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Because time to treatment has been shown to be associated with increase in the risk of death for Non Small Cell Lung Cancer (NSCLC) patients, we examined the prevalence and magnitude of racial disparities in mean time to radiation therapy (TTRT) for Stage I-III non-small cell lung cancer patients across a variety of treatment facilities.Utilizing the United States National Cancer Database (NCDB), we determined differences in TTRT between different races and different treatment facilities.Concordant with past research, we found that non-White patients and patients treated at academic facilities, regardless of race, have longer mean TTRT, and that racial disparities in TTRT extend across all treatment facilities (allThese findings shed light on the potential presence of and impact of structural racism on patients seeking cancer treatment, and the need for further investigation behind the reasonings behind longer TTI for non-White patients. To elucidate the real-world applicability of these results, further investigation into the societal determinants that perpetuate disparity in time to radiation therapy, and potential interventions in the clinical setting to improve cultural and racial sensitivity among healthcare professionals is recommended.

Non-small cell lung cancer (NSCLC) continues to claim millions of lives worldwide. Although its poor prognosis is largely attributed to the lack of adequate and precise detection technologies, cancer cells' suppression of the immune system adds on to the difficulty of identifying abnormal NSCLC tumors in their early stages. Therefore, cancer immunotherapy, which activates the immune system and helps it fight tumors, has recently become the most sought-after technique, especially in the advanced stages of NSCLC, where surgery or chemotherapy may or may not bring about the desired survival benefits in patients.This review focuses on the various immunotherapeutic interventions and their efficacy in advanced NSCLC clinical trials. Monoclonal antibodies like anti-PD-1/PD-L1 agents and anti-CTLA-4 antibodies, cancer vaccines, oncolytic viruses and adoptive T cell therapy have been discussed in brief. Furthermore, the effects of gender, age, and race on the efficacy of immune checkpoint inhibitors and suggest plausible future approaches in the realm of immuno-oncology.Immunotherapy is used alone or in combination either with other immunological agents or with chemotherapy. However, the efficacy of these strategies depends extensively on various demographic variables, as some patients respond perfectly well to immunotherapy, while others do not benefit at all or experience disease progression. By targeting a "hallmark" of cancer (immune evasion), immunotherapy has transformed NSCLC management, though several barriers prevent its complete effectiveness.All these immunological strategies should be interpreted in the current setting of synergistic treatment, in which these agents can be combined with chemotherapy, radiotherapy, and, or surgery following patient and tumor characteristics to proportionate the best-individualized treatment and achieve superior results. To better pursue this goal, further investigations on cost-effectiveness and sex-gender, race, and age differences in immunotherapy are needed.

The novel coronavirus has thrown large sections of our healthcare system into disarray, with providers overburdened by record breaking number of hospitalizations and deaths. The U.S., in particular, has remained the nation with one of the fastest growing case counts in the world. As a consequence, many other critical healthcare needs have not received the necessary resources or consideration. This commentary draws attention to substance use and opioid access during the ongoing crisis, given the potential for breakdowns in treatment access for addiction, the growing concern of mental health comorbidities, and the lack of access for those who require opioids for adequate pain management. Further, the commentary will offer policy and practice recommendations that may be implemented to provide more equitable distribution of care.

Objective: The seven-vaccine series protects infants from several preventable diseases, yet disparities in its use remain in the United States. Methods: We assessed the seven-vaccine immunization rate and its predictors in infants 19–35 months using the National Immunization Survey from 2009 to 2018. Results: The seven-vaccine series rate was 72.8%, well short of the healthy people 2020 target of 90%. African American infants, infants born to mothers with less than high school education, and infants in families with an income below poverty were less likely to get the complete series. Conclusion: Disparities still exist in protecting infants from preventable diseases in the United States.

