Government-funded Insurance Research Articles

Risk of Financial Toxicity Among Adults Undergoing Lung and Esophageal Resections for Cancer

BackgroundAlthough financial toxicity, defined as the harmful financial burden experienced by patients undergoing cancer treatment, has been of growing interest, data in thoracic oncology are lacking. This study aimed to examine the risk of financial toxicity among patients undergoing surgical resection of thoracic malignant diseases. MethodsAdults undergoing lobectomy, pneumonectomy, or esophagectomy for cancer were identified in the 2012 to 2021 National Inpatient Sample. Risk of financial toxicity was defined as health expenditure (total hospitalization costs for the uninsured and maximum out-of-pocket costs for the insured) exceeding 40% of postsubsistence income. Multivariable logistic regressions were used to identify factors associated with financial toxicity risk. ResultsOf 384,340 patients, 69.5% had government-funded insurance, 27.2% had private insurance, and 1.0% were uninsured. Compared with patients with insurance, uninsured patients were more commonly Black and Hispanic and less commonly electively admitted. Mortality, complications, length of stay, and costs were comparable regardless of insurance status. Approximately 68.9% of uninsured and 17.3% of insured patients were at risk of financial toxicity, and the incidence of financial toxicity remained stable over time. After risk adjustment, complications were associated with a greater than 2-fold increased risk of financial toxicity among uninsured patients (adjusted odds ratio, 2.21; 95% CI, 1.38-3.55). Among the insured patients, Black, Hispanic, and publicly insured patients demonstrated a greater risk of financial toxicity, while patients undergoing minimally invasive operations and receiving care at metropolitan hospitals exhibited a lower risk of financial toxicity. ConclusionsConcordant with previous work examining financial toxicity in abdominal oncologic surgery, thoracic surgery demonstrates a comparable burden of financial toxicity. Referral policies and care subsidization may be considered in patients at risk for financial toxicity who are undergoing resections for thoracic malignant diseases.

Disparities in US Retinoblastoma Presentation, Management, and Local Recurrence in the National Cancer Database, 2004–2016

PurposeTo investigate patient-level differences in retinoblastoma presentation, treatments, and outcomes within the United States. DesignRetrospective registry-based analysis. Participants1,404 retinoblastoma cases in the National Cancer Database, 2004-2016, a US-based cancer registry. MethodsPatient characteristics and treatments were investigated over time. Primary treatment was classified as enucleation, local tumor destruction, chemotherapy, and/or radiation. Multivariable logistic regression models evaluated extraocular disease at presentation, treatment, and local recurrence following primary globe-sparing therapy. Main Outcome MeasuresOdds ratios for extraocular disease at presentation; primary treatment modality; local recurrence after primary globe-sparing therapy. ResultsExtraocular disease affected 13% of patients at presentation (N=178). All-cause mortality among the entire cohort was 3.1% (n=44) at last follow-up Those who were non-white, uninsured or had government-funded insurance, or with non-metropolitan residence had significantly greater odds of extraocular disease (OR 2.21-3.64 for non-white vs. white non-Hispanic patients, OR 2.05-2.95 for uninsured or Medicaid/Medicare/government-funded vs. private/commercial insurance, and OR 1.80 for non-metropolitan vs. metropolitan residence). Between 2004-2016, utilization of chemotherapy (55% to 73%) and local tumor destruction (17% to 27%) increased. Enucleations remained over-represented among Hispanic patients (63% received enucleation in 2016, vs. 35% non-Hispanic patients; OR=1.83, (95% CI 1.22-2.75) for enucleation among Hispanic vs. white, non-Hispanic patients). Patients with Medicaid/Medicare/government insurance and non-metropolitan residence also had higher odds of enucleation, and non-metropolitan patients had higher odds of local recurrence after primary globe-sparing therapy. ConclusionsDespite overall decline in enucleation and increase in globe-sparing therapy between 2004-2016, Hispanic, Medicaid/Medicare/government-insured, and non-metropolitan patients continued to have higher odds of extraocular disease at presentation and higher odds of undergoing enucleation as primary therapy. This suggests limitations in access to care and that shifts towards globe-sparing treatment (chemotherapy and local tumor destruction) did not occur equally across all patient groups. Further investigations into these disparities is warranted.

Rehabilitation after musculoskeletal injury: an overview of systems in the United States and Canada.

As North America is largely industrialized with a variety of available private transportation options, trauma is a common occurrence, resulting in significant burdens of disability and costs to the health care system. To meet increasing trauma care needs, there is a robust organization of trauma and rehabilitation systems, particularly within the United States and Canada. The American and Canadian health care systems share multiple similarities, including well-equipped Level I trauma centers, specialized inpatient rehabilitation units for polytrauma patients, and thorough evaluations for recovery and post-discharge placement. However, they also have several key differences. In Canada, the criteria for admission to inpatient rehabilitation vary by location, and inpatient rehabilitation is universally accessible, whereas outpatient rehabilitation services are generally not covered by insurance. In the United States, these admission criteria for post-acute inpatient rehabilitation are standardized, and both inpatient and outpatient services are covered by private and government-funded insurance with varying durations. Overall, both health care systems face challenges in post-acute rehabilitation, including benefit limitations and limited provider access in rural areas, and must continue to evolve to meet the rehabilitation needs of injured patients as they reintegrate into their communities.

