Uninsured Survivors Research Articles

An Analysis of Factors Related to Care Engagement along the Cancer Survivorship Care Continuum for Cancer Survivors in Florida.

This study identifies factors associated with care engagement along the cancer survivorship care continuum for Floridians. We identified patients from the OneFlorida Data Trust with a cancer diagnosis at any age and encounters from 2012-2020. Multivariable logistic regression models produced odds ratios (OR) predicting 1) any outpatient non-acute care visit, 2) cancer-related visit with any provider, 3) cancer-related visit with a cancer provider, and 4) survivorship visit with a cancer provider. Encounter-based independent variables were insurance, Social Deprivation Index quartile, and Rural Urban Continuum Area (adjusted for age, sex, race, ethnicity, and treatment). 662,489 survivors were included in the sample. Those with Medicaid and dual eligible status (Medicare and Medicaid) were more likely to have an outpatient visit (Medicaid OR 2.02, 95%CI 1.93-2.12; dual eligible 3.06, 2.91-3.22) or a cancer-related visit with a cancer provider (Medicaid 1.82, 1.77-1.86; dual eligible 1.32, 1.28-1.35), and less likely to have a survivorship visit (Medicaid 0.27, 0.26-0.28; dual eligible 0.20, 0.19-0.21). Uninsured survivors were less likely to have all visit types, while those with Medicare were more likely. Those from the most socially deprived areas were more likely to have an outpatient visit (1.09, 1.03-1.14) and less likely to have a cancer-related visit with any provider (0.90, 0.88-0.92) or a cancer provider (0.93, 0.91-0.95). Survivors from non-metropolitan areas were more likely to have an outpatient visit (1.38, 1.22-1.56), cancer-related visit (1.22, 1.16-1.28), cancer-related visit with a cancer provider (1.45, 1.39-1.52), and a survivorship visit (1.34, 1.22-1.48). Survivors who have public insurance are more likely to have outpatient visits, and those with Medicaid or dual eligible status are less likely to have survivorship visits. Uninsured status is consistently associated with lack of engagement across the care continuum. Those from areas with higher social deprivation are more likely to have outpatient visits, but less likely to have a cancer-related visit with or without a cancer provider. Survivors from non-metropolitan areas are more likely to engage in all visit types along the care continuum.

Preventative Cancer Screening Rates Among Uninsured Patients in Free Clinics: A Retrospective Cohort Study of Cancer Survivors and Non-cancer Survivors.

BackgroundThere is limited research on screening rates among uninsured cancer survivors. Uninsured cancer survivors are at higher risk of poorer health outcomes than the insured due to limited access to preventative screening for secondary cancers. This study examines the rates of surveillance and screening of uninsured cancer survivors and compares to uninsured patients without a cancer history seen in free clinics.MethodsData were collected retrospectively from electronic medical records and paper charts of patients from 10 free clinics between January 2016 and December 2018 in the Tampa Bay area. The prevalence of socioeconomic characteristics, cancer diagnoses, and screening practices were compared for cancer survivors and free clinic patients without a history of cancer. Study participants were determined to be eligible for cancer screenings based on the United States Preventive Services Task Force guidelines.ResultsOut of 13 982 uninsured patients frequenting free clinics between 2016 and 2018, 402 (2.9%) had a documented history of cancer. Out of the 285 eligible cancer survivors, 44 (15.4%) had completed age-appropriate colon cancer screening. Among the 170 female cancer survivors, 75 (44.1%) had completed breast cancer screenings, and only 5.9% (59/246) had completed cervical cancer screenings. After adjusting for age, gender, race, salary, employment status, and household size, cancer survivors were more likely to undergo colorectal cancer screening (OR: 3.59, 95% CI: 2.10–6.15) and breast cancer screening (OR: 2.13, 95% CI: 1.30–3.84) than patients without a cancer history. This difference was not seen for cervical cancer screening (OR: 0.99, 95% CI: .62–1.58).ConclusionsUninsured cancer survivors frequenting free clinics represent a unique population that is underrepresented in the medical literature. Our results suggest that uninsured survivors use screening services at higher rates when compared to uninsured patients without a reported cancer diagnosis. However, these rates are suboptimal when compared to national screening rates of insured cancer survivors.

