Disparities In Adherence Research Articles

Using Values Affirmation to Reduce the Effects of Stereotype Threat on Hypertension Disparities: Protocol for the Multicenter Randomized Hypertension and Values (HYVALUE) Trial.

BackgroundMedication nonadherence is a significant, modifiable contributor to uncontrolled hypertension. Stereotype threat may contribute to racial disparities in adherence by hindering a patient’s ability to actively engage during a clinical encounter, resulting in reduced activation to adhere to prescribed therapies.ObjectiveThe Hypertension and Values (HYVALUE) trial aims to examine whether a values-affirmation intervention improves medication adherence (primary outcome) by targeting racial stereotype threat.MethodsThe HYVALUE trial is a patient-level, blinded randomized controlled trial comparing a brief values-affirmation writing exercise with a control writing exercise among black and white patients with uncontrolled hypertension. We are recruiting patients from 3 large health systems in the United States. The primary outcome is patients’ adherence to antihypertensive medications, with secondary outcomes of systolic and diastolic blood pressure over time, time for which blood pressure is under control, and treatment intensification. We are comparing the effects of the intervention among blacks and whites, exploring possible moderators (ie, patients’ prior experiences of discrimination and clinician racial bias) and mediators (ie, patient activation) of intervention effects on outcomes.ResultsThis study was funded by the National Heart, Lung, and Blood Institute. Enrollment and follow-up are ongoing and data analysis is expected to begin in late 2020. Planned enrollment is 1130 patients. On the basis of evidence supporting the effectiveness of values affirmation in educational settings and our pilot work demonstrating improved patient-clinician communication, we hypothesize that values affirmation disrupts the negative effects of stereotype threat on the clinical interaction and can reduce racial disparities in medication adherence and subsequent health outcomes.ConclusionsThe HYVALUE study moves beyond documentation of race-based health disparities toward testing an intervention. We focus on a medical condition—hypertension, which is arguably the greatest contributor to mortality disparities for black patients. If successful, this study will be the first to provide evidence for a low-resource intervention that has the potential to substantially reduce health care disparities across a wide range of health care conditions and populations.Trial RegistrationClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).International Registered Report Identifier (IRRID)DERR1-10.2196/12498

Racial and ethnic disparities in medication adherence among privately insured patients in the United States.

ObjectiveTo examine the association between socioeconomic status (SES) and racial and ethnic disparities in medication adherence for three widely prescribed therapeutic classesMethodsWe linked longitudinal claims data from a large US-based insurance provider (2011–2013) to detailed SES information to identify patients treated with oral antidiabetic (N = 56,720), antihypertensive (N = 156,468) or antihyperlipidemic (N = 144,673) medications. We measured adherence and discontinuation by therapeutic class, and conducted regression analysis to quantify the contributions of different factors in the association between race/ethnicity and medication adherence.ResultsDuring an average follow-up period of 2.5 years, average adherence rates of Blacks and Hispanics were at least 7.5 percentage points lower than those of Whites. Controlling for demographics, health status, out-of-pocket costs, convenience of refilling prescriptions and SES attenuated the association by 30 to 50 percent, nonetheless substantial racial disparities persisted (4.1–5.8 percentage points), particularly for asymptomatic conditions. Separating adherence among existing users from those that discontinued therapies indicates that racial/ethnic disparities in adherence reflect inconsistent pill-taking rather than differential rates of discontinuation.ConclusionsRacial/ethnic disparities in adherence are mitigated, but persist after controlling for detailed socioeconomic measures. Interventions should focus more on improving medication adherence of existing users, particularly in treating asymptomatic conditions.

Abstract TMP95: Patients With Stroke Are Not Meeting American Heart Association Secondary Prevention Recommendations

