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Walling AM, Cassel JB, Kerr K, Wenger NS, Garcia-Jimenez M, Meyers K, Zingmond D. Limitations With California Medicaid Data for Palliative and End of Life Care Quality Measures. J Pain Symptom Manage 2024:S0885-3924(24)00904-7. [PMID: 39084412 DOI: 10.1016/j.jpainsymman.2024.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 07/11/2024] [Accepted: 07/17/2024] [Indexed: 08/02/2024]
Abstract
In 2014 the California legislature passed Senate Bill 1004 (SB 1004) that was designed to expand access to specialty palliative care for individuals served by California's Medicaid (known as Medi-Cal) Managed Care Plans (MCPs). The California Department of Health Care Services (DHCS) operationalized the legislation by developing minimum requirements for palliative care programs that all MCPs must meet or exceed.7 Quality and utilization data specific to California's Medicaid population are needed for stakeholders to identify care deficiencies and disparities, describe the end of life experience and utilization patterns of MCP members, compare these patterns to Medicare beneficiaries or other populations, and set appropriate targets to help monitor progress. We evaluated the feasibility of using Medicaid claims data and encounter data either by partnering with MCPs or by obtaining statewide data from DHCS to measure the quality of palliative care and end of life care. In a concurrent but separate effort, we analyzed administrative data supplied by three MCPs as part of a prospective pilot of standards for home-based palliative care in California, including care delivered to Medicaid beneficiaries under SB 1004. Beyond the practical challenges of allowing time for data access and approvals, both projects revealed several limitations to using administrative data to assess quality of palliative and end of life care for a Medicaid population. We describe these challenges that undermined our confidence in analysis results and propose solutions to measuring the quality of palliative and end of life care for Medicaid patients and suggested next steps.
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Affiliation(s)
- Anne M Walling
- Department of Medicine, University of California (A.M.W., N.S.W., M.G.-J., D.Z.), Los Angeles, USA; Department of Medicine,VA Greater Los Angeles Healthcare System (A.M.W.), Los Angeles, California, USA.
| | - J Brian Cassel
- Department of Internal Medicine,Virginia Commonwealth University School of Medicine (J.B.C.), Richmond, VA, USA
| | - Kathleen Kerr
- Transforming Care Partners (K.K.),San Francisco, California, USA
| | - Neil S Wenger
- Department of Medicine, University of California (A.M.W., N.S.W., M.G.-J., D.Z.), Los Angeles, USA
| | - Maria Garcia-Jimenez
- Department of Medicine, University of California (A.M.W., N.S.W., M.G.-J., D.Z.), Los Angeles, USA; Division of Hematology/Oncology, Olive View-UCLA (M.G.-J), Los Angeles, California,USA
| | - Kate Meyers
- California Health Care Foundation (K.M.),Oakland, California, USA
| | - David Zingmond
- Department of Medicine, University of California (A.M.W., N.S.W., M.G.-J., D.Z.), Los Angeles, USA
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Schpero WL, Takvorian SU, Blickstein D, Shafquat A, Liu J, Chatterjee AK, Lamont EB, Chatterjee P. Association Between State Medicaid Policies and Accrual of Black or Hispanic Patients to Cancer Clinical Trials. J Clin Oncol 2024:JCO2301149. [PMID: 39052944 DOI: 10.1200/jco.23.01149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 04/14/2024] [Accepted: 05/10/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE It is unknown whether Medicaid expansion under the Affordable Care Act (ACA) or state-level policies mandating Medicaid coverage of the routine costs of clinical trial participation have ameliorated longstanding racial and ethnic disparities in cancer clinical trial enrollment. METHODS We conducted a retrospective, cross-sectional difference-in-differences analysis examining the effect of Medicaid expansion on rates of enrollment for Black or Hispanic nonelderly adults in nonobservational, US cancer clinical trials using data from Medidata's Rave platform for 2012-2019. We examined heterogeneity in this effect on the basis of whether states had pre-existing mandates requiring Medicaid coverage of the routine costs of clinical trial participation. RESULTS The study included 47,870 participants across 1,353 clinical trials and 344 clinical trial sites. In expansion states, the proportion of participants who were Black or Hispanic increased from 16.7% before expansion to 17.2% after Medicaid expansion (0.5 percentage point [PP] change [95% CI, -1.1 to 2.0]). In nonexpansion states, this proportion increased from 19.8% before 2014 (when the first states expanded eligibility under the ACA) to 20.4% after 2014 (0.6 PP change [95% CI, -2.3 to 3.5]). These trends yielded a nonsignificant difference-in-differences estimate of 0.9 PP (95% CI, -2.6 to 4.4). Medicaid expansion was associated with a 5.3 PP (95% CI, 1.9 to 8.7) increase in the enrollment of Black or Hispanic participants in states with mandates requiring Medicaid coverage of the routine costs of trial participation, but not in states without mandates (-0.3 PP [95% CI, -4.5 to 3.9]). CONCLUSION Medicaid expansion was not associated with a significant increase in the proportion of Black or Hispanic oncology trial participants overall, but was associated with an increase specifically in states that mandated Medicaid coverage of the routine costs of trial participation.
