Managed Care Insurance Research Articles

Sterilization Surgery Trends in Texas After Passage of the Texas Heartbeat Act [ID 2683648

INTRODUCTION: On September 1, 2021, abortion became illegal in Texas once electric embryonic cardiac activity can be detected. Before that, elective abortions were allowed up to 20 weeks postfertilization. In order to primarily avoid unwanted pregnancy, a trend for younger women to seek a definite contraception method has been observed; however, this has not been studied yet. The aim of this study was to compare the characteristics of women requesting surgical sterilization before and after the Texas Heartbeat Act went into effect. METHODS: This is a retrospective study including all women who underwent bilateral salpingectomy for surgical sterilization between May 2020 and November 2022. Women who underwent surgery 15 months before the new laws (controls) were compared to women who underwent surgery 15 months after the change (study group). Demographic, clinical characteristics, operative, and postoperative data were collected from women's medical files. RESULTS: Two hundred five women met inclusion criteria, of them 131 (64%) in the study group and 74 (36) controls. The rate of women with managed care insurance was significantly higher in the study population (P=.04). Median age was similar between the groups (P=.98). Parity was significantly higher in the controls (P=.004); however, the rate of nulliparous women more than doubled in the study population (37 [28%] versus 8 [11%]; P=.004). Surgery as first contraception method was reported in 63 (48%) and 41 (19%) of the women in the study and control groups, respectively (P=.58). Complication rate was found higher for the study group, but the difference did not reach significance [4 (3.1%) versus 0 (0); P=.13]. CONCLUSION: Since the passage of the Texas Heartbeat Act, more women with managed care insurance were undergoing surgical sterilization. Although the mean age to undergo the surgery did not change compared to the period before the change in the law, the rate of nulliparous women preferring this method for contraception significantly increased.

Examining the extent of data available for policy planning and oversight of Medicaid managed care insurers.

Examining the extent of data available for policy planning and oversight of Medicaid managed care insurers.

Poster 156: Investigating Disparity in Follow-Up Rates of Non-Operative Treatment for Anterior Shoulder Instability

Objectives:Racial and ethnic disparities have been documented in numerous aspects of musculoskeletal care. Specifically, the Multicenter Orthopedic Outcomes Network (MOON) Shoulder Instability Group found that amongst patients undergoing surgery for anterior shoulder instability, minorities had a higher frequency of articular cartilage lesions, and increased frequencies of both glenoid bone loss >10% and Hill-Sachs lesions at the time of surgery. Loss to follow-up and failure to comply with initial non-operative management may play a role in the increased disease burden in this group. This study sought to investigate patient demographics associated with poor follow-up after initiation of nonoperative management regimens for anterior shoulder instability. We hypothesized that significant disparities would be observed with nonoperative follow-up rates. More specifically, we predicted that minority patients and those with state or federal dependent insurances such as Medicaid or Medicare will have lower rates of follow-up.Methods:After obtaining IRB approval, demographics and ambulatory care appointment data for new patient visits and subsequent follow-up encounters associated with a diagnosis of “shoulder instability” or/and “labral tear” were extracted from our electronic medical records from 01/01/2010 to 01/31/2020. National Institute of Health (NIH) guidelines were followed for race, ethnicity, and insurance type categorizations. With the standard of care for non-operative management of anterior shoulder instability ranging from 6-12 weeks of physical therapy, the optimal time window for follow-up used for analysis was defined as 4-12 weeks after the initial visit. Chi-squared tests, pairwise comparisons for multiple variables of interest, and parametric between-group comparison and analyses were performed.Results:A total of 10,854 patient visits were identified. After excluding patients that underwent surgical intervention, a total of 2,679 unique patients and their subsequent encounters were analyzed. These patients had a mean age of 31.4 ± 13.6 years, 77.9% were male and 43.9% were white (Table 1). Of these patients, 1,217 (45.4%) followed up at any point and 420 (34.5%) of this subset of patients followed up within 4-12 weeks of their first visit. There was no significant difference between the overall rates of follow up of white versus minority patients (50.6% versus 49.0%, p = 0.64), nor in the rates of follow up within the optimal time window (16.6% versus 16.9%, p = 0.85) (Table 2). There was no significant difference between rates of follow-up at any point based on insurance types (commercial/ managed care, Medicaid, Medicare, self-pay, and workers compensation) (p = 0.084). However, there was a significant difference between rates of optimally timed follow-up based upon insurance type (p = 0.002) (Table 3). 23.2% of patients with Medicare or Medicaid followed up within 4-12 weeks, as compared to 17.2% of patients who paid out-of-pocket and 14.5% of patients with commercial/ managed care insurance.Conclusions:There were no significant racial disparities seen between white and minority patients in regard to the rates of non-operative follow up for anterior shoulder instability in this study. Furthermore, patients with governmental insurance plans successfully followed up within the optimal 4-12 week time period at a higher rate when compared to patients with commercial or self-pay insurance. These findings suggest that a large, urban academic tertiary care center, can successfully employ strategies to retain patients of different minority status and insurance type for follow-up. The presence of satellite clinics minimizing the distance burden of access to care, use of interpreters to bridge language gaps, and systemic implementation of comprehensive discharge instructions used at our institution may be contributing factors to the findings of the investigation. This study may be enhanced by a multicenter investigation in the future in various geographic locations with a diverse patient population and payer mix. The investigation is limited by the large overall number of patients (54.6%) who never followed up. Further investigations are needed to determine what factors may have influenced these patients to not seek follow-up within our institution. In conclusion, this study found that a single tertiary care system equitably retains patients for follow-up for treatment of their anterior shoulder instability. Further work is needed to better understand if this equitable follow-up results in similar outcomes in different patient populations at our institution, and if disparities in follow-up quantity, quality, and timing are associated with the increased burden of disease for minorities with anterior shoulder instability seen at other institutions in previous studies.Table 1.Patient Demographics (2,679 patients)Table 2.Analysis of Follow-Up within 4-12 Week Window Stratified by Racial Groups Table 3.Analysis of Follow-Up within 4-12 Week Window Stratified by Insurance Type

