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Wagle NS, Park S, Washburn D, Ohsfeldt RL, Rich NE, Singal AG, Kum HC. Racial, Ethnic, and Socioeconomic Disparities in Treatment Delay Among Patients With Hepatocellular Carcinoma in the United States. Clin Gastroenterol Hepatol 2023; 21:1281-1292.e10. [PMID: 35933076 PMCID: PMC9898458 DOI: 10.1016/j.cgh.2022.07.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 06/25/2022] [Accepted: 07/23/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Failures have been reported across the cancer care continuum in patients with hepatocellular carcinoma (HCC); however, the impact of treatment delays on outcomes has not been well-characterized. We described the prevalence of treatment delays in a racially and ethnically diverse cohort of patients and its association with overall survival. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified patients diagnosed with HCC between 2001 and 2015. We performed multivariable logistic regression analysis to identify factors associated with treatment delay (ie, receipt of HCC-directed therapy >3 months after diagnosis). Cox proportional hazards regression analysis with a 5-month landmark was used to characterize the association between treatment delay and overall survival, accounting for immortal time bias. RESULTS Of 8450 patients with treatment within 12 months of HCC diagnosis, 1205 (14.3%) experienced treatment delays. The proportion with treatment delays ranged from 6.8% of patients undergoing surgical resection to 21.6% of those undergoing liver transplantation. In multivariable analysis, Black patients (odds ratio, 1.96; 95% confidence interval [CI], 1.21-3.15) and those living in high poverty neighborhoods (odds ratio, 1.55; 95% CI, 1.25-1.92) were more likely to experience treatment delays than white patients and those living in low poverty neighborhoods, respectively. Treatment delay was independently associated with worse survival (hazard ratio 1.15, 95% CI, 1.05-1.25). CONCLUSIONS Nearly 1 in 7 patients with HCC experience treatment delays, with higher odds in Black patients and those living in high poverty neighborhoods. Treatment delays are associated with worse survival, highlighting a need for interventions to improve time-to-treatment.
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Affiliation(s)
- Nikita Sandeep Wagle
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Sulki Park
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Industrial & Systems Engineering, Texas A&M University, College Station, Texas
| | - David Washburn
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Robert L Ohsfeldt
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas
| | - Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas.
| | - Hye-Chung Kum
- Population Informatics Lab, Texas A&M University, College Station, Texas; Department of Health Policy & Management, School of Public Health, Texas A&M Health Science Center, College Station, Texas; Department of Industrial & Systems Engineering, Texas A&M University, College Station, Texas
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Hirschfeld W, Corrado R, Banaag A, Korona-Bailey J, Koehlmoos TP. Identifying prescribing differences of direct oral anticoagulants for atrial fibrillation within the Military Health System. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 26:100258. [PMID: 38510183 PMCID: PMC10945905 DOI: 10.1016/j.ahjo.2023.100258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 03/22/2024]
Abstract
Background Direct oral anticoagulants (DOACs) are a first-line anticoagulant therapy for eligible patients with atrial fibrillation. Prescribing differences in the Military Health System have not yet been assessed. Methods We conducted a retrospective cross-sectional study using administrative claims data from the Military Health System Data Repository from fiscal years 2018-2019. We identified TRICARE Prime and Prime Plus patients between the ages of 18 and 64 with a diagnosis of atrial fibrillation and a CHA2DS2-VASc score of ≥2. Descriptive statistics and odds of receiving DOACs by gender, age, race, and socioeconomic status were calculated. Results A total of 5289 TRICARE Prime and Prime Plus patients within the Military Health System who carried a diagnosis of atrial fibrillation and a CHA2DS2-VASc ≥2 were identified. Of all patients, 2373 (40.71 %) were prescribed a DOAC whereas 287 (4.92 %) were prescribed warfarin within 90 days of diagnosis of atrial fibrillation. Black patients were significantly less likely to be prescribed a DOAC compared to White patients (adjusted odds ratio [aOR], 0.82; 95 % CI 0.68-0.99), as were females compared to males (aOR, 0.64; 95 % CI 0.52-0.79). Senior officers were significantly more likely to be prescribed a DOAC compared to senior enlisted service members (aOR, 0.64; 95 % CI 0.52-0.79). Conclusions Our study shows that differences exist within the Military Health System in the prescription of DOACs for atrial fibrillation by race, gender, and socio-economic status. These differences cannot be explained by differences in access to insurance or cost of medications.