1446Forgoing needed medical care among long-term survivors of childhood cancer: Racial/ethnic-insurance disparities

Abstract Background Among adult childhood cancer survivors, the relationship between race/ethnicity and health insurance status, as a contributor to disparities in healthcare utilization, is poorly understood. Methods We examined racial/ethnic-related disparities by insurance status in “forgoing needed medical care in the last year due to finances” using 3,964 adult childhood cancer survivors (3310 non-Hispanic/Latinx White, 562 non-Hispanic/Latinx Black, and 92 Hispanic/Latinx) participating in the St. Jude Lifetime Cohort Study (SJLIFE). Multivariable logistic regression analyses, guided by Andersen’s Healthcare Utilization Model, were adjusted for “predisposing” (age, sex, childhood cancer diagnosis, cancer treatment, surgery, and treatment era) and “need” (perceived health status) factors. Additional adjustment for income/education and chronic health conditions was considered. Results The risk of forgoing care was highest among non-Hispanic/Latinx Blacks and lowest among Hispanics/Latinxs for each insurance status. Among privately-insured survivors, relative to non-Hispanic/Latinx Whites, non-Hispanic/Latinx Blacks were more likely to forgo care (adjusted OR: 1.82, 95% CI: 1.30–2.54): this disparity remained despite additional adjustment for income/education (adjusted OR: 1.43, 95% CI: 1.01–2.01). In contrast, publicly-insured survivors, regardless of race/ethnicity, had similar risk of forgoing care as privately-insured non-Hispanic/Latinx Whites. All uninsured survivors had high risk of forgoing care. Additional adjustment for chronic health conditions did not alter these results. Conclusions The findings of this study show that provision of public insurance to all childhood cancer survivors may diminish racial/ethnic disparities in forgoing care that exist among the privately-insured and reduce the risk of forgoing care among uninsured survivors to that of privately-insured non-Hispanic/Latinx Whites. Key messages Providing publicly funded health insurance coverage to childhood cancer survivors can reduce disparities in forgoing medical care.

Insurance Status Impacts Hospital Discharge for Penetrating Trauma Survivors.

Despite equalized acute care in trauma, disparities exist in the long-term outcomes of trauma survivors. Prior studies have revealed insurance status plays a role in the discharge destination of blunt trauma survivors. This is yet to be described in patients with penetrating traumatic injury. A retrospective chart review from 2009 to 2019 from an urban Level 1 trauma center identified adult patients who survived penetrating trauma to discharge. Patients were categorized by insurance status. Patient demographics, discharge destination, and hospital length of stay (LOS) were analyzed using the t-test and ANOVA. 1806 patients were identified with 1410 survivors to hospital discharge. Among the survivors, 26.8% were uninsured, 13.1% were privately insured, and 60.0% had Medicare/Medicaid. The uninsured patients were significantly less likely to be discharged to a rehabilitation facility or skilled nursing facility (OR = .49, 95% CI .35-.71) compared to the insured patients. Uninsured survivors had shorter LOS compared to the other groups (5.8 vs. 7.3, P < .01.) Severity of injury did not significantly influence the discharge destination or LOS between the groups. Despite recent health care reform, many trauma patients remain uninsured. Our study shows that uninsured penetrating trauma survivors are less likely to be discharged to rehabilitation and skilled nursing facilities. This may contribute to uninsured trauma survivors not receiving appropriate post-traumatic care and could lead to the accrual of undue disability, long-term complications, and increased societal burdens.

Forgoing needed medical care among long-term survivors of childhood cancer: racial/ethnic-insurance disparities.

