Differential Treatment Patterns Research Articles

Is there evidence of age bias in breast cancer health care professionals’ treatment of older patients?

ObjectivesDespite NICE (2009; 2018) guidelines to treat breast cancer patients ‘irrespective of age’, older women experience differential treatment and worse outcomes beyond that which can be explained by patient health or patient choice. Research has evidenced the prevalence of ageism and identified the role of implicit bias in reflecting and perhaps perpetuating disparities across society, including in healthcare. Yet age bias has rarely been considered as an explanatory factor in poorer outcomes for older breast cancer patients. MethodsThis mixed methods study explored age bias amongst breast cancer HCPs through four components: 1) An implicit associations test (31 HCPs)2) A treatment recommendations questionnaire (46 HCPs).3) An attitudes about older patients questionnaire (31 HCPs).4) A treatment recommendations interview (20 HCPs). ResultsThis study showed that breast cancer HCPs held negative implicit associations towards older women; HCPs were less likely to recommend surgery for older patients; some HCPs held assumptions that older patients are more afraid, less willing and able to be involved in decision-making, and are less willing and able to cope with being informed of a poor treatment prognosis; and conditions which disproportionately affect older patients, such as dementia, are not always well understood by breast cancer HCPs. ConclusionsThese results indicate that there are elements of age bias present amongst breast cancer HCPs. The study's findings of age-based assumptions and a poorer understanding of conditions which disproportionately affect older patients align with patterns of differential treatment towards older breast cancer patients suggesting that age bias may be, at least in part, driving differential treatment.

HSD89 Impact of Race on Utilization of First Vs Second Generation Long-Acting Injectable Antipsychotics Among Medicaid Beneficiaries with Schizophrenia

Differential treatment patterns by race for mental health services for individuals with schizophrenia (SCZ), including disparities in antipsychotic prescription patterns, have been reported. This study assessed differences in utilization of first generation (FG) vs second generation (SG) long-acting injectable antipsychotics (LAIs) between Black and White Medicaid enrollees with SCZ and examined factors associated with FG vs SG LAI initiation, including race.

Use of Antihypertensive Medications and Diagnostic Tests Among Privately Insured Adolescents and Young Adults With Primary Versus Secondary Hypertension

To compare the use of antihypertensive medications and diagnostic tests among adolescents and young adults with primary versus secondary hypertension. We conducted retrospective cohort analysis of claims data for adolescents and young adults (12-21 years of age) with ≥3 years of insurance coverage (≥11 months/year) in a large private managed care plan during 2003-2009 with diagnosis of primary hypertension or secondary hypertension. We examined their use of antihypertensive medications and identified demographic characteristics and the presence of obesity-related comorbidities. For the subset receiving antihypertensive medications, we examined their diagnostic test use (echocardiograms, renal ultrasounds, and electrocardiograms). The study sample included 1,232 adolescents and young adults; 84% had primary hypertension and 16% had secondary hypertension. The overall prevalence rate of hypertension was 2.6%. One quarter (28%) with primary hypertension had one or more antihypertensive medications, whereas 65% with secondary hypertension had one or more antihypertensive medications. Leading prescribers of antihypertensives for subjects with primary hypertension were primary care physicians (80%), whereas antihypertensive medications were equally prescribed by primary care physicians (43%) and sub-specialists (37%) for subjects with secondary hypertension. The predominant hypertension diagnosis among adolescents and young adults is primary hypertension. Antihypertensive medication use was higher among those with secondary hypertension compared with those with primary hypertension. Further study is needed to determine treatment effectiveness and patient outcomes associated with differential treatment patterns used for adolescents and young adults with primary versus secondary hypertension.

Abstract P3-06-11: Disease and treatment characteristics of a large insured female population with advanced or metastatic breast cancer by receipt of HER2-targeted agents

Abstract This retrospective administrative claims study of women diagnosed with advanced or metastatic breast cancer (BC) compared clinical histories and BC treatment by receipt of HER2- targeted agents (2TA), disease stage, and age group. Women ≥ 18 years, diagnosed with stage III or IV BC were selected from the 2008-2012 Truven Health MarketScan databases using ICD-9-CM codes on non-diagnostic medical claims corresponding to BC and local or distant metastases; date of first metastasis was the index date. Patients were followed until the earliest of end of enrollment, inpatient death or 12/31/2012. Those with <12 months continuous enrollment (CE) or non-BC primary cancers pre-index, or HIV or pregnancy anytime were excluded. 2TA was defined as ≥1 medical or pharmacy claim for trastuzumab or lapatinib in the pre- or post-index periods. Study cohorts were women ± 2TA use, 2TA users with stage III and IV BC, and 2TA users age 18-44, 45-64, or 65+ at index. Index demographics, pre-index BC and clinical histories, and post-index BC treatments were compared using t-tests, one-way ANOVA, and chi-square statistics. Of 30,660 eligible women, 14.4% received 2TA at sometime. Compared to non-2TA patients those with 2TA were younger (mean (SD) age 55 (11) vs. 59 (13) years; p≤0.001) and had significantly lower comorbidity burden. While pre-index BC was similar (48% each), 2TA patients had higher rates of pre-index BC surgery (20% vs. 17%), adjuvant/neoadjuvent chemotherapy (74% vs. 53%), radiation treatment (12% vs. 10%), and lower non-2TA biologics use (0% vs. 3%), all p<0.005. Of the 2TA cohort with pre-index BC, 58% used 2TA pre-index. Also among 2TA patients, 57% had Stage III BC at index and 18% were 18-44, 68% 45-64 and 15% 65+. Pre-index BC diagnosis differed by index BC stage (30% III vs. 73% IV) and increased with age (44% 18-44, 48% 45-64, 54% 65+), both p<0.001. Of those with ≥ 3 months CE post-index, 2TA users had higher rates, p<0.001 of BC surgery (53% vs. 47%), radiation (65% vs. 54%) and non-2TA antineoplastic treatment (AT: 89% vs. 83%), compared to non-2TA patients. Of those treated, 2TA users had a higher rate of chemotherapy use (85% vs. 58%), but lower use rates of hormone therapy (56% vs. 78%) and non-2TA biologics (5% vs. 8%), all p<0.001. Receipt of post-index BC surgery was greater among 2TA stage III than stage IV patients (78% vs. 19%) and decreased with age (62% 18-44, 53% 45-64, 42% 65+), both p<0.001. Post-index, stage III 2TA patients were more likely (p<0.001) to have radiation therapy (72% vs. 56%), use 2TA agents post-index (97% vs. 91%), and other AT (92% vs. 84%) compared to stage IV 2TA patients. Radiation declined in the 2TA cohort post-index with increasing age (70%, 65%, 61%, p<0.001). 2TA and AT use also declined with increasing age but these did not reach statistical significance. Receipt of 2TA (vs. non-2TA) was significantly associated with younger age and receipt of pre- and post- BC treatments. Clinical history and BC treatment differences between these cohorts partly reflect differential treatment patterns of HER2- positive and HER2- negative BC patients. Treatment characteristics for the 2TA cohort differ by disease stage and age group. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-06-11.

