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Background: This study sought to identify factors that contribute to disparities in access to bariatric surgery in North Carolina (NC)., Methods: Using the rate of bariatric surgery in the county with the best health outcome as the reference, we calculated the Surgical Equity Index (SEI) in the remaining counties in NC., Results: Approximately 2.95 million individuals (29%) were obese in NC. There were 992 (.5%) bariatric procedures performed on a population of 194 209 individuals with obesity in the Reference County (RC). The mean SEI for bariatric surgery in NC was .47 (SD .17, range .15-.95). A statistically significant difference was observed in 89 counties. Univariable analyses identified the following variables to be significantly associated with the SEI: percent of population living in rural areas (% rural) (relative rate change in SEI [RR] = .994, 95% CI .92-.997; <.0001), median household income (RR = 1.0, 95% CI = 1.0-1.0; P = .0002), prevalence of diabetes (RR = .947, 95% CI .917-.977; .0006), the primary care physician ratio (RR = .995, 95% CI .991-.998; P = .006), and percent uninsured adults (RR = .955, 95% CI .927-.985; P = .003). By multivariable hierarchical regression analysis, only the % rural remained statistically associated with a low SEI (RR = .995 per 1% increase in % rural, 95% CI = .992, .998; P = .0002)., Discussion: The percent rural is the most significant predictor of disparities in access to bariatric surgery. For every 1% increase in % rural, the rate of surgery decreased by .5%. Understanding the characteristics of rurality that are barriers to access is crucial to mitigate disparities in bariatric surgical access in NC., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Reducing disparities in colorectal cancer (CRC) screening rates and mortality remains a priority. Mitigation strategies to reduce these disparities have largely been unsuccessful. The primary aim is to determine variables in models of healthcare utilization and their association with CRC screening and mortality in North Carolina., Methods: A cross-sectional analysis of publicly available data across North Carolina using variable reduction techniques with clustering to evaluate association of CRC screening rates and mortality was performed., Results: Three million sixty-five thousand five hundred thirty-seven residents (32.1%) were aged 50 y or more. More than two-thirds (68.8%) were White, while 20.5% were Black. Approximately 61% aged 50 y or more underwent CRC screening (range: 44.0%-80.5%) and had a CRC mortality of 44.8 per 100,000 (range 22.8 to 76.6 per 100,000). Cluster analysis identified two factors, designated social economic education index (factor 1) and rural provider index (factor 2) for inclusion in the multivariate analysis. CRC screening rates were associated with factor 1, consisting of socioeconomic and education variables, and factor 2, comprised of the number of providers per 10,000 individuals aged 50 y or more and rurality. An increase in both factors 1 and 2 by one point would result in an increase in CRC screening rated by 6.8%. CRC mortality was associated with factor 2. An increase in one point in factor 1 results in a decrease in mortality risk by 10.9%., Conclusions: In North Carolina, using variable reduction with clustering, CRC screening rates were associated with the inter-relationship of the number of providers and rurality, while CRC mortality was associated with the inter-relationship of social, economic, and education variables., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Despite advances in colorectal cancer (CRC) treatment, racial disparities persist. The primary aims of the study were to: evaluate differences in molecular testing rates over time by race; and measure the incidence of tumor mutations by race in patients with metastatic CRC., Methods: A retrospective cohort study was performed of all adult patients with stage IV CRC (2008-2018) identified within the cancer registry of a large regional health system. Demographic/clinical characteristics were collected through primary data abstraction of the electronic health record. Molecular profiling results were obtained directly from Caris Molecular Intelligence and electronic health record., Results: Three hundred eighty-three patients were included: 40.5% (n = 155) were Black and 59.5% (n = 228) were White. Significant increases were observed in microsatellite instability (MSI), KRAS, and BRAF testing rates during the study period (P < 0.0001). The odds of testing over time increased more significantly in Black compared to White patients for MSI testing (White: odds ratio [OR] 1.26 [95% confidence interval [CI] 1.12-1.41], Black: OR 1.69 [95% CI 1.41-2.02], P = 0.005) and BRAF testing (White: OR 1.42 [95% CI 1.26-1.62], Black: OR 1.89 [95% CI 1.51-2.36], P = 0.027). An increase in KRAS testing over time was observed for both cohorts and was independent of race (P = 0.58). Mutation rates did not differ by race: KRAS (Black 55.8% versus White 45.6%, P = 0.13) and BRAF (Black 4.8% versus White 10.0%, P = 0.33)., Conclusions: Within a large regional health system, molecular testing rates in patients with metastatic CRC increased significantly following National Comprehensive Cancer Network guideline