Rifaximin reduces rehospitalization risk in patients with cirrhosis and overt hepatic encephalopathy.

Background/Objectives: Rifaximin is a therapeutic agent for patients with hepatic encephalopathy (HE); however, there is little data on the effects of its long-term (>1 year) administration in Japanese patients with cirrhosis. The effects and safety of 3-year rifaximin treatment on HE was investigated in Japan. Methods: A total of 190 Japanese patients with cirrhosis who were continuously administered rifaximin for more than 1 year suffered overt or covert HE, which was diagnosed by a physician. Laboratory data were collected at baseline, 3, 6, 12, 18, 24, 30, and 36 months following rifaximin administration. We examined the cumulative overt HE incidences, overall survival rates, and hepatic functional reserves following rifaximin treatment. The occurrence of adverse events was also assessed. Results: The levels of ammonia improved significantly after 3 months of rifaximin administration, which continued for 3 years. Serum albumin and prothrombin activity also significantly improved 3 years after initiation of rifaximin treatment. Cumulative overt HE incidences were 12.1%, 19.7%, and 24.9% at 1, 2, and 3 years, respectively. The survival rates following rifaximin treatment were 100%, 88.9%, and 77.8% at 1, 2, and 3 years, respectively. In contrast, renal function and electrolytes did not change following rifaximin administration. Only three (1.6%) patients discontinued rifaximin therapy because of severe diarrhea after 1 year of rifaximin administration. No other serious adverse events were observed. Conclusions: Three years of continuous rifaximin (RFX) treatment was both effective and safe for patients with hepatic encephalopathy. Liver function improved and did not worsen during treatment.

Background Hospitalization for severe inflammatory bowel disease (IBD) flares or complications are a major source of morbidity and healthcare expenditure. Aims To assess temporal trends in 30-day and 90-day re-hospitalization rates among persons with Crohn’s disease (CD) and ulcerative colitis (UC) in the post-biologic era. Methods We conducted a population-based study of all non-elective IBD-related hospitalizations among patients with CD and UC in Ontario, Canada between April 1, 2002 and March 31, 2020. We identified individuals, admissions, and variables of interest from Ontario population health administrative datasets housed at IC/ES. We performed multivariable logistic regression analysis to evaluate the association between time period of hospitalization (2002-2007 vs. 2002-2007 vs. 2007-2012 for CD; 2004-2008 vs. 2008-2012 vs. 2012-2016 vs. 2016-2020 for UC) and rates of 30-day and 90-day re-hospitalization, adjusting for patient age, sex, co-morbidities, residential setting, income quintile, hospital type of initial admission, and clustering of hospital admissions within patients. We excluded patients with elective admissions or length of stay ampersand:003C24 hours, and those without continuous valid Ontario health care registration during the 90-day period following hospital discharge. Results There were 18,625 hospitalizations among 14,868 patients with CD, and 10,830 hospitalizations among 9,264 patients with UC. The 30-day re-hospitalization rate was 8.5% for patients with CD and 9.7% for patients with UC, while the respective 90-day re-hospitalization rates were 15.0% and 13.8%. For CD, re-admission rates differed across the 3 time periods (pampersand:003C0.0001 for 30-day and p=0.012 for 90-day). For UC, re-hospitalization rates differed across the 4 time periods for 30-day re-hospitalization (p=0.048), but not 90-day (p=0.080). There was a higher relative odds of CD-related re-hospitalization in 2002-2007 as compared to 2012-2017 (adjusted odds ratio [aOR] 1.32, 95% confidence interval [CI] 1.16-1.50 for 30-day; aOR 1.14, 95% CI [1.03-1.26] for 90-day). For UC, there was a higher relative odds of re-hospitalization in 2012-2016 as compared to 2016-2020 (aOR 1.26, 95% CI [1.05-1.52] for 30-day; aOR 1.22, 95% CI [1.04-1.43] for 90-day). Conclusions Up to 15% of patients with IBD in Ontario are re-admitted to hospital within 90 days of hospital discharge. The risk of re-hospitalization may have decreased over time in the post-biologic era. Our findings could be explained by changing access to inpatient and/or outpatient resources, improvements to medical and/or surgical care, shifting patient behaviour with respect to healthcare resource utilization, or residual confounding. These results require validation in other jurisdictions. Funding Agencies None