Prevalence of Repeat Prenatal HIV Screening in New York State.

Description: New York State Department of Health (NYSDOH) recommends that all pregnant patients receive human immunodeficiency virus (HIV) screening during pregnancy. This study assessed the prevalence of repeat prenatal HIV testing and factors associated with receipt of the recommended tests. Methods: Data from the NYSDOH newborn screening program were used to randomly select pregnant persons without HIV who delivered a liveborn infant in 2017. Receipt of repeat testing was defined as an initial HIV test in the first or second trimesters and the final in the third trimester (relaxed); or an initial test in the first trimester and the final in the third trimester (strict). Relative risks (RRs) and 95% confidence intervals were calculated in bivariate analyses. Adjusted RRs were calculated to determine associations between demographic and clinical factors and receipt of repeat HIV testing. Results: The cohort included 2,225 individuals. Roughly one quarter (24%) received the recommended tests in the first or second and third trimesters and 17% received them in the first and third trimesters. Individuals who reported Hispanic or Asian race/ethnicities, had government-funded insurance, started prenatal care in the first trimester, delivered in New York City, or received prenatal hepatitis C virus screening were significantly more likely to receive repeat testing using either definition. Conclusions: Despite the benefits and cost-effectiveness, the prevalence of repeat prenatal HIV screening during the third trimester remains persistently low. Improved messaging and targeted education and resources to assist prenatal providers could reinforce the importance of repeat testing and reduce residual perinatal HIV transmission.

COVID-19 Hospitalization in Hawai'i and Patterns of Insurance Coverage, Race and Ethnicity, and Vaccination.

The people of Hawai'i have both high rates of health insurance and high levels of racial and ethnic diversity, but the degree to which insurance status and race and ethnicity contribute to health outcomes in COVID-19 remains unknown. To evaluate the associations of insurance coverage, race and ethnicity (using disaggregated race and ethnicity data), and vaccination with outcomes for COVID-19 hospitalization. This retrospective cohort study included hospitalized patients at a tertiary care medical center between March 2020 and March 2022. All patients hospitalized for acute COVID-19, identified based on diagnosis code or positive results on polymerase chain reaction-based assay for SARS-CoV-2, were included in analysis. Data were analyzed from May 2022 to May 2023. COVID-19 requiring hospitalization. Electronic medical record data were collected for all patients. Associations among race and ethnicity, insurance coverage, receipt of at least 1 COVID-19 vaccine, intensive care unit (ICU) transfer, in-hospital mortality, and COVID-19 variant wave (pre-Delta vs Delta and Omicron) were assessed using adjusted multivariable logistic regression. A total of 1176 patients (median [IQR] age of 58 [41-71] years; 630 [54%] male) were hospitalized with COVID-19, with a median (IQR) body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 (25-36) and Sequential Organ Failure Assessment score of 1 (0-2). The sample included 16 American Indian or Alaska Native patients, 439 Asian (not otherwise specified) patients, 15 Black patients, 66 Chinese patients, 246 Filipino patients, 76 Hispanic patients, 107 Japanese patients, 10 Korean patients, 299 Native Hawaiian patients, 523 Pacific Islander (not otherwise specified) patients, 156 Samoan patients, 5 Vietnamese patients, and 311 White patients (patients were able to identify as >1 race or ethnicity). When adjusting for age, BMI, sex, medical comorbidities, and socioeconomic neighborhood status, there were no differences in either ICU transfer (eg, Medicare vs commercial insurance: odds ratio [OR], 0.84; 95% CI, 0.43-1.64) or in-hospital mortality (eg, Medicare vs commercial insurance: OR, 0.85; 95% CI, 0.36-2.03) as a function of insurance type. Disaggregation of race and ethnicity revealed that Filipino patients were more likely to die in the hospital (OR, 1.79; 95% CI, 1.04-3.03; P = .03). When considering variant waves, mortality among Filipino patients was highest during the pre-Delta time period (OR, 2.72; 95% CI, 1.02-7.14; P = .04), when mortality among Japanese patients was lowest (OR, 0.19; 95% CI, 0.03-0.78; P = .04); mortality among Native Hawaiian patients was lowest during the Delta and Omicron period (OR, 0.35; 95% CI, 0.13-0.79; P = .02). Patients with Medicare, compared with those with commercial insurance, were more likely to have received at least 1 COVID-19 vaccine (OR, 1.85; 95% CI, 1.07-3.21; P = .03), but all patients, regardless of insurance type, who received at least 1 COVID-19 vaccine had reduced ICU admission (OR, 0.40; 95% CI, 0.21-0.70; P = .002) and in-hospital mortality (OR, 0.42; 95% CI, 0.21-0.79; P = .01). In this cohort study of hospitalized patients with COVID-19, those with government-funded insurance coverage (Medicare or Medicaid) had similar outcomes compared with patients with commercial insurance, regardless of race or ethnicity. Disaggregation of race and ethnicity analysis revealed substantial outcome disparities and suggests opportunities for further study of the drivers underlying such disparities. Additionally, these findings illustrate that vaccination remains a critical tool to protect patients from COVID-19 mortality.

