Medicare Enrollees Research Articles

Clotrimazole-Betamethasone Dipropionate Prescribing for Nonfungal Skin Conditions

This cross-sectional study identifies the common diagnoses and physician encounter types associated with clotrimazole-betamethasone dipropionate prescriptions among Medicare enrollees in 2021.

Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With and Without Food Insecurity.

Compared to traditional Medicare (TM), Medicare Advantage (MA) plans impose out-of-pocket cost limits and offer extra benefits, potentially providing financial relief for MA enrollees, especially for those with food insecurity. To examine whether the prevalence of food insecurity differs between TM and MA enrollees at baseline and then examine whether MA enrollment in a baseline year is associated with less financial hardships in the following year, relative to TM enrollment, especially for those experiencing food insecurity. We conducted a retrospective longitudinal cohort study. Our analysis included 2807 Medicare beneficiaries (weighted sample size, 23,963,947) who maintained continuous enrollment in either TM or MA in both 2020 and 2021 from the Medical Expenditure Panel Survey. We assessed outcomes related to financial hardships in health care and non-health care domains (measured in 2021). Our primary independent variables were food insecurity and MA enrollment (measured in 2020). The point estimate of food insecurity prevalence was greater among MA enrollees than TM enrollees, but the difference was not statistically significant (1.1 percentage points [95% CI, - 1.0, 3.4]). Furthermore, there is evidence that compared to TM enrollment, MA enrollment did not mitigate the risk of financial hardship, particularly for food-insecure enrollees. Rather, food-secure MA enrollees faced greater financial hardship in the following year than food-secure TM enrollees (11.2% [8.9-13.6] and 7.6% [6.9-8.3] for problems paying medical bills and 5.5% [4.6-6.4] and 2.8% [2.1-3.6] for paying medical bills over time). Moreover, the point estimate of financial hardship was higher among food-insecure MA enrollees than food-insecure TM enrollees (21.5% [5.4-37.5] and 11.2% [4.1-18.4] and 23.7% [9.6-37.9] and 6.9% [0.5-13.3]) despite the lack of statistical significance. These findings suggest that the promise of financial protection offered by MA plans has not been fully realized, particularly for those with food insecurity.

Federal report reveals lack of BH providers in Medicare, Medicaid programs

Few behavioral health providers in selected counties are actively serving Medicare and Medicaid enrollees, causing enrollees who experience difficulty accessing providers delays in care and the potential to forgo treatment altogether, according to a new report released by the U.S. Department of Health and Human Services' Office of Inspector General (OIG).

Area Vulnerability and Disparities in Therapy for Patients With Metastatic Renal Cell Carcinoma.

Area-level measures of sociodemographic disadvantage may be associated with racial and ethnic disparities with respect to receipt of treatment for metastatic renal cell carcinoma (mRCC) but have not been investigated previously, to our knowledge. To assess the association between area-level measures of social vulnerability and racial and ethnic disparities in the treatment of US Medicare beneficiaries with mRCC from 2015 through 2019. This retrospective cohort study included Medicare beneficiaries older than 65 years who were diagnosed with mRCC from January 2015 through December 2019 and were enrolled in fee-for-service Medicare Parts A, B, and D from 1 year before through 1 year after presumed diagnosis or until death. Data were analyzed from November 22, 2022, through January 26, 2024. Five different county-level measures of disadvantage and 4 zip code-level measures of vulnerability or deprivation and segregation were used to dichotomize whether an individual resided in the most vulnerable quartile according to each metric. Patient-level factors included age, race and ethnicity, sex, diagnosis year, comorbidities, frailty, Medicare and Medicaid dual enrollment eligibility, and Medicare Part D low-income subsidy (LIS). The main outcomes were receipt and type of systemic therapy (oral anticancer agent or immunotherapy from 2 months before to 1 year after diagnosis of mRCC) as a function of patient and area-level characteristics. Multivariable regression analyses were used to adjust for patient factors, and odds ratios (ORs) from logistic regression and relative risk ratios (RRRs) from multinomial logistic regression are reported. The sample included 15 407 patients (mean [SD] age, 75.6 [6.8] years), of whom 9360 (60.8%) were men; 6931 (45.0%), older than 75 years; 93 (0.6%), American Indian or Alaska Native; 257 (1.7%), Asian or Pacific Islander; 757 (4.9%), Hispanic; 1017 (6.6%), non-Hispanic Black; 12 966 (84.2%), non-Hispanic White; 121 (0.8%), other; and 196 (1.3%), unknown. Overall, 8317 patients (54.0%) received some type of systemic therapy. After adjusting for individual factors, no county or zip code-level measures of social vulnerability, deprivation, or segregation were associated with disparities in treatment. In contrast, patient-level factors, including female sex (OR, 0.78; 95% CI, 0.73-0.84) and LIS (OR, 0.48; 95% CI, 0.36-0.65), were associated with lack of treatment, with particularly limited access to immunotherapy for patients with LIS (RRR, 0.25; 95% CI, 0.14-0.43). Associations between individual-level factors and treatment in multivariable analysis were not mediated by the addition of area-level metrics. Disparities by race and ethnicity were consistently and only observed within the most vulnerable areas, as indicated by the top quartile of each vulnerability deprivation index. In this cohort study of older Medicare patients diagnosed with mRCC, individual-level demographics, including race and ethnicity, sex, and income, were associated with receipt of systemic therapy, whereas area-level measures were not. However, individual-level racial and ethnic disparities were largely limited to socially vulnerable areas, suggesting that efforts to improve racial and ethnic disparities may be most effective when targeted to socially vulnerable areas.