To investigate racial/ethnic-related disparities by insurance status in "forgoing needed medical care in the last year due to finances" in childhood cancer survivors. Our study included 3310 non-Hispanic/Latinx White, 562 non-Hispanic/Latinx Black, and 92 Hispanic/Latinx survivors from the St. Jude Lifetime Cohort Study. Logistic regression analyses, guided by Andersen's Healthcare Utilization Model, were adjusted for "predisposing" (survey age, sex, childhood cancer diagnosis and treatment, and treatment era) and "need" (perceived health status) factors. Additional adjustment for household income/education and chronic health conditions was considered. Risk of forgoing care was highest among non-Hispanic/Latinx Blacks and lowest among Hispanics/Latinxs for each insurance status. Among privately insured survivors, relative to non-Hispanic/Latinx Whites, non-Hispanic/Latinx Blacks were more likely to forgo care (adjusted OR: 1.82, 95% CI: 1.30-2.54): this disparity remained despite additional adjustment for household income/education (adjusted OR: 1.43, 95% CI: 1.01-2.01). In contrast, publicly insured survivors, regardless of race/ethnicity, had similar risk of forgoing care as privately insured non-Hispanic/Latinx Whites. All uninsured survivors had high risk of forgoing care. Additional chronic health condition adjustment did not alter these results. Provision of public insurance to all childhood cancer survivors may diminish racial/ethnic disparities in forgoing care that exist among the privately insured and reduce the risk of forgoing care among uninsured survivors to that of privately insured non-Hispanic/Latinx Whites. Under public insurance, childhood cancer survivors had low risk of forgoing care, at the similar level to privately insured non-Hispanic/Latinx Whites, regardless of race/ethnicity.

Abstract S10-04: Disparities in food insecurity among cancer survivors during the U.S. COVID-19 pandemic

Abstract Background: Food insecurity can negatively impact adherence to and receipt of high-quality cancer care. The purpose of the study was to (1) compare the prevalence of COVID-19 associated food insecurity among cancer survivors to adults without a history of cancer and (2) examine determinants associated with COVID-19 related food insecurity among cancer survivors. Methods: We used nationally-representative data from the COVID-19 Household Impact Survey (n = 10,760), collected at three time points: April 20-26, May 4-10, and May 30-June 8 of 2020. Our primary exposure was cancer survivor status, based on participant’s self-report of a cancer diagnosis (n=854, 7.1%). Primary outcomes of food insecurity were categorized on how often (response options: often true, sometimes true, never true) participants reported the following: “We worried our food would run out before we got money to buy more” or “The food that we bought just didn't last, and we didn't have money to get more”; respondents were categorized as food insecure if they chose often true or sometimes true. We also examined use of food pantry assistance or Supplemental Nutrition Assistance Program benefits during the pandemic period; respondents were also categorized as food insecure if they received or applied for these benefits. We compared reported food insecurity among cancer survivors to other U.S. adults using Chi-square tests. Multivariable Poisson regression was used to identify demographic determinants of food insecurity among cancer survivors. Results: Thirty-two percent of cancer survivors were food insecure. Cancer survivors aged 30-44 years and those aged ≥60 were more likely to report being food insecure compared to respondents without a history of cancer in the same age categories (30-44 years, 59.9% versus 41.2% p = 0.01, ≥60 years 27.2% versus 20.2%, p = 0.01). Cancer survivors without a high school diploma were more likely to report food insecurity compared to adults without a high school diploma and no history of cancer (87.0% versus 64.1%, p = 0.001). In examining determinants of food insecurity among cancer survivors, adults aged 45-49 years when compared to those ages ≥60 (aPR = 1.54, 95% CI 1.16-2.03), adults with no high school diploma (aPR = 2.63, 95% CI 1.53-4.50) or a high school degree (aPR = 1.94, 95% CI 1.08-3.49) compared to those with a baccalaureate or above, adults with an annual household income &amp;lt;$30,000 (aPR: 2.16, 95% CI: 1.15-4.07) compared to those earning ≥$100,000, and cancer survivors in rural areas (aPR = 1.51, 95% CI 1.07-2.12) compared those living in urban areas were more likely to report being food insecure. Uninsured cancer survivors (aPR: 2.39, 95% CI: 1.46-3.92) and those on Medicaid (aPR: 2.10, 95% CI: 1.40-3.17) were more likely to report being food insecure than their counterparts. Conclusions: Food insecurity during the COVID-19 pandemic is vast but varies considerably among cancer survivors and adults without a history of cancer. Among cancer survivors, differences in food insecurity were observed by age, SES, and area of residence. Citation Format: Marlene Camacho-Rivera, Jessica Y. Islam, Denise C. Vidot. Disparities in food insecurity among cancer survivors during the U.S. COVID-19 pandemic [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2021 Feb 3-5. Philadelphia (PA): AACR; Clin Cancer Res 2021;27(6_Suppl):Abstract nr S10-04.