Background The results of the Cancer and Leukemia Group B (CALGB) 9343 trial showed that radiation therapy (RT) did not improve survival for women older than 70 y with early-stage estrogen receptor + breast cancer treated with breast conserving surgery and adjuvant endocrine therapy. In 2005, guidelines were modified to allow for RT omission; however, minimal change in clinical practice has occurred. The aim of this study was to determine if CALGB long-term follow-up data have affected RT utilization, and to characterize the population still receiving RT after breast conserving surgery. Methods The Surveillance, Epidemiology, and End Results–Medicare database was used to identify women diagnosed with early-stage breast cancer from 2004 to 2015 who matched the CALGB 9343 inclusion criteria. Multivariate logistic regression was carried out to identify the factors that affect the receipt of radiation therapy. We also plotted the overall use of RT over time juxtaposed with the temporal trends of CALGB 9343 clinical trial data, guideline recommendations, and publishing of long-term survival data. Results The study cohort included 25,723 Medicare beneficiaries, of whom 20,328 (79%) received RT and 5395 (21%) did not receive RT. In a multivariate model, the frequency of RT omission increased over time, with those diagnosed in year 2015 being 2.72 times more likely to omit RT compared with those diagnosed in 2004 (95% confidence interval 2.31-3.19). Conclusions This study investigated the impact of long-term CALGB 9343 data on clinical practice. The results of this study support results from previous studies, extend the dates of analysis, and indicate that after long-term follow-up of CALGB 9343 data, RT was less used, but overall trends did not dramatically decrease.

Background: Rural populations experience a disproportionate cancer burden relative to urban populations. One possibility is that rural populations are more likely to hold counterproductive cancer beliefs such as fatalism and information overload that undermine prevention and screening behaviors. Methods: Between 2016 and 2020, 12 U.S. cancer centers surveyed adults in their service areas using online and in-person survey instruments. Participants (N = 10,362) were designated as rural (n = 3,821) or urban (n = 6,541). All participants were 18 and older (M = 56.97, SD = 16.55), predominately non-Hispanic White (81%), and female (57%). Participants completed three items measuring cancer fatalism (“It seems like everything causes cancer,” “There's not much you can do to lower your chances of getting cancer,” and “When I think about cancer, I automatically think about death”) and one item measuring cancer information overload (“There are so many different recommendations about preventing cancer, it's hard to know which ones to follow”). Results: Compared with urban residents, rural residents were more likely to believe that (i) everything causes cancer (OR = 1.29; 95% CI, 1.17–1.43); (ii) prevention is not possible (OR = 1.34; 95% CI, 1.19–1.51); and (iii) there are too many different recommendations about cancer prevention (OR = 1.26; 95% CI, 1.13–1.41), and cancer is always fatal (OR = 1.21; 95% CI, 1.11–1.33). Conclusions: Compared with their urban counterparts, rural populations exhibited higher levels of cancer fatalism and cancer information overload. Impact: Future interventions targeting rural populations should account for higher levels of fatalism and information overload.

The opioid epidemic has resulted in the deaths of millions of Americans and was declared a public health emergency in 2017. In response, many states have enacted policies and analyzed various interventions for harm reduction and overdose prevention, which have embraced limited success. With more states legalizing medical marijuana, another intervention of interest in pain management, much research has since focused on the potential for medical marijuana laws (MMLs) to curb the opioid epidemic. Nonetheless, marijuana legalization and its use for medical purposes has been a polarizing debate from ethical, social, and clinical perspectives.We examine evidence on the merits of medical marijuana to address its potential as a diversion from prescription painkillers. Additionally, we review the impact of MMLs on opioid-related outcomes. Furthermore, we provide multi-layered recommendations for future directions in the evaluation of medical marijuana and MMLs as potential mitigators of the opioid epidemic.Despite limited and mixed evidence of efficacy, medical marijuana may still play an important role in addressing the opioid epidemic in the United States. Furthermore, we believe coordinated responses among the federal government, states, researchers, and patients are crucial in producing more robust evaluations of medical marijuana and MMLs.