Introduction: Stroke occurs in 795 000 people and causes 133 000 deaths every year in the US. Around 185 000 stroke survivors get recurrent attacks annually. There is a need to understand the adherence to secondary prevention measures if the AHA’s 2020 impact goal is to be achieved. Atherosclerotic cardiovascular disease risk factors remain prevalent in the US but there is limited data on the use of secondary preventive measures among patients with stroke. The objective of this study was to assess the use of secondary preventive measures in patients with stroke and assess for any gender and racial disparities in adherence. Methods: This study is an analysis of the 2015 Behavioral Risk Factor Surveillance System a chronic disease survey conducted by the CDC. The sample included 18 269 subjects with a history of stroke. The secondary preventive measures analyzed included: exercise, diet, smoking cessation, alcohol intake, body mass index, use of blood pressure medications in hypertensives and the use of aspirin. Gender and racial disparities were analyzed using logistic regression analysis and age, race, education, and income were adjusted for in the outcomes. Results: The mean age of the study cohort was 66.8 years (SD =12.1). White, black and Hispanic patients represented 75.1%, 11.5% and 4.7% respectively. Females comprised 58.3%. Comorbidities included: hypertension (73.4%), coronary heart disease (37.5%), dyslipidemia (35.7%), diabetes mellitus (30.4%) and chronic kidney disease (11.6%). Among stroke patients, 57.9% reported ever smoking and 42% of them still smoked. Only 11.3% met both the AHA aerobic and muscle strengthening exercise guidelines. Thirty six percent of stroke patients undertook more than 150 minutes of aerobic exercise and 12% did 1-149 minutes per week. Obesity/overweight was present in 69.9%. Only 59% of patients with stroke were using aspirin while among hypertensive patients, 90.7% took their blood pressure medications. There were major racial and gender disparities in smoking status, obesity, diet, BMI and use of BP medications and aspirin. Conclusion: Patients with stroke do not meet AHA lifestyle modification and aspirin recommendations. There are major gender and racial disparities in the use of stroke secondary preventive measures.

Disparities in adherence to head and neck cancer follow-up guidelines.

In this study, we aim to determine the frequency of adherence to National Comprehensive Cancer Network follow-up guidelines in a population of head and neck cancer patients who received curative treatment. We will also assess the impact of race, ethnicity, socioeconomic status, and treatment setting on utilization of follow-up care. This study included patients with biopsy-proven, nonmetastatic oropharyngeal or laryngeal cancer treated with radiotherapy between January 1, 2014, and June 30, 2016, at a safety-net hospital or adjacent private academic hospital. Components of follow-up care analyzed included an appointment with a surgeon or radiation oncologist within 3 months and posttreatment imaging of the primary site within 6 months. Univariable and multivariable analyses were conducted using a logistic regression model to estimate odds ratios and corresponding 95% confidence intervals. Two hundred and thirty-four patients were included in this study. Of those, 88.8% received posttreatment imaging of the primary site within 6 months; 88.5% attended a follow-up appointment with a radiation oncologist within 3 months; and 71.1% of patients attended a follow-up appointment with a surgeon within 3 months. On multivariable analysis, private academic hospital treatment versus safety-net hospital treatment was associated with increased utilization of both surgical and radiation oncology follow-up. Non-Hispanic black (NHB) patients, Hispanic patients, and those with a low socioeconomic status were also less likely to receive follow-up. Safety-net hospital treatment, socioeconomic status, Hispanic ethnicity, and NHB race were associated with decreased follow-up service utilization. Quality improvement initiatives are needed to reduce these disparities. 2b Laryngoscope, 129:2303-2308, 2019.

The Effect of Sleeping Environment and Sleeping Location Change on Positive Airway Pressure Adherence.

Poor adherence undermines the effectiveness of positive airway pressure (PAP) therapy for sleep apnea. Disparities exist in PAP adherence by race/ethnicity and neighborhood socioeconomic status (SES), but the etiology of these differences is poorly understood. We investigated whether home environmental factors contribute to PAP adherence and whether identified factors explain disparities in adherence by SES. Adult patients with sleep apnea were surveyed at clinic visits about their sleep environment. Medical records were abstracted for demographic data, sleep apnea severity, comorbidities, and objective PAP adherence. We evaluated the association between aspects of home sleep environment with PAP adherence using multivariate linear and logistic regression, and assessed effect modification by SES factors. Participants (n = 119) were diverse, with 44% nonwhite and 35% uninsured/Medicaid. After adjusting for age, sex, race/ethnicity, insurance, neighborhood SES, education, and marital status, participants who endorsed changing sleeping location once per month or more (18%, n = 21) had 77% lower odds of meeting PAP adherence criteria (> 4 h/night for 70% of nights) and less PAP use (median -11 d/mo, 95% confidence intervals -15.3, -6.5). Frequency of sleeping location change was the only environmental factor surveyed associated with PAP adherence. Frequent change in sleeping location is associated with reduced PAP adherence, independent of sociodemographic factors. This novel finding has implications for physician-patient dialogue. PAP portability considerations in device selection and design may modify adherence and potentially improve treatment outcomes. Prospective investigation is needed to confirm this finding and inform design of possible interventions.