Medicaid Managed Care: Access To Primary Care Providers Who Prescribe Buprenorphine.

Medicaid managed care insurers play a crucial role in facilitating access to buprenorphine to treat opioid use disorder. Using a novel set of provider directory and prescription claims data, we examined variation in access to in-network buprenorphine-prescribing primary care providers among Medicaid managed care enrollees. Approximately 32.2percent of enrollees had fewer than one in-network buprenorphine prescriber per 100,000 county residents. On average, there were a greater number of in-network buprenorphine-prescribing primary care providers in states with higher compared with lower overdose death rates. However, most enrollees lived in areas with a shortage of these providers. We found that a 25percent higher network participation rate by prescribers compared with nonprescribers could improve the probability that enrollees see a prescriber by approximately 25percent. Policies to improve access within Medicaid managed care include using primary care provider assignment algorithms to match patients with buprenorphine prescribers and requiring that networks include a minimum number of buprenorphine prescribers.

The Bridge Between Racial Justice and Clinical Practice.

The Bridge Between Racial Justice and Clinical Practice.

Navigating Through Right Career Choice After Gastroenterology and Hepatology Fellowship.

Navigating Through Right Career Choice After Gastroenterology and Hepatology Fellowship.

Universal Healthcare Coverage Does Not Ensure Adherence to Initial Colorectal Cancer Screening Guidelines.

Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system. This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified. This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44). Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities.

Disparities by race, socioeconomic status, and insurance type in the receipt of NCCN guideline concordant care for select cancer types in California.