Disparities in Eye Care Utilization Among Refugee and Migrant Populations.

In this cross-sectional study, we examined refugee/migrant participants' health and eye care utilization compared to controls in San Diego County. Data were collected from electronic health records (EHRs) at UCSD Health-affiliated medical centers. Through a manual review of EHRs, eligibility criteria to identify a cohort were developed. A total of 64 refugee/migrant participants and 95 control participants matched based on country of origin, age, and sex were included in the analysis. Demographic characteristics, insurance type, and vision/eye care utilization were compared between the two groups. A greater proportion of refugee/migrant participants were more likely to be enrolled in government-sponsored insurance programs, predominantly Medicaid when compared to controls (55% vs. 24%, P = < 0.01). When adjusting for age, history of ophthalmic procedure, and surgery, refugee status was associated with fewer encounters with ophthalmologists in a multivariable linear regression model (coefficient = -1.66 [95% confidence interval [CI] = -2.89 to -0.44], P = 0.009). This study highlights disparities in eye care utilization for refugee/migrant populations. When compared to controls, a larger proportion of refugees/migrants had government-funded insurance, and refugee status was associated with fewer encounters with ophthalmologists. These findings underscore the need for further research on this population to better understand potential healthcare barriers these individuals may encounter. This analysis of EHR data illustrates disparities in eye care experienced by refugees/migrants, highlighting potential gaps in care in a vulnerable population.

Scoping Review of Healthcare Disparities in Treatment of Craniosynostosis: Assessing Impacts of Race, Insurance, and Socioeconomic Status

Background: Racial and socioeconomic factors persist as barriers to timely diagnosis and treatment for children with craniosynostosis, contributing to inequitable care. This scoping review aims to better understand how disparities influence differences in services, approach, and outcomes for patients undergoing surgical corrections for craniosynostosis. Methods: We conducted a PRISMA systematic review of all articles published between 2003 and 2023 within PubMed/Medline, Embase, and a Scopus cited review. Variables of interest included sociodemographic factors such as race, socioeconomic status (SES), and insurance status, and measurements of treatment access or outcomes within craniosynostosis surgical repair. Results: The final analysis included 28 studies, of which 21 studies examined race, 13 examined insurance status, and 5 examined household income or other socioeconomic factors. Overall, non-White, minority patients, patients with Medicaid or government-funded insurance, and patients from lower SES were more likely to experience delays in diagnosis and presentation for surgery compared to White and privately-insured patients. Black and Hispanic patients and patients with public insurance were more likely to undergo open cranial vault reconstruction (CVR) at an older age and experience longer total surgery time, increasing perioperative complication risk, compared to patients who underwent endoscopic procedures. Sociodemographic factors including non-White race, lower SES, and being underinsured or uninsured predisposed patients to the more expensive CVR procedure, increased hospital length of stay (LOS), and a higher rate of readmission, accumulating to greater total cost of care. Conclusion: Significant disparities continue to exist in craniosynostosis management. It is still unknown whether these discrepancies in the type of operation lead to significant clinical differences in neurocognitive outcomes, revision operations, or patient/parent satisfaction with appearance. This study highlights gaps in the current body of knowledge to better inform future aeas of investigation to ensure the best outcomes for all children born with craniosynostosis regardless of patient demographic.

Severe COVID-19 infection: An institutional review and literature overview.

Our study aimed to describe the group of severe COVID-19 patients at an institutional level, and determine factors associated with different outcomes. A retrospective chart review of patients admitted with severe acute hypoxic respiratory failure due to COVID-19 infection. Based on outcomes, we categorized 3 groups of severe COVID-19: (1) Favorable outcome: progressive care unit admission and discharge (2) Intermediate outcome: ICU care (3) Poor outcome: in-hospital mortality. Eighty-nine patients met our inclusion criteria; 42.7% were female. The average age was 59.7 (standard deviation (SD):13.7). Most of the population were Caucasian (95.5%) and non-Hispanic (91.0%). Age, sex, race, and ethnicity were similar between outcome groups. Medicare and Medicaid patients accounted for 62.9%. The average BMI was 33.5 (SD:8.2). Moderate comorbidity was observed, with an average Charlson Comorbidity index (CCI) of 3.8 (SD:2.6). There were no differences in the average CCI between groups(p = 0.291). Many patients (67.4%) had hypertension, diabetes (42.7%) and chronic lung disease (32.6%). A statistical difference was found when chronic lung disease was evaluated; p = 0.002. The prevalence of chronic lung disease was 19.6%, 27.8%, and 40% in the favorable, intermediate, and poor outcome groups, respectively. Smoking history was associated with poor outcomes (p = 0.04). Only 7.9% were fully vaccinated. Almost half (46.1%) were intubated and mechanically ventilated. Patients spent an average of 12.1 days ventilated (SD:8.5), with an average of 6.0 days from admission to ventilation (SD:5.1). The intermediate group had a shorter average interval from admission to ventilator (77.2 hours, SD:67.6), than the poor group (212.8 hours, SD:126.8); (p = 0.001). The presence of bacterial pneumonia was greatest in the intermediate group (72.2%), compared to the favorable group (17.4%), and the poor group (56%); this was significant (p<0.0001). In-hospital mortality was seen in 28.1%. Most patients were male, obese, had moderate-level comorbidity, a history of tobacco abuse, and government-funded insurance. Nearly 50% required mechanical ventilation, and about 28% died during hospitalization. Bacterial pneumonia was most prevalent in intubated groups. Patients who were intubated with a good outcome were intubated earlier during their hospital course, with an average difference of 135.6 hours. A history of cigarette smoking and chronic lung disease were associated with poor outcomes.

