Higher Copayments Research Articles

8193 Mauriac Syndrome Uncovered, The Insulin Access Impact in Type 1 Diabetes Mellitus

Abstract Disclosure: D.H. Sacoto: None. R. Belokovskaya: None. K. Gebran: None. K. Madani: None. A. De Rosairo: None. D. Patel: None. A.A. Franco-Akel: None. Introduction: Mauriac syndrome is a rare complication of poorly controlled type 1 diabetes mellitus (T1DM). It is reversible with appropriate glycemic control; however, factors affecting healthcare access to insulin are leading to its re-emergence. We present a case of Mauriac syndrome as a complication of uncontrolled T1DM due to insulin access. Case: A 22-year-old Hispanic female with a history of T1DM presented to the emergency department with a two-day history of abdominal pain. She was diagnosed with diabetic ketoacidosis (DKA) (blood glucose: 802 mg/dL; pH 7.14; bicarbonate: 7 mmol/L; anion gap: 34; positive serum ketones). Incidental transaminitis was noted. R factor showed a cholestatic pattern of 0.6 (AST: 136 U/L, ALT: 49 U/L, alkaline phosphatase:286 U/L). US liver revealed an enlarged liver (craniocaudal: 16.5 cm) without biliary obstruction. Her phenotype consisted of short stature (4.8 feet) with a moon face and a protuberant abdomen. Her records revealed a normal karyotype 46 XX, with a bone age of 4 years, pubertal delay, low insulin-like growth factor-1 levels (58 ng/mL), and long-standing hyperlipidemia. Over the years, she experienced multiple DKA episodes in the context of uncontrolled T1DM (hemoglobin A1c:11-13 %). The main problem identified included difficulty with insulin access, specifically related to insurance coverage as well as managing her disease. Glycemic control has significantly improved with continuous glucose monitoring and updated insurance status. Discussion: Mauriac syndrome is characterized by hepatomegaly, transaminitis, delayed pubertal maturation, growth failure, and cushingoid features. Hyperglycemia leads to intrahepatic glycogen deposition and the lack of insulin to lipolysis and ketosis, leading to high cortisol levels and growth delay. Factors leading to uncontrolled T1DM include lack of insulin access. The high cost is considered a major barrier, with an average price per millimeter of insulin tripled from 231 to 736 US dollars. Even patients with insurance tend to have high co-pays and deductibles, with a 61% chance of delay or denial due to pre-approval requirements. Lower socioeconomic status, lack of access to devices such as insulin pumps, migratory status, social support, and ethnic background are other factors related to glycemic control. Our patient belongs to a family of immigrants with low socioeconomic status, which might have contributed to the development of Mauriac syndrome. Since clinical and laboratory abnormalities are reversible with appropriate glycemic control, advocating for policies that facilitate better insulin access is paramount. Presentation: 6/2/2024

Measuring Pectus Excavatum Severity, External Caliper, or Cross-Sectional Imaging: Family Perceptions

IntroductionPatients with pectus excavatum (PE) often undergo cross-sectional imaging (CSI) to quantify severity for insurance authorization before surgical repair. The modified percent depth (MPD), an external caliper-based metric, was previously validated to be similar to the pectus index and correction index. This study explored family perceptions of CSI and MPD with respect to value and costs. MethodsThis is a cross-sectional survey study including families of patients enrolled in an ongoing prospective multicenter study evaluating the use of MPD as an alternative to CSI for quantifying PE severity. Families of PE patients who underwent both MPD and CSI completed a survey to determine their perceptions of MPD and costs of CSI. Responses were described and associations were evaluated using chi squared, Wilcoxon rank-sum test and logistic regression as appropriate. Statistical significance was set to 0.05. ResultsThere were 136 surveys completed for a response rate of 88%. Respondents were confident in MPD (86%) and confident in its similarity to CSI (76%). Families of females were less confident in the measurements than males (55% versus 80%, P = 0.02; odds ratio 0.30 (0.11, 0.83). Obtaining CSI required time off work/school in 90% and a copay in 60%. Nearly half (49%) of respondents reported CSI was a time/financial hardship. Increasing copay led to decreased reassurance in CSI (55%: copay > $100 versus 77%: lower copay/75%: no copay; P = 0.04). ConclusionsFrom the family perspective, MPD is valuable in assessing the severity of PE. Obtaining CSI was financially burdensome, particularly for those with higher copays. MPD measurements provide high value at low cost in assessing the severity of PE.