BackgroundRifaximin therapy reduced risk of hepatic encephalopathy (HE) recurrence and HE-related hospitalisations during a 6-month, randomised, placebo-controlled trial (RCT) and a 24-month open-label maintenance (OLM) study. However, the impact of crossover from placebo to rifaximin therapy is unclear.AimTo study the impact of crossing over from placebo to rifaximin treatment on breakthrough HE and hospitalisation rates using a within-subjects design.MethodsAdults with cirrhosis and history of overt HE episodes, currently in HE remission, received placebo during the RCT and crossed over to rifaximin 550 mg twice daily during the OLM study. Rate of breakthrough overt HE episodes, hospitalisations and incidence and rate of adverse events (AEs) were analysed during RCT and first 6 months of OLM.ResultsOf 82 patients randomised to placebo in the RCT who crossed over to the OLM study, 39 experienced an HE episode during the RCT compared with 14 during the OLM study (P < 0.0001). Significantly lower rates of HE events were observed with rifaximin treatment compared with placebo treatment (P < 0.0001). Rates of HE-related hospitalisation were numerically lower during rifaximin treatment compared with placebo treatment, although not significant. Rates of most common AEs, serious AEs and infection-related AEs were similar between the two treatments.ConclusionsThis analysis confirms the repeatability of results from the RCT on safety and efficacy of rifaximin 550 mg twice daily in reducing the risk of hepatic encephalopathy recurrence, and suggests these findings are translatable outside of a rigorous, controlled trial setting.

Disparities in Absolute Denial of Modern Hepatitis C TherapybyType of Insurance.

Risk of myocardial infarction, ischemic stroke, and cardiovascular death in patients with atopic dermatitis

Although early diagnosis improves long-term outcomes, patients with juvenile idiopathic arthritis (JIA) often experience prolonged, circuitous paths to diagnosis. To inform diagnostic improvement, we sought to characterize health care utilization in the year preceding diagnosis. We identified 10,021 patients with an incident diagnosis of JIA and 20,042 age- and sex-matched healthy controls in the Merative MarketScan administrative datasets (2014-2022). Using negative binomial or hurdle models, we calculated incidence rate ratios (IRRs) comparing outpatient, inpatient, and emergency department or urgent care (ED/UC) utilization between patients with JIA and controls. In the year before diagnosis, patients with JIA had significantly increased health care utilization compared to controls (IRR 2.55 [95% confidence interval (CI) 2.49-2.62], P < 0.001). Accounting for sex, age, and insurance, utilization was increased across care settings: outpatient (IRR 2.56 [95% CI 2.49-2.62], P < 0.001), inpatient (IRR 2.00 [95% CI 1.48-2.71], P < 0.001), and ED/UC encounters (IRR 1.76 [95% CI 1.67-1.86], P < 0.001). The most common visits by patients with JIA preceding diagnosis were to a general practitioner (91.8%), ED/UC (47.0%), and orthopedist (22.9%). Health care utilization increased as the index date approached. In patients insured by Medicaid, ED/UC care was more frequent (odds ratio 2.05 [95% CI 1.89-2.23]) and orthopedic care less frequent (odds ratio 0.27 [95% CI 0.24-0.34]) than in patients with commercial insurance. In the year before diagnosis, children with JIA have significantly higher health care utilization compared to healthy peers. There are differences in the patterns of utilization in patients with Medicaid versus commercial insurance. There may be opportunities for earlier identification of JIA in primary care, orthopedics, and ED/UC.

Impact of the COVID-19 Pandemic on Urological Care Delivery in the United States.