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

The purpose of the study is to examine disparities in AET adherence and discontinuation among Texas Medicaid-insured early-stage breast cancer patients. Texas Cancer Registry Medicaid-linked database was used from 2000 to 2007 for breast cancer patients aged 20-64. Multivariable logistic regression was performed to test the association of race/ethnicity and geographic factors with AET adherence and discontinuation. Of the 1240 women with breast cancer, 60.8% of non-Hispanic white vs 46.6% of Black patients were adherent to AET in the first year. After adjusting for confounding, Black patients had lower odds of adherence compared to non-Hispanic white patients (Odds ratio 0.62, 95% CI 0.44-0.87), but they were not more likely to discontinue therapy during the study period. Patients from the Texas/Mexico border had higher odds of adherence compared to other regions (OR 2.32, 95% CI 1.29-4.18). There are substantial racial and geographic disparities in AET adherence and discontinuation among Texas Medicaid-insured women.

Disparities in Adherence to National Comprehensive Cancer Network Treatment Guidelines and Survival for Stage IB-IIA Cervical Cancer in California.

To evaluate the association of sociodemographic and hospital characteristics with adherence to National Comprehensive Cancer Network treatment guidelines for stage IB-IIA cervical cancer and to analyze the relationship between adherent care and survival. This is a retrospective population-based cohort study of patients with stage IB-IIA invasive cervical cancer reported to the California Cancer Registry from January 1, 1995, through December 31, 2009. Adherence to National Comprehensive Cancer Network guideline care was defined by year- and stage-appropriate surgical procedures, radiation, and chemotherapy. Multivariate logistic regression, Kaplan-Meier estimate, and Cox proportional hazard models were used to examine associations between patient, tumor, and treatment characteristics and National Comprehensive Cancer Network guideline adherence and cervical cancer-specific 5-year survival. A total of 6,063 patients were identified. Forty-seven percent received National Comprehensive Cancer Network guideline-adherent care, and 18.8% were treated in high-volume centers (20 or more patients/year). On multivariate analysis, lowest socioeconomic status (adjusted odds ratio [OR] 0.69, 95% CI 0.57-0.84), low-middle socioeconomic status (adjusted OR 0.76, 95% CI 0.64-0.92), and Charlson-Deyo comorbidity score 1 or higher (adjusted OR 0.78, 95% CI 0.69-0.89) were patient characteristics associated with receipt of nonguideline care. Receiving adherent care was less common in low-volume centers (45.9%) than in high-volume centers (50.9%) (effect size 0.90, 95% CI 0.84-0.96). Death from cervical cancer was more common in the nonadherent group (13.3%) than in the adherent group (8.6%) (effect size 1.55, 95% CI 1.34-1.80). Black race (adjusted hazard ratio 1.56, 95% CI 1.08-2.27), Medicaid payer status (adjusted hazard ratio 1.47, 95% CI 1.15-1.87), and Charlson-Deyo comorbidity score 1 or higher (adjusted hazard ratio 2.07, 95% CI 1.68-2.56) were all associated with increased risk of dying from cervical cancer. Among patients with early-stage cervical cancer, National Comprehensive Cancer Network guideline-nonadherent care was independently associated with increased cervical cancer-specific mortality along with black race and Medicaid payer status. Nonadherence was more prevalent in patients with older age, lower socioeconomic status, and receipt of care in low-volume centers. Attention should be paid to increase guideline adherence.

Disparities in Adherence to Pediatric Diabetic Ketoacidosis Management Guidelines Across a Spectrum of Emergency Departments in the State of Indiana: An Observational In Situ Simulation-Based Study.

