Dataset Information

Socioeconomic Disparities in Mortality Among Women With Incident Breast Cancer Before and After Implementation of Medicare Part D.

ABSTRACT: Breast cancer patients exhibit survival disparities based on socioeconomic status (SES). Disparities may be attributable to access to expensive oral endocrine agents.Define recent socioeconomic disparities in breast cancer survival and determine whether these improved after implementation of the Medicare Part D program.Difference-in-difference natural experiment of women diagnosed and treated before or after implementation of Medicare Part D.Female Medicare beneficiaries with early-stage breast cancer: 54,772 diagnosed in 2001 and 46,371 in 2007.SES was based on Medicaid enrollment and zip code per capita income, all-cause mortality from Medicare, and cause of death from National Death Index.Among women diagnosed pre-Part D, 40.5% of poor beneficiaries had died within 5 years compared with 20.3% of high-income women (P<0.0001). Post-Part D, 33.6% of poor women and 18.4% of high-income women died by 5 years. After adjustment for potential confounders, improvement in all-cause mortality post-Part D was greater for poorer women compared with more affluent women (P=0.002). However, absolute improvement in breast cancer-specific mortality was 1.8%, 1.2%, and 0.8% (P=0.88 for difference in improvement by SES), respectively for poor, near-poor, and high-income women, whereas analogous improvement in mortality from other causes was 5.1%, 3.8%, and 0.9% (P=0.067 for difference in improvement by SES).Large survival disparities by SES exist among breast cancer patients. The Part D program successfully ameliorated SES disparities in all-cause mortality. However, improvement was concentrated in causes of death other than breast cancer, suggesting remaining gaps in care.

SUBMITTER: Nattinger AB

PROVIDER: S-EPMC5391268 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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Socioeconomic Disparities in Mortality Among Women With Incident Breast Cancer Before and After Implementation of Medicare Part D.

Nattinger Ann B AB Wozniak Erica M EM McGinley Emily L EL Li Jianing J Laud Purushottam P Pezzin Liliana E LE

Medical care 20170501 5

<h4>Background</h4>Breast cancer patients exhibit survival disparities based on socioeconomic status (SES). Disparities may be attributable to access to expensive oral endocrine agents.<h4>Objectives</h4>Define recent socioeconomic disparities in breast cancer survival and determine whether these improved after implementation of the Medicare Part D program.<h4>Design</h4>Difference-in-difference natural experiment of women diagnosed and treated before or after implementation of Medicare Part D.< ...[more]

PMID: 28030476

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Project description:Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance.ContextDisparities in breast cancer survival by socioeconomic status (SES) exist despite the "safety net" programs Medicare and Medicaid. What is less clear is the extent to which SES disparities affect various racial and ethnic groups and whether causes differ across populations.MethodsWe conducted a tapered matching study comparing 1,890 low-SES (LSES) non-Hispanic white, 1,824 black, and 723 Hispanic white women to 60,307 not-low-SES (NLSES) non-Hispanic white women, all in Medicare and diagnosed with invasive breast cancer between 1992 and 2010 in 17 US Surveillance, Epidemiology, and End Results (SEER) regions. LSES Medicare patients were Medicaid dual-eligible and resided in neighborhoods with both high poverty and low education. NLSES Medicare patients had none of these factors.Measurements5-year and median survival.FindingsLSES non-Hispanic white patients were diagnosed with more stage IV disease (6.6% vs 3.6%; p < 0.0001), larger tumors (24.6 mm vs 20.2 mm; p < 0.0001), and more chronic diseases such as diabetes (37.8% vs 19.0%; p < 0.0001) than NLSES non-Hispanic white patients. Disparity in 5-year survival (NLSES - LSES) was 13.7% (p < 0.0001) when matched for age, year, and SEER site (a 42-month difference in median survival). Additionally, matching 55 presentation factors, including stage, reduced the disparity to 4.9% (p = 0.0012), but further matching on treatments yielded little further change in disparity: 4.6% (p = 0.0014). Survival disparities among LSES blacks and Hispanics, also versus NLSES whites, were significantly associated with presentation factors, though black patients also displayed disparities related to initial treatment. Before being diagnosed, all LSES populations used significantly less preventive care services than matched NLSES controls.ConclusionsIn Medicare, SES disparities in breast cancer survival were large (even among non-Hispanic whites) and predominantly related to differences of presentation characteristics at diagnosis rather than differences in treatment. Preventive care was less frequent in LSES patients, which may help explain disparities at presentation.