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Affiliation(s)
- William L Schpero
- Division of Health Policy and Economics, Department of Population Health Sciences, Weill Medical College, Cornell University, New York, NY
- Center for Health Equity, Cornell University, New York, NY
| | - Samuel U Takvorian
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | | | - Jingshu Liu
- Medidata AI, a Dassault Systèmes Company, New York, NY
| | | | | | - Paula Chatterjee
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Nguyen RH, Silva Y, Lu J, Chen Z, Gadi V. Race and Ethnicity Reporting and Enrollment Disparities in Clinical Trials Leading to FDA Approvals for Breast Cancer Between 2010 and 2020. Clin Breast Cancer 2023:S1526-8209(23)00096-4. [PMID: 37296063 DOI: 10.1016/j.clbc.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/03/2023] [Accepted: 05/06/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND We determined the race and ethnicity demographics and reporting trends of clinical trials leading to Food and Drug Administration (FDA) approvals for breast cancer. METHODS We collected enrollment and reporting data from clinical trials leading to FDA novel and new use approvals for breast cancer from 2010 to 2020 from Drugs@FDA, ClinicalTrials.gov, and associated journal manuscripts. Enrollment demographics were compared to the US cancer population estimates obtained using National Cancer Institute-Surveillance, Epidemiology, and End Results and 2010 US Census databases. RESULTS Seventeen drugs received approval based on 18 clinical trials with a total enrollment of 12,334. For approvals from 2010 to 2015 and from 2016 to 2020, there was no significant difference in race (80% vs. 91.6%, P = .34) or ethnicity reporting (20% vs. 33.3%, P = .5) on ClinicalTrials.Gov, manuscripts, and FDA labels. For trials that reported race and ethnicity, White, Asian, Black, and Hispanic patients represented 73.8%, 16.4%, 3.7%, and 10.4% of trial participants. Relative to their US cancer incidence, Black (31% of expected) patients were underrepresented compared with White (90% of expected), Hispanic (115%), and Asian (327% of expected) patients. CONCLUSION We observed no significant difference in race and ethnicity reporting in pivotal clinical trials leading to FDA approval for breast cancer from 2010 to 2020. Black patients were underrepresented in these pivotal trials relative to White, Hispanic, and Asian patients. Ethnicity reporting remained low throughout the study period. Innovative approaches are needed to ensure equitable benefit of novel therapeutics.
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Affiliation(s)
- Ryan H Nguyen
- Division of Hematology and Oncology, University of Illinois Chicago, Chicago, IL.
| | - Yomaira Silva
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Jun Lu
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL; Biostatistics Shared Resource Core, University of Illinois Cancer Center, Chicago, IL
| | - Zhengjia Chen
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL; Biostatistics Shared Resource Core, University of Illinois Cancer Center, Chicago, IL
| | - Vijayakrishna Gadi
- Division of Hematology and Oncology, University of Illinois Chicago, Chicago, IL
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Riggan KA, Rousseau A, Halyard M, James SE, Kelly M, Phillips D, Allyse MA. "There's not enough studies": Views of black breast and ovarian cancer patients on research participation. Cancer Med 2023; 12:8767-8776. [PMID: 36647342 PMCID: PMC10134334 DOI: 10.1002/cam4.5622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Black breast and ovarian cancer patients are underrepresented in clinical cancer trials disproportionate to the prevalence of these cancers in Black females. Historically, lower enrollment has been attributed to individualized factors, including medical mistrust, but more recently structural factors, including systemic racism, have received additional scrutiny. We interviewed Black women with a personal or family history of breast and ovarian cancer to understand their views and experiences related to research participation. METHODS Qualitative interviews were conducted via telephone or video conference and transcribed verbatim. Transcripts were qualitatively analyzed for iterative themes related to the offer and participation in cancer clinical trials and research studies, impact on cancer care, and recommendations to increase enrollment of Black patients. RESULTS Sixty-one Black women completed an interview. Participants expressed that Black women are underrepresented in cancer research, and that this negatively impacted their own care. Many cited past historical abuses, including the Tuskegee syphilis trial, as a potential factor for lower enrollment but suggested that lower enrollment was better understood in the context of the entirety of their healthcare experiences, including present-day examples of patient mistreatment or dismissal. Participants suggested that proactive community engagement, transparency, and increased representation of Black research team members were strategies likely to foster trust and bolster research participation. CONCLUSION(S) Medical mistrust is only a partial factor in the lower participation of Black patients in cancer research. Researchers should implement the strategies identified by our participants to promote diverse enrollment and ensure that Black patients are included in future therapeutic advances.