Diabetic ketoacidosis (DKA) is a common presentation to an emergency department (ED), with the majority presenting to community EDs. Adherence to clinical guidelines in these EDs can reduce morbidity and mortality. Few methods to describe practice gaps for DKA management have been reported. We hypothesized that high-fidelity in situ simulation can be used to measure and compare the quality of the care provided to pediatric patients with DKA presenting to community EDs in the state of Indiana. This observational study examined multiprofessional teams caring for a simulated pediatric patient who presented with DKA to community EDs. The primary outcome was overall adherence to pediatric DKA guidelines as measured by a validated performance checklist. A composite adherence score (CAS) was calculated using the sum of 9 checklist performance parameters. Multivariable logistic regression was used to examine the impact of ED volume and characteristics on the scores. A 49 multiprofessional teams from 13 sites were enrolled. Of the 252 participants, 26 (10.3%) were physicians, 143 (56.7%) registered nurses, 25 (9.9%) respiratory therapists, and 58 (23.0%) were other. The overall CAS for all sites was 55.6% (25th, 75th interquartile range, 44.4%, 66.7%). Excessive intravenous fluid boluses were given by 53.1%, whereas 30.6% and 26.5% incorrectly administered insulin and sodium bicarbonate boluses, respectively. Only 10.2% used an appropriate intravenous fluid rate, and 57.1% performed an hourly glucose. No significant difference in the CAS was found due to pediatric ED volume or presence of an inpatient pediatric service. Using validated in situ simulation; we revealed high variability in adherence to the pediatric DKA management guidelines at a wide range of community EDs. A statewide education initiative focused on decreasing variation and improving adherence to pediatric DKA guidelines is necessary for patient safety.

Socioeconomic Disparities in Adherence and Outcomes After Heart Transplant

There is mixed evidence of racial and socioeconomic disparities in heart transplant outcomes. Their underlying cause-and whether individual- or community-level traits are most influential-remains unclear. The current study aimed to characterize socioeconomic disparities in outcomes and identify time trends and mediators of these disparities. We used United Network for Organ Sharing registry data and included 33 893 adult heart transplant recipients between 1994 and 2014. Socioeconomic status (SES) indicators included insurance, education, and neighborhood SES measured using a composite index. Black race and multiple indicators of low SES were associated with the primary outcome of death or retransplant, independent of baseline clinical characteristics. Blacks had lower HLA and race matching, but further adjustment for these and other graft characteristics only slightly attenuated the association with black race (HR, 1.25 after adjustment). This and the associations with neighborhood SES (HR, 1.19 for lowest versus highest decile), Medicare (HR, 1.17), Medicaid (HR, 1.29), and college education (HR, 0.90) remained significant after full adjustment. When comparing early (1994-2000) and late (2001-2014) cohorts, the disparities associated with the middle (second and third) quartiles significantly decreased over time, but those associated with lowest SES quartile and black race persisted. Low neighborhood SES was also associated with higher risks of noncompliance (HR, 1.76), rejection (HR, 1.28), hospitalization (HR, 1.13), and infection (HR, 1.10). Racial and socioeconomic disparities exist in heart transplant outcomes, but the latter may be narrowing over time. These disparities are not explained by differences in clinical or graft characteristics.

The Association between Socioeconomic Status and Adherence to Health Check-up in Korean Adults, Based on the 2010-2012 Korean National Health and Nutrition Examination Survey.

BackgroundWe investigated the association between socioeconomic status and adherence to health check-ups in a Korean population aged 40 years or older.MethodsThis cross-sectional study included 12,311 participants who participated in the 2010–2012 Korean National Health and Nutrition Examination Survey. Self-reported questionnaires were used to assess each participant's socioeconomic status (household income, occupation, and education) and adherence to health check-ups.ResultsMen with a higher income (highest vs. lowest: odds ratio [OR], 1.799; 95% confidence interval [CI], 1.296–2.497) and men with a higher education level (≥12 vs. <6 years: OR, 1.488; 95% CI, 1.078–2.054) and office workers compared with manual workers (men: OR, 1.431; 95% CI, 1.077–1.902; women: OR, 1.783; 95% CI, 1.256–2.532) appeared to undergo more health check-ups. In particular, men and women with a higher income and education appeared more likely to undergo opportunistic health check-ups (men: highest vs. lowest income: OR, 2.380; 95% CI, 1.218–4.653; ≥12 vs. <6 years education: OR, 2.121; 95% CI, 1.142–3.936; women: highest vs. lowest income: OR, 4.042; 95% CI, 2.239–7.297; ≥12 vs. <6 years education: OR, 2.475; 95% CI, 1.283–4.775).ConclusionA higher socioeconomic status was associated with a higher rate of participation in health check-ups. More efforts are needed to identify the factors associated with disparity in adherence to health check-ups.