Letermovir use for cytomegalovirus prophylaxis following lung transplantation: A single-center review

Cytomegalovirus (CMV) remains a major cause of infection following solid organ transplant and valganciclovir prophylaxis is the standard of care. However, valganciclovir associated myelosuppression limits its tolerability and can require dose reduction in immunosuppression, particularly cell cycle inhibitors, or changes in antimicrobial prophylaxis. Letermovir, a viral terminase inhibitor, is approved by the FDA for use as CMV prophylaxis in kidney transplant recipients; data on its use in lung transplant recipients (LTRs) is limited. We performed a single-center retrospective cohort study of LTRs prescribed letermovir for prophylaxis between 1/1/18-9/1/23. Over the study period, 88 LTRs were prescribed letermovir with most (93%) switching due to myelosuppression while on valganciclovir. Of those prescribed letermovir, 67 (76%) actually started letermovir, with the primary barrier being insufficient insurance coverage or high copay cost. Among LTRs who started letermovir due to myelosuppression, 90% had improvement in their leukopenia or neutropenia, with a significant increase in white blood cell count one month after switching therapy (P<0.0001). Additionally, 46% of those who were not receiving a cell cycle inhibitor previously were able to restart this after switching to letermovir. CMV was detected in 14 LTRs following letermovir switch, with two discontinuing letermovir due to breakthrough CMV. Our findings support the use of letermovir for CMV prophylaxis in LTRs with possible benefits over valganciclovir, although a direct comparison is needed.

Long-Term HIV Pre-Exposure Prophylaxis Persistence and Reinitiation in Connecticut from 2012 to 2018.

HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention for HIV infections. PrEP persistence is critical to achieving optimal protection against HIV infection. However, little is known about PrEP persistence in the United States. This study utilized the Connecticut All-Payer Claims Database (APCD) to identify PrEP persistence among patients who filled their PrEP prescriptions in the state. The authors identified 1,576 PrEP patients who picked up PrEP prescriptions and extracted medical and pharmacy claims to evaluate a longitudinal cohort during 2012-2018 based on the Connecticut APCD. Patients who did not pick up medication for one consecutive month (ie, 30 days) were defined as discontinuing PrEP. Kaplan-Meier Survival Curve and proportional hazard regression were used to describe PrEP persistence. Of the 1,576 patients who picked up PrEP prescriptions, the median age was 32.0 (interquartile range [IQR]: 22.0-44.0). The majority were male individuals (93%). Of 1,040 patients who discontinued PrEP, 702 (67.5%) restarted PrEP at least once. The median time of PrEP persistence was 3 months (IQR: 1-6 months) for initial PrEP use. The median time on PrEP was also around 3 months in the following episodes of PrEP use. Being female, being on parent's insurance, and having high co-pays were associated with shorter periods of PrEP persistence. PrEP persistence was low among patients who picked up PrEP prescriptions. Although many patients restarted PrEP, persistence remained low during follow-up PrEP use and possibly led to periods of increased HIV risk. Effective interventions are needed to improve PrEP persistence and reduce HIV incidence.

Advancing breast cancer care for underserved women: A study of the Pink Ribbon Mammogram Program in Oakland County.

11053 Background: The Pink Ribbon Mammogram program, a non-profit initiative in Oakland County, Michigan, aims to provide free breast cancer screening (BCS) to underserved and uninsured women, in partnership with Trinity Health Oakland. The program has served approximately 1500 women since 2009. This study aims to highlight the program’s effectiveness in providing free BCS and gather participant feedback to address challenges and improve its operational efficiency. The study also aims to evaluate the factors associated with participants' perceptions of BCS using the Revised Champion’s Health Belief Model scale (RCHBMS) and open-ended questions. Methods: A survey with open- and close-ended items was conducted among 253 women who participated in the program from 2019-2023 via structured telephone interviews. The RCHBMS, a validated tool, was used to measure participants’ perceptions of breast cancer susceptibility and screening benefits and barriers using a 5-point Likert scale (1=strongly disagree, 5=strongly agree). SPSS 28 was used for analysis, with a p-value&lt;0.05 indicating statistical significance. Results: Over the last 5 years, the program has conducted 363 mammograms, 59 ultrasounds, and 2 biopsies, leading to 1 confirmed and treated case of breast cancer. Among 253 individuals with valid contact details, 96 consented to participate in the survey. Participant demographics are as follows: mean age 50 years; 80% Hispanic, 15% White, 5% Black; 76% primarily Spanish-speaking; all are uninsured or with high copay. The main reasons for participating included the benefit of free coverage (32.3%) and reassurance of being breast cancer-free (31.3%). 44% reported no issues in attending their appointments, while 8.4% faced logistical challenges, equally divided between work commitments and transportation issues, which were the main causes for missed appointments. The primary motivation for 81.3% of participants undergoing mammogram screening was early breast cancer detection. Using RCHBMS, the study also revealed a correlation between participants’ perceived susceptibility for breast cancer and their attitudes toward mammogram screening. Those who felt more susceptible to breast cancer also perceived greater barriers and lesser benefits to screening (p&lt;0.05). Factors such as younger age, disability, and having private insurance with high copay were associated with increased perceived susceptibility to breast cancer (p&lt;0.05). Conclusions: This study serves as an important evaluation of a community-driven BCS initiative, highlighting its successes and areas for improvement to better serve underserved populations. This program can serve as a model to increase BCS nationwide. Insights into factors influencing screening perceptions among underserved women offer valuable guidance for healthcare providers and policymakers to improve screening outcomes in similar communities.