Abstract A019: Substance use in uninsured cancer survivors from free clinics

Abstract Introduction: Approximately 8% of Americans suffer from alcoholism and roughly one-third of Americans endorse illicit drug use. Compared to the general population, substance abuse disorders only occur within 5% of the cancer population. Among cancer survivors, the use of alcohol was comparable to non-cancer survivors while the use of tobacco and illicit drugs was lower. Substance use can decrease treatment adherence, impede pain management, and undermine their network of social support. Our study aims to document the prevalence of substance use in uninsured cancer survivors. Methods: A retrospective chart review was conducted to manually collect chronic disease parameters from electronic medical records and paper charts at 9 free clinics in the Tampa Bay Area of Florida. Data was abstracted using a questionnaire on Redcap software. There were 222 patients with a documented history of cancer in the study and 6,768 patients with a documented negative history of cancer. Demographics were compared between cancer survivors and patients without reported cancer history using chi-square test or independent samples t-test using an alpha of 0.05 for all tests. Results: The majority of the cancer patients were female, n=146 (66.1%). Survivors were significantly older than patients without cancer 54.1 (SD=12) vs. 41 (SD=16.7), p&amp;lt;0.001. Cancer survivors were largely of Caucasian race (n=79, 44.1%) and Hispanic ethnicity (n=79, 44.1%). Patients with a reported cancer history were significantly less likely to be African American (n=6, 3.4%) compared to patients without a history of cancer (n=696, 14.1%) p&amp;lt;0.001. There was no significant difference in current or past drug use between two groups. Cancer survivors were more likely to be current smokers (n=43, 25.6%) compared to patients without cancer history (n=763, 16.1%), p&amp;lt;0.001. Cancer survivors were more likely to be past smokers (n=34, 20.2%) compared to patients without cancer history (n=472, 9.9%), p&amp;lt;0.001. Patients with a history of cancer were more likely to be current drinkers (n=34, 26%) compared to patients without a cancer diagnosis in the study (n=942, 22.9%), p=0.003. Cancer survivors were also more likely to report a history of drinking (n=13, 9.9%) than patients without a history of cancer (n=139, 3.4%), p=0.003. Conclusions: Although current literature demonstrates substance use is associated with socioeconomic disparity, there is limited research on the prevalence of alcohol, tobacco, and illicit drug use among uninsured cancer survivors in the United States. Our study finds that uninsured cancer survivors are more likely to be current and past alcohol users but are just as likely to use illicit substances as uninsured patients without a history of cancer. Our study suggests survivors continue to be at risk for tobacco and alcohol use. More research is needed to evaluate substance use among uninsured cancer survivors. Citation Format: Madeline MacDonald, Shreni Shah, Justin Swanson, Ethan Song, Rahul Mhaskar, Smitha Pabbathi, Abu-Sayeef Mirza. Substance use in uninsured cancer survivors from free clinics [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A019.

The complex comorbidities of uninsured cancer patients.

e19054 Background: Uninsured patients diagnosed with cancer receive fewer screenings, frequently present with later-stage cancer, and are often unable to access standard-of-care treatment when compared to insured patients. We previously performed a study demonstrating that uninsured patients with cancer histories have higher levels of comorbidity. However, there is limited data on long-term studies describing comorbid chronic conditions among uninsured cancer patients. Here we examine socioeconomic factors and comorbid chronic conditions in uninsured patients with a cancer history over a period of three years. Methods: A retrospective chart review was conducted from 10 free clinics around the Tampa Bay region. Patients with any documented history of cancer who utilized a free clinic between 2016 and 2018 were included. Patients with no documentation of cancer history were excluded. Demographics, chronic disease parameters, and Charlson Comorbidity Index (CCI) scores were extracted and analyzed. Results: Between 2016 – 2018, a total of 17,003 uninsured patients were treated at 10 free clinics. Of these patients, 455 (2.7%) had a documented history of cancer, 9021 (53.1%) had no history of cancer, and 7527 (44.3%) had no documentation of cancer in their charts. Cancer patients were mostly women (305, 67.0%) and the average age was 55.2 years. Patients with cancer had significantly higher CCI scores compared to patients without cancer in 2016 (3.0 [2.0 SD] versus 0.94 [1.2 SD]), 2017 (2.71 [2.38 SD] versus 0.93 [1.26 SD]), and 2018 (3.27 [2.22 SD] versus 1.08 [1.26 SD]), p &lt; 0.001. Patients with a cancer history were also more likely to be current drinkers (16.9% versus 13.0%) or smokers (17.8% versus 11.0%) compared to patients without a history of cancer. Conclusions: The results demonstrate that uninsured cancer patients consistently have higher levels of chronic disease and comorbidity compared to uninsured patients without a cancer diagnosis. This study increases awareness of the disease burden and mortality risk specific to uninsured cancer survivors which could inform free clinics and volunteer providers to better address the needs of this vulnerable population.