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Affiliation(s)
- William Hirschfeld
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Richele Corrado
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Amanda Banaag
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement in Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Jessica Korona-Bailey
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement in Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Tracey Perez Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Park S, Meyers DJ, Rivera-Hernandez M. Enrollment in Supplemental Insurance Coverage Among Medicare Beneficiaries by Race/Ethnicity. J Racial Ethn Health Disparities 2022; 9:2001-2010. [PMID: 34580825 PMCID: PMC9190066 DOI: 10.1007/s40615-021-01138-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/20/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The objective of this study was to examine racial/ethnic differences in enrollment trends for supplemental insurance coverage among traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries. STUDY DESIGN We employed a retrospective cohort study design using the 2010-2016 Medicare Current Beneficiary Survey. METHODS We included two types of outcomes: 1) seven exclusive types of insurance coverage in a given year and 2) changes in insurance coverage in the next year for those with each of the seven exclusive types of insurance coverage. Our primary independent variable was race/ethnicity. We conducted regression while controlling for demographic, socioeconomic, and health characteristics. We calculated the adjusted value of the outcome by race/ethnicity after adjusting for demographic, socioeconomic, and health status characteristics. RESULTS We found substantial racial/ethnic differences in supplemental insurance coverage among TM and MA beneficiaries. Compared to White beneficiaries, racial/ethnic minority beneficiaries had lower adjusted rates of enrollment in Medigap among TM beneficiaries and higher enrollment in Medicaid among both TM and MA beneficiaries. Trends in enrollment differed by supplemental insurance coverage, but an increasing trend in enrollment among MA beneficiaries without supplemental insurance coverage and MA beneficiaries with Medicaid was notable. Overall trends were consistent across all racial/ethnic groups. Finally, most beneficiaries were less likely to change insurance coverage in the next year, but a distinct phenomenon was observed among Black beneficiaries with the lowest rates of remaining in Medigap or MA only. CONCLUSIONS Our findings indicate the minority Medicare beneficiaries may not have equitable access to supplemental insurance coverage.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA, 19104, USA.
| | - David J Meyers
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, RI, 02912, Providence, USA
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, RI, 02912, Providence, USA
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Koehlmoos TP, Korona-Bailey J, Janvrin ML, Madsen C. Racial Disparities in the Military Health System: A Framework Synthesis. Mil Med 2021; 187:e1114-e1121. [PMID: 34910808 DOI: 10.1093/milmed/usab506] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/25/2021] [Accepted: 12/11/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Racial disparities in health care are a well-documented phenomenon in the USA. Universal insurance has been suggested as a solution to mitigate these disparities. We examined race-based disparities in the Military Health System (MHS) by constructing and analyzing a framework of existing studies that measured disparities between direct care (care provided by military treatment facilities) and private sector care (care provided by civilian health care facilities). MATERIALS AND METHODS We conducted a framework synthesis on 77 manuscripts published in partnership with the Comparative Effectiveness and Provider-Induced Demand Collaboration Project that use MHS electronic health record data to present an overview of racial disparities assessed for multiple treatment interventions in a nationally representative, universally insured population. RESULTS We identified 32 studies assessing racial disparities in areas of surgery, trauma, opioid prescription and usage, women's health, and others. Racial disparities were mitigated in postoperative complications, trauma care, and cancer screenings but persisted in diabetes readmissions, opioid usage, and minimally invasive women's health procedures. CONCLUSION Universal coverage mitigates many, but not all, racial disparities in health care. An examination of a broader range of interventions, a closer look at variation in care provided by civilian facilities, and a look at the quality of care by race provide further opportunities for research.
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Affiliation(s)
- Tracey Pérez Koehlmoos
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Cathaleen Madsen
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
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Magarinos J, Patel T, Strunk J, Naunheim K, Erkmen CP. A History of Health Policy and Health Disparity. Thorac Surg Clin 2021; 32:1-11. [PMID: 34801189 DOI: 10.1016/j.thorsurg.2021.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Civil Rights legislation and court decisions influenced health care policy, which attempted to provide health care to elderly and low-income populations. Passing Medicaid and Medicare was monumental in increasing access to health insurance. The Affordable Care Act aimed to increase access to and affordability of health care to alleviate some disparities in health care. The Affordable Care Act established the National Institute of Minority and Health Disparity and Offices of Minority Health. However, disparities of access, care, morbidity, and mortality among marginalized populations persist. We in the thoracic community must leverage all means to mitigate the injustice of health disparities.