Getting what you pay for: impact of copayments on physical therapy and opioid initiation, timing, and continuation for newly diagnosed low back pain

BACKGROUND CONTEXTPhysical therapy (PT) is an important component of low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common. PURPOSEWe sought to understand how copayments impact timing and utilization of PT in newly diagnosed LBP. STUDY DESIGN/SETTINGThe IBM Watson Health MarketScan claims database was used in a longitudinal setting. PATIENT SAMPLEAdult patients with LBP. OUTCOME MEASURESThe primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing. METHODSActual and inferred copayments based on nonnonprimary care provider visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage. RESULTSOverall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days postdiagnosis (IQR 1–55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use (0.77 prescriptions/patient [$0 PT copayment] versus 1.07 prescriptions/patient [$50–74 PT copayment]; 1.15 prescriptions/patient [$75+ PT copayment]). Among patients with known opioid and PT copayments, higher PT copayments were correlated with faster opioid use while higher opioid copayments were correlated with faster PT use (Spearman p<.05). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50–75th and 75–100th percentiles was significantly lower than those below the 50th percentile (HR=0.893 [95%CI 0.887–0.899] and HR=0.905 [95%CI 0.899–0.912], respectively). CONCLUSIONSHigher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Copays may impact long-term adherence to PT.

Does financial assistance reduce catastrophic spending for patients prescribed oral anti-cancer medications at an integrated Specialty Pharmacy?

27 Background: High copayments for oral anti-cancer medications (OAMs) can lead to detrimental financial and clinical outcomes for patients. Most patients insured by Medicare and prescribed an OAM reach the catastrophic phase of spending.1 Financial assistance programs are increasingly used to defray high out of pocket costs, though their ultimate impact on catastrophic spending has not been well-characterized. This study investigated whether receipt of financial assistance reduced likelihood of catastrophic spending for patients prescribed OAMs. Methods: This retrospective, single-institution, cross-sectional study included all patients prescribed an OAM with a &gt;$0 annual copay at an academic integrated Specialty Pharmacy between 1/1-12/31/2021. Data were sourced through a prescribing-level pharmacy database and through a third-party (Vivor/TailorMed) database. A fixed-effects linear regression model was used to identify the impact of financial assistance (binary predictor) on catastrophic spending (binary outcome), defined as spending above $4430/yr based on the average Medicare Part D threshold from 2022 to enter the catastrophic copayments phase. The model was adjusted for demographic and clinical covariates. Results: 1,186 patients were included in the analysis. Average annual copayment on OAMs was $862.50 (SD = $4,673.47) with 5.6% of patients faced catastrophic spending. 37% of patients received some form of financial assistance. Patients who received assistance had significantly lower annual spending on OAMs overall (ß= -$1236; 95% CI: -$1841-658, p&lt;0.001), but assistance was not associated with less catastrophic spending (OR=0.44; 95% CI: 0.14-1.38, p=0.16). Patients who were male, older, retired, insured by Medicare, and had higher annual household income by census tract were more likely to face catastrophic spending. Those who spoke English as a second language and lived in rural settings were less likely to face catastrophic spending. (Table). Conclusions: Financial assistance programs can decrease overall spending on OAMs but may not address financial burden for patients facing catastrophic level spending. Older adults with incomes too high to qualify for safety net or financial assistance programs may be at uniquely increased risk of catastrophic spending. Future studies should evaluate OAM-induced financial toxicity across diverse delivery systems and develop targeted interventions for patients who spend at catastrophic levels. [Table: see text]

Patients’ factors of choice in dental care and impact of the Covid-19 pandemic – a systematic review

Abstract Background Patients often face individual challenges at their dentist, e.g., high co-payments. Why patients decide for or against dental treatment can be determined by many factors: own financial resources, preferences, and external circumstances. The study's aim is to identify these factors with an international perspective. Methods We systematically searched for literature in three biomedical databases. Factors of choice etc. were extracted from relevant publications. We used a qualitative approach for analysis, and the MMAT (Mixed Methods Appraisal Tool) for quality assessment. Results After multistage screening of n = 4,226 publications by two reviewers, n = 233 relevant articles of different study types [qualitative (n = 42), quantitative (n = 177), and mixed-methods (n = 14)] were included in the analysis. Data collection was realized across different settings [e.g., practice (n = 18)] and approaches (e.g., interviews) in n = 49 countries. Included studies focused on specific treatments (e.g., caries treatment) or treatments in general (e.g., dental tourism). Across countries, various factors of choice (n = 101) were identified, divided into three categories: (I) ‘dentist &amp; dental institution’ (e.g., communication), (II) ‘patient’ (e.g., fear), and (III) ‘treatment’ (e.g., durability). Cost and dental fear were mentioned most frequently (n = 148, n = 73). In countries with most articles [UK (n = 28), Saudi Arabia (n = 23), USA (n = 22), India (n = 19), and Brazil (n = 14)], the cost factor was identified most often [e.g., USA (n = 16, 73%)]. One publication addressed the Covid-19 pandemic reporting that treatment appointments were cancelled by patients due to their fear of infection with SARS-CoV2. Study quality is highly variable. Conclusions A variety of factors influence patients’ choice regarding dental treatment. There is little research on impact of the Covid-19 pandemic. Regulatory measures and information efforts should be adapted to reduce patients’ access barriers to dental care. Key messages • A variety of factors influence patients’ choice regarding dental treatment. • Fear of SARS-CoV2 infection is a new factor of choice in dental care from patients’ perspective.