Which medicare advantage enrollees are at highest one-year mortality risk?

BackgroundWhile a number of tools exist to predict mortality among older adults, less research has described the characteristics of Medicare Advantage (MA) enrollees at higher risk for 1 year mortality. ObjectivesTo describe the characteristics of MA enrollees at higher mortality risk using patient survey data. Research DesignRetrospective cohort. SubjectsMA enrollees completing the 2019 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. MeasuresLinked demographic, health, and mortality data from a sample of MA enrollees were used to predict 1-year mortality risk and describe enrollee characteristics across levels of predicted mortality risk. ResultsThe mortality model had a 0.80 c-statistic. Mortality risks were skewed: 6 % of enrollees had a ≥ 10 % 1-year mortality risk, while 45 % of enrollees had 1 % to < 5 % 1-year mortality risk. Among the high-risk (≥10 %) group, 47 % were age 85+ versus 12 % among those with mortality risk <5 %. 79 % were in fair or poor self-rated health versus 29 % among those with mortality risk of <5 %. 71 % reported needing urgent care in the prior 6 months versus 40 % among those with a mortality risk of 1 to<5 %. ConclusionsRelatively few older adults enrolled in MA are at high 1-year mortality risk. Nonetheless, MA enrollees over age 85, in fair or poor health, or with recent urgent care needs are far more likely to be in a high mortality risk group.

Disparities in Access to Diagnostic Evaluation for Alzheimer's Disease in Individuals Dually Eligible for Medicare and Medicaid: A Modeling Study.

Individuals dually eligible for Medicare and Medicaid (duals) may face greater obstacles to access to disease-modifying Alzheimer's treatments in spite of their higher disease burden, because of clinicians' reluctance to accept Medicaid and the so-called "lesser of" policy, under which Medicaid may pay providers lower rates. To project differential wait times for duals compared to Medicare-only beneficiaries by state. We used State Medicaid payment policy and Medicare enrollment data and a Markov model to predict differential wait times for duals and non-duals from 2023 to 2050. We estimated available diagnostic appointments by state for both groups based on reluctance of clinicians to accept Medicaid and the "lesser of" policy for each year. We estimate overall average wait times of almost two years (22.9 months) but almost three times as long for duals (59.8 months) than non-duals (20.7 months) because of higher disease burden. The effects of Medicaid payment policy would increase average wait times for duals to 89 months with 20 states having wait times of 99 months or more, which would effectively deprive duals of access. The added average wait times in many states would effectively deprive duals from access to treatment and translate into avoidable disease progression and mortality. Policy interventions to reduce financial and nonfinancial obstacles are dearly needed to avoid deepening disparities. Examples are coverage arrangements that integrate Medicare and Medicaid coverage, covering the co-payment for physician services in full, and stricter network adequacy requirements for Medicaid Managed Care plans.

High-need beneficiary enrollment patterns in Medicare Advantage and traditional Medicare.

