Albert J. Farias

Association Between Out-Of-Pocket Costs, Race/Ethnicity, and Adjuvant Endocrine Therapy Adherence Among Medicare Patients With Breast Cancer

Purpose Previous studies suggest that adherence to adjuvant endocrine therapy (AET) for patients with breast cancer is suboptimal, especially among minorities, and is associated with out-of-pocket medication costs. This study aimed to determine whether there are racial/ethnic differences in 1-year adherence to AET and whether out-of-pocket costs explain the racial/ethnic disparities in adherence. Methods This retrospective cohort study used the SEER-Medicare linked database to identify patients ≥ 65 years of age with hormone receptor-positive breast cancer who were enrolled in Medicare Part D from 2007 to 2009. The cohort included non-Hispanic whites, blacks, Hispanics, and Asians. Out-of-pocket costs for AET medications were standardized for a 30-day supply. Adherence to tamoxifen, aromatase inhibitors (AIs), and overall AET (tamoxifen or AIs) was assessed using the medication possession ratio (≥ 80%) during the 12-month period. Results Of 8,688 patients, 3,197 (36.8%) were nonadherent to AET. Out-of-pocket costs for AET medication were associated with lower adjusted odds of adherence for all four cost categories compared with the lowest category of ≤

Measuring the impact of outreach and enrollment strategies for public health insurance in California.

2.65 ( P < .01). In the univariable analysis, Hispanics had higher odds of adherence to any AET at initiation (OR, 1.30; 95% CI, 1.07 to 1.57), and blacks had higher odds of adherence to AIs at initiation (OR, 1.27; 95% CI, 1.04 to 1.54) compared with non-Hispanic whites. After adjusting for copayments, poverty status, and comorbidities, the association was no longer significant for Hispanics (OR, 0.95; 95% CI, 0.78 to 1.17) or blacks (OR, 0.96; 95% CI, 0.77 to 1.19). Blacks had significantly lower adjusted odds of adherence than non-Hispanic whites when they initiated AET therapy with tamoxifen (OR, 0.54; 95% CI, 0.31 to 0.93) after adjusting for socioeconomic, clinic, and prognostic factors. Conclusion Racial/ethnic disparities in AET adherence were largely explained by womens differences in socioeconomic status and out-of-pocket medication costs.

Factors Associated with Adherence to Adjuvant Endocrine Therapy Among Privately Insured and Newly Diagnosed Breast Cancer Patients: A Quantile Regression Analysis

UNLABELLED OBJECTIVE AND STUDY SETTING: To evaluate the effectiveness of different approaches to outreach on public health insurance enrollment in 25 California counties with a Childrens Health Initiative. DATA SOURCE Administrative enrollment databases. STUDY DESIGN The use of eight enrollment strategies were identified in each quarter from 2001 to 2007 for each of 25 counties (county quarter). Strategies were categorized as either technology or nontechnology. New enrollments were obtained for Medi-Cal, Healthy Families, and Healthy Kids. Bivariate and multivariate analyses assessed the link between each strategy and new enrollments rates of children. DATA COLLECTION Methods Surveys of key informants determined whether a specific outreach strategy was used in each quarter. These were linked to new enrollments in each county quarter. PRINCIPAL FINDINGS Between 2001 and 2007, enrollment grew in all three childrens health programs. We controlled for the effects of counties, seasons, and county-specific child poverty rates. There was an increase in enrollment rates of 11 percent in periods when technology-based systems were in use compared with when these approaches were inactive. Non-technology-based approaches, including school-linked approaches, yielded a 12 percent increase in new enrollments rates. Deploying seven to eight strategies yielded 54 percent more new enrollments per 10,000 children compared with periods with none of the specific strategies. CONCLUSIONS AND IMPLICATIONS National health care reform provides new opportunities to expand coverage to millions of Americans. An investment in technology-based enrollment systems will maximize new enrollments, particularly into Medicaid; nontechnological approaches may help identify harder-to-reach populations. Moreover, incorporating several strategies, whether phased in or implemented simultaneously, will enhance enrollments.

Changes in uncompensated pediatric ambulatory care visits for uninsured children among safety net providers after implementing a health insurance program for children of low-income families.

BACKGROUND Adherence to adjuvant endocrine therapy (AET) for estrogen receptor-positive breast cancer remains suboptimal, which suggests that women are not getting the full benefit of the treatment to reduce breast cancer recurrence and mortality. The majority of studies on adherence to AET focus on identifying factors among those women at the highest levels of adherence and provide little insight on factors that influence medication use across the distribution of adherence. OBJECTIVE To understand how factors influence adherence among women across low and high levels of adherence. METHODS A retrospective evaluation was conducted using the Truven Health MarketScan Commercial Claims and Encounters Database from 2007-2011. Privately insured women aged 18-64 years who were recently diagnosed and treated for breast cancer and who initiated AET within 12 months of primary treatment were assessed. Adherence was measured as the proportion of days covered (PDC) over a 12-month period. Simultaneous multivariable quantile regression was used to assess the association between treatment and demographic factors, use of mail order pharmacies, medication switching, and out-of-pocket costs and adherence. The effect of each variable was examined at the 40th, 60th, 80th, and 95th quantiles. RESULTS Among the 6,863 women in the cohort, mail order pharmacies had the greatest influence on adherence at the 40th quantile, associated with a 29.6% (95% CI = 22.2-37.0) higher PDC compared with retail pharmacies. Out-of-pocket cost for a 30-day supply of AET greater than

Racial Differences in Adjuvant Endocrine Therapy Use and Discontinuation in Association with Mortality among Medicare Breast Cancer Patients by Receptor Status

20 was associated with an 8.6% (95% CI = 2.8-14.4) lower PDC versus

The Association Between Out-of-Pocket Costs and Adherence to Adjuvant Endocrine Therapy Among Newly Diagnosed Breast Cancer Patients.