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Affiliation(s)
| | - Abigail Rousseau
- Biomedical Ethics Research ProgramMayo ClinicRochesterMinnesotaUSA
| | - Michele Halyard
- Department of Radiation OncologyMayo ClinicPhoenixArizonaUSA
- Coalition of Blacks Against Breast CancerPhoenixArizonaUSA
- ADVANCE Community Advisory BoardPhoenixArizonaUSA
| | - Sarah E. James
- Department of Radiation OncologyMayo ClinicPhoenixArizonaUSA
- Coalition of Blacks Against Breast CancerPhoenixArizonaUSA
| | - Marion Kelly
- Coalition of Blacks Against Breast CancerPhoenixArizonaUSA
- ADVANCE Community Advisory BoardPhoenixArizonaUSA
- Department of Community EngagementMayo ClinicScottsdaleArizonaUSA
| | - Daphne Phillips
- ADVANCE Community Advisory BoardPhoenixArizonaUSA
- Department of Speech PathologyMayo ClinicPhoenixArizonaUSA
| | - Megan A. Allyse
- Biomedical Ethics Research ProgramMayo ClinicRochesterMinnesotaUSA
- Department of Obstetrics & GynecologyMayo ClinicRochesterMinnesotaUSA
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Aranda MP, Marquez DX, Gallagher-Thompson D, Pérez A, Rojas JC, Hill CV, Reyes Y, Dilworth-Anderson P, Portacolone E. A call to address structural barriers to Hispanic/Latino representation in clinical trials on Alzheimer's disease and related dementias: A micro-meso-macro perspective. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2023; 9:e12389. [PMID: 37287471 PMCID: PMC10242183 DOI: 10.1002/trc2.12389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/04/2023] [Accepted: 04/09/2023] [Indexed: 06/09/2023]
Abstract
Introduction This perspective paper addresses the US Hispanic/Latino (herein, Latino) experience with regards to a significant public health concern-the underrepresentation of Latino persons in Alzheimer's disease and related dementias (AD/ADRD) clinical trials. Latino individuals are at increased risk for AD/ADRD, experience higher disease burden, and low receipt of care and services. We present a novel theoretical framework-the Micro-Meso-Macro Framework for Diversifying AD/ADRD Trial Recruitment-which considers multi-level barriers and their impact on Latino trial recruitment. Methods Based on a review of the peer-reviewed literature and our lived experience with the Latino community, we drew from our interdisciplinary expertise in health equity and disparities research, Latino studies, social work, nursing, political economy, medicine, public health, and clinical AD/ADRD trials. We discuss factors likely to impede or accelerate Latino representation, and end with a call for action and recommendations for a bold path forward. Results In the 200+ clinical trials conducted with over 70,000 US Americans, Latino participants comprise a fraction of AD/ADRD trial samples. Efforts to recruit Latino participants typically address individual- and family-level factors (micro-level) such as language, cultural beliefs, knowledge of aging and memory loss, limited awareness of research, and logistical considerations. Scientific efforts to understand recruitment barriers largely remain at this level, resulting in diminished attention to upstream institutional- and policy-level barriers, where decisions around scientific policies and funding allocations are ultimately made. These structural barriers are comprised of inadequacies or misalignments in trial budgets, study protocols, workforce competencies, healthcare-related barriers, criteria for reviewing and approving clinical trial funding, criteria for disseminating findings, etiological focus and social determinants of health, among others. Conclusion Future scientific work should apply and test the Micro-Meso-Macro Framework for Diversifying AD/ADRD Trial Recruitment to examine structural recruitment barriers for historically underrepresented groups in AD/ADRD research and care.