Despite the achieved advancement in pharmacological cancer treatments, the majority of postmenopausal women with hormone receptor-positive metastatic breast cancer (mBC) will experience disease progression. Research into alternative therapies with improved efficacy and reduced side effects has led to the development of a new class of oral anticancer medications, the cyclin-dependent kinase (CDK) 4/6 inhibitors, which include palbociclib, ribociclib, and abemaciclib. Nonetheless, there is growing evidence that the effectiveness of oral anticancer medications is sub-optimal, being influenced by low adherence, sociodemographic factors, and adverse effect profiles. In addition, there is a disconnect between the high price tags of CDK 4/6 inhibitors and their observed effectiveness, raising questions about their value. Currently, the existing knowledge base on the effectiveness and cost-effectiveness of newer oral anticancer medications in understudied populations with possible health disparities is scant. This commentary discusses what is known about palbociclib's clinical effectiveness, safety, and adherence and suggests the need for further studies of real-world effectiveness and cost-effectiveness to help establish the value of newer oncologic drugs, such as palbociclib. DISCLOSURES: No funding supported the writing of this article. The authors have nothing to disclose.

Using long-term survival data from the C9343 trial as a temporal reference point, this study aimed to determine radiation therapy (RT) treatment trends for older patients with early-stage breast cancer. The study also examined rates of adherence to adjuvant endocrine therapy (AET). The surveillance, epidemiology, and end results–medicare database was used to identify women with a diagnosis of breast cancer from 2007 through 2016. Bivariate associations were calculated to determine variable characteristics by time frame (group 1: 2007–2012 vs. group 2: 2013–2016). Multivariate logistic regression was used to estimate the effect of group on the RT use and AET adherence. The temporal rates for both RT and AET adherence over time were plotted. The final study cohort included 12,210 Medicare beneficiaries. Use of RT differed significantly between the groups, with a higher proportion omitting RT in the later period (25% of group 2 vs. 20% of group 1; p

OBJECTIVE To examine trends in uninsured rates between 2012 and 2016 among low-income adults aged RESEARCH DESIGN AND METHODS Data for 3,129 U.S. counties, obtained from the Small Area Health Insurance Estimates and Area Health Resources Files, were used to analyze trends in uninsured rates among populations with a household income ≤138% of the federal poverty level. Multivariable analysis adjusted for the percentage of county populations aged 50–64 years, the percentage of women, Distressed Communities Index value, and rurality. RESULTS In 2012, 39% of the population in the Diabetes Belt and 34% in non-Belt counties were uninsured (P < 0.001). In 2016 in states where Medicaid was expanded, uninsured rates declined rapidly to 13% in Diabetes Belt counties and to 15% in non-Belt counties. Adjusting for county demographic and economic factors, Medicaid expansion helped reduce uninsured rates by 12.3% in Diabetes Belt counties and by 4.9% in non-Belt counties. In 2016, uninsured rates were 15% higher for both Diabetes Belt and non-Belt counties in the nonexpansion states than in the expansion states. CONCLUSIONS ACA-driven Medicaid expansion was more significantly associated with reduced uninsured rates in Diabetes Belt than in non-Belt counties. Initial disparities in uninsured rates between Diabetes Belt and non-Belt counties have not existed since 2014 among expansion states. Future studies should examine whether and how Medicaid expansion may have contributed to an increase in the use of health services in order to prevent and treat diabetes in the Diabetes Belt.

PURPOSE: A key challenge regarding the current opioid epidemic is understanding how concerns regarding opioid-related harms affect access to pain management, an essential element of cancer care. In certain regions of the United States where disproportionately high cancer mortality and opioid fatality rates coexist (such as southwest Virginia in central Appalachia), this dilemma is particularly pronounced. METHODS: This longitudinal, exploratory, secondary analysis used the Commonwealth of Virginia All Payer Claims Database to describe prescription opioid medication (POM) prescribing patterns and potential harms for adult patients with cancer living in rural southwest Virginia between 2011 and 2015. Descriptive and inferential statistical analyses were conducted at the patient, prescriber, and prescription levels to identify patterns and predictors of POM prescribing and potential harms. To explore geographic patterns, choropleth and heat maps were created. RESULTS: Of the total sample of patients with cancer (n = 4,324), less than 25% were prescribed a Controlled Substance Schedule II POM at least three times in any study year. More than 60% of patients never received a Controlled Substance Schedule II POM prescription. Six hundred fifty-two patients (15.1%) experienced 1,599 hospitalizations for any reason; 10 or fewer patients were admitted for 11 opioid use disorder–related hospitalizations. The main findings suggest potential undertreatment of cancer-related pain; no difference in risk for opioid-related hospitalization on the basis of frequency of POM prescriptions; and geographic disparities where opioid overdoses are occurring versus where POM prescription use is highest. CONCLUSION: These findings have significant opioid policy and practice implications related to the need for cancer-specific prescribing guidelines, how to optimally allocate health delivery services, and the urgent need to improve data interoperability and access related to POMs.