7031 Background: There are a limited number of studies that have evaluated the association between National Comprehensive Cancer Network (NCCN) guideline adherence and survival across different cancers. We aim to assess the relationship between race/ethnicity, socioeconomic status (SES), insurance type and the receipt of NCCN guideline concordant cancer care and survival. Methods: This is a retrospective population-based cohort study of patients with 7 types of invasive cancer using the California Cancer Registry. Adherence with NCCN guidelines was defined by appropriate surgical, radiation, and chemo- or hormonal therapies. Multivariate logistic regression was used to evaluate the relationship between the patient, insurance type, tumor, and guideline adherence. Disease-specific survival analysis was performed using multivariate proportional hazards model. Results: A total of 543,198 patients were identified with invasive cancer between 2004-2017 (cases by disease type: breast 189,311, prostate 156,502, colon 80,102, liver 25,857, gastric 22,066, ovary 22,551, and cervix 16,691). The proportion of patients receiving NCCN guideline-concordant care varied by disease type. Non-concordant guideline treatment was associated with increased disease-specific mortality across all cancer types: breast (HR 1.28, 95%CI 1.23-1.33), prostate (HR 1.31, 95%CI 1.22-1.41), colon (HR 1.73, 95%CI 1.67-1.78), liver (HR 2.52, 95%CI 2.42-2.63), gastric (HR 2.38, 2.28-2.49), ovary (HR 1.32, 95%CI 1.26-1.38), and cervical cancer (HR 1.17, 95%CI 1.08-1.26). In multivariate models, compared to White, black patients were less likely to receive guideline concordant care for breast (OR 0.88, 95%CI 0.84-0.92), prostate (OR 0.90, 95%CI 0.86-0.93), colon (OR 0.85, 95%CI 0.79-0.92), and ovarian cancer (OR 0.71, 95%CI 0.62-0.82). Compared to Managed care insurance patients, Medicaid payer status was also associated with lower guideline concordant care for breast (OR 0.81, 95%CI 0.78-0.84), prostate (OR 0.91, 95%CI 0.86-0.97), colon (OR 0.70, 95%CI 0.65-0.75), gastric (OR 0.69, 95%CI 0.63-0.75), and liver cancer (OR 0.66, 95%CI 0.61-0.72). Conclusions: Less than half of cancer patients received NCCN guideline concordant care. There was an incremental relationship observed between SES and the likelihood of receiving guideline concordant care. Patients receiving non-guideline concordant care had worse disease-specific survival.

Comparison of Office-Based Physician Participation in Medicaid Managed Care and Health Insurance Exchange Plans in the Same US Geographic Markets

Several recent policy proposals have sought to expand the role of Medicaid in providing health insurance for low-income Americans, but there is little recent information on how physician participation in Medicaid compares with alternative forms of coverage for low-income Americans. To compare the number of office-based physicians included in Medicaid managed care and health insurance exchange plans that operate in the same geographic markets. This cross-sectional study used administrative data from physician network directories and survey data from office-based physicians for Kansas, Nebraska, New York, Tennessee, and Washington. The number of participants totaled 67 057 office-based physicians in the 5 sample states. Data were collected and analyzed from May 2018 to June 2019. Physician participation in a Medicaid managed care or health insurance exchange plan network. The percentage of office-based physicians in a county who indicated during a phone survey that they participated in Medicaid; the percentage of office-based physicians in a county who participated in each Medicaid managed care and health insurance exchange plan network; and the percentage of office-based physicians in a county who participated in at least 1 Medicaid managed care plan or, separately, at least 1 health insurance exchange plan. Of the 67 057 office-based physicians in our sample, 49 983 reported in a telephone survey that they accepted Medicaid. This survey-based measure undercounted the percentage of physicians participating in Medicaid by 5.2% (95% CI, 2.3%-8.1%; P < .001) relative to a measure based on physician network directories. Medicaid managed care physician networks covered a median (interquartile range) of 63.4% (48.0%-81.3%) of office-based physicians compared with health insurance exchange physician networks, which covered 51.0% (31.0%-70.5%). In adjusted analyses, Medicaid managed care plans covered 6.2% (95% CI, 3.2%-9.3%, P < .001) more office-based physicians than health insurance exchange plans operating in the same counties. In the states where the same insurers participated in both markets (New York, Tennessee, Washington), the Medicaid managed care physician networks were 6.5% (95% CI, 3.2%-9.8%, P < .001) larger than the health insurance exchange networks offered by the same insurer. In this cross-sectional study of physician network data, Medicaid managed care physician networks included more office-based physicians than the physician networks of health insurance exchange plans operating in the same geographic markets. This suggests that Medicaid remains a viable option for expanding coverage in the United States.

Out-of-Pocket Spending for Thumb Carpometacarpal Arthritis: Capitation Matters.