Cancer treatment refusal decisions in advanced cancer: a retrospective case–control study

ObjectiveCancer remains one of the leading causes of death worldwide. Despite advancements in anticancer therapy, some patients decide against treatment. Our study focused on characterising therapy refusal in advanced-stage malignancies...

Racial Variation in Visual Impairment of Patients With Keratoconus at Presentation.

This study aimed to investigate racial disparities in the severity of keratoconus (KCN) at presentation, their intersection with socioeconomic variables, and other factors associated with visual impairment. This retrospective cohort study examined medical records of 1989 patients (3978 treatment-naive eyes) with a diagnosis of KCN seen at Wilmer Eye Institute between 2013 and 2020. A multivariable regression model adjusting for age, sex, race, insurance type, KCN family history, atopy, smoking status, and vision correction method examined factors associated with visual impairment, defined as a best available visual acuity of worse than 20/40 in the better eye. Demographically, Asian patients were the youngest (33.4 ± 14.0 years) ( P < 0.001), and Black patients had the highest median area deprivation index (ADI) of 37.0 [interquartile range (IQR): 21.0-60.5] ( P < 0.001). Multivariable analysis showed a higher risk of visual impairment for Black (OR 2.25, 95% CI, 1.71-2.95) versus White patients. Medicaid (OR 2.59, 95% CI, 1.75-3.83) and Medicare (OR 2.48, 95% CI, 1.51-4.07) were also associated with a higher odds of visual impairment compared with private insurance, and active smokers were more likely to have visual impairment than those with no prior smoking history (OR 2.17, 95% CI, 1.42-3.30). Eyes of Black patients had the highest maximum keratometry (Kmax) (56.0 ± 11.0D) ( P = 0.003) and the lowest thinnest pachymetry (463.2 ± 62.5 µm) ( P = 0.006) compared with eyes of other races. Black race, government-funded insurance, and active smoking were significantly associated with increased odds of visual impairment in adjusted analyses. Black race was also associated with higher Kmax and lower thinnest pachymetry, suggesting that Black patients have more severe disease at presentation.

Risk of treatment refusal in male patients with advanced-stage cancers.

e18690 Background: A previous study conducted revealed that males with advanced cancer(CA) were 1.6 times more likely to refuse treatment(TX) than females. Based on this study, we sought to determine factors associated with TX refusal in males. Methods: Retrospective review. Inclusion criteria: male, 18-75 years, stage IV CA, between 01/01/2010-12/31/2015, refused any CA TX(refusal group(RG)). A randomly selected group of stage IV males who accepted TX in the same timeframe was used for comparison(acceptance group(AG)). Geisinger Health System’s data was used. Results: RG had 307 males; AG had 298. Mean age of RG was 62.9 (standard deviation(SD)7.9) and 59.2 (SD9.8) in AG; p &lt; 0.001. Lung CA was the most prevalent CA in both groups: 29.9% in AG and 34.9% in RG. Median interval-to-mortality was 42 days in RG (IQR 101.5), and 387 days in AG (IQR 686.5) p &lt; 0.001. Median Charlson Comorbidity Index(CCI) was greater in AG (9, IQR 6) than RG (median 5, IQR 5.5). BMI, PHQ score, median household income, mean number of years educated and tobacco use history were not associated with TX decisions. While 38.3% of AG had government-funded insurance(GFI), 67.1% of RG had GFI; p &lt; 0.001, OR 3.3, 95% CI 2.3-4.6. The prevalence of alcohol use disorder in RG was 9.8% compared with 3.4% in AG; p = 0.001, OR 3.1, 95% CI 1.5-6.5. RG had a greater prevalence of pre-cancer use of: antidepressants (28.3%) vs AG (14.4%)(p &lt; 0.001, OR 2.3, 95% CI 1.6-3.5), antipsychotics (20.8%) vs 11.1% in AG(p = 0.001, OR 2.1, 95% CI 1.3-3.3), benzodiazepines (24.1%) vs 16.8% in AG(p = 0.03, OR 1.6, 95% CI 1.1-2.4), non-benzodiazepine anxiolytics (26.7%) vs 19.8% in AG(p = 0.04, OR 1.5, 95% CI 1.0-2.2), mood stabilizers(15.6%) vs 7% in AG(p &lt; 0.001; OR 2.4; 95% CI 1.4-4.2). After cancer diagnosis(dx), the use of psychiatric medications becomes more prevalent in the AG. RG had a lower prevalence of post-cancer use of: antipsychotics(42.0%) vs 61.4% in AG (p &lt; 0.001, OR 0.5, 95% CI 0.3-0.6), benzodiazepines (51.5%) vs in 76.5% AG(p &lt; 0.001, OR 0.3, 95% CI 0.2-0.5), non-benzodiazepine anxiolytics(37.8%) vs 78.2% in AG(p &lt; 0.001, OR 0.2, 95% CI 0.1-0.2); mood stabilizers(16.6%) vs 28.2% in AG(p &lt; 0.001, OR 0.5, 95% CI 0.3-0.8). A married status was more prevalent in AG(58.4%) than RG(47.2%)(p = 0.005, OR 0.6, 95% CI 0.5-0.9). Only 19.2% and 20.1% in RG and AG, respectively, were referred to palliative medicine. Conclusions: TX refusal in males with advanced CA is associated with older age, GFI and a lower comorbid burden. Survival in males who accepted TX was 9 times longer. Males with private insurance were 3 times more likely to accept TX. TX of psychiatric disorders was more prevalent in the refusal group prior to CA dx but becomes more prevalent in the acceptance group after CA dx; this may indicate an increased prevalence of psychiatric disease in males who refused TX before CA dx, and a potential lack of psychiatric disease TX after CA dx. Married males were 1.6 times more likely to accept TX than single males.