Objective Treatment options for HER-2-positive metastatic breast cancer (mBC) patients have expanded markedly since trastuzumab approval in 1998. Several other regimens are now available, including pertuzumab plus trastuzumab plus docetaxel, T-DM1, capecitabine plus lapatinib, and trastuzumab plus lapatinib. This study assesses the cost-effectiveness of four treatment sequences for HER-2-positive mBC according to the Taiwanese National Health Insurance Administration (TNHIA). Methods Costs (U.S. Dollars) and effectiveness (quality-adjusted life years) of four treatment sequences for HER-2-positive mBC patients were examined using a Markov model over a lifetime horizon. Transition probabilities, disease progression, and probability of adverse events and survival were derived from clinical trial data. Costs and health utilities were estimated from TNHIA, Taipei Medical University Hospital, and the literature. Deterministic, probabilistic sensitivity analyses and a scenario analysis examined parameter uncertainty and accounted for drug wastage in dosage and cost calculations. Results Sequence 3 (1st line: trastuzumab plus docetaxel; 2nd line: T-DM1; 3rd line: trastuzumab plus lapatinib) was the most cost-effective sequence followed by sequence 1 (1st line: pertuzumab plus trastuzumab plus docetaxel; 2nd line: T-DM1; 3rd line: capecitabine plus lapatinib), and sequence 4 (1st line: trastuzumab plus docetaxel; 2nd line: trastuzumab plus lapatinib; 3rd line: trastuzumab plus capecitabine), respectively. The model was sensitive to costs and transition probabilities, but not particularly sensitive to the wastage assumption. Conclusions From the perspective of the TNHIA, trastuzumab plus docetaxel as 1st line followed by T-DM1 and trastuzumab plus lapatinib as 2nd and 3rd line represents the most cost-effective strategy among the four sequences considered for treating HER-2-positive mBC patients., Highlights • In health systems in which resources are scarce, treatment selection should be carefully considered to preserve efficiency. • We conducted a CEA of four treatment sequences for HER-2-positive mBC in Taiwan, accounting for intravenous drug wastage. • Results of such analyses can be useful to policymakers as they decide on coverage of expensive new anticancer treatments.

For patients with diabetes, annual preventive care is essential to reduce the risk of complications. Local healthcare resources affect the utilization of diabetes preventive care. Our objectives were to evaluate the relative efficiency of counties in providing diabetes preventive care and explore potential to improve efficiencies. The study setting is public and private healthcare providers in US counties with available data. County-level demographics were extracted from the Area Health Resources File using data from 2010 to 2013, and individual-level information of diabetes preventive service use was obtained from the 2010 Behavioral Risk Factor Surveillance System. 1112 US counties were analyzed. Cluster analysis was used to place counties into three similar groups in terms of economic wellbeing and population characteristics. Group 1 consisted of metropolitan counties with prosperous or comfortable economic levels. Group 2 mostly consisted of non-metropolitan areas between distress and mid-tier levels, while Group 3 were mostly prosperous or comfortable counties in metropolitan areas. We used data enveopement analysis to assess efficiencies within each group. The majority of counties had modest efficiency in providing diabetes preventive care; 36 counties (57.1%), 345 counties (61.1%), and 263 counties (54.3%) were inefficient (efficiency scores

The novel coronavirus has thrown large sections of our healthcare system into disarray, with providers overburdened by record breaking number of hospitalizations and deaths. The U.S., in particular, has remained the nation with one of the fastest growing case counts in the world. As a consequence, many other critical healthcare needs have not received the necessary resources or consideration. This commentary draws attention to substance use and opioid access during the ongoing crisis, given the potential for breakdowns in treatment access for addiction, the growing concern of mental health comorbidities, and the lack of access for those who require opioids for adequate pain management. Further, the commentary will offer policy and practice recommendations that may be implemented to provide more equitable distribution of care.