Background: Patients are increasingly responsible for direct medical expenditures with a growth in out-of-pocket (OOP) expenses, which can impede access to care and affect treatment. This study aims to investigate the impact of capitation on OOP expenses for surgical and presurgical treatment for thumb carpometacarpal (CMC) joint arthritis. Methods: Patients with a diagnosis of thumb CMC arthritis who underwent surgery (2009-2016) comprised our study cohort. Sociodemographic data, total cost, and OOP expenses were collected at the time of surgery and 2 years prior. Patients were stratified by insurance type: fee-for-service (FFS), managed care (MC), Medicare-MC, and Medicare-FFS. Capitated plans were included in the MC and Medicare-MC groups. A generalized linear regression was performed to investigate the association between OOP expenses and insurance type. Results: Our cohort consisted of 7780 patients with FFS insurance, 953 with MC insurance, 2136 with Medicare-FFS, and 265 with Medicare-MC. There was no difference in total costs for FFS and MC (FFS $7281 vs. MC $7306, P = .73; Medicare-FFS $6663 vs. Medicare-MC $6183, P = .19). However, patients with FFS incurred significantly greater OOP costs (FFS $952 vs. MC $434, P < .01; Medicare-FFS $343 vs. Medicare-MC $232, P < .01). In the adjusted regression, MC, Medicare-FFS, and Medicare-MC had approximately 21% to 46% of the predicted OOP expenses of patients with FFS plans (P < .01). Conclusion: Despite similar total costs, OOP expenses were significantly greater for patients with FFS or Medicare-FFS insurance. With healthcare costs transitioning to patients, providers should consider cost sharing when conferring care to help alleviate the financial burden placed on patients.

U.S. Health Care in the Trump Era: A Data Update.

We present a summary of recent studies and data regarding the state of health and health care in the United States. Health care remains unaffordable to many Americans, including many with insurance. Health outcomes are stagnating or deteriorating. Police killings disproportionately target minority men. The search for profits from prescription drug companies, medical device firms, and for-profit medical providers places patients at risk. The public Medicare and Medicaid insurance programs, which increasingly subcontract with private managed care insurers, now account for the majority of private insurers' total business. Insurance firms continue to avoid unprofitable enrollees and impose a mounting bureaucratic burden on medical providers. Meanwhile, recent polls show mounting public support for single-payer national health insurance.

Challenges of Securing Growth Hormone Coverage for Idiopathic Short Stature: Review of the 7-Year Experience at one Institution

Despite U.S. Food & Drug Administration (FDA) approval of growth hormone (GH) for idiopathic short stature (ISS), many providers face challenges obtaining insurance coverage. We reviewed the insurance coverage experience for ISS at our hospital to identify factors predictive of approval or denial. We reviewed charts of patients who underwent GH stimulation testing from July 1, 2009, to April 30, 2017, to identify ISS patients (height <-2.25 SD, subnormal predicted adult height (PAH) and peak GH >10 ng/mL). Eighty-seven patients met ISS criteria, of whom 47 (29 male/18 female) had a GH request submitted to insurance. Mean age, height, and growth velocity were 8.6 ± 2.7 years, 2.83 ± 0.4 SD, and 4.4 ± 1.7 cm/year, respectively. Mean PAH based on bone age was -2.50 ± 0.9 SD, equaling 62 inches for males and 58 inches for females. Most had private managed care insurance (74%). Overall, 17/47 (36%) received treatment approval, 7 immediately and 10 more on appeal. There were no differences in age, height SD, growth rate, insurance type, or PAH between the 17 who were approved and the 30 denied. For 21 patients who were treated, a mean increase in 0.6 SD in height was seen after 1 year. At our institution, GH coverage requests for ISS included very short children mostly ages 6 to 11, with heights well below -2.25 SD and poor PAH. Only 36% were approved even after appeal. This highlights the challenge in our area to secure GH treatment for a FDA-approved indication. Collaboration between pediatric endocrinologists and insurers focusing on height SD and PAH, may improve cost-effective coverage to deserving short children who meet FDA guidelines for ISS treatment. FDA = Food and Drug Administration; GH = growth hormone; IGF-1 = insulin-like growth factor 1; ISS = idiopathic short stature; PAH = predicted adult height.

Concordance with BRCA1/2 testing guidelines among women in The Health of Women (HOW) Study®.