Making sense of the dollars: Evaluation of financial toxicity in patients of breast medicine receiving oral chemotherapy at Roswell Park.

e18519 Background: Increasing costs of oral chemotherapy have become a significant barrier to cancer care with the potential to cause treatment abandonment and noncompliance. The primary objective of this study is to evaluate the financial toxicity of oral chemotherapy in the Breast Medicine Service at Roswell Park Comprehensive Cancer Center (RPCCC). Methods: This was a retrospective chart review of patients at RPCCC who were diagnosed with breast cancer and prescribed oral chemotherapy between 8/1/21 - 7/31/22. The primary outcome evaluated was average out-of-pocket (OOP) cost of an oral chemotherapy prescription. Secondary outcomes studied included 1) the number of patients enrolled in manufacturer patient assistance programs (PAPs), copay cards, foundation grants, and/or New York State Elderly Pharmaceutical Insurance Coverage (EPIC) program, and 2) median days to treatment start date, approval of prior authorization (PA) and/or PAPs. For patients who filled at outside pharmacies, days to first insurance claim were collected and compared to days to first fill for patients who filled at Roswell Park Pharmacy. Results: A total of 116 patients with a median age of 64 and 122 oral chemotherapy prescriptions were included. Majority of the patients were white (n = 93; 80%) and enrolled in Medicare managed plans (n = 58; 50%). Palbociclib (n = 47; 39%) and capecitabine (n = 29; 24%) were most commonly prescribed. 49 patients filled at Roswell Park Pharmacy; average OOP cost was $48.00 (range: 0-2239.50) per prescription claim. Average OOP cost was $85.18 for patients with Medicare managed plans, $23.35 for patients with commercial insurance, and $3.66 for patients with government-funded insurance. Twenty patients (17%) enrolled in PAPs, foundation grants, copay cards, and/or EPIC program. OOP costs prior to any financial assistance was available for thirteen patients; median OOP cost was $2491.51 (403.62-18165.94). Median days to approval of PAPs and approval of PA was 10 (1-50) and 0 (0-14), respectively. When filling internally at Roswell Park Pharmacy, median days to treatment start date was 6 (0-61) compared to 9 (0-67) for those who filled at outside pharmacies. There was a significant difference (p = 0.0111) between the median days to first fill for patients who filled at Roswell Park Pharmacy (0 days [0-25]) and the median time to first insurance claim (2 days [0-20]) for patients filling at outside pharmacies. Conclusions: Despite utilization of financial assistance program, OOP costs remain high for cancer patients. Having a defined workflow to screen and identify patients at risk for financial toxicity and the ability to refer to appropriate resources to mitigate OOP costs promptly is vital to prevent delays in treatment. Utilizing an integrated health-system specialty pharmacy can be helpful to streamline patient access and avoid further treatment delays.

AMRI Hospitals:

AMRI Hospitals has three hospitals in Kolkata and one in Bhubaneswar in the eastern part of India. With its 5000 doctors and employees, they serve 450,000 patients annually. The group incurred an operating loss in the first quarter of 2020-21 due to the covid pandemic. The pandemic continued; the subsequent quarterly financial result was not encouraging as they have merely scrapped through operating losses. AMRI Hospitals are feeling challenged: It needs to expedite covid vaccination program to cover the maximum number of people; It needs to decide about continuing with its two centers in Bangladesh since these have become almost non-viable due to restrictions on international travel due to the pandemic; It needs to develop an economic model for treating the patients covered under the state government-funded insurance scheme 'Swasthya Sathi' as offered rates are not meeting the expenses.