High-need Medicare beneficiaries require elevated levels of care and coordination to manage their conditions. We evaluated the extent to which high-need beneficiaries enrolled in Medicare Advantage (MA) or traditional Medicare (TM) accountable care organizations (ACOs) relative to TM non-ACOs. Using Medicare claims and MA encounter data, we identified 3 groups of high-need beneficiaries: (1) individuals younger than 65 years with a disability or end-stage kidney disease, (2) frail individuals, and (3) older individuals with major complex or multiple noncomplex chronic conditions. For comparison, we included non-high-need beneficiaries in the analysis, including those with minor complex chronic conditions. Descriptive analysis of Medicare enrollment patterns and beneficiary characteristics of high-need and other beneficiaries between 2016 and 2019. In 2019, high-need beneficiaries accounted for 18 million or 32% of enrollees in TM and MA, an increase of approximately 1 million since 2016, driven by growth in MA. A larger share of beneficiaries in TM ACOs was high need (38%) compared with MA (24%). Although the totalcount of high-need beneficiaries in TM remained stable from 2016 to 2019, ACOs saw an increase of almost 1.5 million high-need beneficiaries (39% increase), and TM non-ACOs saw a decrease of 1.9 million (23% decrease). We found that high-need beneficiaries were more likely to be in TM non-ACOs than in MA through 2019. However, an increasing number of these beneficiaries are enrolling in MA or aligned with a TM ACO. A projected increase in the population of older adults will increase the economic burden of caring for high-need individuals.

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement

ObjectivesAssess prevalence of serious mental illness (SMI) alone, and co-occurring with Alzheimer disease and related dementias (ADRD), among Medicare beneficiaries in assisted living (AL). Examine the association between permanent nursing home (NH) placement and SMI, among residents with and without ADRD. Design2018-2019 retrospective cohort of Medicare beneficiaries in AL. Residents were followed for up to 2 years to track their NH placement. We used data from the Medicare Enrollment Database, the Medicare Beneficiary Summary File, Minimum Data Set, and a national directory of state-licensed AL communities. AL residents were identified using a validated, previously reported 9-digit zip code methodology. Setting and ParticipantsA cross-sectional study sample included 289,350 Medicare beneficiaries in 17,265 AL communities across 50 states and in the District of Columbia. MethodsThe outcome was permanent NH placement: a continuous stay for more than 90 days. Key independent variable was presence of SMI—schizophrenia, bipolar disorder, and major depression. Other covariates included sociodemographic factors and presence of other chronic conditions, including ADRD. A linear probability model with robust SEs, and AL-level random effects, was used to test the association between SMI diagnoses, ADRD, and their interactions on NH placement. ResultsMore than half (55.65%) of AL residents had a diagnosis of SMI, among them 93.2% had major depression, 28.5% schizophrenia, and 22.2% bipolar disorder. Individuals with schizophrenia and bipolar disorder had a significantly lower probability of NH placement, a 32% and a 15% decrease relative to the cohort mean, respectively. Placement risk was significantly greater for residents with ADRD compared to those without, increasing for those who also had schizophrenia or bipolar disorder, 12.9% and 1.5% relative to the sample mean, respectively. Conclusion and ImplicationsPresence of schizophrenia and bipolar disorder, in conjunction with ADRD, significantly increases the risk of long-term NH placement, suggesting that ALs may not be well prepared to care for these residents.

Socioeconomic Deprivation and Health Care Use in Patients Enrolled in SWOG Cancer Clinical Trials

Reducing acute care use is an important strategy for improving value. Patients with cancer are at risk for unplanned emergency department (ED) visits and hospital stays (HS). Clinical trial patients have homogeneous treatment; despite this, structural barriers to care may independently impact acute care use. To examine whether ED visits and HS within 12 months of trial enrollment are more common among Medicare enrollees who live in areas of socioeconomic deprivation or have Medicaid insurance. This cohort study included patients with cancer who were 65 years or older and treated in SWOG Cancer Research Network trials from 1999 to 2018 using data linked to Medicare claims. Data were collected from 1999 to 2019 and analyzed from 2022 to 2024. Outcomes were ED visits, HS, and costs in the first year following enrollment. Neighborhood socioeconomic deprivation was measured using patients' zip code linked to the Area Deprivation Index (ADI), measured on a 0 to 100 scale for increasing deprivation and categorized into tertiles (T1 to T3). Type of insurance was classified as Medicare with or without commercial insurance vs dual Medicare and Medicaid. Demographic, clinical, and prognostic factors were captured from trial records. Multivariable regression was used, and the association of ADI and insurance with each outcome was considered separately. In total, 3027 trial participants were analyzed. The median (range) age was 71 (65-98) years, 1280 (32.3%) were female, 221 (7.3%) were Black patients, 2717 (89.8%) were White patients, 90 (3.0%) had Medicare and Medicaid insurance, and 660 (22.3%) were in the areas of highest deprivation (ADI-T3). In all, 1094 patients (36.1%) had an ED visit and 983 patients (32.4%) had an HS. In multivariable generalized estimating equation, patients living in areas categorized as ADI-T3 were more likely to have an ED visit (OR, 1.34; 95% CI, 1.10-1.62; P = .004). A similar but nonsignificant pattern was observed for HS (OR, 1.36; 95% CI, 0.96-1.93; P = .08). Patients from areas with the highest deprivation had a 62% increase in risk of either an ED visit or HS (OR, 1.62; 95% CI, 1.25-2.09; P < .001). Patients with Medicare and Medicaid were 96% more likely to have an ED visit (OR, 1.96; 95% CI, 1.56-2.46; P < .001). In this cohort of older patients enrolled in clinical trials, neighborhood deprivation and economic disadvantage were associated with an increase in ED visits and HS. Efforts are needed to ensure adequate resources to prevent unplanned use of acute care in socioeconomically vulnerable populations.