The introduction of biosimilars and novel delivery devices between 2014 and 2019 may have changed the utilization of granulocyte colony-stimulating factors (G-CSF). To assess utilization trends of G-CSFs for primary prophylaxis of febrile neutropenia (FN) among patients with cancer receiving myelosuppressive chemotherapy with commercial or Medicare insurance. This cross-sectional study assessed G-CSF utilization trends overall and stratified by regimen febrile neutropenia risk level. Associations between patient characteristics and G-CSF use were evaluated. Patients with cancer, including breast, lung, colorectal, esophageal and gastric, pancreatic, prostate, ovarian, and non-Hodgkin lymphomas, initiating myelosuppressive chemotherapy courses were included from the 2014 to 2019 commercial insurance and 2014 to 2018 Medicare fee-for-service claims databases. Data were analyzed from March to June 2021. Year of chemotherapy initiation. The main outcomes were use and trends of G-CSFs for primary prophylaxis, from completion to 3 days after in the first chemotherapy cycle. In total, 86 731 chemotherapy courses (mean [SD] age, 57.7 [11.5] years; 57 838 [66.7%] women and 28 893 [33.3%] men) were identified from 82 410 patients in the commercial insurance database and 32 398 chemotherapy courses (mean [SD] age, 71.8 [8.3] years; 18 468 [57.0%] women and 13 930 [43.0%] men) were identified from 30 279 patients in the Medicare database. Among the commercially insured population, 39 639 patients (45.7%) received G-CSFs, and 12 562 patients (38.8%) received G-CSFs among Medicare insured patients. Overall G-CSF use increased significantly throughout the study period in both populations, from 45.1% (95% CI, 44.4%-45.7%) of patients in 2014 to 47.5% (95% CI, 46.5%-48.5%) of patients in 2019 (P = .001) in the commercially insured population and from 36.0% (95% CI, 34.2%-38.0%) of patients in 2014 to 39.1% (95% CI, 38.1%-40.1%) of patients in 2018 (P < .001) in the Medicare population. The greatest increases in G-CSF use were observed among patients with high FN risk, from 75.0% (95% CI, 74.1%-76.0%) of patients to 83.2% (95% CI, 82.0%-84.2%) of patients (P < .001) among the commercially insured population and 75.3% (95% CI, 71.8%-78.6%) of patients to 86.2% (95% CI, 84.7%-87.6%) of patients (P < .001) among the Medicare population. Use of G-CSFs decreased in the commercially insured population among patients with intermediate FN risk (from 27.5% [95% CI, 26.4%-28.5%] of patients to 20.4% [95% CI, 19.1%-21.7%] of patients; P < .001) or low FN risk (from 19.3% [95% CI, 18.3%-20.4%] of patients to 16.3% [95% CI, 14.7%-18.0%] of patients; P < .001) and remained stable in the Medicare population (intermediate risk: from 26.4% [95% CI, 23.8%-29.2%] of patients to 28.4% [95% CI, 27.0%-29.8%] of patients; P = .35; low risk: from 19.6% [95% CI, 17.0%-22.4%] of patients to 20.9% [95% CI, 19.6%-22.3%] of patients; P = .58). Factors associated with increased odds of G-CSF use included older age (commercial insurance: adjusted odds ratio [aOR], 1.50 [95% CI, 1.41-1.59]; Medicare: aOR, 1.36 [95% CI, 1.08-1.71]), receiving a regimen with high FN risk (commercial insurance: aOR, 16.01 [95% CI, 15.17-16.90]; Medicare: aOR, 17.17 [95% CI, 15.76-18.71]), and history of neutropenia (commercial insurance: 3.90 (3.67-4.15); Medicare: 3.82 (3.50-4.18). This cross-sectional study found that utilization of G-CSFs increased among patients with cancer with high FN risk in both a commercially and Medicare-insured population, but 14% to 17% of patients still did not receive preventive treatment.