To evaluate factors associated with compliance to the National Comprehensive Cancer Network (NCCN) guidelines for BRCA1/2 testing and identify groups who are at risk of under- and over-use of BRCA1/2 testing. Data included 20,758 women from Dr. Susan Love Research Foundation's The Health of Women (HOW) Study®. Multinomial logistic regression was used to examine the association of socioeconomic and demographic characteristics with whether the woman was over-, under-, or appropriately tested for BRCA1/2 mutations, per 2015 NCCN guidelines. 3894 women (18.8%) reported BRCA1/2 testing. 5628 (27.1%) women who met NCCN criteria for testing were not tested. Among women with a history of breast cancer, those without health insurance were more likely to be under-tested (OR 2.04, 95% CI 1.15-3.60) than those with managed care insurance, and higher education was associated with a lower likelihood of under-testing (Graduate/professional degree OR 0.71, 95% CI 0.55-0.91). Almost 30% of women were under-tested, indicating that many high-risk women who may benefit from genetic testing are currently being missed. Without appropriate testing, providers are unable to tailor screening recommendations to those carrying mutations who are at highest risk. Patient and healthcare provider education and outreach targeted to low-income and under-served populations may assist in reducing under-testing.

Relative risk of all-cause mortality in patients with nontuberculous mycobacterial lung disease in a US managed care population.

The risk of all-cause mortality of nontuberculous mycobacterial lung disease (NTMLD) in the United States (US) population is not well established. This study aims to assess the public health burden of NTMLD in the US by comparing the relative risk of all-cause mortality in the NTMLD population with an age- and sex-matched cohort from the general population. Patients with physician claims for NTMLD (ICD-9 0.031; ICD-10 A31.0) were identified between 2007 and 2016 from a large US national managed care insurance plan covering approximately 15-18 million members annually. A control group with no NTMLD ICD-9 or 10 codes was randomly selected from the general population and matched 3:1 to the NTMLD sample according to birth year, gender, and insurance benefit coverage. The date of first NTMLD diagnosis of each patient was assigned to the matched controls as the index date. The Cox proportional hazard method compared survival between cohorts, adjusting for demographic factors and baseline comorbidities. A total of 2005 patients with NTMLD and 6014 controls were identified, with a mean follow-up duration of 3.4 years and 3.7 years, respectively. The NTMLD group had substantially higher proportions of patients with asthma (23.3% versus 3.5%), bronchiectasis (36.5% versus 0.1%), COPD (52.0% versus 5.9%), arrhythmia (22.6% versus 6.5%), coronary artery disease (18.5% versus 6.6%), heart failure (11.9% versus 4.1%), and cancer (18.5% versus 5.0%). The unadjusted rate of all-cause mortality from the index date was 20.7 per 1000 person-years in the NTMLD group vs 5.6 per 1000 person-years in the control group (rate ratio = 3.73; 95% CI: 2.93-4.75). Multivariable Cox regression, adjusted for the above variables as well as all other important baseline covariates, showed a doubling risk of all-cause mortality (hazard ratio [HR] = 2.06; CI: 1.52-2.79; P < 0.001) in the NTMLD vs control group. All-cause mortality, adjusted for other factors, more than doubled with NTMLD compared with an age-sex-matched control group in a large US national managed care insurance plan.

Health Care Utilization and Expenditures Following Diagnosis of Nontuberculous Mycobacterial Lung Disease in the United States.