Confounder-dependent Bayesian mixture model: Characterizing heterogeneity of causal effects in air pollution epidemiology.

Several epidemiological studies have provided evidence that long-term exposure to fine particulate matter (pm2.5) increases mortality rate. Furthermore, some population characteristics (e.g., age, race, and socioeconomic status) might play a crucial role in understanding vulnerability to air pollution. To inform policy, it is necessary to identify groups of the population that are more or less vulnerable to air pollution. In causal inference literature, the group average treatment effect (GATE) is a distinctive facet of the conditional average treatment effect. This widely employed metric serves to characterize the heterogeneity of a treatment effect based on some population characteristics. In this paper, we introduce a novel Confounder-Dependent Bayesian Mixture Model (CDBMM) to characterize causal effect heterogeneity. More specifically, our method leverages the flexibility of the dependent Dirichlet process to model the distribution of the potential outcomes conditionally to the covariates and the treatment levels, thus enabling us to: (i) identify heterogeneous and mutually exclusive population groups defined by similar GATEs in a data-driven way, and (ii) estimate and characterize the causal effects within each of the identified groups. Through simulations, we demonstrate the effectiveness of our method in uncovering key insights about treatment effects heterogeneity. We apply our method to claims data from Medicare enrollees in Texas. We found six mutually exclusive groups where the causal effects of pm2.5 on mortality rate are heterogeneous.

Insurance-based Disparities in Outcomes and Extracorporeal Membrane Oxygenation Utilization for Hospitalized COVID-19 Patients.

The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19. Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased. Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased. Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.

Abstract 4795: Social capital and screening mammography rates in the United States

Abstract Background: Social capital may play a role in screening mammogram utilization by influencing individuals' access to information and providing social support for healthy behaviors. However, few studies have examined associations between community-level social capital and screening mammography use. The purpose of this study was to examine the association between county-level social capital and screening mammography rates in the United States (U.S.). Methods: We conducted a cross-sectional study of social capital and screening mammography rates across 2,613 U.S. counties for 2014. We obtained county-level data on (1) screening mammography rates for female Medicare enrollees aged 67-69 years and (2) social capital (Penn State Social Capital Index). Multivariable regression models were used to evaluate associations between social capital quartiles and mammography screening rates. Models were adjusted for county-level socioeconomic, demographic, and access to care factors. Results: Average county-level screening mammography rates were 60.5% ± 8.3% (range 26%-88%). Across all U.S. counties, social capital was associated with county-level mammography rates, after adjusting for covariates (p &amp;lt;0.001). This association did not vary by urban-rural classification. In analyses by region, associations between social capital and screening mammography rates were strongest in the West region (p&amp;lt;0.001). Conclusions: In this nationwide study, social capital was significantly associated with screening mammography. Our findings suggest that there are regional variations in the association between social capital and mammography rates. The relationship between social capital and cancer screening behaviors warrants further investigation, particularly in the U.S. West. Citation Format: Tracy Huang, Christine Ekenga. Social capital and screening mammography rates in the United States [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4795.