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Affiliation(s)
- María P Aranda
- University of Southern California Alzheimer's Disease Research Center Los Angeles California USA
- USC Suzanne Dworak-Peck School of Social Work Edward R. Roybal Institute on Aging University of Southern California USC Montgomery Ross Fisher Building Los Angeles California USA
| | - David X Marquez
- Department of Kinesiology and Nutrition University of Illinois Chicago Chicago Illinois USA
- Rush Alzheimer's Disease Center Chicago Illinois USA
| | - Dolores Gallagher-Thompson
- Department of Psychiatry & Behavioral Sciences Stanford University School of Medicine Palo Alto California USA
| | - Adriana Pérez
- Leonard Davis Institute of Health Economics University of Pennsylvania School of Nursing Philadelphia Pennsylvania USA
| | - Julio C Rojas
- Memory and Aging Center UCSF Weill Institute for Neurosciences University of California San Francisco Memory and Aging Center San Francisco California USA
| | - Carl V Hill
- Chief of Diversity Equity and Inclusion Alzheimer's Association Chicago Illinois USA
| | - Yarissa Reyes
- Director of Diversity Equity and Inclusion Alzheimer's Association Chicago Illinois USA
| | - Peggye Dilworth-Anderson
- Health Policy and Management Gillings School of Global Public Health 1104 D McGavran Greenberg, University of North Carolina-Chapel Hill North Carolina USA
| | - Elena Portacolone
- Institute for Health and Aging University of California San Francisco Philip Lee Institute for Health Policy Studies University of California San Francisco San Francisco California USA
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Ghooi RB. Clinical trial agreements and insurance policies - role of the EC. Perspect Clin Res 2022; 13:121-122. [PMID: 35928640 PMCID: PMC9345259 DOI: 10.4103/picr.picr_271_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022] Open
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Abbas A, Diaz A, Obeng-Gyasi S, Cloyd JM, Ejaz A, Stewart JH, Pawlik TM. Disparity in Clinical Trial Participation Among Patients with Gastrointestinal Cancer. J Am Coll Surg 2022; 234:589-598. [PMID: 35290279 DOI: 10.1097/xcs.0000000000000129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinical trial participation among cancer patients remains low. We sought to examine the impact of patient- and system-level factors on clinical trial participation among gastrointestinal (GI) surgical patients. STUDY DESIGN Adult patients with a GI cancer who underwent oncologic surgery who were enrolled in National Cancer Institute (NCI)-funded clinical trials from 2000 through 2019 were compared with trial-eligible adult patients in the National Cancer Database (NCDB) between 2004 and 2017. Multivariable logistic regression was used to identify factors associated with clinical trial participation. RESULTS Participants from 36 NCI-funded clinical trials (n = 10,518) were compared with 2,255,730 trial-eligible nonparticipants from the NCDB. Patients aged 65 years or younger (odds ratio [OR] = 0.5, 95% CI 0.47-0.53), Medicare (OR = 0.46, 95% CI 0.43-0.49) or Medicaid (OR = 0.51, 95% CI 0.46-0.58) insurance, as well as lower levels of education (OR = 0.82, 95% CI 0.75-0.89) were associated with a lower likelihood of clinical trial enrollment. Black (OR = 0.72, 95% CI 0.67-0.78) and Asian/Pacific Islander (OR = 0.96, 95% CI 0.85-1.08) patients were less likely to participate in trials vs White patients. There were interactions between race/ethnicity and income; high-income (OR = 0.67, 95% CI 0.55-0.81) and low-income Black (OR = 0.75, 95% CI 0.66-0.87) patients were less likely, respectively, to participate than high- or low-income White individuals (p < 0.001). CONCLUSIONS Clinical trial participation is low among adult GI cancer patients who undergo surgery in the US. Programs aimed at improving trial participation among vulnerable populations are needed to improve trial participation.