Nontuberculous mycobacterial lung disease (NTMLD) is an important public health concern that has been increasing in prevalence. To (a) describe hospitalizations and health care expenditures among patients with newly diagnosed NTMLD and (b) estimate attributable hospitalizations and expenditures to NTMLD in the United States. In this matched cohort study, patients and controls were identified from a large U.S. national managed care insurance database containing aggregated health claims of up to 18 million fully covered members annually. NTMLD was defined based on diagnostic claims for NTMLD on ≥ 2 separate occasions ≥ 30 days apart between 2007 and 2016. Thirty-six months of continuous enrollment (12 months before and 24 months after the first diagnostic claim) was required. Health care utilization and standardized health care expenditures were summarized over 12 months before NTMLD diagnosis and for 2 subsequent years. The percentage of patients that were hospitalized in years 1 and 2 was evaluated using a generalized mixed effects model with adjustment for baseline hospitalizations, Charlson Comorbidity Index, and baseline diseases. A general estimating equation model was used to evaluate health care expenditures. There were 1,039 patients in the NTMLD cohort and 2,078 in the control cohort. NTMLD patients had a 55.0% risk of hospitalization in year 1 (95% CI = 45.4-64.3) and a 38.8% risk in year 2 (95% CI = 30.0-48.4). The adjusted risk of hospitalization was significantly higher in the NTMLD group compared with the control group in year 1 (OR = 4.64; 95% CI = 3.74-5.76; P < 0.001) and year 2 (OR = 2.26; 95% CI = 1.78-2.87; P < 0.001). Year 1 adjusted mean health care expenditures for the total NTMLD patient population were $72,475 (95% CI = $58,510-$86,440) and for the matched control population were $28,405 (95% CI = $8,859-$47,950), with a difference of $44,070 (95% CI = $27,132-$61,008; P < 0.001). Year 2 adjusted mean expenditures for the overall NTMLD patient group were $48,114 (95% CI = $31,722-$64,507) and for the matched control group were $28,990 (95% CI = $9,429-$48,552), with a difference of $19,124 (95% CI = $7,865-$30,383; P < 0.001). Patients with NTMLD have a significantly greater risk of hospitalization and higher total health care expenditures than matched control patients without NTMLD. This study was financially sponsored by Insmed. Marras reports fees from Insmed, Astra Zeneca, RedHill, and Horizon, all outside the current work. Mirsaeidi has nothing to disclose. Eagle, Q. Zhang, Chou, and Leuchars are employees of Insmed. R. Zhang is a contracted consultant at Insmed. The views expressed here are those of the authors and are not to be attributed to their respective affiliations.

The Effect of Impactful Articles on Clinical Practice in the United States: Corticosteroid Injection for Patients with Lateral Epicondylitis.

Following publication of high-level evidence demonstrating that it is not an effective treatment for lateral epicondylitis, a reduction in the corticosteroid injection rate would be expected. The authors aimed to clarify current clinical practice pattern for lateral epicondylitis and identify factors that influence the introduction of evidence into clinical practice. In this administrative claims analysis, the authors used 2009 to 2015 Truven MarketScan data to extract claims for corticosteroid injection, physical therapy, platelet-rich plasma injection, and surgery for lateral epicondylitis. The authors performed multivariable analysis using a generalized estimating equation model to identify the variables that potentially affect the odds of receiving a given treatment. Among 711,726 claims, the authors found that the odds of receiving a corticosteroid injection increased slightly after publication of contradictory evidence (OR, 1.7; 95 percent CI, 1.04 to 1.11 in 2015). Being male (OR, 1.21; 95 percent CI, 1.19 to 1.23), older (OR, 1.16; 95 percent CI, 1.13 to 1.19), and having managed care insurance (OR, 1.15; 95 percent CI, 1.13 to 1.18) significantly contributed to increased odds of receiving corticosteroid injections. Patients seen at facilities in the South (OR, 1.33; 95 percent CI, 1.30 to 1.36 compared with the Northeast) and by plastic/orthopedic surgeons (OR, 2.48; 95 percent CI, 2.43 to 2.52) also had increased odds of receiving corticosteroid injection. Corticosteroid injection use did not decrease after publication of impactful articles, regardless of provider specialty or other patient-related factors. This finding emphasizes that there are various barriers for even high-level evidence to overcome the inertia of current practice.

Abstract P6-08-04: National trends in mastectomy for operable breast cancers treated with neoadjuvant chemotherapy