Current rates of purchasing of antibiotics without a prescription across sub-Saharan Africa; rationale and potential programmes to reduce inappropriate dispensing and resistance

ABSTRACT Introduction Antimicrobial resistance (AMR) is a global concern. Currently, the greatest mortality due to AMR is in Africa. A key driver continues to be high levels of dispensing of antibiotics without a prescription. Areas covered A need to document current rates of dispensing, their rationale and potential ways forward including antimicrobial stewardship programmes (ASPs). A narrative review was undertaken. The highest rates of antibiotic purchasing were in Eritrea (up to 89.2% of antibiotics dispensed), Ethiopia (up to 87.9%), Nigeria (up to 86.5%), Tanzania (up to 92.3%) and Zambia (up to 100% of pharmacies dispensing antibiotics without a prescription). However, considerable variation was seen with no dispensing in a minority of countries and situations. Key drivers of self-purchasing included high co-payment levels for physician consultations and antibiotic costs, travel costs, convenience of pharmacies, patient requests, limited knowledge of antibiotics and AMR and weak enforcement. ASPs have been introduced in some African countries along with quality targets to reduce inappropriate dispensing, centering on educating pharmacists and patients. Expert Opinion ASP activities need accelerating among community pharmacies alongside quality targets, with greater monitoring of pharmacists’ activities to reduce inappropriate dispensing. Such activities, alongside educating patients and healthcare professionals, should enhance appropriate dispensing of antibiotics and reduce AMR.

Association of patient copayment and medication adherence in systemic lupus erythematosus

ObjectiveTo investigate the association of medication copayment and treatment adherence to hydroxychloroquine and immunosuppressants for SLE.MethodsWe conducted a retrospective analysis of health claims data using Optum’s de-identified Clinformatics Data Mart...

Key participant characteristics influencing completion of a phase II cardiac rehabilitation program: A cross-sectional analysis

Study objectiveCardiac rehabilitation (CR) programs are effective at reducing cardiovascular disease risk factors, yet programs in the United States (US) have poor participation and completion. The current study evaluates characteristics related to completion and drop-out for CR participants. DesignA cross-sectional study design compared participants who completed the program (finishers) and those did not finish (non-finishers). Variables were compared to determine differences between the dichotomous groups included demographic data, initial six-minute walk test, Zung Depression Index, and Quality of Life Measure (QLM). Logistical regression using variables with differences between groups determined impact on program completion. SettingPhase two outpatient hospital based cardiac rehabilitation program. ParticipantsNinety-seven participants were part of the sample; 61 completed the program, and 36 dropped out. Main outcome measureCompletion of CR. ResultsNinety-seven participants are included; 61 (63 %) were finishers and 36 (37 %) were non-finishers. Finishers were older, had a higher proportion of females and Medicare insurance recipients, had lower depression scores, and reported higher quality of life. Results of the final logistic regression revealed finishers were more likely to have Medicare (odds ratio (OR) = 5.215, confidence interval (CI) 1.897–14.338), be female (OR = 4.597, 95 % CI 1.532–13.795) and have higher QLM Family Sub scores (OR = 1.129, 95 % CI 1.023–1.246). The model correctly classified 71.9 % of cases. ConclusionThe analysis highlights Medicare insurance and family support are associated with program completion. Interventions to increase family and social support, and to provide financial assistance for those with financial burden through lack of insurance or high co-pays may increase cardiac rehabilitation completion rates.