Racial and Ethnic Differences in Telemedicine Use

Individuals of racial and ethnic minority groups may be less likely to use telemedicine in part due to lack of access to technology (ie, digital divide). To date, some studies have found less telemedicine use by individuals of racial and ethnic minority groups compared with White individuals, and others have found the opposite. What explains these different findings is unclear. To quantify racial and ethnic differences in the receipt of telemedicine and total visits with and without accounting for demographic and clinical characteristics and geography. This cross-sectional study included individuals who were continuously enrolled in traditional Medicare from March 2020 to February 2022 or until death. Race and ethnicity, which was categorized as Black non-Hispanic, Hispanic, White non-Hispanic, other (defined as American Indian/Pacific Islander, Alaska Native, and Asian), and unknown/missing. Total telemedicine visits (audio-video or audio); total visits (telemedicine or in-person) per individual during the study period. Multivariable models were used that sequentially adjusted for demographic and clinical characteristics and geographic area to examine their association with differences in telemedicine and total visit utilization by documented race and ethnicity. In this national sample of 14 305 819 individuals, 7.4% reported that they were Black, 5.6% Hispanic, and 4.2% other race. In unadjusted results, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 16.7 (95% CI, 16.1-17.3), 32.9 (95% CI, 32.3-33.6), and 20.9 (95% CI, 20.2-21.7) more telemedicine visits per 100 beneficiaries, respectively. After adjustment for clinical and demographic characteristics and geography, compared with White individuals, Black individuals, Hispanic individuals, and individuals of other racial groups had 7.9 (95% CI, -8.5 to -7.3), 13.2 (95% CI, -13.9 to -12.6), and 9.2 (95% CI, -10.0 to -8.5) fewer telemedicine visits per 100 beneficiaries, respectively. In unadjusted and fully adjusted models, and in 2019 and the second year of the COVID-19 pandemic, Black individuals, Hispanic individuals, and individuals of other racial groups continued to have fewer total visits than White individuals. The results of this cross-sectional study of US Medicare enrollees suggest that although nationally, Black individuals, Hispanic individuals, and individuals of other racial groups received more telemedicine visits during the pandemic and disproportionately lived in geographic regions with higher telemedicine use, after controlling for geographic region, Black individuals, Hispanic individuals, and individuals of other racial groups received fewer telemedicine visits than White individuals.

Abstract 4816: Racial disparities in adjunctive supportive care medication use in pancreatic cancer patients

Abstract Background: Beyond its well-known lethality, pancreatic cancer (PC) is associated with a wide variety of physical and psychological complications. These complications collectively lead to an increase in symptom burden experienced by patients with PC, as compared to other cancer types, leading to lower health-related quality of life (HRQoL) and worsened clinical outcomes. Reducing symptom burden is often achieved through the use of supportive care medications (SCM). Racial disparities have been described in the use of pain and psychiatric medications but limited research has explored potential disparities in access to and utilization of other SCM among diverse racial and ethnic groups. The goal of this study was to illustrate the presence of racial/ethnic disparities in the treatment patterns of supportive care medications in end-of-life care of PC patients Methods: We used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database from 2005 to 2017. Participants were identified using ICD9 and ICD10 diagnostic codes. Patients diagnosed with PC and have died in 2005-2007 with more than 1 year of Medicare enrollment before death were included. Logistic regression models to assess the association between use of supportive care medications and race, adjusting for covariates (sex, race, age, marital status, education, income, residence, CCI, year of diagnosis of PC, cancer stage). Results: After the application of the inclusion/exclusion criteria, 74,309 patients were included in the final analysis (White: 72.53%, Black 11.01%, Hispanic 9.60%, Asian/Pacific Islander 6.58%) Racial and ethnic disparities in the use of multiple SCM drug classes were identified. The results are summarized in Table 1. Conclusion: Disparities in the use of SCM were found in patients with PC. Minorities had significantly less use of sleep aids and headache aids, and increased use of cognitive aids and appetite stimulants. AAs also had lower uses of anti-emetics. AA Hispanic Asian SCM Drug Class aOR 95% CI aOR 95% CI aOR 95% CI Anti-emetics 0.77 (0.73, 0.81) 0.98 (0.93, 1.03) 1.01 (0.95, 1.08) Appetite stimulants 1.06 (1.01, 1.11) 1.01 (0.96, 1.06) 1.28 (1.20, 1.36) Cognitive aids 1.38 (1.25, 1.53) 1.04 (0.93, 1.17) 1.11 (0.97, 1.26) Headache aids 0.68 (0.63, 0.74) 0.81 (0.74, 0.87) 0.85 (0.77, 0.93) Sleep aids 0.71 (0.67, 0.75) 0.87 (0.82, 0.92) 0.87 (0.81, 0.93) Citation Format: Olga M. Trejos Kweyete, Yi Guo, Sherise C. Rogers, Lisa Scarton, David L. DeRemer, Chardae L. Whitner, Diana J. Wilkie, John M. Allen. Racial disparities in adjunctive supportive care medication use in pancreatic cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4816.

