University Hospitals Geauga Medical Center

PURPOSE: Results of a study of economic and patient satisfaction outcomes of implementing a "layered learning model" (LLM) in a community hospital are presented. METHODS: An LLM consisting of a clinical pharmacist, two postgraduate year 1 pharmacy residents, and pharmacy students participating in rounds and providing patient education was implemented at a small community hospital. The primary endpoint was the difference in mean total drug cost per discharge in cases managed by physicians who rounded with pharmacy representatives (the intervention group) and cases managed by physicians who rounded with no pharmacist present (the control group). Secondary outcomes were drug expenditures associated with eight common diagnoses and patient satisfaction scores in medication education domains of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Statistical analysis was performed using Student's t test and chi-square tests. RESULTS: The intervention-group data comprised 2737 hospital discharges, as compared with 3983 discharges for the control group. The geometric mean total drug cost per discharge was $161.52 for the intervention group, as compared with $210.15 for the control group (difference, $48.63; p < 0.001); drug costs for pneumonia and urinary tract infection were significantly lower for the intervention group. Patient satisfaction scores were significantly improved in the intervention group relative to baseline scores (8th percentile versus 39th percentile, p < 0.001). CONCLUSION: Implementation of the LLM in a small community hospital reduced medication costs and improved HCAHPS patient satisfaction scores.

STUDY OBJECTIVE: Tramadol is metabolized by cytochrome P450 (CYP) 2D6 to form an active metabolite that exhibits its analgesic effect. Medications that inhibit this enzyme are used often in practice, yet the clinical impact of this interaction on the analgesic effects of tramadol has yet to be fully described. The objective was to determine whether a clinically relevant decrease in pain control is observed in patients taking scheduled tramadol concomitantly with a strong CYP2D6 inhibitor. DESIGN: Retrospective cohort study. SETTING: Large health care system. PATIENTS: One hundred fifty-two adult inpatients who received scheduled tramadol for at least 24 hours with (76 patients) or without (76 patients) a strong CYP2D6 inhibitor between January 1, 2012, and February 28, 2017, were included in the analysis. Patients hospitalized for opioid use disorder or those receiving substandard dosing of tramadol were excluded. MEASUREMENTS AND MAIN RESULTS: The primary outcome was mean breakthrough opiate consumption in the presence and absence of CYP2D6 inhibitors. Secondary outcomes included mean pain scores, length of hospital stay, tramadol discontinuation rates, and prespecified subgroup analyses based on patient sex, race, and specific CYP2D6 inhibitor administered. Patients receiving concurrent CYP2D6 inhibitors required significantly more breakthrough morphine milligram equivalents per day compared with patients receiving scheduled tramadol without CYP2D6 inhibitors (geometric mean ± SD 18.2 ± 6.3 vs 5.7 ± 6.7 mg morphine milligram equivalents, p<0.001). No significant differences existed between cohorts for mean pain score, length of hospital stay, or tramadol discontinuation rate. CONCLUSION: This study demonstrated a clinically relevant decrease in the efficacy of tramadol when used for pain control in patients receiving a strong CYP2D6 inhibitor. These results should encourage clinicians to review medication lists for this interaction and adjust regimens accordingly to ensure adequate pain control.

OBJECTIVE: The number of procedures conducted within the radiology department using moderate sedation is rising. Anecdotal evidence suggests that there is an inconsistency in the education of radiology trainees regarding moderate sedation. CONCLUSION: The purpose of this article is to give an overview and concise summary of the use of moderate sedation as put forth by the American Society of Anesthesia, American College of Radiology, and Society of Interventional Radiology. In addition, we will review the commonly used medications for moderate sedation and their reversal agents.