The time toxicity of CAR-T cell therapy for non-Hodgkin's lymphoma

ObjectiveThe objective of this study was to compare persistence, costs, and healthcare resource utilization in patients with schizophrenia and cardiometabolic comorbidities treated with once-monthly paliperidone palmitate or an oral atypical antipsychotic.MethodsMedicaid data from six states (07/2009–03/2015) were used to identify adults with schizophrenia and cardiometabolic comorbidities initiated on once-monthly paliperidone palmitate or an oral atypical antipsychotic (index date) on 01/2010 or after. Persistence to index medication at 12 months (no gap ≥ 90 days) was compared between patients taking once-monthly paliperidone palmitate and an oral atypical antipsychotic using Chi-squared tests. The 12-month post-index healthcare costs and healthcare resource utilization were compared using multivariate ordinary least squares and Poisson regression, respectively.ResultsSelected patients taking once-monthly paliperidone palmitate (n = 371) were younger (mean age: 45.0 vs. 47.5 years, standardized difference = 24%) than patients taking oral atypical antipsychotics (n = 8296). Persistence at 12 months was higher in patients taking once-monthly paliperidone palmitate (40 vs. 33%, p = 0.006). Adjusted all-cause medical costs were lower in patients taking once-monthly paliperidone palmitate vs. patients taking oral atypical antipsychotics (mean monthly cost differences = US $ − 369, p = 0.004) while all-cause pharmacy costs were higher (mean monthly cost differences = US $279, p < 0.001), resulting in no significant difference in total costs (mean monthly cost differences = US $ − 90, p = 0.357). No significant difference was observed in cardiometabolic comorbidity-related pharmacy or medical costs. Compared with patients taking oral atypical antipsychotics, patients taking once-monthly paliperidone palmitate had more schizophrenia-related outpatient visits (incidence rate ratio = 1.44, p < 0.001) but fewer cardiometabolic comorbidity-related inpatient admissions (incidence rate ratio = 0.73, p < 0.001) with shorter lengths of stay (incidence rate ratio = 0.72, p = 0.020), and fewer cardiometabolic comorbidity-related long-term care admissions (incidence rate ratio = 0.56, p = 0.016).ConclusionsMedicaid beneficiaries with schizophrenia and cardiometabolic comorbidities who were initiated on once-monthly paliperidone palmitate had similar 12-month total healthcare costs compared with oral atypical antipsychotics. Cardiometabolic comorbidity-related utilization of inpatient and long-term care services was lower in patients taking once-monthly paliperidone palmitate.Electronic supplementary materialThe online version of this article (10.1007/s40801-018-0130-4) contains supplementary material, which is available to authorized users.