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Affiliation(s)
- Alizeh Abbas
- From the Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Abbas, Diaz, Obeng-Gyasi, Cloyd, Ejaz, Pawlik)
| | - Adrian Diaz
- From the Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Abbas, Diaz, Obeng-Gyasi, Cloyd, Ejaz, Pawlik)
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI (Diaz)
| | - Samilia Obeng-Gyasi
- From the Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Abbas, Diaz, Obeng-Gyasi, Cloyd, Ejaz, Pawlik)
| | - Jordan M Cloyd
- From the Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Abbas, Diaz, Obeng-Gyasi, Cloyd, Ejaz, Pawlik)
| | - Aslam Ejaz
- From the Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Abbas, Diaz, Obeng-Gyasi, Cloyd, Ejaz, Pawlik)
| | - John H Stewart
- Department of Surgery, Louisiana State University, New Orleans, LA (Stewart)
| | - Timothy M Pawlik
- From the Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH (Abbas, Diaz, Obeng-Gyasi, Cloyd, Ejaz, Pawlik)
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Eskander MF, Gil L, Beal EW, Li Y, Hamad A, Oppong B, Obeng-Gyasi S, Tsung A. Access Denied: Inequities in Clinical Trial Enrollment for Pancreatic Cancer. Ann Surg Oncol 2021; 29:1271-1277. [PMID: 34655352 DOI: 10.1245/s10434-021-10868-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/11/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The influence of social determinants of health (SDH) on participation in clinical trials for pancreatic cancer is not well understood. In this study, we describe trends and identify disparities in pancreatic cancer clinical trial enrollment. PATIENTS AND METHODS This is a retrospective study of stage I-IV pancreatic cancer patients in the 2004-2016 National Cancer Database. Cohort was stratified into those enrolled in clinical trials during first course of treatment versus not enrolled. Bivariate analysis and logistic regression were used to understand the relationship between SDH and clinical trial participation. RESULTS A total of 1127 patients (0.4%) enrolled in clinical trials versus 301,340 (99.6%) did not enroll. Enrollment increased over the study period (p < 0.001), but not for Black patients or patients on Medicaid. The majority enrolled had metastatic disease (65.8%). On multivariate analysis, in addition to year of diagnosis (p < 0.001), stage (p < 0.001), and Charlson score (p < 0.001), increasing age [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.96-0.97], non-white race (OR 0.54, CI 0.44-0.66), living in the South (OR 0.42, CI 0.35-0.51), and Medicaid, lack of insurance, or unknown insurance (0.41, CI 0.31-0.53) were predictors of lack of participation. Conversely, treatment at an academic center (OR 6.36, CI 5.4-7.4) and higher neighborhood education predicted enrollment (OR 2.0, CI 1.55-2.67 for < 7% with no high school degree versus > 21%). DISCUSSION Age, race, insurance, and geography are barriers to clinical trial enrollment for pancreatic cancer patients. While overall enrollment increased, Black patients and patients on Medicaid remain underrepresented. After adjusting for cancer-specific factors, SDH are still associated with clinical trial enrollment, suggesting need for targeted interventions.
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Affiliation(s)
- Mariam F Eskander
- Division of Surgical Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave, Columbus, OH, USA.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Lindsay Gil
- Division of Surgical Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave, Columbus, OH, USA
| | - Eliza W Beal
- Division of Surgical Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave, Columbus, OH, USA
| | - Yaming Li
- Division of Surgical Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave, Columbus, OH, USA
| | - Ahmad Hamad
- Division of Surgical Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave, Columbus, OH, USA
| | - Bridget Oppong
- Division of Surgical Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave, Columbus, OH, USA
| | - Samilia Obeng-Gyasi
- Division of Surgical Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave, Columbus, OH, USA
| | - Allan Tsung
- Division of Surgical Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute at the Ohio State University Wexner Medical Center, N924 Doan Hall, 410 W 10th Ave, Columbus, OH, USA.