Changes in Noninsurance and Care Unaffordability Among Cancer Survivors Following the Affordable Care Act.

Little is known about changes in socioeconomic disparities in noninsurance and care unaffordability among nonelderly cancer survivors following the Affordable Care Act (ACA). Cancer survivors aged 18-64 years nationwide were identified from the Behavioral Risk Factor Surveillance System. Trend and difference-in-differences analyses were conducted to examine changes in percent uninsured and percent reporting care unaffordability pre-(2011 to 2013) and post-(2014 to 2017) ACA Medicaid expansion, by sociodemographic factors. A total of 118 631 cancer survivors were identified from Medicaid expansion (n = 72 124) and nonexpansion (n = 46507) states. Following the ACA, percent uninsured and percent reporting care unaffordability decreased nationwide. Medicaid expansion was associated with a 1.8 (95% confidence interval [CI] = 0.1 to 3.5) percentage points (ppt) net decrease in noninsurance and a 2.9 (95% CI = 0.7 to 5.1) ppt net decrease in care unaffordability. In stratified analyses by sociodemographic factors, substantial decreases were observed in female survivors, those with low or medium household incomes, the unemployed, and survivors with multiple comorbidities. However, we observed slightly increased percentages in reporting noninsurance (ppt = 1.7; 95% CI = -1.2 to 4.5) and care unaffordability (ppt = 3.1, 95% CI = -0.4 to 6.5) in nonexpansion states between 2016 and 2017, translating to 67163 and 124160 survivors, respectively. We observed reductions in disparities by sociodemographic factors in noninsurance and care unaffordability among nonelderly cancer survivors following the ACA, with largest decreases in women, those with low or medium income, multiple comorbid conditions, the unemployed, and those residing in Medicaid expansion states. However, the uptick of 82750 uninsured survivors in 2017, mainly from nonexpansion states, is concerning. Ongoing monitoring of the effects of the ACA is warranted, especially in evaluating health outcomes.

Abstract 2432: Prevalence of depression and other chronic diseases among uninsured cancer survivors: A free clinic study