Characterizing “no treatment” decisions in patients with advanced-stage cancers.

76 Background: Cancer (CA) is one of the leading causes of death worldwide. In 2020 CA was the second leading cause of mortality in the US. Novel treatments for various malignancies are discovered each passing year. Despite these advancements, some patients refuse to receive treatment. Our study focused on characterizing the group of patients with advanced malignancies who refused therapy. Methods: We performed a retrospective chart review of patients diagnosed with advanced malignancies, aged 18-75 years, between 01/01/ 2010 and 12/31/2015, who refused any therapy. We used Geisinger Health System’s data. Results: Our search provided 644 patients who met our inclusion criteria. The mean age of patients was 63.2 years (standard deviation (σ) 8.3). Female patients made up 40.4% (260/644), while 59.6% (384/644) were male. Most patients were Caucasian (96.9%, 624/644), 1.9% (12/644) were Black; 0.6% (4/644) were Asian, and 0.6% (4/644) were of unknown racial background. Marital status was evenly distributed with 50.0% (322/644) being married and 50.0% (322/644) being non-married. Most of the study population (52.3%, 337/644) had government-funded insurance at the time of CA diagnosis; 46.6% (300/644) had private insurance, and 1.1% (7/644) had no insurance. Stage 3 disease, according to American Joint Committee on Cancer staging was noted in 21.1% (136/644), while 78.9% (508/644) had stage 4 disease. The mean BMI was 28.2 (σ 8.3). Most patients were either overweight or obese (60.6%, 350/577; 67 patients did not have data on BMI available). A history of cigarette smoking was present in 73.0% (438/600). Adenocarcinomas (323/639, 50.5%) were the most prominent histological subtype. The most common site of malignancy was the respiratory system (220/644, 34.2%). Only 9.6% (62/644) of patients had a history of previous CA, while a family history of CA was present in 29.5% (190/644). Most patients (62.1%, 400/644) had a Charleston Comorbidity Index (CCI) &gt; 5; the mean CCI was 6.4 (σ 3.7). In 17.1% (110/644) a palliative medicine referral was made. Substance use disorders were present in 23.8% (153/644); 14.4% (93/644) had a history of depression, and anxiety 10.1% (65/644). Conclusions: Male patients made up a larger proportion of the group of advanced-stage patients who declined therapy. The racial distribution in this group of patients appeared to reflect the local population. Most patients who refused therapy had stage 4 disease, and they appeared to have severe underlying comorbidities, with an average CCI &gt;5. Despite treatment refusal, a surprisingly low percentage of patients were referred to palliative medicine.[Table: see text][Table: see text]

Factors influencing “no treatment” decisions in advanced stage cancers.

77 Background: Several studies have attempted to explore treatment refusal in patients with cancer (CA). We performed a study that focused on patients with advanced CAs, characterizing those in this group that refused therapy. Based on this study, we sought to determine if some variables significantly correlated with ‘no treatment’ decisions, compared with a group of similar patients who accepted therapy. Methods: Our inclusion criteria were patients aged 18-75 years, diagnosed with stage IV CAs (per the American Joint Committee on Cancer staging) between 1/1/2010 and 12/31/2015 and refused therapy (Cohort 1). A randomly selected group of patients with stage IV CAs who accepted treatment in the same timeframe were used for comparison (Cohort 2). We used Proc SurveySelect and a simple random sampling method to create Cohort 2. Geisinger Health System’s data was used. Results: We found 508 patients for cohort 1, and 100 patients for cohort 2. The significance level was &lt; 0.05. Female sex was associated with treatment acceptance (51/100, 51.0%) compared with refusal (201/508, 39.6%); p = 0.03. There was no association between treatment decision and race, marital status, BMI, tobacco use, previous CA history, or family CA history. Government-funded insurance was associated with therapy refusal (337/508, 66.3%) than acceptance (35/100, 35.0%); p &lt; 0.0001. Cohort 1 had an older population compared with cohort 2 (p &lt; 0.0001). The mean age of cohort 1 was 63.1 years (standard deviation (σ) 8.1), and 59.2 (σ 9.9) in cohort 2. The most common malignancy site in both cohorts was the respiratory system but this was not related to treatment decisions. Patients with pancreatic CA tended to refuse treatment (p = 0.0009). Only 19.1% (97/508) in cohort 1 were referred to palliative medicine, with 18% (18/100) in cohort 2; p = 0.8. There was an insignificant trend for patients who accepted treatment to have more comorbidities per the Charleston Comorbidity Index (CCI) (p = 0.08). The mean CCI in cohort 1 was 6.5 (σ 3.7), and 8.0 (σ 3.9) in cohort 2. Treatment of psychiatric disorders after CA diagnosis was inversely associated with treatment refusal (p &lt; 0.0001). Conclusions: Male sex, older age, government-funded health insurance, and pancreatic CAs were associated with treatment refusal in advanced CA patients. Those who refused treatment were not increasingly referred to palliative medicine. Treatment of psychiatric disorders after CA diagnosis was associated with treatment acceptance.[Table: see text]

Sociodemographic Disparities in Access to Cleft Rhinoplasty.