Abstract 4794: Impact of prior upper endoscopy on gastric cancer stage and survival

Abstract Background: While gastric cancer (GC) incidence in the US has decreased, 5-year survival remains at 34.5%. Early diagnosis offers curative or treatable options, yet many cases are detected at an advanced stage with poor prognosis. In high-incidence East Asian countries with established screening programs, endoscopic screening demonstrates stage shift towards early GC diagnosis and reduced GC-related mortality. Analyses of these programs have reported benefit of endoscopic screening up to 36 months prior to diagnosis. This study explores the impact of esophagogastroduodenoscopy (EGD) in this timeframe on GC stage at diagnosis and survival in an older US population. Methods: The SEER-Medicare database was queried from 2000 to 2017 for patients 68 years of age or older with histologically confirmed GC with continuous Medicare enrollment for at least 36 months prior to GC diagnosis. We excluded patients with prior cancer history and those diagnosed by autopsy or death certificate. Medicare claims files were searched for EGD claims 6-36 months prior to GC diagnosis. We excluded claims in the 6 months prior to diagnosis to avoid capturing potential diagnostic EGD. We defined the exposed group as patients with an EGD claim 6-36 months prior to GC diagnosis (Prior EGD) and the unexposed group as patients with no EGD claim in this period (No Prior EGD). Propensity score analysis balanced baseline differences for patients with and without Prior EGD using covariates sex, age and year of diagnosis, race and ethnicity, rural/urban, comorbidity, SES, and marital status. The primary outcome was in situ/local-stage GC (early) at diagnosis compared to regional/distant-stage (advanced). Secondary outcomes were 5-year overall and GC-specific survival. The adjusted odds of having in situ/local-stage GC diagnosis compared to regional/distant-stage was estimated using logistic regression, and survival analysis was done using the Kaplan-Meier method. Results: In 10,572 patients with GC (57.5% male, mean age 78.8 years), 16.4% had Prior EGD (n=1,736). Patients with Prior EGD had a significantly higher proportion of GC diagnosed in local stage compared to patients with No Prior EGD (45.7% vs. 30.2%, p &amp;lt; 0.001). After controlling for confounders, Prior EGD group had two-fold increased odds of GC diagnosis at early-stage compared with No Prior EGD (OR=1.99, 95% CI: 1.88-2.10). Compared with No Prior EGD, Prior EGD was associated with higher overall survival (5-year survival 32.1% vs. 22.7%, p&amp;lt;0.001) and GC-specific survival (5-year survival 46.0% vs. 31.1%, p&amp;lt;0.001), both driven by early-stage disease. Conclusions: Our analysis demonstrates that EGD up to 36 months prior to the diagnosis of GC is associated with earlier stage at diagnosis and improved overall and GC-specific survival. This study of an older population suggests that endoscopic screening may be beneficial even in a low-incidence country such as the US and warrants further study. Citation Format: Sophie Wagner, Jennifer S. Ferris, Josephine Soddano, Ji Yoon Yoon, Sheila D. Rustgi, Haley Zylberberg, Jeong Yun Yang, Yongmei Huang, Ling Chen, Chin Hur. Impact of prior upper endoscopy on gastric cancer stage and survival [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4794.

Abstract P115: Urban Greenspace and All-Cause, Cardiovascular Disease-Specific, and Breast Cancer-Specific Mortality Among Older Women With Breast Cancer in the United States: Regional Variations Within the Surveillance, Epidemiology, and End Results and Medicare Linked Database

Background: Cardiovascular disease (CVD) and cancer are leading causes of morbidity and mortality in the US. Cancer survivors are at increased risk for adverse CVD outcomes due to multiple factors, including cardiotoxicity. Research suggests that greenspace contributes to better health outcomes, including CVD and breast cancer (BC). Objective: To explore relationships between urban greenspace and all-cause (ACM), CVD-specific (CVDSM), and BC-specific (BCSM) mortality and explore regional differences among older women diagnosed with BC in the US SEER-Medicare database. Methods: The 2011 national landcover database was linked to the 2010 census tracts and the 2010-2017 SEER-Medicare BC cohort. Women were included if they were 66+ years at diagnosis, had invasive BC, enrolled in Medicare Part A and Part B for 12 months before diagnosis, and had a census tract match for greenspace. Independent variable ‘greenspace’ was census tract percent tree canopy quartiles. Outcomes were all-cause, CVD, and BC-specific survival. Censoring was determined by the end of the study date, 12/31/2018. Covariates included age and comorbidity at BC diagnosis, race/ethnicity, dual enrollment in both Medicare and Medicaid eligibility, neighborhood social vulnerability, and tumor stage. Results: Regional variations in association between greenspace and BC survival were observed (Table 1). Greenspace is protective for ACM and BCSM in California, Washington, New Jersey, and Michigan, while no significant associations were observed in Georgia or Louisiana. For CVDSM, greenspace is protective in CA, while no significant differences were observed in Washington, Louisiana, and Michigan. An inverse relationship is observed for CVDSM in Georgia and New Jersey. Discussion: Our findings warrant more studies to investigate why greenspace is protective in some areas (i.e., CA, NJ, MI) or hazardous in other areas (i.e., GA). There is a need to identify critical factors and pathways contributing to these greenspace-survival differences.