In myeloma, achievement of very good partial response (VGPR) post-transplant is associated with prolonged overall (OS) and progression-free survival (PFS). In this study of bortezomib, pegylated liposomal doxorubicin, and dexamethasone (VDD) in 40 patients with newly diagnosed myeloma (median follow-up 45.1 months), 2-/4-year OS estimates were 95.7%/86.5% versus 82.4%/58.2% for patients achieving ≥VGPR versus <VGPR to VDD (p=0.0241). In 30 patients undergoing transplant, PFS (p = 0.0357) and OS (p = 0.0272) were longer in patients achieving ≥VGPR to VDD. Achievement of ≥VGPR was predicted by a novel model based on occurrence after two cycles of ≥90% involved free light chain reduction, free light kappa/lambda ratio normalization, and/or ≥90% M-protein reduction. Prediction of ≥VGPR was associated with superior PFS and OS in patients with transplant. These findings emphasize the importance of achieving ≥VGPR to initial therapy, associated with prolonged OS. The predictive model provides a potential basis for developing individualized therapy, which requires further study.

BACKGROUND: Technologies that enhance motor learning-based therapy and are clinically deployable may improve outcome for those with neurological deficits. The MyoPro™ is a customized myoelectric upper extremity orthosis that utilizes volitionally generated weak electromyographic signals from paretic muscles to assist movement of an impaired arm. Our purpose was to evaluate MyoPro as a tool for motor learning-based therapy for individuals with chronic upper limb weakness. METHODS: = 6) who participated in a single group interventional study consisting of 2 phases. The in-clinic phase included 18 sessions (2x per week, 27hrs of face-to-face therapy) plus a home exercise program. The home phase included practice of the home exercise program. The study did not include a control group. Outcomes were collected at baseline and at weeks 3, 5, 7, 9, 12, 15, and 18. Statistics included mixed model regression analysis. RESULTS: Statistically significant and clinically meaningful improvements were observed on Fugl-Meyer (+7.5 points). Gains were seen at week 3, increased further through the in-clinic phase and were maintained during the home phase. Statistically significant changes in Modified Ashworth Scale, Range of Motion, and Chedoke Arm and Hand Activity Inventory were seen early during the in-clinic phase. Orthotic and Prosthetic User's Survey demonstrated satisfaction with the device throughout study participation. Both stroke and TBI participants responded to the intervention. CONCLUSIONS: Use of MyoPro in motor learning-based therapy resulted in clinically significant gains with a relatively short duration of in-person treatment. Further studies are warranted. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier: NCT03215771.

Accreditation standards set forth by the American Society of Health‐System Pharmacists note that postgraduate year one programs should have a formal process in place to screen candidates based upon predetermined criteria to ensure applicants have the appropriate qualifications to complete residency training. This standard encourages programs to have a set of consistent criteria and an objective approach to evaluate each applicant. As a result, many programs rely heavily on accessible metrics, such as grade point average (GPA), to quickly compare candidates. The GPA has many flaws that, if utilized by residency programs, could result in screening out highly qualified candidates early in the application review process who possess the skills that residency program directors covet, such as work ethic, passion, adaptability, leadership, research experience, communication skills, professionalism, cultural competency, and personality fit. To identify qualified candidates for postgraduate residency training, the application review process must be reexamined to promote a more holistic approach, going beyond the student's ability in the classroom. Further discussion is needed regarding the pros and cons of utilization of standardized and consistent assessments of residency applicants' knowledge, skills, behaviors, and attitudes to complete a holistic review of candidates as discussed in this article. Further research is needed to identify the factors defining a successful resident and tools to predict those factors.

INTRODUCTION: The development of molecularly targeted anticancer therapies and immunotherapy continues to revolutionize the treatment of cancer. FDA accelerated approvals of novel targeted therapies allowed for introduction of these agents into the clinic at a rapid rate. On-and off-target ocular toxicities are prevalent treatment-related adverse events of newer therapies including antibody drug conjugates (ADCs) and immunotherapy. Ocular toxicities associated with ADCs and immunotherapy have heterogeneous presentations and pathogenesis requiring unique and often complex monitoring, and management. AREAS COVERED: In this article, we provide an updated review of treatment-emergent ocular toxicity associated with new and novel oncologic therapies and summarize guidelines and best practice strategies for prevention, monitoring and management. A literature search was performed through PubMed, ClinicalTrials.gov, and FDA website (1 January 2017 to 10 May 2023) to identify relevant information. EXPERT OPINION: The implementation of a strategy for monitoring, prevention, and management of treatment-related ocular toxicities involves a multi-disciplinary, often cross-center approach. Communication with infusion nursing leadership, clinic staff, and eye care providers is crucial to the successful implementation of eye care plans to prevent and manage ocular toxicity.