Abstract Objective: Although neoadjuvant chemotherapy (NAC) has not been shown to improve survival compared with adjuvant therapy for patients with operable invasive breast cancer (IBC), it is often used to allow more limited surgery in the breast and axilla without compromising local control. We sought to evaluate national trends in mastectomy among patients with operable breast cancer treated with NAC and to characterize the contribution of demographic and tumor characteristics to changing trends. Methods: We queried the National Cancer Database (NCDB) 2014 Participant User File for adult women who underwent surgery and received chemotherapy for unilateral T1-3N0-3M0 IBC diagnosed between 2010 and 2014. Surgery was classified as lumpectomy (BCS), unilateral mastectomy (UM) or bilateral mastectomy (BM). Molecular subtype was categorized according to ER, PR, and HER2 status. We used logistic regression to model surgery use (BM or UM vs BCS), adjusting for the following clinical covariates that were selected a priori: age, race/ethnicity, year of diagnosis, comorbidity score, metropolitan vs urban/rural residence, patient distance from treating facility, % with less than high school education (zip code based), insurance type, clinical stage, histology, and molecular subtype. As those who achieved pathologic complete response (pCR) after NAC should be ideal candidates for BCS, we also looked at this group separately. We then performed sensitivity analyses further controlling for region of the country and facility type, and for facility. Results: We identified 235,339 patients who fulfilled our inclusion criteria. Of these patients, 25.3% were treated with NAC. Rates of pCR increased from 33.3% in 2010 to 46.3% in 2014 (p&amp;lt;0.001). Rates of BCS increased from 37.0% in 2010 to 40.8% in 2014 (p&amp;lt;0.001). While rates of UM decreased from 43.3% in 2010 to 34.7% in 2014 (p&amp;lt;0.001), rates of BM with or without reconstruction increased from 19.7% in 2010 to 24.6% in 2014 (p&amp;lt;0.001). Rates of BM without immediate reconstruction remained stable over time, from 11.8% in 2010 to 11.5% in 2014. Among patients who received NAC, factors that were independently associated with both UM and BM (versus BCS) for both the entire cohort and those who achieved pCR included younger age, greater patient distance from facility, and higher clinical stage. Factors that were inversely associated with both UM and BM included black race and ductal histology. More recent year of diagnosis was inversely associated with UM and directly associated with BM. Asian race was associated with UM while non-Hispanic white race was associated with BM. Private or managed care insurance and higher area education were also associated with BM. These results were materially unchanged in sensitivity analyses. Conclusion: Rates of pCR have increased over time among patients with operable IBC treated with NAC. While the rate of UM has declined over time, the rate of BM has increased. Significant sociodemographic differences exist between women who undergo BCS, and women who undergo UM and BM. Further study of factors that influence surgical decision-making in the NAC setting is warranted. Citation Format: Pollom E, Qian Y, Dirbas F, Horst K, Tsai CJ. National trends in mastectomy for operable breast cancers treated with neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-04.

Exploring the relationship of self-reported lack of appetite to patient characteristics and symptom burden.

187 Background: Cancer anorexia-cachexia syndrome (CACS) in patients is associated with decreases in lean body mass and body weight. Self-reported lack of appetite may be an important indicator for early identification of CACS. The current analyses examined the relationship of perceived lack of appetite to patient characteristics and overall symptom burden in a large mixed cancer sample referred to a palliative care clinic. Methods: We conducted a retrospective review of patients newly referred to an outpatient palliative care clinic over a two-year period. Data on demographic and clinical characteristics and patient-reported symptom scores on the Edmonton Symptom Assessment Scale (ESAS) were abstracted. Pearson’s correlations and ANOVAs were used to assess relationships between variables. Multiple regression analysis was used to evaluate the relative contribution of variables that were significantly correlated with lack of appetite at the univariate level. Results: Data on 544 patients ( M=53.7 years) showed that older age (r=12, p&lt;.01), not being married or in a marriage-like relationship (r=.09, p=.04), having insurance other than managed care insurance (r=.10, p=.02), lower body mass index (BMI; r=.11, p&lt;.01), marijuana use (r=.18, p&lt;.0001), and overall symptom burden (ESAS total score r=.52, p &lt; .0001) were associated with worse lack of appetite ( M=3.5, SD=3.1). Patients who were underweight (BMI &lt;18.5, 46.7%) reported significantly worse lack of appetite than patients who were normal weight, overweight, or obese ( M=3.9, SD=3.2, p&lt;.01). The final hierarchical regression model accounted for 34% of the variance in lack of appetite, with age, marital status, BMI, marijuana use, and total symptom burden remaining significant independent correlates (p’ s &lt;.01). Conclusions: Contrary to expectations, relatively few clinical correlates were associated with self-reported lack of appetite. Future research should explore inter-individual genetic factors to explain alterations in lean body mass and body weight that may contribute to poor appetite in patients. Such factors may be important indicators for early identification of CACS.