Association of Prescription Co-payment With Adherence to Glucagon-Like Peptide-1 Receptor Agonist and Sodium-Glucose Cotransporter-2 Inhibitor Therapies in Patients With Heart Failure and Diabetes

Type 2 diabetes (T2D) and heart failure (HF) prevalence are rising in the US. Although glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve outcomes for these conditions, high out-of-pocket costs may be associated with reduced medication adherence. To compare 1-year adherence to GLP1-RA and SGLT2i therapies by prescription co-payment level in individuals with T2D and/or HF. This retrospective cohort study used deidentified data from Optum Insight's Clinformatics Data Mart Database of enrollees with commercial and Medicare health insurance plans. Individuals aged 18 years or older with T2D and/or HF who had a prescription claim for a GLP1-RA or SLGT2i from January 1, 2014, to September 30, 2020, were included. Prescription co-payment, categorized as low (<$10), medium ($10 to<$50), and high (≥$50). The primary outcome was medication adherence, defined as a proportion of days covered (PDC) of 80% or greater at 1 year. Logistic regression models were used to examine the association between co-payment and adherence, adjusting for patient demographics, medical comorbidities, and socioeconomic factors. A total of 94 610 individuals (mean [SD] age, 61.8 [11.4] years; 51 226 [54.1%] male) were prescribed GLP1-RA or SGLT2i therapy. Overall, 39 149 individuals had a claim for a GLP1-RA, of whom 25 557 (65.3%) had a PDC of 80% or greater at 1 year. In fully adjusted models, individuals with a medium (adjusted odds ratio [AOR], 0.62; 95% CI, 0.58-0.67) or high (AOR, 0.47; 95% CI, 0.44-0.51) co-payment were less likely to have a PDC of 80% or greater with a GLP1-RA compared with those with a low co-payment. Overall, 51 072 individuals had a claim for an SGLT2i, of whom 37 339 (73.1%) had a PDC of 80% or greater at 1 year. Individuals with a medium (AOR, 0.67; 95% CI, 0.63-0.72) or high (AOR, 0.68; 95% CI, 0.63-0.72) co-payment were less likely to have a PDC of 80% or greater with an SGLT2i compared with those with a low co-payment. In this cohort study of individuals with T2D and/or HF, 1-year adherence to GLP1-RA or SGLT2i therapies was highest among individuals with a low co-payment. Improving adherence to guideline-based therapies may require interventions that reduce out-of-pocket prescription costs.

Patient access to precision medicine: Identifying barriers to biomarker testing in non-small cell lung cancer.

3131 Background: The growing number of targeted therapies approved to treat non-small cell lung cancer (NSCLC) has anchored biomarker testing in clinical practice. Despite general concordance across international guidelines recommending advanced NSCLC patients be tested for oncogenic alterations and immune biomarkers, this is not always the case. This study uses real-world data to explore the barriers to testing across US, Japan, Germany and China. Methods: Ipsos’ Biomarker Testing Rate Monitor is a multi-stakeholder, physician-reported syndicated patient record database. 206 cancer-treating physicians (US=69, Japan=37, Germany=41, China=59) were screened for seniority and caseload and submitted data on 990 NSCLC patients (aggregate) in which biomarker testing had not taken place. Data were collected online January – December 2022. Results: Analyzing physician cited barriers why patients were not tested, choosing not to test at patient’s current stage was highest in the reported US patient cohort, guidelines not calling for testing at this point was more frequently cited in the Japan (27%) and Germany (25%) patient cohort and patient’s co-pay was more frequently cited in the China cohort (34%). The Japan cohort had higher mentions of tissue not being available. Country disparities in the reported metastatic (IIIB-IV) cohort included lack of tissue in Japan (48%) and Germany (25%), deferring testing to a later point in the US (21%) and high co-pay in China (50%). The top cited reasons are shown. Conclusions: Results from this study indicate that, despite guidelines, not all oncology patients receive biomarker testing. While reimbursement structures are difficult to overcome, a concerted effort is needed to raise awareness of the clinical utility of biomarker testing and of the importance of collecting sufficient tissue during the biopsy to allow patients the chance of benefiting from precision medicines. Similarly, calls for earlier testing would support efforts that ensure the best available treatment options are available to patients throughout their journey. Further investigation using comparator cohort is warranted. [Table: see text]

Receipt of financial drug assistance for oral targeted therapy among older adults with advanced non-small cell lung cancer (NSCLC).