PURPOSE: This article highlights one health system's response to the market influx of biosimilars with the establishment of a process for formulary review and selection of preferred agents and support for therapeutic interchanges. SUMMARY: Through assessment of available literature, insurance payor coverage, and manufacturer-anticipated approvals of biosimilars, a strategic stance was developed to guide biosimilar order preparation, review, adoption, and implementation. The electronic medical record (EMR) is prepared for biosimilar implementation at least 6 to 12 months ahead of anticipated formulary review. The review includes assessment of a class (reference product and available biosimilars) after at least 2 biosimilars become available. Key health-system departments and clinicians are enlisted to support review of clinical, safety, and economic implications. Implementation of a preferred product relies on standard education, formulary availability, and staff awareness to address any perceived patient safety concerns and gather provider support. The standard steps developed now apply to all future biosimilar reviews, adoption plans, and ongoing monitoring. Barriers evaluated include changes in payor coverage and challenges in preparation of the EMR for future biosimilars, meeting precertification team education needs, and providing operational support for pharmacy inventory. CONCLUSION: To date, use of 5 preferred biosimilar products has led to significant cost savings to the institution, and the process has been endorsed by providers. The institution's successes can be attributed to clear communication with stakeholders and the development of a deliberate process, led by a multidisciplinary leadership team, for managing formulary, safety, and operational barriers in a thoughtful and systematic manner.

Objective: The objective was to compare task performance in individuals with upper limb impairments with and without a myoelectric arm orthosis. Design: Three-month observational study. Participants met at 4 time points after receiving their myoelectric orthosis (2-Weeks, Month-1, Month-2, Month-3) to complete 4 standardized common daily tasks. Setting: Nationwide sessions completed remotely over videoconference calls at home. There were no specific clinic affiliations. Participants: Adults with upper limb impairment due to stroke who were in the process of being fit with a myoelectric arm orthosis as a first-time user. Interventions: The orthosis was a custom-fabricated myoelectric arm orthosis called the MyoPro®. Main Outcome Measures: Functional tasks were completed at each session with and without the MyoPro. Participants were evaluated on their success and the time required to complete each functional task. Longitudinal mixed and longitudinal mixed logistic regression models were analyzed. Results: Eighteen individuals with chronic arm weakness due to stroke were included in the analysis. Statistically significant and clinically meaningful improvements were observed on the functional tasks in the participants' homes. By 3 months, participants successfully used the MyoPro to accomplish the tasks, reduced the amount of time spent to complete the tasks, and had a higher probability of success as compared with at 2 weeks. With the MyoPro, participants showed significant improvement in overall task completion and completed the tasks in a significantly decreased time as compared with without the MyoPro. Conclusions: The MyoPro provides a stabilizing support to the weak arm of individuals after stroke and enables individuals to use their impaired arm to complete functional tasks independently in the home environment.