PURPOSE: Prolonged opioid use is common and associated with lower survival rates in breast cancer survivors. We explored whether opioid use in elderly breast cancer survivors using adjuvant endocrine therapy (AET) regimens was affected by the prevalence of mental health comorbidity and, in turn, how this affected survival in this population. METHODS: This retrospective study analyzed 2006 to 2012 SEER-Medicare data sets and followed patients for at least 2 years from the index date, defined as the first date they filled an AET prescription. The study included adult women with incident, primary, hormone receptor–positive, stage I to III breast cancer. They were also first-time AET users and fee-for-service Medicare enrollees continuously enrolled in Medicare Parts A, B, and D. We measured whether patients with a clinical diagnosis of a mental health comorbid condition used opioids after the initiation of AET and their survival at the end of the study period. RESULTS: A total of 10,452 breast cancer survivors who began AET treatments were identified, among whom the most commonly diagnosed mental health comorbidities were depression (n = 554) and anxiety (n = 246). Using a propensity score risk adjustment model, we found that opioid use was significantly higher in women with a mental health comorbidity (odds ratio,1.33; 95% CI, 1.06 to 1.68). In addition, mental health comorbidity was associated with a significantly increased hazard of mortality in this population (hazard ratio, 1.49; 95% CI, 1.02 to 2.18). CONCLUSION: The presence of mental health comorbidity in breast cancer survivors significantly increases the risk of opioid use and mortality, which highlights the need for better management of comorbid mental health conditions.

To examine the association of geographic access to providers with racial/ethnic variations in treatment quality among youth with depression.The geographic access to providers who initiated the depression treatment was measured using the travel distance estimated based on Google Maps® and the provider density within a 5-mile radius of each patient residence. Depression treatment quality was measured as treatment engagement, defined as having ≥2 prescriptions or psychotherapy with 2-month following a new depression diagnosis, and treatment completion defined as having ≥8 sessions of psychotherapy within 12 weeks or received ≥84 days of continuous treatment with antidepressants within 114 days following the treatment initiation.The results of multivariate logistic regression analysis have demonstrated that the travel distance to provider was only negatively associated with the treatment engagement of Hispanics (5.0 - 14.9 vs ≤ 4.9 miles: OR=0.74, 95% CI [0.54-0.88]; ≥15 vs ≤ 4.9 miles: OR=0.82, 95% CI [0.56-0.97]), while a higher mental health specialist density was only positively associated with the treatment engagement of Blacks (1.00-1.99 vs1.00: OR=1.63, 95% CI [1.03-4.51]; 2.00-4.99 vs1.0: OR=2.28, 95% CI [1.21-7.11]). Among those who have engaged in the treatment, travel distance was associated with a lower likelihood of treatment completion in all racial/ethnic groups.The study did not account for types of transportation used by patients.Geographic access barriers had a negative association with treatment quality of pediatric depression. Minority children were more sensitive to the barriers than Whites.

Understanding the patterns of antihypertensive drug use and blood pressure (BP) control among stroke survivors in the “real‐world” setting is important to identify gaps in treatment and control, if any. The objective of our study was to assess trends and patterns in antihypertensive drug use and BP control among stroke survivors in the United States. We performed a retrospective cross‐sectional analysis of the 2003‐2014 National Health and Nutrition Examination Survey (NHANES). Stroke and hypertension diagnoses were self‐reported. Information regarding the use of antihypertensive drugs was collected during an in‐person interview. Measurement of BP was performed by trained medical professionals in mobile examination centers. A total 1244 adult stroke survivors (equating to 6 232 215 stroke survivors nationwide) were identified, of which 956 had hypertension. Antihypertensive drug use increased from 2003 (79.5%) to 2014 (92.2%; P for trend