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Merkhofer C, Chennupati S, Sun Q, Eaton KD, Martins RG, Ramsey SD, Goulart BHL. Effect of Clinical Trial Participation on Costs to Payers in Metastatic Non-Small-Cell Lung Cancer. JCO Oncol Pract 2021; 17:e1225-e1234. [PMID: 34375561 PMCID: PMC8360452 DOI: 10.1200/op.20.01092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 06/06/2021] [Accepted: 06/22/2021] [Indexed: 02/02/2023] Open
Abstract
PURPOSE The costs associated with clinical trial enrollment remain uncertain. We hypothesized that trial participation is associated with decreased total direct medical costs to health care payers in metastatic non-small-cell lung cancer. METHODS In this retrospective cohort study, we linked clinical data from electronic medical records to sociodemographic data from a cancer registry and claims data from Medicare and two private insurance plans. We used a difference-in-difference analysis to estimate mean per patient per month total direct medical costs for patients enrolled on a second-line (2L) trial versus patients receiving standard-of-care 2L systemic therapy. RESULTS Among 70 eligible patients, the difference-in-difference of mean per patient per month total direct medical costs between 2L trial participants and nonparticipants was -$6,663 (P = .01), for a mean savings of $45,308 per patient for the duration of 2L trial therapy. In a secondary analysis by primary insurance payer, this difference-in-difference was -$5,526 (P = .26) for patients with commercial insurance and -$7,432 (P = .01) for patients with Medicare. CONCLUSION Participation in a 2L trial was associated with a $6,663 per month cost savings to health care payers for the duration of trial participation. Further studies are necessary to elucidate differences in cost savings from trial participation for Medicare and commercial payers. If confirmed, these results support health care payer investment in programs to improve clinical trial access and enrollment.
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Affiliation(s)
- Cristina Merkhofer
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Shasank Chennupati
- Hutchinson Institute for Cancer Outcomes Research, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Qin Sun
- Hutchinson Institute for Cancer Outcomes Research, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Keith D. Eaton
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Renato G. Martins
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott D. Ramsey
- Hutchinson Institute for Cancer Outcomes Research, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA
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Sadigh G, Gray RJ, Sparano JA, Yanez B, Garcia SF, Timsina LR, Sledge GW, Cella D, Wagner LI, Carlos RC. Breast cancer patients' insurance status and residence zip code correlate with early discontinuation of endocrine therapy: An analysis of the ECOG-ACRIN TAILORx trial. Cancer 2021; 127:2545-2552. [PMID: 33793979 DOI: 10.1002/cncr.33527] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/25/2021] [Accepted: 02/02/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Early discontinuation is a substantial barrier to the delivery of endocrine therapies (ETs) and may influence recurrence and survival. The authors investigated the association between early discontinuation of ET and social determinants of health, including insurance coverage and the neighborhood deprivation index (NDI), which was measured on the basis of patients' zip codes, in breast cancer. METHODS In this retrospective analysis of a prospective randomized clinical trial (Trial Assigning Individualized Options for Treatment), women with hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer who started ET within a year of study entry were included. Early discontinuation was calculated as stopping ET within 4 years of its start for reasons other than distant recurrence or death via Kaplan-Meier estimates. A Cox proportional hazards joint model was used to analyze the association between early discontinuation of ET and factors such as the study-entry insurance and NDI, with adjustments made for other variables. RESULTS Of the included 9475 women (mean age, 55.6 years; White race, 84%), 58.0% had private insurance, whereas 11.7% had Medicare, 5.8% had Medicaid, 3.8% were self-pay, and 19.1% were treated at international sites. The early discontinuation rate was 12.3%. Compared with those with private insurance, patients with Medicaid (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.23-1.92) and self-pay patients (HR, 1.65; 95% CI, 1.25-2.17) had higher early discontinuation. Participants with a first-quartile NDI (highest deprivation) had a higher probability of discontinuation than those with a fourth-quartile NDI (lowest deprivation; HR, 1.34; 95% CI, 1.11-1.62). CONCLUSIONS Patients' insurance and zip code at study entry play roles in adherence to ET, with uninsured and underinsured patients having a high rate of treatment nonadherence. Early identification of patients at risk may improve adherence to therapy. LAY SUMMARY In this retrospective analysis of 9475 women with breast cancer participating in a clinical trial (Trial Assigning Individualized Options for Treatment), Medicaid and self-pay patients (compared with those with private insurance) and those in the highest quartile of neighborhood deprivation scores (compared with those in the lowest quartile) had a higher probability of early discontinuation of endocrine therapy. These social determinants of health assume larger importance with the expected increase in unemployment rates and loss of insurance coverage in the aftermath of the coronavirus disease 2019 pandemic. Early identification of patients at risk and enrollment in insurance optimization programs may improve the persistence of therapy.
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Affiliation(s)
| | - Robert J Gray
- ECOG-ACRIN Biostatistics Center, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Joseph A Sparano
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | | | | | - Lava R Timsina
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Lynne I Wagner
- Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Ruth C Carlos
- University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan
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