OBJECTIVE: Metformin is the first-line oral type 2 diabetes treatment. Despite an abundance of evidence, metformin is routinely underused. This study evaluated the rates of metformin use in an appropriate outpatient type 2 diabetes population and identified predictors of metformin use. METHODS: A national cross-sectional study was conducted using data from the National Ambulatory Medical Care Survey. Office visits involving patients aged 18-79 years with a diagnosis of type 2 diabetes were included, and visits involving patients with a diagnosis of chronic renal failure or heart failure were excluded. The primary outcome was metformin-prescribing rate. Multivariate logistic regression identified variables associated with metformin prescribing. RESULTS: A total of 2348 patient visits were eligible for inclusion, representing 88,671,714 office visits nationally. Metformin was continued or initiated in 40.6% of these visits. The strongest independent predictors of metformin prescribing were insulin use (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.21-0.47), presence of four or more chronic conditions (OR 0.58; 95% CI 0.34-0.98), patients with Medicare insurance (OR 0.57; 95% CI 0.39-0.83), visit with a surgical specialist (OR 0.39; 95% CI 0.25-0.61) or a medical specialist (OR 0.59; 95% CI 0.38-0.92), and Hispanic ethnicity (OR 2.03; 95% CI 1.28-3.22). CONCLUSION: Metformin-prescribing rates are low, particularly in patients receiving insulin, with Medicare insurance, seen by medical or surgical specialists, or with four or more chronic conditions. The observed low rates of metformin use represent an important opportunity to improve the quality of care for patients with type 2 diabetes.

OBJECTIVE: To evaluate the net clinical benefit of tranexamic acid use in patients undergoing total knee or total hip replacement. METHODS: This is a retrospective study of patients undergoing total knee or total hip replacement. The primary outcome was the net clinical benefit of tranexamic acid use. Secondary outcomes included length of stay, incidence of venous thromboembolism, change in hemoglobin, and number of units of blood transfused. RESULTS: Four hundred and six patients were screened for inclusion and 327 patients met inclusion criteria; 174 patients received tranexamic acid versus 153 patients who received usual care. Tranexamic acid demonstrated a positive net clinical benefit versus usual care (40.8% vs 13.7%, P < .01) but did not affect length of stay (3.39 vs 3.37 days, respectively, P = .76). Venous thromboembolism was comparable between groups (2.3% vs 0.7%, P = .38). Average change in hemoglobin and need for transfusion were lower in the treatment group versus the usual care group, respectively (3.46 vs 4.26 mg/dL, P < .01). CONCLUSION: Tranexamic acid demonstrated a significant benefit in decreasing change in hemoglobin as well as the need for blood transfusion with no increase in the risk of venous thromboembolism in patients undergoing total knee or total hip replacement.

WHAT IS KNOWN AND OBJECTIVE: Current evidence-based guidelines for the treatment of acute low back pain (ALBP) recommend the use of opioid medications only after failure of nonpharmacological therapy, non-steroidal anti-inflammatory drugs and skeletal muscle relaxants and after thorough evaluation of risks and benefits. Despite this recommendation and the state of the opioid epidemic in the United States (US), opioids remain a common drug of choice for ALBP in the emergency department (ED). The purpose of this study was to quantify the prevalence and identify predictors of opioid prescribing for acute lower back pain (ALBP) in emergency departments (EDs) in the United States. METHODS: This was a national, cross-sectional study of the National Hospital Ambulatory Care Survey from 2013-2016. ED visits for patients aged ≥18 years treated for ALBP were included. Patients presenting with specified reasons that an opioid may be indicated were excluded. The primary endpoint was frequency of opioids prescribed. A multivariate logistic regression model identified patient- and provider-level predictors of opioid use. RESULTS AND DISCUSSION: This analysis included 2260 visits for ALBP. Opioids were prescribed in 32.3% of visits. Positive predictors of opioid prescribing were pain score of 7-10 (OR 1.85; 95% CI 1.26-2.70), and patients seen in the Southern (OR 2.53; 95% CI 1.47-4.36) or Western US (OR 2.10; 95% CI 1.19-3.70). Opioids were prescribed less often to patients who received a NSAID or acetaminophen (OR 0.38; 95% CI 0.28-0.52 and OR 0.03; 95% CI 0.01-0.10, respectively). WHAT IS NEW AND CONCLUSION: Opioid prescribing rates for ALBP remain high and the predictors identified demonstrate that this prescribing pattern is not uniformly distributed across the patient and provider characteristics studied.