changes for both Black and White patients. Black and White patients who underwent molecular testing had similar rates of MSI, KRAS, and BRAF mutations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: There is a perception, with mixed literary support, that patients are transferred from community hospitals to tertiary medical centers for non-clinical reasons (ie, payor, race, and admission time). Over-triage risks unequally burdening the tertiary medical centers within a trauma system. This study aims to identify potential non-clinical factors associated with the transfer of injured patients., Methods: Using the 2018 North Carolina State Inpatient Database, patients with a primary diagnosis of spine, rib or extremity fractures, or TBI were identified using ICD-10-CM code and admission type of "Urgent," "Emergency," or "Trauma." Patients were divided into cohorts of "retained" (at community hospital) or "transferred" (Level-1 or 2 trauma centers)., Results: 11,095 patients met inclusion criteria; 2432 (21.9%) patients made up the transfer cohort. The mean ISS for all retained patients was 2.2 (±.9) and 2.9 (±1.4) for all transferred patients. The transfer cohort was younger (mean age 66 v 75.8), underinsured, and more likely to be admitted after 1700 ( P < .001). Similar differences were seen regardless of injury pattern., Conclusions: Patients transferred to trauma centers were more likely to be underinsured and be admitted outside of normal business hours. These transferred patients had longer lengths of stay and higher mortality rates. Across all cohorts, similar ISS suggests that a portion of the transfers could be managed at a community hospital. After hours transfers suggest a need for more robust community hospital coverage. Intentional triage of the injured patient encourages appropriate utilization of resources and is crucial to maintaining high-functioning trauma centers and systems., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: To identify predictors of screening mammography use and the effect of screening mammography on breast cancer mortality in North Carolina., Methods: This cross-sectional study integrated publicly available data from government and private data repositories to model predictors of screening mammography and breast cancer mortality in North Carolina., Results: In North Carolina during 2008-2010, on average, 68.1% of women aged 40-74 years underwent a screening mammogram in the previous two years (range: 38.7%-82.1). The ordinary least squares (OLS) regression demonstrated counties experiencing persistent poverty have mammography screening rates that are 4.3% less, on average, than counties without persistent poverty (estimate (SE) = - 4.283 (2.105), p = 0.045). As the percentage of women with a college education increases, the mammography screening rates increase by approximately 0.3% (estimate (SE) = 0.319 (0.078), P < .001) and as the health literacy score increases, the mammography screening rate decreases by 0.3% (estimate (SE) = - 0.318 (0.104), p = 0.003). These variables explain 7.0% of the variability in mammographic screening rates. The OLS regression analysis demonstrated that age-adjusted breast cancer incidence (Estimate (SE) = 0.074 (0.024), p = 0.003) and health literacy score (estimate (SE) = - 0.175 (0.083), p = 0.039) are significantly related to breast cancer mortality., Conclusions: Demographic, socioeconomic, and environmental variables explain only a small percentage of the variability in the rates of screening mammography and breast cancer mortality in North Carolina. Advances in the available treatments are likely the major contributor to improving breast cancer mortality., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Disparities in access to surgical care are associated with poorer outcomes in patients with cancer. We sought to determine whether vulnerable populations undergo an expected rate of surgery for Stage I-IIIA lung cancer in North Carolina (NC)., Methods: We calculated the proportional surgical ratio (PSR) to identify a potential disparity in surgery rates for early stage (I-IIIA) lung cancer, first in the five counties with the worst health outcomes (LRC) and subsequently the entire state. The reference was the five healthiest counties (HRC), initially, and then the single county with the best health outcomes., Results: In 2016, 3,452 individuals with Stage I-IIIA lung cancer were diagnosed in NC of which 246,854 resided in LRC, whereas 1,865,588 resided in HRC. A total of 453 operable lung cancers were diagnosed in the HRC and 107 in the LRC. The observed lobectomy rate in HRC was 40.1% (range 20.2-58.3%) of early-stage lung cancer and 19% (range 12-36%) for LRC. The PSR was 0.65 (95% confidence interval [CI] = 0.35, 0.90). For all 99 counties across NC, the PSR ranged from 0.33 to 0.96 (mean = 0.49, standard deviation [SD] = 0.10). In a multivariable model, only other primary care provider ratio (relative rate per 100 increase = 0.997; 95% CI = 0.994, 0.999) was significantly associated with PSR., Conclusions: Individuals residing in LRC in NC are 42% less likely to undergo surgery for operable lung cancer than patients living in HRC. Understanding how factors impact access is key to designing informed interventions., (© 2022. Society of Surgical Oncology.)