e18916 Background: Financial drug assistance programs are a critical resource to mitigate financial toxicity for oral targeted therapy but can be challenging to access and navigate. Older adults with cancer frequently face high copayments for oral targeted therapy, yet they may be less able to navigate assistance programs due to functional and cognitive impairments. To identify potential barriers to receipt of assistance among older adults with advanced NSCLC, we evaluated associations between demographic, clinical, and geriatric assessment characteristics and receipt of financial drug assistance. Methods: We conducted a prospective cohort study at a Comprehensive Cancer Center where thoracic oncology nurses and pharmacists are available to help patients navigate financial drug assistance applications. We enrolled adults age &gt; 65 with advanced NSCLC starting a new chemotherapy, immunotherapy, and/or oral targeted therapy regimen with non-curative intent. For this analysis, we included only older adults who received oral targeted therapy. Patients completed a pretreatment geriatric assessment to evaluate function, cognition, social support, comorbidities, mood, and nutrition. Receipt of financial drug assistance was abstracted from the medical record. We used Fisher’s exact tests to evaluate for differences in demographic, clinical, and geriatric assessment characteristics between those who did and did not receive financial drug assistance. Results: Of the 168 older adults with advanced NSCLC in the parent cohort study, 45 received oral targeted therapy and were included in this analysis. Median age was 74 (range 65-94); 56% were White, 40% Asian, 2% Black, and 2% Hispanic. The majority had Medicare (76%) followed by private insurance (18%), Medicare and Medicaid (4%), and Medicaid alone (2%). On the geriatric assessment, 60% were dependent in instrumental activities of daily living, 20% were dependent in basic activities of daily living, 51% had an abnormal Montreal Cognitive Assessment, and 42% had poor tangible social support. Overall, 9 older adults (20%) received financial drug assistance for their oral targeted therapy. Older adults with a lower household income were more likely to receive financial drug assistance (p = 0.007). There were no statistically significant differences in receipt of financial drug assistance according to other demographic, clinical, or geriatric assessment characteristics including function, cognition, and social support. Conclusions: Older adults with advanced NSCLC on oral targeted therapy with lower household incomes were appropriately more likely to receive financial drug assistance. The lack of associations between receipt of financial drug assistance and function, cognition, and social support suggests that thoracic oncology staff are successfully helping older adults navigate financial drug assistance programs.

Demographic and socioeconomic determinants to the access to hematopoietic stem cell transplantation (HSCT) in multiple myeloma (MM): A National Cancer Database (NCDB) analysis of years 2004-2017.

e20013 Background: Despite the advent of novel chemo-immunotherapies in multiple myeloma (MM), hematopoietic stem cell transplantation (HSCT) remains a crucial aspect of therapy in eligible patients. However, disparities in access to HSCT have been well documented. In this IRB approved retrospective analysis, the NCDB was used to evaluate the determinants of access to HSCT among MM patients who were treated in Commission on Cancer (CoC) accredited facilities across the USA. Methods: Using the NCDB, we identified N = 171,261 patients diagnosed and treated for MM from 2004 to 2017. Multivariable logistic regression analysis was conducted to identify the predictors for receiving HSCT, using significance level of p &lt; 0.05. SAS version 9.4 was used to analyze the data. Results: Multivariable logistic regression analysis showed that there were 12 significant factors associated with HSCT: age, sex, race, ethnicity, facility, insurance, median income, education level, year of diagnosis, distance to facility, Charlson score, and type of treatment regimen. Patients of age 65-75 (OR = 0.65, p &lt; 0.0001) and age ≥ 75 (OR = 0.04, p &lt; 0.0001) were less likely to receive HSCT compared to patients of age &lt; 55. Male patients were more likely to be treated with HSCT compared to female patients (OR = 1.08, p = 0.005). Black patients were predicted to have less access to HSCT compared to White patients (OR = 0.69, p &lt; 0.0001). Patients of non-Hispanic ethnicity were predicted to have better access to HSCT compared to Hispanic patients (OR = 1.25, p = 0.0007). Furthermore, subjects who were treated in non-academic facilities were less likely to receive HSCT compared to the ones who received care in academic or research centers (OR = 0.51, p &lt; 0.0001). Patients with Medicare (OR = 0.79, p &lt; 0.0001), Medicaid (OR = 0.77, p &lt; 0.0001), and no insurance (OR = 0.38, p &lt; 0.0001) were less likely to receive HSCT compared to patients with private insurance. Interestingly, the lower median income &lt; $38,000 was associated with increased frequency of HSCT in comparison with higher median income ≥ $63,000 (OR = 1.17, p &lt; 0.0001). This may be due to reduced access to novel agents by lower income patients who typically cannot afford high co-payment associated with novel agents. In contrast, subjects with a lower level of education (no high school diploma in 21% or more) were predicted to have less access to HSCT in comparison with subjects who had a higher level of education (no high school diploma in less than 7%) (OR = 0.57, p &lt; 0.0001). Detailed analysis will be presented. Conclusions: Our study shows that Black and Hispanic patients as well as those with non-private insurance were less likely to receive HSCT in this large cohort of real world data set from across the USA. These results further corroborate the need to improve equitable access to care to all myeloma patients to ameliorate outcomes.

645 Getting What You Pay For: Impact of Copayments on Physical Therapy Initiation, Timing, and Continuation for Acute-Onset Low Back Pain