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Affiliation(s)
- Jessica Magarinos
- Department of Surgery, Temple University Health Systems, 3401 N. Broad, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA; Department of General Surgery, Temple University Hospital, 3401 N. Broad, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA
| | - Takshaka Patel
- Department of Surgery, Temple University Health Systems, 3401 N. Broad, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA; Department of General Surgery, Temple University Hospital, 3401 N. Broad, Parkinson Pavilion, Suite C405, Philadelphia, PA 19140, USA
| | - Jason Strunk
- Department of Surgery, Inspira Health Network, Vineland, NJ, USA
| | | | - Cherie P Erkmen
- Center for Asian Health, Lewis Katz School of Medicine at Temple University Hospital, 3401 N. Broad Street, Suite 501, Parkinson Pavilion, Philadelphia, PA 19140, USA; Department of Thoracic Medicine and Surgery, Temple University Health Systems, 3401 N. Broad Street, Suite 501, Parkinson Pavilion, Philadelphia, PA 19140, USA.
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Guadamuz JS, Ozenberger K, Qato DM, Ko NY, Saffore CD, Adimadhyam S, Cha AS, Moran KM, Sweiss K, Patel PR, Chiu BCH, Calip GS. Mediation analyses of socioeconomic factors determining racial differences in the treatment of diffuse large B-cell lymphoma in a cohort of older adults. Medicine (Baltimore) 2019; 98:e17960. [PMID: 31725657 PMCID: PMC6867777 DOI: 10.1097/md.0000000000017960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Despite near universal health coverage under Medicare, racial disparities persist in the treatment of diffuse large B-cell lymphoma (DLBCL) among older patients in the United States. Studies evaluating DLBCL outcomes often treat socioeconomic status (SES) measures as confounders, potentially introducing biases when SES factors are mediators of disparities in cancer treatment.To examine differences in DLBCL treatment, we performed causal mediation analyses of SES measures, including: metropolitan statistical area (MSA) of residence; census-tract poverty level; and private Medicare supplementation using the Surveillance, Epidemiology and End Results-Medicare linked database between 2001 and 2011. In this retrospective cohort study of DLBCL patients ages 66+ years, we conducted a series of multivariable logistic regression analyses estimating odds ratios (OR) and 95% confidence intervals (CI) relating chemo- and/or immuno-therapy treatment and each SES measure, comparing non-Hispanic (NH)-black, Hispanic/Latino, and Asian/Pacific Islander (API) to NH-white patients.Compared to NH-white patients, racial/ethnic minority patients had lower odds of receiving chemo- and/or immuno-therapy treatment (NH-black: OR 0.84, 95% CI 0.65, 1.08; API: OR 0.80, 95% CI 0.64, 1.01; Hispanic/Latino: OR 0.78, 95% CI 0.64, 0.96) and higher odds of lacking private Medicare supplementation and residence within an urban MSA and poor census tracts. Adjustment for SES measures as confounders nullified observed racial differences. In causal mediation analyses, between 31% and 38% of race/ethnicity differences were mediated by having private Medicare supplementation.Providing equitable access to Medicare supplementation may reduce disparities in receipt of chemo- and/or immuno-therapy treatment in older DLBCL patients.
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Affiliation(s)
- Jenny S. Guadamuz
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
- Institute of Minority of Health Research, University of Illinois at Chicago
| | - Katharine Ozenberger
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
| | - Dima M. Qato
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
- Division of Biostatistics and Epidemiology, University of Illinois at Chicago, Chicago, IL
| | - Naomi Y. Ko
- Section of Hematology Oncology, Boston University School of Medicine, Boston, MA
| | | | - Sruthi Adimadhyam
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
| | - Ashley S. Cha
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
| | - Kellyn M. Moran
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
| | - Karen Sweiss
- Department of Pharmacy Practice, University of Illinois at Chicago
| | - Pritesh R. Patel
- Division of Hematology Oncology, University of Illinois at Chicago
| | - Brian C.-H. Chiu
- Department of Public Health Sciences, The University of Chicago, Chicago, IL
| | - Gregory S. Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
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