Pharmacy residency programs have become increasingly competitive in recent years, and changes to the residency search and application process have altered the process for matching with a residency. In this article, major residency topics, from the benefits of residency training to searching for and ranking programs, are summarized. A discussion of tips and tricks for applying for residencies and interviewing for positions is included along with specific suggestions developed with data following the implementation of the Pharmacy Online Residency Centralized Application Service (PhORCAS). The article is organized in a question and answer format to help facilitate understanding of key concepts and common questions that may arise from applicants. Many changes have taken place in the residency search and application process in recent years, and the process of obtaining a residency is complex. Residency applicants and those advising applicants may find value in the answers to commonly asked residency application questions to help ensure the greatest chance of a successful residency match.

Background and Objective In the United States, hypertension remains a significant cause of cardiovascular disease mortality and morbidity, affecting various racial and ethnic groups. High blood pressure is a common health concern, given its high frequency among all populations and racial groups in the United States; nevertheless, the condition remains untreated in most individuals. It affects a significant number of individuals in the African American community and contributes to a notable proportion of deaths. Arguably more prevalent, severe, and tends to occur earlier in African Americans compared to some other races. This lack of blood pressure control may contribute to the increasing mortality rates associated with hypertension-related cardiovascular diseases in the United States, while notable race and sex disparities persist. This study aims to compare the number of deaths caused by each cardiovascular disease (hypertension) in African Americans to those of people of other races. Methodology To understand the impact of hypertension on mortality rates among different racial groups, this study utilized the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) dataset, which includes death certificates filed in the United States. The research focused on individuals aged 25 years or older with a mention of hypertension and cardiovascular disease as the underlying cause of death between 1999 and 2019. The study analyzed hypertension-associated deaths by different cardiovascular disease subtypes, such as ischemic heart disease, heart failure (HF), and cerebrovascular diseases that include acute ischemic attacks, which are the most frequent in the United States, with specific assessments for African Americans, White, and other races' decedents. Results The study findings indicated that African American males had higher mortality rates from cardiovascular diseases compared to African American females. The prevalence of hypertension was also higher among African Americans (87.47%) compared to Whites (30.33%), Asian/Pacific Islanders (40.26%), and American Indians/Alaska Natives (61.18%). Additionally, the study identified regional variations in mortality rates, with states like Arizona, California, Texas, Florida, and Washington having higher rates, while Vermont, North Dakota, and Wyoming had lower rates. The northwest region had lower mortality compared to the western and southwestern regions. Conclusions Within the studied period, there was an increase in the prevalence of mortality due to hypertension amongst African Americans when compared to other races. These findings underscore the pressing need to address the increasing prevalence of hypertension and mortality rates among African American. More efforts should focus on prevention of CVD and hypertension and the associated risk factors based on the World Health Organization (WHO) recommendations, which include the promotion of healthy lifestyle behaviors, improvement of access to quality healthcare, and implementation of culturally sensitive interventions tailored for African American communities.

Background: Citation counts have often been used as a surrogate for the scholarly impact of a particular study, but they do not necessarily correlate with higher-quality investigations. In recent decades, much of the literature regarding shoulder instability is focused on surgical techniques to correct bone loss and prevent recurrence. Purpose: To determine (1) the top 50 most cited articles in shoulder instability and (2) if there is a correlation between the number of citations and level of evidence or methodological quality. Study Design: Cross-sectional study. Methods: A literature search was performed on both the Scopus and the Web of Science databases to determine the top 50 most cited articles in shoulder instability between 1985 and 2019. The search terms used included “shoulder instability,” “humeral defect,” and “glenoid bone loss.” Methodological scores were calculated using the Modified Coleman Methodology Score (MCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS) score. Results: The mean number of citations and mean citation density were 222.7 ± 123.5 (range, 124-881.5) and 16.0 ± 7.9 (range, 6.9-49.0), respectively. The most common type of study represented was the retrospective case series (evidence level, 4; n = 16; 32%) The overall mean MCMS, Jadad score, and MINORS score were 61.1 ± 10.1, 1.4 ± 0.9, and 16.0 ± 3.0, respectively. There were also no correlations found between mean citations or citation density versus each of the methodological quality scores. Conclusion: The list of top 50 most cited articles in shoulder instability comprised studies with low-level evidence and low methodological quality. Higher-quality study methodology does not appear to be a significant factor in whether studies are frequently cited in the literature.