INTRODUCTION: Physical therapy (PT) is an important component of acute low back pain (LBP) management. Despite established guidelines, heterogeneity in medical management remains common. METHODS: The IBM Watson Health MarketScan claims database was queried for adult patients with new-onset idiopathic LBP. The primary outcomes-of-interest were timing and overall utilization of PT services. Additional outcomes-of-interest included timing of opioid prescribing. Actual and inferred copayments based on specialist visit claims were used to evaluate the relationship between PT copayment and incidence of PT initiation. Multivariable regression models were used to evaluate factors influencing PT usage. RESULTS: Overall, 2,467,389 patients were included. PT initiation, among those with at ≥1 PT service during the year after LBP diagnosis (30.6%), occurred at a median of 8 days post-diagnosis (IQR 1-55). Among those with at least one PT encounter, incidence of subsequent PT visits was significantly lower for those with high initial PT copayments. High initial PT copayments, while inversely correlated with PT utilization, were directly correlated with subsequent opioid use. High PT copayments affected relative timing of PT and opioid initiation, with every $10 increase associated with a delay in PT initiation of 3.06 days (95%CI 2.76-3.36) and an advancement of opioid prescription by 2.58 days (95%CI 2.24-2.92). For multivariable whole-cohort analyses, incidence of PT initiation among patients with inferred copayments in the 50-75th and 75th-100th percentiles was significantly lower than those below the 50th percentile (HR = 0.893 [95% CI 0.887-0.899] and HR=0.905 [95% CI 0.899-0.912], respectively). CONCLUSIONS: Higher PT copayments correlated with reduced PT utilization; higher PT copayments and lower opioid copayments were independent contributors to delayed PT initiation and higher opioid use. In patients covered by plans charging high PT copayments, opioid use was significantly higher. Co-pays impact long-term adherence to PT.

Abstract 01: Association of Copayment Level and Glucagon-Like Peptide-1 Receptor Agonist and Sodium-Glucose Cotransporter 2 Inhibitor Adherence in Diabetes and Heart Failure

Introduction: Diabetes and heart failure (HF) rates are rising. Glucagon-like peptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with improved outcomes in these conditions. Out-of-pocket cost may reduce medication adherence. We examined the association of medication copayment with 1-year adherence to these agents in individuals with diabetes and HF. Hypothesis: Individuals with high copayments have reduced adherence to GLP1RAs and SGLT2is. Methods: Using the Optum de-identified Clinformatics Data Mart Database, individuals with diabetes and HF and ≥12 months of enrollment with a GLP1RA or SLGT2i claim from 2014-2021 were included. We defined adherence as the proportion of days covered (PDC) ≥80%. We used multivariable logistic regression models to examine the adjusted odds of adherence by copayment level, defined as low (&lt;$10 USD), medium ($10-&lt;$50), and high (≥$50). Covariates included patient socioeconomic and clinical comorbidities. Results: We identified 94,610 individuals (age 61.8±11.4 years; 45.9% female) prescribed GLP1RAs or SGLT2is from 1/1/2014-9/30/2020, Overall, 39,149 individuals had a claim for a GLP1RA, of whom 25,557 (65.3%) had PDC ≥80%. In fully adjusted models, individuals with medium (adjusted odds ratio, aOR 0.61, 95% CI, 0.57-0.66) and high copayment (aOR 0.48, 95% CI, 0.44-0.51) were less likely to have PDC ≥80% with GLPRAs compared to those with low copayment ( Figure ). Overall, 51,072 individuals had a claim for an SGLT2i, of whom 37,339 (73.1%) individuals had PDC ≥80% at 1 year. Individuals with medium (aOR 0.67, 95% CI, 0.62-0.71) and high copayment (aOR 0.69, 95% CI, 0.64-0.74) were less likely to have PDC ≥80% with SGLT2is compared to those with low copayment. Conclusion: In a large cohort of individuals with diabetes and HF, 1-year adherence to GLP1RA or SGLT2i therapies was highest among individuals with low copayment. Improving adherence to guideline-based therapies requires interventions that reduce prescription costs.

Experience of a demand-side subsidy scheme for residential long-term care: perspectives of elderly and their carers

BackgroundVouchers, which are demand-side subsidies to targeted groups, are a type of consumer-led near-cash social transfer for specified benefits that have been used in education, health and other sectors. To provide better access to residential care services and an additional choice for elderly people in need, a novel means-tested residential care service voucher has been introduced in Hong Kong for elderly people to purchase places in the private sector to enable consumer-directed care. The objectives of this paper are to analyze the perspectives of voucher users and their carers toward the voucher scheme and to identify key elements in the design that will contribute to meeting the scheme’s objectives.MethodsAn exploratory sequential mixed method design was adopted with initial explorative qualitative data collection of the perspectives of elderly people and their carers (Phase 1), which informed the design of the subsequent questionnaire survey (Phase 2). Thirty carers in 5 focus groups and 20 individual interviews with elderly people were conducted between April and May 2018. A total of 401 respondents (373 carers and 28 elderly people) completed the survey questionnaire. Findings from both phases were integrated both narratively and via a joint display.ResultsFive key themes summarized the features in two main elements of the design and implementation of the voucher scheme: awareness, meaning that inadequate knowledge and understanding of voucher schemes hinder participation; service needs and types, indicating that the urgent need for residential care services is the key reason for participation; shared responsibility, meaning that a high copayment level discourages participation; choice and flexibility, reflecting appreciation of the additional choices provided by voucher schemes although the availability of residential care beds limits choices; and service quality, indicating mixed perceptions of service quality and the impact of the voucher scheme. Voucher users believe that the voucher scheme is more helpful for relieving the financial burden (98.7%), reducing carers’ stress (97.0%) and reducing the waiting time for subsidized homes for elderly people (89.0%) than for increasing choice and flexibility (78.1%) and improving service quality (62.1%).ConclusionsThis study demonstrates how the design of a voucher scheme affects its take-up by targeted beneficiaries. When a voucher scheme is implemented in a long-term care system, it must consider the congruence with existing policies in long-term care provision and financing. The voucher scheme in Hong Kong has been able to generate the utilization of nonsubsidized places in homes for elderly people that were underutilized, but its effectiveness is limited by inadequate knowledge and understanding of the voucher scheme and the availability of residential care places. Giving the purchasing power and choice of providers to beneficiaries has the potential to enhance the quality of services, which will contribute to meeting the objectives. The study findings carry significant implications for long-term care policies and provide insights into the key features of the voucher scheme for residential care services and how to best design and implement a voucher scheme for elderly people in the context of policy objectives and a long-term care policy.