Racial and Ethnic Disparities in Community Mental Health Use Among Autistic Adolescents and Young Adults

PurposeThe purpose of this cohort study was to evaluate differences in rate of co-occurring mental health (MH) conditions among transition-age autistic youth (TAYA) who are Black, indigenous, and other people of color, and to identify enabling variables associated with any community MH visit in this population. MethodsMedicare-Medicaid Linked Enrollees Analytic Data Source 2012 data were used for this study. TAYA 14–29 years old who received fee-for-service Medicare, Medicaid, or both were included. Predisposing, enabling, and need variables associated with both presence of MH conditions and any community MH visit were examined with general linear modeling. ResultsN = 122,250 TAYA were included. Black, Asian/Pacific Islander, and Hispanic TAYA were significantly less likely than White TAYA to have a diagnosis of substance-use, depressive, anxiety, attention-deficit hyperactivity disorder, or post-traumatic stress disorders. These groups were also significantly less likely to have had a community MH visit in the past year after controlling for predisposing, enabling, and need variables. Enabling variables associated with greater use of at least one community MH visit included dual enrollment in both Medicare and Medicaid and 12+ months of enrollment in 1115 or 1915(C) Medicaid waivers. DiscussionService delivery factors are an important area of future research, particularly dual enrollment and coverage disparities for Black, indigenous, and other people of color TAYA. Examining coverage of managed care enrollees, including differences by state, may offer additional insights on how these factors impact care.

Breast cancer screening among Medicare Advantage enrollees with dementia

BackgroundThe decision to screen for breast cancer among older adults with dementia is complex and must often be individualized, as these individuals have an elevated risk of harm from over-screening. Medicare beneficiaries with dementia are increasingly enrolling in Medicare Advantage plans, which typically promote receipt of preventive cancer screening among their enrollees. This study examined the utilization of breast cancer screening among Medicare enrollees with dementia, in Medicare Advantage and in fee-for-service Medicare.MethodsWe conducted a pooled cross-sectional study of women with Alzheimer’s disease and related dementias or cognitive impairment who were eligible for mammogram screening. We used Medicare Current Beneficiary Survey data to identify utilization of biennial mammogram screening between 2012 and 2019. Poisson regression models were used to estimate prevalence ratios of mammogram utilization and to calculate adjusted mammogram rates for Medicare Advantage and fee-for-service Medicare enrollees with dementia, and further stratified by rurality and by dual eligibility for Medicare and Medicaid.ResultsMammogram utilization was 16% higher (Prevalence Ratio [PR] 1.16; 95% CI: 1.05, 1.29) among Medicare Advantage enrollees with dementia, compared to their counterparts in fee-for-service Medicare. Rural enrollees experienced no significant difference (PR 0.99; 95% CI: 0.72, 1.37) in mammogram use between Medicare Advantage and fee-for-service Medicare enrollees. Among urban enrollees, Medicare Advantage enrollment was associated with a 21% higher mammogram rate (PR 1.21; 95% CI: 1.09, 1.35). Dual-eligible Medicare Advantage enrollees had a 34% higher mammogram rate (PR 1.34; 95% CI: 1.10, 1.63) than dual-eligible fee-for-service Medicare enrollees. Among non-dual-eligible enrollees, adjusted mammogram rates were not significantly different (PR 1.11; 95% CI: 0.99, 1.24) between Medicare Advantage and fee-for-service Medicare enrollees.ConclusionsMedicare beneficiaries age 65–74 with Alzheimer’s disease and related dementias or cognitive impairment had a higher mammogram use rate when they were enrolled in Medicare Advantage plans compared to fee-for-service Medicare, especially when they were dual-eligible or lived in urban areas. However, some Medicare Advantage enrollees with Alzheimer’s disease and related dementias or cognitive impairment may have experienced over-screening for breast cancer.