Objective: Although preventable through established infection control practices, catheter-associated urinary tract infections (CAUTIs) remain prevalent in acute-care settings. Our goal was to improve the CAUTI rates through multiple hospitals through implementing sustainable practices, including enhancing communication, provider engagement, accountability, and transparency in reporting to achieve long-term improvements. Design: Quality improvement with multiple levels of interventions. Setting: A health system in northern Ohio with 21 affiliated hospitals across 16 counties. Patients: Adult patients admitted to the hospital between June 2020 and June 2023. Methods: A broad set of quality improvement (QI) strategies was developed by an interdisciplinary team and guided by the Fractal Management System framework to ensure accountability, communication, and alignment across teams and facilities. Key drivers were indwelling urinary catheter (IUC) alternatives, insertion, maintenance, removal, and smart diagnostics. The main outcome measures were standardized infection ratios (SIR) and standardized utilization ratio (SUR), comparing period 1 (P1, June 2020 to December 2021) and period 2 (P2, January 2022 to June 2023). Results: Enhanced communication and management played crucial roles in minimizing IUC placement. Updated policies and protocols, coupled with clear guidelines and decision support tools, facilitated effective urinary management. Performance tracking and visual management boards provided real-time insights, while collaborative efforts, including staff huddles and multidisciplinary teamwork, ensured consistent adherence to best practices. Conclusions: A systemwide QI initiative focused on enhanced communication, management, and collaboration contributed to improved SIR and reduced CAUTI rates across multiple hospitals, highlighting the impact of strong communication and proactive management in healthcare settings.

Background: Selective anti-polysaccharide antibody deficiency (SPAD) with CD5 B-cell predominance and autoimmune phenomena was identified in a male cohort first reported by Antall et al in 1999. The phenotypically likewise and genotypically identical X-linked immunodeficiency with magnesium defect, Epstein-Barr Virus infection, and neoplasia (XMEN) disease was defined as a novel primary immunodeficiency (PID) in 2011. Recent studies of the magnesium transporter 1 (MAGT1) gene mutation reveal glycosylation defects contributing to more phenotypic variance than the "XMEN" title pathologies. The updated title, "X-linked MAGT1 deficiency with increased susceptibility to EBV-infection and N-linked glycosylation defect," was proposed in 2020. Objectives: To reflect the patient population more accurately, a prospective classification update may consider MAGT1 glycobiological errors contributing to phenotypic variance but also pre-genetic testing era reports with CD5 B-cell predominance. Methods: Patient 1 from Antall et al presented at 28 years of age for further immunological evaluation of his CD5/CD19 B-cell predominance diagnosed at 5 years old. Design: Immune re-evaluation done through flow cytometry and next-generation sequencing. Results: Flow cytometry B-cell phenotyping revealed persistent CD5+CD19+ (93%). Flow cytometric histogram quantified reduced activator CD16+CD56+ natural killer and CD8+ T-cell receptor, Group 2, Member D (NKG2D) glycoprotein expression. A c.923-1_934 deletion loss of function mutation was identified in the MAGT1 gene. Conclusion: We suggest the novel PID XMEN, based on its CD5 B-cell predominance, had been discovered and reported over a decade earlier as CD5+ PID based on the MAGT1 mutation found in the same. We encourage consideration of combining these labels and recent findings to offer the most accurate classification of this disease.