Assessment of Gender and Racial Disparities in Quality of Care Indicators for Inflammatory Bowel Disease

Introduction: Gender and racial inequality in healthcare quality has been extensively documented. Furthermore,high variation in the care received by inflammatory bowel diseases (IBD) patients has also been reported. We aimed to assess potential gender or racial disparities in adherence to established IBD quality of care indicators (QIs) by gastroenterologists practicing in the community and in a specialized IBD practice at an academic medical center. Methods: A prospective review of consecutive outpatient visits at the gastroenterology clinic at a tertiary academic medical center was conducted over 4 months (January-April 2017). Demographic information and QIs developed by the AGA and CCFA including documentation of IBD phenotype, vaccination status, corticosteroid usage, and appropriate endoscopic evaluation were recorded. We analyzed for gender and racial (Caucasian vs. African American) differences in QIs using t-test and Chi square test. (Prism, Irving CA). Results: Over the study period, 478 patients (median age 42 years, 51% female, 14% African American) were evaluated in the IBD clinics. Disease duration was a median of 14 years, and 55% had Crohn's disease. There was no significant gender (male vs. females) differences in QIs: IBD phenotype documentation (67% vs. 68%), HBV vaccination (74% vs. 69%), Influenza vaccination (54% vs. 50%), Pneumovax vaccination (31% vs. 35), and steroid use greater than 12 weeks (25% vs. 28%), colorectal cancer surveillance (58% vs. 64%), endoscopy within 6 months of modifying therapy (45% vs. 39%). There were no significant racial (Caucasian vs. African American) differences in adherence to most QIs: IBD phenotype documentation (71% vs 67%), HBV vaccination (71% vs. 76%), Influenza vaccination (50% vs. 66%, p=0.01), Pneumovax vaccination(32% vs 42%, p=0.08), steroid use greater than 12 weeks (26% vs 28%), colorectal cancer surveillance (65% vs. 60%), and endoscopy within 6 months of modifying therapy (46% vs. 37%,). In addition, race and gender did not contribute to significant differences in QIs in subgroups of patients managed either by community general gastroenterologists vs IBD specialists at an academic medical center. Conclusion: There was no consistent evidence of gender or racial disparities in adherence to most of the quality of care indicators in IBD either in community or specialized IBD practices. This requires confirmation in future studies replicated at other community and academic IBD practices.

Reexamining medication adherence in black patients with hypertension through the lens of the social determinants of health.

Reexamining medication adherence in black patients with hypertension through the lens of the social determinants of health.

Stage IA-IIA cervical cancer: Disparities in adherence to treatment guidelines and survival in California

Stage IA-IIA cervical cancer: Disparities in adherence to treatment guidelines and survival in California

Abstract A52: Racial Differences in Prevention Decision Making among Women at High Risk of Breast Cancer

Abstract Background &amp; Objectives: Prior research has documented significant racial disparities in adherence to breast cancer screening recommendations, use of breast-conserving surgery by early stage breast cancer patients, and breast cancer mortality. Decision making about breast cancer prevention options among high risk women has been less thoroughly studied, and racial differences remain mostly unexplored in this arena. The current study employs semi-structured interviews and inductive analytic methods to explore prevention decision making among African American and White women. Its core objective is to investigate the degree to which decision-making processes and outcomes differ across racial groups, and the specific content of these differences, in order to support interventions and programs to facilitate empowered, preventive decision making. Methods: In-depth, semi-structured interviews were conducted with 20 African American and 30 non-Hispanic White women at elevated risk of breast cancer. Allowing women to speak in their own words, these interviews explore women's perception of their risk status; the sources and content of risk information they have obtained; their understanding and consideration of prevention options; decision-making processes; decision-making networks, psychosocial well-being; and women's use of financial, time, and energy resources in coping with risk and prevention. Interviews ranged in length from 30 to 140 minutes and were professionally transcribed. Transcribed data are analyzed through grounded theory methods, using the NVivo 10 software package for qualitative data. Results: High risk African American women's experiences are distinct from those of their White counterparts in a range of ways, including the following. (1) African American women are much less frequently aware of the existence of prophylactic surgeries and chemoprevention options are clinically recommended for women at their own level of risk. (2) Among women who do know about these prevention options, African American women are less likely to consider or undertake prophylactic surgeries or chemoprevention to lower their breast cancer risk. (3) A much higher proportion of African American women have experienced several different types of cancer among their loved ones. These women tend to perceive of themselves as at risk for cancer in general, and not to perceive a specific high risk for breast or ovarian cancer. (4) African American women experience considerably more financial limitations on their ability to access health care and engage in specific prevention activities. Most have been uninsured for some period, and have had at least one health care decision affected by financial constraints. (5) African American women are considerably more likely to reference faith, spirituality, and religion in discussing their perceived risk of cancer and their attitudes toward prevention behavior. Conclusions &amp; Implications: High risk women's narratives reveal substantial racial differences in perceptions, feelings, and choices related to breast cancer prevention. African American women who are clinically determined to be at high risk for breast and ovarian cancer are less likely than similar White women to understand this specific risk, to know about prevention options that could lower the risk, or to consider using these options even when they do know about them. The processes through which African American women navigate risk and prevention are also more heavily influenced by religious faith and financial constraint than those of White women. These distinctions merit further investigation, and confirmation with larger samples. Ultimately, knowledge of such inter-group differences may contribute to tailored interventions to support empowered and health-protective decision making among women at elevated risk. Citation Format: Tasleem J. Padamsee, Anna Muraveva, Electra D. Paskett. Racial Differences in Prevention Decision Making among Women at High Risk of Breast Cancer. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A52.