<sec> <title>BACKGROUND</title> Clinical practice guidelines (CPGs) summarize the best available evidence in a specific field. To improve patient-centered outcomes, guidelines have to be implemented, using, for example, information and communications technology. Although there are CPGs addressing multimorbidity, there is still a lack of studies investigating their implementation. </sec> <sec> <title>OBJECTIVE</title> This study aimed to evaluate whether the implementation of a CPG for multimorbidity using a digital tool is feasible and explore possible effects of this intervention. </sec> <sec> <title>METHODS</title> A pilot cluster randomized clinical trial based on telephone interviews was conducted from October 25, 2023, to September 8, 2024. Patients enrolled in any disease management program who were aged ≥65 years and had at least 2 additional chronic conditions were randomly selected from 20 general practitioner (GP) practices and contacted for informed consent. Each practice was randomized after baseline interviews of all participating patients in the practice were finished. The use of a web application facilitating collection and documentation of treatment-relevant data in accordance with the German CPG for multimorbidity was compared with treatment as usual. The primary outcome was time spent in hospital. As a secondary outcome, the number of patients with at least one hospital admission was calculated. Further secondary outcomes included outpatient health care use, quality of life, patient satisfaction, and quality of care. Feasibility assessment included examination of sample size, participation rate, and compliance with the study protocol. Outcome measures were analyzed using linear, logistic, and negative binomial regressions with random intercepts for practices. </sec> <sec> <title>RESULTS</title> Of 384 patients who were contacted, 123 (32%) agreed to participate, and 120 (31.3%, including 54/120, 45% in the intervention group and 66/120, 55% in the control group) completed baseline and follow-up assessments. Mean age was 75.4 (SD 6.6) years, and 51.7% (62/120) were women. The compliance rate, or the proportion of patients who were treated per protocol, was 89% (48/54). In our data, the incidence rate of hospital days was comparable in both groups (incidence rate ratio [IRR] 0.94, 95% CI 0.09-9.42; &lt;i&gt;P&lt;/i&gt;=.96), but the odds of hospital admission were almost reduced by half in the intervention group (odds ratio 0.51, 95% CI 0.17-1.54; &lt;i&gt;P&lt;/i&gt;=.23). Our data also suggest a higher incidence rate of GP contacts (IRR 1.13, 95% CI 0.83-1.53; &lt;i&gt;P&lt;/i&gt;=.43) and lower incidence rate of contacts with outpatient specialists (IRR 0.79, 95% CI 0.54-1.15; &lt;i&gt;P&lt;/i&gt;=.24) in the intervention group compared to usual care. Moreover, patients and GPs reported a better quality of care (mean difference 0.51, 95% CI −0.12 to 1.14; &lt;i&gt;P&lt;/i&gt;=.12 and mean difference 1.19, 95% CI 0.13-2.25; &lt;i&gt;P&lt;/i&gt;=.03, respectively) in the intervention group. </sec> <sec> <title>CONCLUSIONS</title> Implementation of the CPG using a digital tool was feasible. Our data suggest that the probability of hospital admissions and contacts with outpatient specialists might be reduced and quality of care might be improved. </sec> <sec> <title>CLINICALTRIAL</title> ClinicalTrials.gov NCT06061172; https://clinicaltrials.gov/study/NCT06061172 </sec>