Background: The 2010 Patient Protection and Affordable Care Act mandated preventive screening coverage and provided support to participating states for Medicaid coverage. The association of Medicaid expansion with colon cancer stage at diagnosis is unknown., Objective: This study aimed to determine whether the proportion of patients diagnosed with early stage colon cancer changed over time within states that expanded Medicaid compared with nonexpansion states., Design: This is a cross-sectional cohort study., Setting: This study evaluated multicenter registry data from the National Cancer Database (2006-2016)., Patients: There were 25,462 uninsured or Medicaid-insured patients with newly diagnosed colon cancer who resided in 2014 Medicaid expansion or nonexpansion states., Main Outcome Measures: This study assessed the annual proportion of patients with early stage (I-II) versus late stage (III-IV) colon cancer., Results: A total of 10,289 patients were identified in expansion states and 15,173 patients in nonexpansion states. Cohorts were similar in age (median 55 years) and sex (46.7% female). A greater proportion of patients in nonexpansion states were Black (33.4% vs 24.0%) and resided in a zip code with median income <$38,000 (39.7% vs 28.2%) and lower educational status (37.4% vs 28.1%). In 2006, the proportions of patients with early stage colon cancer in expansion and nonexpansion cohorts were similar (33.2% vs 32.5%). The proportion of patients with early stage colon cancer within nonexpansion states declined by 0.8% per year after 2014, whereas the proportion within expansion states increased by 0.9% per year after 2014 ( p < 0.05). By 2016, the absolute difference in the propensity-adjusted proportion of early stage colon cancer was 8.8% (39.7% vs 30.9%, p < 0.001)., Limitations: National Cancer Database data are obtained only from Commission on Cancer-accredited sites and are not population based., Conclusions: After Medicaid expansion in 2014, the proportion of patients diagnosed and treated at Commission on Cancer-accredited facilities with early stage colon cancer increased within expansion states and decreased in nonexpansion states. Increase in insurance coverage may have facilitated earlier diagnosis among patients in expansion states. See Video Abstract at http://links.lww.com/DCR/B804 ., Cambios En La Proporcin De Pacientes Que Presentan Cncer De Colon En Estadio Temprana a Lo Largo Del Tiempo Entre Los Estados De Expansin Y No Expansin De Medicaid Un Estudio Transversal: ANTECEDENTES:La Ley del Cuidado de Salud a Bajo Precio del 2010 ordenó la cobertura de exámenes preventivos y brindó apoyo a los estados participantes para la cobertura de Medicaid. Se desconoce la asociación de la expansión de Medicaid con el estadio del cáncer de colon en el momento del diagnóstico.OBJETIVO:Determinar si la proporción de pacientes diagnosticados con cáncer de colon en estadio temprano cambió con el tiempo dentro de los estados que expandieron Medicaid en comparación con los estados sin expansión.DISEÑO:Estudio de cohorte transversal.ENTORNO CLINICO:Datos de registro multicéntrico de la Base de datos nacional de cáncer (2006-2016).PACIENTES:Había 25,462 pacientes sin seguro o asegurados por Medicaid con cáncer de colon recién diagnosticado. Exposición: Residencia en estados de expansión o no expansión de Medicaid en el 2014.PRINCIPALES MEDIDAS DE RESULTADO:Proporción anual de pacientes con cáncer de colon en estadio temprano (I-II) versus tardío (III-IV).RESULTADOS:Se identificaron un total de 10.289 pacientes en estados de expansión y 15.173 pacientes en estados de no expansión. Las cohortes fueron similares en edad (mediana de 55 años) y sexo (46,7% mujeres). Una mayor proporción de pacientes en estados sin expansión eran de raza negra (33,4% vs 24,0%) y residían en un código postal con ingresos medios <$38 000 (39,7% vs 28,2%) y un nivel educativo más bajo (37,4% vs 28,1%). En el 2006, las proporciones de pacientes con cáncer de colon en estadio temprano en cohortes en expansión y sin expansión fueron similares (33,2% vs 32,5%). La proporción de pacientes con estadio temprano dentro de los estados sin expansión disminuyó en un 0,8% por año después del 2014, mientras que la proporción dentro de los estados de expansión aumentó en un 0,9% por año después del 2014 (p <0,05). Para el 2016, la diferencia absoluta en la proporción ajustada por propensión de cáncer