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 ≤ $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 women's differences in socioeconomic status and out-of-pocket medication costs.

Geographic disparities in adherence to adjuvant endocrine therapy in Appalachian women with breast cancer.

Appalachia is a largely rural, mountainous, poor and underserved region of the United States. Adherence to adjuvant endocrine therapy among Appalachian women with breast cancer is suboptimal. To explore small-area geographic variations and clustering patterns of breast cancer patient adherence to adjuvant endocrine therapy and associated factors in Appalachia. In this retrospective study, we analyzed Medicare claims data linked with cancer registries from four Appalachian states (PA, OH, KY, and NC) in 2006-2008. We included adult women who were diagnosed with stage I-III, hormone-receptor positive, primary breast cancer and who newly started adjuvant endocrine therapy after the primary treatment for breast cancer. Hot spot analysis was conducted to explore geographic variations in adjuvant endocrine therapy adherence. Geographically weighted logistic regression (GWLR) was used to examine whether the impacts of factors associated with adherence varied across the region. Breast cancer patients living in PA and OH showed higher adherence to adjuvant endocrine therapy than those living in KY and NC. We identified clusters of high adherence in most of PA but poor adherence in Erie County, PA and in Buncombe, Transylvania, Henderson, and Polk Counties, NC. Adherence to adjuvant endocrine therapy was significantly associated with the Health Professional Shortage Area designation, catastrophic coverage, dual-eligibility status of Medicaid and Medicare, adjuvant endocrine therapy drug class, and side effects. And among these factors, the impacts of dual-eligibility status and the use of pain medications to treat side effects on adherence were more pronounced in KY and NC than in PA. There were significant geographic disparities in adherence to adjuvant endocrine therapy in the Appalachian counties in PA, OH, KY, and NC. This study explored these geographic areas with poor adherence as well as geographically varying effects of predictors on adherence; our results may provide more localized information that may be used to improve adjuvant therapy use and breast cancer care in these high-risk and underserved areas.

Effects of Hospital Type and Distance on Lymph Node Assessment for Colon Cancer Among Metropolitan and Nonmetropolitan Patients in Appalachia.

We studied differences in access to large or accredited cancer programs as a possible explanation for geographic disparities in adherence to the national guideline on lymph node assessment for Stages I to III colon cancer. State cancer registries were linked with Medicare claims of patients diagnosed from 2006 to 2008 from Appalachian counties of four states. Metropolitan and nonmetropolitan patients differed on adherence, proximity to high-volume or accredited hospitals, and hospital type. We modeled effects of hospital type on adherence with ordinary least squares and instrumental variables (instrumenting for hospital type with relative distance). The evidence was strongest for improved adherence in high-volume hospitals for nonmetropolitan patients. We estimate that roughly 100 deaths might be prevented over 5 years among each year's incident cases if the nonmetropolitan disparity in hospital volume were eliminated nationally. We conclude that regionalization or targeting smaller hospitals would improve adherence in nonmetropolitan areas, but also argue for improving adherence generally.