Background/Objectives: Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) are non-melanoma skin cancers (NMSCs) and the most prevalent cancers in the United States. Image-guided superficial radiotherapy (IGSRT) is a relatively new treatment option that uses high-resolution dermal ultrasound integrated with superficial radiotherapy to improve tumor visualization. IGSRT is a clinically equivalent non-surgical alternative to Mohs micrographic surgery at 2 years of follow-up in early-stage NMSC, but larger cohort studies with longer follow-up periods that allow for analysis of patient outcomes by demographic and disease characteristics are needed. Methods: This large, retrospective cohort study was conducted to determine the effect of risk factors (tumor location, tumor stage, and sex) on 2-, 4-, and 6-year freedom from recurrence rates in 19,988 NMSC lesions treated with IGSRT, including lesions with complete treatment courses. Results: Overall freedom from recurrence rates were 99.68% at 2 years, 99.54% at 4 years, and 99.54% at 6 years; rates did not differ significantly by tumor location (head/neck versus other locations, p = 0.9) or sex (male versus female, p = 0.4). In contrast, there was a significant difference in freedom from recurrence rates when analyzed by tumor stage (p = 0.004). Conclusions: There was no significant effect of tumor location or sex on freedom from recurrence in IGSRT-treated NMSC. Although there was a significant difference according to tumor stage, freedom from recurrence rates exceeded 99% at all stages.

Non-melanoma skin cancers (NMSCs), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are highly prevalent and a significant cause of morbidity. Image-guided superficial radiation therapy (IGSRT) uses integrated high-resolution dermal ultrasound to improve lesion visualization, but it is unknown whether efficacy varies by histology. This large retrospective cohort study was conducted to determine the effect of tumor histology on freedom from recurrence in 20,069 biopsy-proven NMSC lesions treated with IGSRT, including 9928 BCCs (49.5%), 5294 SCCs (26.4%), 4648 SCCIS cases (23.2%), and 199 lesions with ≥2 NMSCs (1.0%). Freedom from recurrence at 2, 4, and 6 years was 99.60%, 99.45%, and 99.45% in BCC; 99.58%, 99.49%, and 99.49% in SCC; and 99.96%, 99.80%, and 99.80% in SCCIS. Freedom from recurrence at 2, 4, and 6 years following IGSRT did not differ significantly comparing BCC vs. non-BCC or SCC vs. non-SCC but were slightly lower among SCCIS vs. non-SCCIS (p = 0.002). There were no significant differences in freedom from recurrence when stratifying lesions by histologic subtype. This study demonstrates that there is no significant effect of histology on freedom from recurrence in IGSRT-treated NMSC except in SCCIS. These findings support IGSRT as a first-line therapeutic option for NMSC regardless of histology.

Background: Non-melanoma skin cancers (NMSCs) are the most common cancers in the United States. Image-guided superficial radiation therapy (IGSRT) is an effective treatment for NMSCs. Patient comorbidities and socioeconomic status (SES) are known contributors to health disparities. However, the impact of comorbidities or SES on the outcomes of IGSRT-treated NMSCs has not yet been studied. This study evaluated freedom from recurrence in IGSRT-treated NMSCs stratified by SES and the number of comorbidities. Methods: This large retrospective cohort study evaluated associations between SES (via Area Deprivation Index (ADI)) or comorbidity (via Charlson Comorbidity Index (CCI)) and 2-, 4-, and 6-year year freedom from recurrence in patients with IGSRT-treated NMSC (n = 19,988 lesions). Results: Freedom from recurrence in less (ADI ≤ 50) vs. more (ADI &gt; 50) deprived neighborhoods was 99.47% vs. 99.61% at 6 years, respectively (p = 0.2). Freedom from recurrence in patients with a CCI of 0 (low comorbidity burden) vs. a CCI of ≥7 (high comorbidity burden) was 99.67% vs. 99.27% at 6 years, respectively (p = 0.9). Conclusions: This study demonstrates that there are no significant effects of SES or comorbidity burden on freedom from recurrence in patients with IGSRT-treated NMSC. This supports the expansion of IGSRT in deprived neighborhoods to increase access to care, and IGSRT should be a consideration even in patients with a complex comorbidity status.