0-

Racial and geographic disparities in adherence and discontinuation to adjuvant endocrine therapy in Texas Medicaid-insured patients with breast cancer

9.99. The main factors that influenced adherence at the 95th quantile were mail order pharmacies, associated with a 4.4% higher PDC (95% CI = 3.8-5.0) versus retail pharmacies, and switching AET medication 2 or more times, associated with a 5.6% lower PDC versus not switching (95% CI = 2.3-9.0). CONCLUSIONS Factors associated with adherence differed across quantiles. Addressing the use of mail order pharmacies and out-of-pocket costs for AET may have the greatest influence on improving adherence among those women with low adherence. DISCLOSURES This research was supported by a Ruth L. Kirschstein National Research Service Award for Individual Predoctoral Fellowship grant from the National Cancer Institute (grant number F31 CA174338), which was awarded to Farias. Additionally, Farias was funded by a Postdoctoral Fellowship at the University of Texas School of Public Health Cancer Education and Career Development Program through the National Cancer Institute (NIH Grant R25 CA57712). The other authors declare no conflicts of interest. DISCLAIMER The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health. Farias was primarily responsible for the study concept and design, along with Hansen and Zeliadt and with assistance from the other authors. Farias, Hansen, and Zeliadt took the lead in data interpretation, assisted by the other authors. The manuscript was written by Farias, along with Thompson and assisted by the other authors, and was revised by Ornelas, Li, and Farias, with assistance from the other authors.

Exploring the role of physician communication about adjuvant endocrine therapy among breast cancer patients on active treatment: a qualitative analysis

The role of the safety net has been debated in various proposals for healthcare reform in the United States. Yet little is known about how health coverage expansion affects the use of safety net services. This study uses data from Los Angeles County to analyze how the expansion of health insurance for low-income uninsured children has affected their utilization of ambulatory care services in safety net hospitals and health centers. In the Los Angeles Healthy Kids program, 40 000 mostly immigrant children ineligible for State Childrens Health Insurance Program or Medicaid, were enrolled in a new insurance program called Healthy Kids. Coverage expansion was associated with a decrease in the utilization of pediatric services in two county-funded programs for the uninsured: directly operated healthcare services and private contracted programs. Thus, coverage expansion may have saved more than

Ethnic differences in initiation and timing of adjuvant endocrine therapy among older women with hormone receptor-positive breast cancer enrolled in Medicare Part D.

37 million in compensated care for children. For public hospitals and other safety net clinics, these data and previous studies suggest that insurance not only improves access but also reconfigures where people get care. It also helps reduce uncompensated care and provides new avenues to support and stabilize the healthcare safety net. These data suggest that a state or jointly funded insurance expansion will help offset the growing burden of uncompensated care among safety net providers while improving utilization and health status among children. Universal coverage programs are not only good for children but also help stabilize the fragile healthcare safety net by reducing the demand for uncompensated care at county facilities.

Association of physicians perceived barriers with human papillomavirus vaccination initiation

Background: There are racial disparities in breast cancer mortality. Our purpose was to determine whether racial/ethnic differences in use and discontinuation of adjuvant endocrine therapy (AET) differed by hormone receptor status and whether discontinuation was associated with mortality. Methods: We conducted a retrospective cohort study with SEER/Medicare dataset of women age ≥65 years diagnosed with stage I–III breast cancer in Medicare Part-D from 2007 to 2009, stratified by hormone receptor status. We performed multivariable logistic regressions to assess racial differences for the odds of AET initiation and Cox proportional hazards models to determine the risk of discontinuation and mortality. Results: Of 14,902 women, 64.5% initiated AET <12 months of diagnosis. Among those with hormone receptor–positive cancer, 74.8% initiated AET compared with 5.6% of women with negative and 54.0% with unknown-receptor status. Blacks were less likely to initiate [OR, 0.76; 95% confidence interval (CI), 0.66–0.88] compared with whites. However, those with hormone receptor–positive disease were less likely to discontinue (HR, 0.89; 95% CI, 0.80–0.98). Women who initiated with aromatase inhibitors had increased risk of discontinuation compared with women who initiated tamoxifen (HR, 1.12; 95% CI, 1.05–1.20). Discontinuation within 12 months was associated with higher risk of all-cause (HR, 1.75; 95% CI, 1.74–2.00) and cancer-specific mortality (HR, 2.76; 95% CI, 1.74–4.38) after controlling for race/ethnicity. Conclusions: There are racial/ethnic differences in AET use and discontinuation. Discontinuing treatment was associated with higher risk of all-cause and cancer-specific mortality regardless of hormone receptor status. Impact: This study underscores the need to study factors that influence discontinuation and the survival benefits of receiving AET for hormone receptor–negative breast cancer. Cancer Epidemiol Biomarkers Prev; 26(8); 1266–75. ©2017 AACR.