Association Between Copayment Amount and Filling of Medications for Angiotensin Receptor Neprilysin Inhibitors in Patients With Heart Failure.

Background Angiotensin receptor neprilysin inhibitors (ARNI) reduce mortality and hospitalization for patients with heart failure. However, relatively high copayments for ARNI may contribute to suboptimal adherence, thus potentially limiting their benefits. Methods and Results We conducted a retrospective cohort study within a large, multi-site health system. We included patients with: ARNI prescription between November 20, 2020 and June 30, 2021; diagnosis of heart failure or left ventricular ejection fraction ≤40%; and available pharmacy or pharmacy benefit manager copayment data. The primary exposure was copayment, categorized as $0, $0.01 to $10, $10.01 to $100, and >$100. The primary outcome was prescription fill nonadherence, defined as the proportion of days covered <80% over 6 months. We assessed the association between copayment and nonadherence using multivariable logistic regression, and nonbinarized proportion of days covered using multivariable Poisson regression, adjusting for demographic, clinical, and neighborhood-level covariates. A total of 921 patients met inclusion criteria, with 192 (20.8%) having $0 copayment, 228 (24.8%) with $0.01 to $10 copayment, 206 (22.4%) with $10.01 to $100, and 295 (32.0%) with >$100. Patients with higher copayments had higher rates of nonadherence, ranging from 17.2% for $0 copayment to 34.2% for copayment >$100 (P<0.001). After multivariable adjustment, odds of nonadherence were significantly higher for copayment of $10.01 to $100 (odds ratio [OR], 1.93 [95% CI, 1.15-3.27], P=0.01) or >$100 (OR, 2.58 [95% CI, 1.63-4.18], P<0.001), as compared with $0 copayment. Similar associations were seen when assessing proportion of days covered as a proportion. Conclusions We found higher rates of not filling ARNI prescriptions among patients with higher copayments, which persisted after multivariable adjustment. Our findings support future studies to assess whether reducing copayments can increase adherence to ARNI and improve outcomes for heart failure.

Association Between Copayment and Adherence to Medications for Pulmonary Arterial Hypertension.

Background Pharmacologic treatment for pulmonary arterial hypertension (PAH) improves exercise capacity, functional class, and hemodynamic indexes. However, monthly prescription costs often exceed $4000. We examined associations between (1) medication copayment and (2) annual household income with adherence to pulmonary vasodilator therapy among individuals with PAH. Methods and Results We used administrative claims data from an insured population in the United States to identify individuals diagnosed with PAH between 2015 and 2020. All individuals had ≥1 medication claim for endothelin receptor antagonists, phosphodiesterase type-5 inhibitors, prostanoids or prostacyclin receptor agonists, or the soluble guanylate cyclase stimulator riociguat. We defined copayments as low, medium, or high, as determined by their distributions for each medication class. Annual household income was categorized as <$40 000, $40 000 to $74 999, and ≥$75 000. The primary outcome was medication adherence, defined by proportion of days covered ≥80%. We studied 4025 adults (aged 65.9±13.3 years; 71.2% women). Compared with those with annual household income ≥$75 000, individuals in the <$40 000 and $40 000 to $74 999 categories had no significant differences in medication adherence. Compared with those with low copayments, individuals with high copayments had decreased adherence to prostanoids (odds ratio [OR], 0.36 [95% CI, 0.20-0.65]; P<0.001) and combination therapy with endothelin receptor antagonist and phosphodiesterase type-5 inhibitor (OR, 0.61 [95% CI, 0.38-0.97]; P=0.03). Conclusions We identified associations between copayment and adherence to prostanoids and combination therapy among individuals with PAH. Copayment may be a structural barrier to medication adherence and merits inclusion in studies examining access to pharmacotherapy among individuals with PAH.