Comparing the Centers for Medicare and Medicaid Services (CMS) enrollment data death dates to the National Death Index (NDI).

In the United States, the National Death Index (NDI) is the most complete source of death information, while epidemiologic studies with mortality outcomes often rely on U.S. Medicare data for outcome ascertainment. The purpose of this study was to assess the agreement of death information between the Centers for Medicare & Medicaid Services (CMS) Medicare enrolment data and NDI. Using Medicare and NDI data from 1999 through 2016, we identified Medicare beneficiaries who were reported dead in the CMS Medicare enrolment database (EDB) and Common Medicare Environment (CME), linked these beneficiaries to the NDI using CMS Health Insurance Claim number, and compared death dates between the two data sources. To assess agreement between our data sources, we calculated kappa scores; where a kappa of 1 indicates perfect agreement and a kappa of 0 indicates agreement equivalent to chance. We also examined CMS to NDI linkage and death date matching for stability over time. Of the 36 785 640, Medicare beneficiaries reported dead in CMS enrollment data from 1999 to 2016, 97.5% were linked to the NDI. A kappa score of 0.98 showed a near perfect agreement between NDI and CMS reported deaths. The percentage of linked cases exactly matching on death dates increased from 94.8% in 1999 to 99.4% in 2016. Our findings suggest strong concordance between death dates as recorded by CMS enrollment data and the NDI in the entire Medicare population.

Real-World Effectiveness of Preventive Pharmacological Therapy in Patients With Urolithiasis: A Retrospective Cohort Study

Data supporting the efficacy of preventive pharmacological therapy (PPT) to reduce urolithiasis recurrence are based on clinical trials with composite outcomes that incorporate imaging findings and have uncertain clinical significance. This study evaluated whether the use of PPT leads to fewer symptomatic stone events. Retrospective cohort study. Medicare enrollees with urolithiasis who completed 24-hour urine collections that revealed hypercalciuria, hypocitraturia, low urine pH, or hyperuricosuria. PPT (thiazide diuretics for hypercalciuria, alkali for hypocitraturia or low urine pH, or uric acid lowering drugs for hyperuricosuria) categorized as (1) adherent to guideline-concordant PPT, (2) nonadherent to guideline-concordant PPT, or (3) untreated. Symptomatic stone event occurrence (emergency department [ED] visit or hospitalization for urolithiasis or stone-directed surgery). Cox proportional hazards regression. Among 13,942 patients, 31.0% were prescribed PPT. Compared with no treatment, concordant/adherent PPT use was associated with a significantly lower hazard of symptomatic stone events for patients with hypercalciuria (HR, 0.736 [95% CI, 0.593-0.915]) and low urine pH (HR, 0.804 [95% CI, 0.650-0.996]) but not for patients with hypocitraturia or hyperuricosuria. These associations were largely driven by significantly lower rates of ED visits after initiating PPT among the concordant/adherent group versus untreated patients. Patients with hypercalciuria had adjusted 2-year predicted probabilities of a visit of 3.8% [95% CI, 2.5%-5.2%%] and 6.9% [95% CI, 6.0%-7.7%] for the concordant/adherent PPT and no-treatment groups, respectively. Among patients with low urine pH, these probabilities were 4.3% (95% CI, 2.9%-5.7%) and 7.3% (95% CI, 6.5%-8.0%) for the concordant/adherent PPT and no-treatment groups, respectively. Potential bias from the possibility that patients prescribed PPT had more severe disease than untreated patients. Patients with urolithiasis and hypercalciuria who were adherent to treatment with thiazide diuretics as well as those with low urine pH adherent to prescribed alkali therapy had fewer symptomatic stone events than untreated patients. Despite multiple clinical trials demonstrating the efficacy of thiazide diuretics and alkali for secondary prevention of kidney stones, they are infrequently prescribed due in part to a lack of data about their effectiveness in real-world settings. We analyzed medical claims from older adults with kidney stones for whom urine chemistry data were available. We found that patients who took prescribed thiazide diuretics for elevated urine calcium levels or alkali for low urinary pH were less likely to experience symptomatic stone recurrences than untreated patients. This benefit was expressed as lower rates of emergency department visits after initiating therapy. Our findings should inform the prescription of and adherence to treatment with thiazide diuretics and alkali for the prevention of recurrent kidney stones.