Project description:ImportanceIn patients with paroxysmal atrial fibrillation (AF), rhythm control with either antiarrhythmic drugs (AADs) or catheter ablation has been associated with decreased symptoms, prevention of adverse remodeling, and improved cardiovascular outcomes. Adoption of advanced cardiovascular therapeutics, however, is often slower among patients from racial/ethnic minority groups and those with lower income.ObjectiveTo ascertain the cumulative rates of AAD and catheter ablation use for the management of paroxysmal AF and to investigate for the presence of inequities in AF management by evaluating the association of race/ethnicity and socioeconomic status with their use in the United States.Design, setting, and participantsThis cohort study obtained inpatient, outpatient, and pharmacy claims data from the Optum Clinformatics Data Mart between October 1, 2015, and June 30, 2019. Adult patients (aged ≥18 years) in the database with a diagnosis of incident paroxysmal AF were identified. Patients were excluded if they did not have continuous insurance enrollment for at least 1 year before and at least 6 months after study entry.ExposuresRace/ethnicity and zip code-linked median household income.Main outcomes and measuresTreatment with a rhythm control strategy, and catheter ablation specifically, among those who received rhythm control. Multivariable logistic regression models were used to assess the association of race/ethnicity and zip code-linked median household income with a rhythm control strategy (AADs or catheter ablation) vs a rate control strategy as well as with catheter ablation vs AADs among those receiving rhythm control.ResultsOf the 109 221 patients who met the inclusion criteria, 55 185 were men (50.5%) and 73 523 were White (67.3%), with a median (interquartile range) age of 75 (68-82) years. A total of 86 359 patients (79.1%) were treated with rate control, 19 362 patients (17.7%) with AADs, and 3500 (3.2%) with catheter ablation. Between 2016 and 2019, the cumulative percentage of patients treated with catheter ablation increased from 1.6% to 3.8%. In multivariable analyses, Black race (adjusted odds ratio [aOR], 0.89; 95% CI, 0.83-0.94; P < .001) and lower zip code-linked median household income (aOR for <$50 000: 0.83 [95% CI, 0.79-0.87; P < .001]; aOR for $50 000-$99 999: 0.92 [95% CI, 0.88-0.96; P = <.001] compared with ≥$100 000) were independently associated with lower use of rhythm control. Latinx ethnicity (aOR, 0.73; 95% CI, 0.60-0.89; P = .002) and lower zip code-linked median household income (aOR for <$50 000: 0.61 [95% CI, 0.54-0.69; P < .001]; aOR for $50 000-$99 999: 0.81 [95% CI, 0.72-0.90; P < .001] compared with ≥$100 000) were independently associated with lower catheter ablation use among those receiving rhythm control.Conclusions and relevanceThis study found that despite increased use of rhythm control strategies for treatment of paroxysmal AF, catheter ablation use remained low and patients from racial/ethnic minority groups and those with lower income were less likely to receive rhythm control treatment, especially catheter ablation. These findings highlight inequities in paroxysmal AF management based on race/ethnicity and socioeconomic status.

Project description:Black patients with peripheral arterial disease undergo amputation at two to four times the rate of white patients. In order to determine whether differences in attempts at limb salvage might contribute to this disparity, we studied the limb care received prior to amputation by black patients compared with whites.Using inpatient Medicare data for the years 2003 through 2006, we identified a retrospective sample of all beneficiaries who underwent major lower extremity amputation. "Limb salvage care" was defined as limb-related admissions and procedures that occurred during the 2 years prior to amputation. We used multiple logistic regression to compare rates of revascularization and other limb care received by black versus white amputees, adjusting for individual patient characteristics. We then controlled for hospital referral region in order to assess whether differences in care might be attributable to the geographic regions in which black and white patients received care. Finally, we examined the timing of revascularization relative to amputation for both races.Our sample included 24,600 black and 65,881 white amputees. Compared with whites, black amputees were more likely to be female and had lower socioeconomic status. Average age, rates of diabetes, and levels of comorbidity were similar between races. Black amputees were significantly less likely than whites to have undergone revascularization (23.6% vs 31.6%; P < .0001), any limb-related admission (39.6% vs 44.7%; P < .0001), toe amputation (12.9% vs 13.8%; P < .0005), or wound debridement (11.6% vs 14.2%; P < .0001) prior to amputation. After adjusting for differences in individual patient characteristics, black amputees remained significantly less likely than whites to undergo revascularization (odds ratios [OR], 0.72 [95% confidence interval, .68-.76]), limb-related admission (OR, 0.81 [0.78-0.84]), or wound debridement prior to amputation (OR, 0.80 [0.75-0.85]). Timing of revascularization relative to amputation was similar between races. Observed differences in care were shown to exist within hospital referral regions and were not accounted for by regional differences in where black and white patients received care.Black patients are much less likely than whites to undergo attempts at limb salvage prior to amputation. Further studies should explore whether this disparity might be attributable to race-related differences in severity of arterial disease, patient preferences, or physician decision making.

Project description:BackgroundStroke has become a significant public health issue in China. Although studies have shown that women's age at first live birth (AFLB) might be associated with incident stroke, there is limited evidence on this relationship among Chinese parous women. Likewise, the nature of this association across urban-rural socioeconomic status (SES) has yet to be explored. In this prospective study, we sought to investigate the associations of women's AFLB with the risk of incident stroke and its subtypes (ischaemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage) and to explore the differences of these associations as well as the population-level impacts across SES classes.MethodsWe used data on 290 932 Chinese parous women from the China Kadoorie Biobank who were recruited in the baseline survey between 2004 and 2008 and followed up until 2015. We used latent class analysis to identify urban-rural SES classes and Cox proportional hazard regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for AFLB's association with incident stroke. We then calculated population attributable fraction (PAF) to demonstrate the population-level impact of later AFLB on stroke.ResultsAround 8.9% of parous women developed stroke after AFLB. Compared with women with AFLB <22 years, those with older AFLB had a higher risk of total stroke, with fully adjusted HRs (95% CI) of 1.71 (95% CI = 1.65-1.77) for 22-24 years and 3.37 (95% CI = 3.24-3.51) for ≥25 years. The associations of AFLB with ischaemic stroke were stronger among rural-low-SES participants. We found the highest PAFs of ischaemic stroke (60.1%; 95% CI = 46.2-70.3) associated with later AFLB for urban-high-SES individuals.ConclusionsOlder AFLB was associated with higher risks of incident stroke and its subtypes among Chinese parous women, with stronger associations between AFLB and ischaemic stroke among rural-low-SES participants. Targeted medical advice for pregnant women of different ages could have long-term benefits for stroke prevention.

Dataset Information

Socioeconomic Disparities in Mortality Among Women With Incident Breast Cancer Before and After Implementation of Medicare Part D.

Publications

Socioeconomic Disparities in Mortality Among Women With Incident Breast Cancer Before and After Implementation of Medicare Part D.

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