During the COVID-19 pandemic children and young people (CYP) mortality in England reduced to the lowest on record, but it is unclear if the mechanisms which facilitated a reduction in mortality had a longer lasting impact, and what impact the pandemic, and its social restrictions, have had on deaths with longer latencies (e.g., malignancies). The aim of this analysis was to quantify the relative rate, and causes, of childhood deaths in England, before, during, and after national lockdowns for COVID-19 and its social changes. Deaths of all children (occurring before their 18th birthday) occurring from April 2019 until March 2023 in England were identified. Data were collated by the National Child Mortality Database. Study population size and the underlying population profile was derived from 2021 Office of National Statistics census data Mortality for each analysis year was calculated per 1,000,000 person years. Poisson regression was used to test for an overall trend across the time period and tested if trends differed between April 2019 to March 2021 (Period 1)) and April 2021 to March 2023 (Period 2: after lockdown restrictions). This was then repeated for each category of death and demographic group. Twelve thousand eight hundred twenty-eight deaths were included in the analysis. Around 59.4% of deaths occurred under 1 year of age, 57.0% were male, and 63.9% were of white ethnicity. Mortality rate (per 1,000,000 CYP per year) dropped from 274.2 (95% CI 264.8-283.8) in 2019-2020, to 242.2 (95% CI 233.4-251.2) in 2020-2021, increasing to 296.1 (95% CI 286.3-306.1) in 2022-2023. Overall, death rate reduced across Period 1 (Incidence rate ratio (IRR) 0.96 (95% CI 0.92-0.99)) and then increased across Period 2 (IRR 1.12 (95% CI 1.08-1.16)), and this pattern was also seen for death by Infection and Underlying Disease. In contrast, rate of death after Intrapartum events increased across the first period, followed by a decrease in rate in the second (Period 1 IRR 1.15 (95% CI 1.00-1.34)) versus Period 2 (IRR 0.78 (95% CI 0.68-0.91), pdifference = 0.004). Rates of death from preterm birth, trauma and sudden unexpected deaths in infancy and childhood (SUDIC), increased across the entire 4-year-study period (preterm birth, IRR 1.03 (95% CI 1.00-1.07); trauma IRR 1.12 (95% CI 1.06-1.20); SUDIC IRR 1.09 (95% CI 1.04-1.13)), and there was no change in the rate of death from Malignancy (IRR 1.01 (95% CI 0.95-1.06)). Repeating the analysis, split by child characteristics, suggested that mortality initially dropped and subsequently rose for children between 1 and 4years old (Period 1 RR 0.85 (95% CI 0.76-0.94) versus Period 2 IRR 1.31 (95% CI 1.19-1.43), pdifference < 0.001. For Asian, black and Other ethnic groups, we observed increased rates of deaths in the period 2021-2023, and a significant change in trajectory of death rates between Periods 1 and 2 (Asian (Period 1 IRR 0.93 (95% CI 0.86-1.01) versus Period 2 IRR 1.28 (95% CI 1.18-1.38), pdifference < 0.001); black (Period 1 IRR 0.97 (95% CI 0.85-1.10) versus Period 2 IRR 1.27 (95% CI 1.14-1.42), pdifference = 0.012); Other (Period 1 IRR 0.84 (95% CI 0.68-1.04) versus Period 2 IRR 1.45 (95% CI 1.20-1.75), pdifference = 0.003). Similar results were observed in CYP in the most deprived areas (Period 1 IRR 0.95 (95% CI 0.89-1.01) versus Period 2 IRR 1.18 (95% CI 1.12-1.25), pdifference < 0.001). There was no change in the trajectory of death rates for children from white (p = 0.601) or mixed (p = 0.823) ethnic backgrounds, or those in the least deprived areas (p = 0.832), between Periods 1 and 2; with evidence of a rise across the whole study period for children from white backgrounds (IRR 1.05 (95% CI 1.03-1.07), p < 0.001) and those in the least deprived areas (IRR 1.06 (95% CI 1.01-1.10), p < 0.001). Limitations include that the population at risk was estimated at a mid-point of the study, and changes may have biased our estimates. In particular, absolute rates should be interpreted with caution. In addition, child death in England is rare, which may further limit interpretation; particularly in the stratified analyses. In this study, overall child mortality in England after the national lockdowns was higher than before them. We observed different temporal profiles across the different causes of death, with reassuring trends in deaths from Intrapartum deaths after lockdowns were lifted. However, for all other causes of death, rates are either static, or increasing. In addition, the relative rate of dying for children from non-white backgrounds, compared to white children, is now higher than before or during the lockdowns.

Operative mortality traditionally has been defined as the rate within 30 days or during the initial hospitalization, and studies that established the volume-outcome relationship for pancreatectomy used similar definitions. Pancreatectomies reported to the National Cancer Data Base (NCDB) during 2007-2010 were examined for 30- and 90-day mortality. Unadjusted mortality rates were compared by type of resection, stage, comorbidities, and average annual hospital volume. Hierarchical logistic regression models generated risk-adjusted odds ratios for 30- and 90-day mortality. After 21,482 pancreatectomies, the unadjusted 30-day mortality rate was 3.7 % (95 % confidence interval [CI] 3.4-3.9 %), which doubled at 90 days to 7.4 % (95 % CI 7.0-7.8). The unadjusted and risk-adjusted mortality rates were higher at 30 days with increasing age, increasing stage, male gender, lower income, low hospital volume, resections other than distal pancreatectomy, Medicare or Medicaid insurance coverage, residence in a Southern census division, history of prior cancer, and multiple comorbidities. The lowest-volume hospitals (<5 per year) performed 19 % of the pancreatectomies, with a risk-adjusted odds ratios for mortality that were 4.2 times higher (95 % CI 3.1-5.8) at 30 days and remained 1.9 times higher (95 % CI 1.5-2.3) at 30-90 days compared with hospitals that had high volumes (≥40 per year). Mortality rates within 90 days after pancreatic resection are double those at 30 days. The volume-outcome relationship persists in the NCDB. Reporting mortality rates 90 days after pancreatectomy is important. Hospitals should be aware of their annual volume and mortality rates 30 and 90 days after pancreatectomy and should benchmark the use of high-volume hospitals.