de colon en estadio temprano fue de 8.8% (39.7% vs 30.9%, p <0.001).LIMITACIONES:Los datos de la Base de datos nacional de cáncer se obtienen únicamente de los sitios acreditados por la Comisión de cáncer y no se basan en la población.CONCLUSIONES:Después de la expansión de Medicaid en el 2014, la proporción de pacientes diagnosticados y tratados en instalaciones acreditadas por la Comisión de Cáncer en pacientes con cáncer de colon en estadio temprano aumentó dentro de los estados de expansión y disminuyó en los estados de no expansión. El aumento de la cobertura del seguro puede haber facilitado un diagnóstico más temprano entre los pacientes en estados de expansión. Consulte Video Resumen en http://links.lww.com/DCR/B804 . (Traducción- Dr. Francisco M. Abarca-Rendon )., (Copyright © The ASCRS 2021.)

Background: NIH-established indications for bariatric surgery were set close to 3 decades ago., Objectives: The purpose of this study was to evaluate outcomes in patients undergoing bariatric surgery with class I obesity, a class that does not fall into current indications., Setting: University Hospital., Methods: De-identified records from a clinic system's Electronic Health Record database were accessed to identify adult patients undergoing Roux-en-Y gastric bypass (RYGB) (n = 566) and sleeve gastrectomy (SG) (n = 730). Patients were compared in terms of resolution of co-morbidities and weight loss outcomes at 3 years following surgery. A mixed effects model was used, adjusting for the type of surgery, the number of quarters after the surgery when the averaged measurements were taken, and the interaction between these two variables., Results: Patients lost up to 20% of their initial body mass index (BMI). Being of younger age, female, and having an obesity-related co-morbidity were associated with greater weight loss. At around 2 years after the surgery, the likelihood of being in remission from type 2 diabetes reached 45%. Remission probabilities for hypertension are 60% for RYGB and 50% for SG, 3 years after the surgery. On the other hand, the probabilities of remission from hyperlipidemia are close to 50% and 25% for RYGB and SG at 2 years. There was no difference between the BMI trajectories and remission from type 2 diabetes (T2D) when comparing the 2 groups., Conclusions: Bariatric surgery is effective in weight loss and resolution of comorbidities in patients with class I obesity. This data further supports the need to revisit the current indication criteria., (Copyright © 2022 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Bariatric surgery has shown an improvement in obesity and obesity-related disease in many clinical trials and single center studies. However, real-world data, including data from non-centers of excellence, is sparse., Objectives: To provide clinical outcomes of patients who underwent bariatric surgery in real-world clinical setting., Setting: Academic Institution., Methods: Adults with obesity undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and a control group (CG) between 2007 and 2019 were identified. The CG represented patients with a previous visit to a bariatric surgeon without a subsequent surgery. Cohorts were matched on age, gender, ethnicity, baseline body mass index (BMI), and presence of diabetes and hypertension. Groups were compared in terms of co-morbidities, weight loss, and chronic conditions for three years., Results: A total of 61 313 patients were identified. From these, 14 916 RYGB and 20 867 SG patients were matched to the CG (n = 16 562). The median BMI loss three years after surgery was 28.7% (interquartile range [IQR] 20.8%-36.2%) and 20.5% (IQR 13.5%-28.6%) for RYGB and SG groups, respectively. The CG had a median BMI loss of 6.7% with IQR of 20.4% decrease to 1.78% gain. At three years postoperatively, HbA1C decreased by 13% for RYGB and 5.9% for the SG group. The probabilities of remission from diabetes, hypertension, and low high-density lipoprotein cholesterol were significantly higher among patients who had surgery compared to the CG. For both RYGB and SG, the estimated probabilities of remission were similar., Conclusion: This study shows that bariatric surgery performed in the real-world clinical setting is an effective therapy for various expressions of the metabolic syndrome with results that are comparable to randomized control trials., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)