Survival differences among American Indians/Alaska natives with head and neck squamous cell carcinoma

American Indians/Alaska Natives experience poor overall survival. Data are limited on American Indians/Alaska Natives with head and neck squamous cell carcinoma (HNSCC). We identified all cases of HNSCC among American Indians/Alaska Natives, and white patients from 1996 to 2007 using the Surveillance, Epidemiology, and End Results (SEER) database. Univariate, multivariate, and Cox models were fit to analyze racial differences in sex, age, stage, treatment, and survival. American Indians/Alaska Natives experienced decreased survival for oropharyngeal cancer (hazard ratio [HR] = 1.4; p = .008). After adjusting for demographic factors, survival was decreased for oral cavity cancer (HR = 1.3; p = .05) and hypopharyngeal/laryngeal cancer (HR = 1.6; p = .04). These disparities were eliminated after adjusting for treatment for oral cavity cancer (HR = 1.2; p = .17) and stage for hypopharyngeal/laryngeal cancer (HR = 1.4; p = .12). American Indians/Alaska Natives received less surgery for oral cavity cancer (78% vs 85%; p = .02). Disparities in survival exist among American Indians/Alaska Natives patients with HNSCC. They are related to stage and differential treatment patterns.

Survival Differences in American Indians with Head and Neck Cancer

Objective: American Indians and Alaska Natives (AI/AN) experience poor overall survival. The specific aim of this study was to analyze disparities in survival between AI/AN and white patients with squamous cell carcinoma of the head and neck. Method: We identified all incident cases of oropharyngeal, oral cavity, and hypopharyngeal/laryngeal squamous cell carcinoma among AI/AN and white patients from 1996 to 2007 using the SEER database. Univariate, multivariate, and sequential Cox proportional hazard models were fit to analyze racial differences in sex, age, stage, treatment patterns, and overall survival. Results: For cancer of the oropharynx, AI/AN experienced decreased overall survival after adjusting for age, sex, stage, and type of treatment (hazard ratio (HR) = 1.4, P = .008). For cancer of the oral cavity, AI/AN experienced decreased survival after adjusting for patient age and sex (HR =1.3, P = .05). This difference was eliminated after adjusting for type of treatment (HR=1.2, P = .17). AI/AN were significantly less likely to receive surgery (odds ratio=0.57, P = .02). For hypopharyngeal/laryngeal cancer, AI/AN experienced decreased survival after adjusting for patient age and sex (HR = 1.6, P = .04). Adjusting for stage at diagnosis eliminated the disparity (HR =1.4, P = .12). Conclusion: Significant disparities in survival exist among AI/AN patients with head and neck cancer. These disparities are variably related to stage at presentation and differential treatment patterns. Future research is needed to understand how to implement programs to reduce these differences in care and outcomes.

Equal Treatment in Swedish Economic Crime Investigations: Do Professional Specialization and the Suspect's Social Background Matter?

Although equality before the law is one of the fundamental principles of modern democracy, current Western research has shown that discrimination exists within the justice system when enforcing traditional crimes. However, in Scandinavian research on economic crime, the question of equal treatment has been neglected. Based on Swedish data of suspected offenders during 2003, we examined whether different social groups received differential treatment in investigations of traditional and economic crimes. Further, we compared the Regular Police with the Economic Crimes Bureau (ECB) to examine whether the professional specialization of street-level bureaucrats influence the occurrence of differential treatment. We also examined the efficiency of the authorities and more specifically to what extent they issue a waiver of prosecution, a prosecutor's fine, or a court indictment. Besides supporting earlier research on traditional crime, our results show that differential treatment also exists in relation to economic crime, but the patterns of differential treatment are not identical with the ones for traditional crimes. We also found that the two agencies, the ECB and the Regular Police, treat diverse social groups differently. Although the ECB is somewhat more efficient, professional specialization does not appear to be an important factor concerning the issue of differential treatment. It exists regardless of investigating authority. Further action is being taken more often in relation to men and those with a lower level of education at both agencies. However, in some cases the suspect's background does have a different effect on the work of the two agencies, with the ECB less often taking further action against ‘Swedes’ and those on ‘high incomes’, while the Regular Police less often take further action against ‘immigrants’ and those on ‘low and middle incomes’.