Objective:Much of the research on the effects of childhood adversity on mental health has focused on adults. The objective of our study was to examine the individual and cumulative effect of childhood adversity on mental health service use among children.Methods:We used data from the 2011-2012 National Survey of Children’s Health (n = 79 834) to determine the use of mental health services in the past 12 months among children aged 2-17. The independent variables of interest were experiencing any 1 of 9 adverse family experiences (AFEs). We used logistic regression models to determine if each AFE was associated with mental health service use. We also examined AFEs as a continuous measure, representing the number of AFEs (ranging from 0 to 9) that summed them individually, and we examined age-by-AFE and age-by-need interaction terms. We adjusted all models for confounders.Results:Compared with not experiencing an AFE, experiencing all AFEs was associated with higher odds of mental health service use. Neighborhood violence was associated with the greatest increase in odds of mental health service use (adjusted odds ratio [aOR] = 2.35; 95% confidence interval [CI], 2.00-2.77). When measured as a continuous scale, each additional AFE was associated with higher odds of mental health service use (aOR = 1.33; 95% CI, 1.28-1.37). The effect of AFEs on mental health service use decreased with age.Conclusions:The observed association between AFEs and use of mental health services may be attributable to more severe or poorly managed mental illness among these children. Efforts are needed to increase access to and quality of mental health care among children affected by AFEs.

Introduction: The relationship between survival and time to the start of adjuvant chemotherapy (AC) among breast cancer patients is unclear. Most breast cancer patients start adjuvant chemotherapy within a few weeks after surgery, but it is still unclear whether a delay in the initiation of chemotherapy will lead to adverse outcomes.Methods: Women diagnosed between 2004 and 2016 with invasive breast cancer (stages I-III) and treated with surgery and adjuvant chemotherapy were selected from the National Cancer Database (n= 443,100). We evaluated factors associated with prolonged time to start adjuvant chemotherapy (≥60, ≥90, and ≥120 days after surgical resection) using multivariable log binomial models to estimate risk ratios (RRs) and 95% CIs. Cox proportional hazards model was used to investigate the effect of delay on survival.Results: The average time to adjuvant chemotherapy was 47.93 days (±29.17 days). Non-Hispanic African American patients had higher risk of 60-day delay (RR, 1.41; 95% CI, 1.38 to 1.43), 90-day delay (RR, 1.55; 95% CI, 1.50 to 1.60), and 120-day delay (RR, 1.69; 95% CI, 1.61 to 1.78) compared with non-Hispanic white patients. Early initiation of chemotherapy, less than 1 month (RR, 0.893; 95% CI, 0.86 to 0.92), 1-2 month (RR, 0.80; 95% CI, 0.77 to 0.82), and 2-3 month (RR, 0.87; 95% CI, 0.84 to 0.90); was associated with decreased overall mortality. Non-Hispanic African Americans (RR, 1.16; 95% CI, 1.13 to 1.19) were associated with increased overall mortality compared to non-Hispanic whites. Conclusion: Black breast cancer patients experience clinically relevant delays in the initiation of adjuvant chemotherapy more often than white patients, which may in part explain the increased mortality observed among black patients. Efforts should be made to reduce the time to surgery when possible to enhance overall survival.

Background Acute myeloid leukemia, the most common acute leukemia in adults, has a poor overall survival. Studies have suggested that certain socioeconomic factors such as living in a rural or farming area are associated with worse outcomes. Since 42% of acute myeloid leukemia patients seen in our academic center reside in a rural area, we have a unique opportunity to study outcomes of patients in rural versus urban settings. Aim This analysis evaluates the effect of geography and socioeconomic factors on the biology, treatment, and overall survival of patients with acute myeloid leukemia, with the goal of understanding health care disparities. Methods and results Patient characteristics, cytogenetic data, treatment history, and overall survival were collected and analyzed to identify differences between urban and rural residency. This cohort included 42% of patients who resided in a rural area at the time of acute myeloid leukemia diagnosis. There was no difference in overall survival between the cohorts. The 1 year overall survival for the entire cohort was 47.9%. There was no difference detected in rates of adverse cytogenetics between the rural and urban cohorts. Similar numbers of patients received induction chemotherapy or proceeded to allogeneic stem cell transplant between the cohorts. Conclusions This study highlights that similar outcomes can be achieved in rural and urban patients, suggesting that intensive efforts at telehealth, education, and collaboration with local oncology practices may be beneficial.