Background: Evidence-based recommendations for the management of metastatic breast cancer (MBC) endorse confirmation of recurrence with biopsy and reassessment of biomarker status. National guidelines support numerous treatment options and do not capture the nuances of real-world practice. Real world data may demonstrate disparities in adherence to guidelines. Methods: We collaborated with Hutchinson Institute for Cancer Outcomes Research (HICOR) to link enrollment and insurance claims records with Washington State cancer registries from 2008-2017. Our cohort comprised of women &amp;gt; 18 years old with MBC who met enrollment criteria in one of four payors (Premara, Regence, Medicare, or Medicaid). We identified receipt of biopsy and biomarker re-assessment at time of recurrence, receipt of first line treatment, categorized as CDK4/6 inhibitors (CDKi), chemotherapy (CT), or hormone therapy (HT) and examined factors influencing these practice patterns. Results: We identified 1,101 patients with MBC (recurrent MBC, N = 715; de novo MBC, N = 386) with a median age of 66 (range 54 – 74). Of the patients with MBC, there were a total of 677 patients with ER+/HER2- MBC. Table 1 shows demographic data. Most of the cohort were White (89%). Approximately 15% of patients lived in areas of high deprivation (area of deprivation index, ADI, 8-10). Patients had either Commercial (47%), Medicaid (4%), Medicare (35%) or multiple (13%) insurance. Of the patients with recurrent MBC, 49.5% received a biopsy to confirm metastatic diagnosis. Similarly, 48.7% of recurrent MBC patients underwent biomarker reassessment. Patients with highest co-morbidity index (2) were more likely to undergo biopsy confirmation (20.3% vs 13.0%, p = 0.02). Biopsy was more often performed at recurrence in patients receiving care at a high-volume center (74.3% vs 67.6%, p = 0.03) compared to low volume center (18.6% vs 26.6%, p = 0.03). First line treatment selection was directly associated with receipt of biopsy and biomarker testing. Hormone therapy only was more common in patients who did not undergo biopsy (62.3% vs 37.7%, p &amp;lt; 0.001) or biomarker reassessment (62.7% vs 37.3%, p &amp;lt; 0.001). Of the patients with ER+/HER2- MBC, the majority of patients received ET alone (69%), followed by chemotherapy (22%), and CDK4/6i + ET (9%). Dual agent CT was the more commonly prescribed compared to single agent in those who received CT (56% vs 44%). The majority of patients who received CDKi + ET were &amp;lt; 65 years old (65.2%, p &amp;lt; 0.02). Insurance influenced first line therapy selection and patients with commercial insurance were more likely to receive CDK4/6i + ET compared to those with Medicare/Medicaid. (60.9% vs 26.1%, p = 0.10). Patients with de novo MBC were more likely to receive CT (43.1% vs 13.4%, p &amp;lt; 0.001) and less likely to receive ET alone (47.9% vs 78.0%, p &amp;lt; 0.001). Almost all patients treated with CDK4/6i + ET received care a high-volume center (91.3%, p = 0.11). Conclusion:Our findings highlight key gaps for future investigations in the management of MBC and serve as a launching point for new patient-centered and quality-promoting research initiatives. Table 1: Baseline Demographics 1# of patients treated annually, high = &amp;gt;100, medium 25-100, low &amp;lt;25. Citation Format: Poorni Manohar, Hannah Linden, Veena Shankaran, Catherine Fedorenko, Jenna Voutsinas, Qin Sun, Vicky Wu. Real-world practice patterns in the management of metastatic breast cancer in Washington State [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-47.

Count Data in Medical Research: Poisson Regression and Negative Binomial Regression