Various sociodemographic factors affect patient access to care. This study aims to assess how factors such as government-funded insurance and socioeconomic status impact the ability of adolescents with cleft lip-associated nasal deformities to access secondary rhinoplasty procedures. Patients older than 13 years old with a history of cleft lip/palate were identified in the National Inpatient Sample database from 2010 to 2012. Those who received a secondary rhinoplasty were identified using the International Classification of Diseases, Ninth Revision (ICD-9) procedural codes. A multivariate logistic regression model with post hoc analyses was performed to analyze if insurance status, socioeconomic status, and hospital-level variables impacted the likelihood of undergoing rhinoplasty. Of the 874 patients with a cleft lip/palate history, 154 (17.6%) underwent a secondary rhinoplasty. After controlling for various patient-level and hospital-level variables, living in a higher income quartile (based on zip code of residence) was an independent predictor of receiving a secondary cleft rhinoplasty (odds ratio=1.946, P =0.024). Patients had lower odds of receiving a cleft rhinoplasty if care occurred in a private, nonprofit hospital compared with a government-owned hospital (odds ratio=0.506, P =0.030). Income status plays a significant role in cleft rhinoplasty access, with patients from lower income households less likely to receive a secondary cleft rhinoplasty. Hospital-specific factors such as geographic region, bed size, urbanization, and teaching status may also create barriers for patients and their families in accessing surgical care for cleft lip nasal deformities.

Insurance-based disparities and risk of financial toxicity among patients undergoing gynecologic cancer operations

ObjectiveTo evaluate the risk of financial toxicity (FT) among inpatients undergoing gynecologic cancer resections and the association of insurance status with clinical and financial outcomes. MethodsUsing the 2008–2019 National Inpatient Sample, we identified adult hospitalizations for hysterectomy or oophorectomy with a diagnosis of cancer. Hospitalization costs, length of stay (LOS), mortality, and complications were assessed by insurance status. Risk of FT was defined as health expenditure exceeding 40% of post-subsistence income. Multivariable regressions were used to analyze costs and factors associated with FT risk. ResultsOf 462,529 patients, 49.4% had government-funded insurance, 44.3% private, and 3.2% were uninsured. Compared to insured, uninsured patients were more commonly Black and Hispanic, admitted emergently, and underwent open operations. Uninsured patients experienced similar mortality but greater rates of complications, LOS, and costs. Overall, ovarian cancer resections had the highest median costs of $17,258 (interquartile range: 12,187–25,491) compared to cervical and uterine. Approximately 52.8% of uninsured and 15.4% of insured patients were at risk of FT. As costs increased across both cohorts over the 12-year study period, the disparity in FT risk by payer status broadened. After risk adjustment, perioperative complications were associated with nearly 2-fold increased risk of FT among uninsured (adjusted odds ratio 1.75, 95% confidence interval 1.46–2.09, p < 0.001). Among the insured, Black and Hispanic race, public insurance, and open operative approach exhibited greater odds of FT. ConclusionPatients undergoing gynecologic cancer operations are at substantial risk of FT, particularly those uninsured. Targeted cost-mitigation strategies are warranted to minimize financial burden.

The effects of dual antiplatelet therapy (DAPT) adherence on survival in patients undergoing revascularization and the determinants of DAPT adherence

BackgroundThe prevalence and burden of coronary heart disease (CHD) has increased substantially in India, accompanied with increasing need for percutaneous coronary interventions (PCI). Although a large government-funded insurance scheme in Maharashtra, India covered the cost of PCI for low-income patients, the high cost of post-PCI treatment, especially Dual Antiplatelet Therapy (DAPT), still caused many patients to prematurely discontinue the secondary prevention. Our study aimed to investigate the effectiveness of DAPT adherence on all-cause mortality among post-PCI patients and explore the potential determinants of DAPT adherence in India.MethodWe collected clinical data of 4,595 patients undergoing PCI in 110 participating medical centers in Maharashtra, India from 2012 to 2015 by electronic medical records. We surveyed 2527 adult patients who were under the insurance scheme by telephone interview, usually between 6 to 12 months after their revascularization. Patients reporting DAPT continuation in the telephone survey were categorized as DAPT adherence. The outcome of the interest was all-cause mortality within 1 year after the index procedure. Multivariate Cox proportional hazard (PH) model with adjustment of potential confounders and standardization were used to explore the effects of DAPT adherence on all-cause mortality. We further used a multivariate logistic model to investigate the potential determinants of DAPT adherence.ResultsOut of the 2527 patients interviewed, 2064 patients were included in the analysis, of whom 470 (22.8%) discontinued DAPT prematurely within a year. After adjustment for baseline confounders, DAPT adherence was associated with lower one-year all-cause mortality compared to premature discontinuation (less than 6-month), with an adjusted hazard ratio (HR) of 0.52 (95% Confidence Interval (CI) = (0.36, 0.67)). We also found younger patients (OR per year was 0.99 (0.97, 1.00)) and male (vs. female, OR of 1.30 (0.99, 1.70)) had higher adherence to DAPT at one year as did patients taking antihypertensive medications (vs. non medication, OR of 1.57 (1.25, 1.95)).ConclusionThese findings suggest the protective effects of DAPT adherence on 1-year mortality among post-PCI patients in a low-income setting and indicate younger age, male sex and use of other preventive treatments were predictors of higher DAPT adherence.