Analysis of real-world health care costs among immunocompetent patients aged 50 years or older with herpes zoster in the United States

ABSTRACTFew peer-reviewed publications present real-world United States (US) data describing resource utilization and costs associated with herpes zoster (HZ) and postherpetic neuralgia (PHN). The primary objective of this analysis (GSK study identifier: HO-14–14270) was to assess direct costs associated with HZ and PHN in the US using a retrospective managed care insurance claims database. Patients ≥ 50 y at HZ diagnosis were selected. Patients were excluded if they were immunocompromised before diagnosis or received an HZ vaccine at any time. A subsample of patients with PHN was identified. Each patient with HZ was matched to ≤ 4 controls without HZ based on age, sex, and health plan enrollment. Incremental differences in mean HZ-related costs (“incremental costs”) were assessed overall and stratified by age. Multivariable regression models controlled for the effect of demographic characteristics, prediagnosis costs, and comorbidity burden on costs using a recycled predictions approach. Overall, 142,519 patients with HZ (9,470 patients [6.6%] had PHN) and 357,907 matched controls without HZ were identified. Resource utilization was greater among patients with HZ than controls. After adjusting for demographic and clinical characteristics, annual incremental health care costs for HZ patients vs. controls were $1,210 for patients aged 50–59 years, $1,629 for those 60–64 years, $1,876 for those 65–69 years, $2,643 for those 70–79 years, and $3,804 for those 80+ years; adjusted annual incremental costs among PHN patients vs. controls were $4,670 for patients 50–59 years, $6,133 for those 60–64 years, $6,451 for those 65–69 years, $8,548 for those 70–79 years, and $11,147 for those 80+ years. HZ is associated with a significant cost burden, which increases with advancing patient age. Vaccination may reduce costs associated with HZ through case avoidance.

Healthcare Resource Utilization and Costs Following Diagnosis of Nontuberculous Mycobacterial Lung Disease in the USA

BackgroundDespite increasing awareness of nontuberculous mycobacterial lung disease (NTMLD), reports on the economic impact of healthcare resource utilization (HCRU) and costs are limited.MethodsThe national managed care insurance database was searched for physician claims for NTMLD (ICD9 031.0 or ICD10 A31.0) on ≥2 separate occasions ≥30 days apart between 2007 and 2016. A patient cohort (n = 1039) was selected by including those who were insured continuously over 36 months. A control group (n = 2078) was randomly selected from the plan members without NTMLD and matched 2:1 to the NTMLD sample by age and sex. The diagnosis date of NTMLD patient was assigned to the matched controls as the index date. HCRU and standardized costs were summarized over 12 months (baseline) before NTMLD diagnosis and 2 subsequent years.ResultsMean age was 68 years with 67% women. Charlson comorbidity score was 2.0 (±2.2) in NTMLD vs 0.5 (±1.3) in control. NTMLD patients had substantially more respiratory and other disorders compared with the control group (20.6% vs 3.5% asthma, 36.7% vs 0.3% bronchiectasis, 50% vs 6% ColoradoPD, 2% vs 0% cystic fibrosis, 41.6% vs 1.4% pneumonia, 7.8% vs 0% tuberculosis) and had greater immunosuppressant use (43.8% vs 11.9%). NTMLD vs control group had a 30.5% vs 6.0% rate of hospitalization at baseline, 35.1% vs 6.9% at year 1, and 23% vs 7.3% at year 2. Mean (median) total annual healthcare costs in NTMLD vs control were $35,145 ($15,493) vs $5,660 ($587) at baseline, $47,248 ($18,626) vs $6,692 ($745) at year 1, and $28,959 ($11,385) vs $7,184 ($819) at year 2. Medical costs were $26,626 ($11,701) vs $4,370 ($209) at baseline, $35,508 ($12,416) vs $5,248 (288) at year 1, and $20,036 ($6,715) vs $5,488 ($400) at year 2; pharmacy spending was $8,519 ($2,209) vs $1,290 ($21) at baseline, $11,739 ($3,957) vs $1,444 ($45) at year 1, and $8,923 ($2,418) vs $1,696 ($55) at year 2.ConclusionObserved HCRU and costs are substantially higher in NTMLD vs control group and increase from baseline to year 1 then decrease to year 2 in NTMLD but continue to rise in control group. The reversed U-shape of total costs in patients with NTMLD may reflect joint economic outcomes of disease, comorbidity, and management.Disclosures E. Chou, Insmed Incorporated: Employee, Salary; G. Eagle, Insmed Incorporated: Employee, Salary; R. Zhang, Insmed Incorporated: Consultant, Consulting fee; P. Wang, Insmed Incorporated: Employee, Salary; Q. Zhang, Insmed Incorporated: Employee, Salary