, 0.40-0.42) and social vulnerability (reference: low Social Vulnerability Index; odds ratio, 0.64, 95% confidence interval, 0.63-0.65) remained independently associated with lower odds of dying at home compared with an inpatient hospital. Notably, 65% of the overall race-based association with death at inpatient hospital was driven indirectly through social determinants of health.

CONCLUSION : Social determinants are important drivers of end-of-life care and impact the potential ability of patients with cancer to die at home.

American Society for Gastrointestinal Endoscopy guideline on role of endoscopy in the diagnosis and management of solid pancreatic masses: methodology and review of evidence.