A National Assessment of Medication Adherence to Statins by the Racial Composition of Neighborhoods.

Adherence to statins is lower in black and Hispanic patients and is linked to racial/ethnic disparities in cardiovascular mortality. Poverty, education, and prescription coverage differentials are typically invoked to explain adherence disparities, but analyses at the level of neighborhoods and their pharmacies may provide additional insights. Among individuals filling new statin prescriptions in a national pharmacy chain (N=326,171), we compared adherence for patients residing in mostly minority neighborhoods to those living in mainly white areas. In analyses adjusting for patient-level factors associated with poor adherence, including age, insurance, payer, prescription cost, and convenience, patients residing in black and Hispanic neighborhoods had 2-3weeks less statin therapy over 1year, a pattern not seen in Asian areas. In black and Hispanic neighborhoods, good adherence was associated with co-pays under $10, the use of 90-day refills, and payers other than Medicaid. Efforts to improve medication adherence for vulnerable populations may benefit from interventions at the level of local pharmacies, as well as medication benefit redesign.

Abstract A81: Relationship between out-of-pocket cost and use of tyrosine kinase inhibitors for the treatment of chronic myeloid leukemia

Abstract Targeting tyrosine kinase activity in cancer cells represents one of the greatest innovations in cancer treatment. Yet the high cost of tyrosine kinase inhibitors (TKIs) and the cumulative financial burden to patients associated with their use may lead to disparities in medication adherence. This study investigated the relationship between out-of-pocket cost and adherence to TKIs among a cohort of commercially insured chronic myeloid leukemia (CML) patients. The Truven Health Marketscan database was used to identify prevalent cases of CML with &amp;gt;1 prescription claim for a guideline-recommended first-line TKI, imatinib, nilotinib, or dasatinib. Out-of-pocket cost was calculated longitudinally using any amount paid by the patient towards a deductible, copayment, and coinsurance. Adherence was assessed using the medication possession ratio (MPR), calculated between the first and last TKI claims occurring between 2011 and 2013, and conditional on continuous insurance plan enrolment. Nonadherence was classified as an MPR &amp;lt;80%. In addition to out-of-pocket cost, insurance plan, region, and area-level socioeconomic variables were assessed as determinants of adherence using logistic regression modeling to calculate and odds ratio (OR) and 95% confidence interval (CI). A total of 5,669 CML patients were identified from the Marketscan database between 2011 and 2013. Over that time period out-of-pocket costs for a 30-day supply of TKIs ranged from $0 to $1800, with means of $60 for dasatinib, $65 for imatinib, and $72 for nilotinib. Patients with relatively higher out-of-pocket costs (highest 75th percentile) were 27% more likely (OR 1.27, 95% 1.22 – 1.32) to be nonadherent to TKI therapy than patients with lower out-of-pocket costs. With the possibility of a generic version of imatinib on the horizon, understanding the association between out-of-pocket costs and adherence may have important implications for reducing disparities in adherence to TKIs for the treatment of CML. Citation Format: Jean A. McDougall, Caroline S. Bennette, Scott D. Ramsey, Sean D. Sullivan. Relationship between out-of-pocket cost and use of tyrosine kinase inhibitors for the treatment of chronic myeloid leukemia. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A81.

Impact of Medicare Part D on Racial Disparities in Adherence to Cardiovascular Medications Among the Elderly.

Medicare Part D improved medication adherence among the elderly, but to date, its effect on disparities in adherence remains unknown. We estimated Part D impact on racial/ethnic disparities in adherence to cardiovascular medications among seniors, using pooled data from the Medical Expenditure Panel Survey (2002-2010) on 14,221 Medicare recipients (65+ years) and 3,456 near-elderly controls (60-64 years). Study sample included White, Black, or Hispanic respondents who used at least one cardiovascular medication. Twelve-month adherence was measured as having an overall proportion of days covered ≥80%. Adherence disparities were defined according to the Institute of Medicine framework. Using difference-in-differences logistic regression, we found Part D to be associated with a 16-percentage-point decrease in the White-Hispanic disparity in overall adherence among seniors, net of the change among controls. Black-White disparities worsened only among men, by 21 percentage points. Increasing access and improving quality of medication use among disadvantaged seniors should remain a policy priority.