Cost Effectiveness of Ribociclib and Palbociclib in the Second-Line Treatment of Hormone Receptor-Positive, HER2-Negative Metastatic Breast Cancer in Post-Menopausal Indian Women

In this study, we evaluate the cost and outcomes of cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) plus fulvestrant, fulvestrant alone, and conventional chemotherapy as the second-line therapy for hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) metastatic breast cancer (MBC) in India. Using a Markov model, the clinical effectiveness of managing HR+, HER2- MBC in postmenopausal women with either aCDK4/6i (either ribociclib or palbociclib) and fulvestrant, fulvestrantalone, and chemotherapy (single-agent paclitaxel or capecitabine) was measured in terms of quality-adjusted life-years (QALYs). The costs were estimated from two different points of view: scenario I, as per the prevailing market prices of the drugs; and scenario II, as per the reimbursement rates set up by the publicly financed national health insurance scheme. Incremental cost per QALY gained with a given treatment option was compared against the next best alternative and was assessed for cost effectiveness using a threshold of 1-time the per capita gross domestic product (GDP) in India from a societal perspective. In scenario I, an MBC patient was found to incur a lifetime cost of Indian Rupees (₹)2.54 million ($34,644), ₹2.53 million ($34,496), ₹512,598 ($6,984), ₹326,026 ($4,442) and ₹237,115 ($3,230) for the ribociclib and palbociclib combination arms, fulvestrant monotherapy, single-agent paclitaxel and the single-agent capecitabine treatment arms, respectively. The lifetime cost for CDK4/6i (ribociclib and palbociclib) combination therapy, fulvestrant monotherapy, paclitaxel, and capecitabine arms was estimated to be ₹1.94 million ($26,459), ₹1.92 million ($26,220), ₹315,387 ($4,296), ₹187,392 ($2,553) and ₹153,263 ($2,088), respectively, in scenario II. The mean QALYs lived per MBC patient with CDK4/6i (either ribociclib or palbociclib) combination therapy, fulvestrant, paclitaxel and capecitabine were estimated to be 1.4, 1.0, 0.9 and 0.7, respectively. None of the treatment arms are cost effective at current prices and reimbursement rates at a threshold of 1-time the per capita GDP of India. However, a 78% reduction in the current market price or a 72% reduction in the reimbursement rate of fulvestrant in the government-funded insurance program will make it a cost-effective treatment option for HR+, HER2- MBC patients in India. CDK4/6i (ribociclib and palbociclib) therapyis not a cost-effective treatment option for MBC patients. A 72% reduction in the reimbursement rate for fulvestrant monotherapy will make it a cost-effective treatment option in the Indian context.

Assessing the long-term effects of Basic Medical Insurance on catastrophic health spending in China.

Many developing countries have implemented social health insurance programmes to protect their citizens against the financial risks of seeking healthcare. While many studies have explored how individual insurance enrolments affect catastrophic health spending (CHS) in the short term, there is a lack of evidence on the long-term macro-level effects of social health insurance on CHS in low- and middle-income countries. This study examines the long-term effects of Basic Medical Insurance (BMI) on individual CHS in China, a middle-income country that has witnessed one of the highest worldwide increases in CHS rates despite its remarkable achievement of universal health insurance coverage. Specifically, we used existing longitudinal data from 1989 to 2015, therein assessing BMI policy effects by constructing two macro-level indicators, including the year of BMI presence at the prefectural level and number of years relative to BMI introduction. We employed a three-level difference-in-differences approach for the estimation. There were two main findings. First, BMI policy did not significantly reduce the probability of incurring CHS for BMI enrollees over time. Years after BMI was introduced, the policy even predicted a significant increase in the probability of incurring CHS for individuals who shifted their enrolments from traditional insurance to BMI. Second, BMI policy had spillover effects on the increase in the probability of incurring CHS for non-BMI individuals a few years after its inception. We believe there are three possible explanations for these findings: (1) shrinking BMI service coverage compared to pre-existing government-funded insurance schemes, (2) a profit-driven hospital reform that induces the overuse of expensive medicines and diagnostic tests and (3) the absence of strategic purchasing among local BMI agencies. We also discuss how relevant policy interventions may alleviate insurance-driven financial risks.