Allogeneic hematopoietic cell transplantation (HCT) is a standard therapy for patients with intermediate to high-risk acute myeloid leukemia (AML) and is associated with improved long-term disease-free survival. Disparity exists in access to HCT among different patient populations and requires further study. In this study, we compared HCT rates for AML among different regions in the state of Virginia and identified geographic and socioeconomic factors associated with the likelihood of receiving HCT. We conducted a retrospective, cohort study of patients 18 to 74 years of age diagnosed with AML in Virginia from 2013 to 2017 as reported to the Virginia Cancer Registry (VCR); the VCR was further linked with the Center for International Blood and Marrow Transplant Research database for identification of patients who had undergone HCT within 2 years of diagnosis. Socioeconomic data were generated from the VCR and the American Community Survey. Univariate and multivariable logistic regression models were used to examine selected socioeconomic factors of interest, including patient-level information such as sex, age, race, marital status, and primary insurance payer, as well as factors associated with geography, including the Social Vulnerability Index (SVI) and percentage of African Americans residing in the region. In Virginia, 818 patients were diagnosed with AML from 2013 to 2017, and, of these, 168 patients (21%) underwent HCT within 2 years of diagnosis. Median age was lower in the HCT cohort (55 years) versus the non-HCT cohort (64 years) (P.001). There was a higher proportion of married patients in the HCT cohort (67%) versus the non-HCT cohort (53%) (P = .005). The rate of HCT varied by geographic region (P = .004). The multivariable analyses (without including SVI) showed decreased likelihood of HCT with increasing age (odds ratio [OR], .96; 95% confidence interval [CI], .95 to .98). Patients from regions that had a greater than 25% African American population were less likely to undergo HCT (OR, .58; 95% CI, .38 to .89). Patients who were not married were less likely to undergo HCT compared with married patients (OR, .56; 95% CI, .36 to .88). Patients with government-sponsored insurance as the primary payer were less likely to undergo HCT compared with patients with private insurance (OR, .49; 95% CI, .32 to .77). Patients living in Zip Code areas with a greater percentage of population with a bachelor's or graduate degree were more likely to undergo HCT (OR, 1.02; 95% CI, 1.00 to 1.03). In a separate multivariate model with SVI, patients residing in a Zip Code with higher SVI were less likely to undergo HCT (OR, .37; 95% CI, .16 to .82). From 2013 to 2017, we found that the likelihood of a patient undergoing HCT in Virginia for AML within 2 years of diagnosis was negatively associated with increasing age, percent of African Americans residing in the region, not-married relationship status, government-sponsored insurance as primary payer, higher SVI, and decreased percent of population with a bachelor's or graduate degree. Resources should be directed toward at-risk patient populations to remove barriers to improve access to HCT. The SVI can be used to identify communities at risk nationwide.

Behavioral Health (BH) screening is critical for early diagnosis and treatment of pediatric mental disorders. The objective of this study was to assess the impact of geographic access to primary care providers (PCP) on pediatric BH screening in children with different race/ethnicity. A retrospective cohort study was conducted using the 2013–2016 administrative claims data from a large pediatric Medicaid Managed Care Plan that have been linked to 2010 US Census data and the 2017 National Provider Identifier (NPI) Registry. Geographic access was defined as the actual travel distance to nearest PCP and the PCP density within 10-mile travel radius from each individual's residence. Stratified multivariate logistic regression was conducted to examine the association between the geographic access to PCP and the likelihood of receiving screening for behavioral disorders within each racial/ethnic group. BH screening rate was 12.6% among 402,655 children and adolescents who met the inclusion criteria. Multivariable analysis stratified by individual race/ethnicity revealed that Hispanic and Black children were more vulnerable to the geographic access barriers than their non-Hispanic White counterparts. The increase in travel distance to the nearest PCP was negatively associated with screening uptake only among Hispanics (10–20 miles vs. 0–10 miles: OR = 0.78, 95% CI [0.71–0.86]; 20–30 miles vs. 0–10 miles: OR = 0.35, 95% CI [0.23–0.54]). In a subgroup that had access to at least one PCP within 10 miles of travel distance, the variation in PCP density had a greater impact on the screening uptake among Hispanics and Blacks than that in non-Hispanic Whites.