Abstract Introduction: Free clinics play an important role in providing health care services to the poor and uninsured. Limited data exist on chronic disease burden and patient characteristics of cancer survivors outside the network of insured health systems. In this study we describe characteristics of cancer patients utilizing free clinics for chronic disease management and mental health services in order to evaluate associations between chronic conditions. Methods: Nine free clinics in the Tampa Bay area were included in this study. A retrospective review of patient charts from 01/01/2016 to 12/31/2017 was conducted. Data on patient characteristics and prevalence of chronic diseases were abstracted through an online questionnaire using Redcap software. Patients with a documented history of cancer were considered cancer survivors. Chi-square test was used to compare patient characteristics and p-values were reported. Logistic regressions were used to examine associations between diseases and socio-demographic factors. Odds ratios (OR) and 95% confidence intervals (CI) were reported. Results: From 2016 to 2017, 208 cancer survivors were managed in nine free clinics. The average age was 54 years and 138 (66%) were women. The prevalence of depression was 11.14%. The prevalence of depression was higher among women (12.7%) compared to men (8.8%), p-value 0.001. The prevalence was significantly highest among patients who were 18-44 years, non-Hispanics, white race, unemployed and considered low-income. In univariate analyses, the prevalence of depression was significantly associated with cancer (OR 2.12; 95%CI: 1.23-3.67), diabetes (OR 1.59; 95%CI: 1.21-2.08), cerebrovascular accident (OR 3.25; 95%CI: 1.71-6.21), cardiovascular disease (OR 2.10; 95%CI: 1.26-3.51), hypertension (OR 1.96; 95%CI: 1.58-2.43), and hyperlipidemia (OR 2.30; 95%CI: 1.79-2.94). Unemployment, lower income level, and higher BMI were also factors positively associated with the prevalence of depression. Additional relationships and multivariate analyses are available. Conclusion: Despite having access to limited resources, free clinics receive mainly poor, women, middle-aged, and uninsured patients. Comorbidities such as cancer and other chronic conditions are often directly associated with depression among patients managed in free clinics. Mental health support is critically needed in free clinics, especially for those who are cancer survivors. Citation Format: Sayeef Mirza, Shams Rahman, Madeline Macdonald, Alexandra Towne, Katherine Robinson, Amber Todd, Wei Wang, Deanna Wathington. Prevalence of depression and other chronic diseases among uninsured cancer survivors: A free clinic study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2432.

Rates and patterns of uninsured cancer survivors before and after implementation of the Affordable Care Act, 2000-2017.

e18105 Background: Cancer survivors experience difficulties in maintaining healthcare coverage, however the reasons and risk factors for lack of insurance are poorly defined. We sought to assess self-reported reasons for not having insurance and to assess demographic and socioeconomic factors associated with non-insurance among cancer survivors, before and after implementation of the Affordable Care Act (ACA) in 2014. Methods: We used the National Health Interview Survey to identify adult participants (18-64 years) reporting a cancer diagnosis between 2000-2017. Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds being uninsured. The prevalence of the most common self-reported reasons for not having insurance (unemployment, employment-related reason, family-related) were estimated, with AORs for each of the reasons defined by multivariable logistic regression. Results: Among 17,806 survey participants, 10.3% reported not having health insurance. Individuals surveyed in 2000-2013 had higher odds of not having insurance as compared to those surveyed in 2014-2017 (10.6% vs. 6.2%, AOR 1.75, 95% CI 1.49-2.08). Variables associated with higher odds of non-insurance throughout the entire study interval included younger age, annual family income below the poverty threshold, black race, Hispanic ethnicity, non-citizen status and current smoking (p &lt; 0.001 for all). After implementation of the ACA, increasing interval from cancer diagnosis and black race were no longer associated with not having insurance. The most commonly cited reason for not having insurance were cost followed by unemployment, both of which decreased after ACA implementation (cost: 49.6% vs. 37.6%, AOR 0.62, 95% CI 0.46-0.85; unemployment: 37.1% vs. 28.5%, AOR 0.62, 95% CI 0.45-0.87). Conclusions: The proportion of uninsured cancer survivors decreased after implementation of the ACA, however certain subgroups remain at greater risk of being uninsured. Cost remains the primary barrier to obtaining insurance, although more than half of cancer survivors reported other barriers to coverage. Given the growing number of cancer survivors in conjunction with rising health costs, efforts addressing barriers to insurance coverage are needed for this population.

Mental health insurance access and utilization among childhood cancer survivors: a report from the childhood cancer survivor study.

To describe and compare the prevalence of mental health access, preference, and use among pediatric cancer survivors and their siblings. To identify factors associated with mental health access and use among survivors. Six hundred ninety-eight survivors in the Childhood Cancer Survivor Study (median age = 39.4; median years from diagnosis = 30.8) and 210 siblings (median age = 40.4) were surveyed. Outcomes included having mental health insurance coverage, delaying care due to cost, perceived value of mental health benefits, and visiting a mental health provider in the past year. There were no differences in mental health access, preferences, and use between survivors and siblings (p > 0.05). Among respondents with a history of distress, most reported not having seen a mental health provider in the past year (80.9% survivors vs. 77.1% siblings; p = 0.60). Uninsured survivors were more likely to defer mental health services due to cost (24.6 vs. 8.4%; p < 0.001). In multivariable models, males (OR = 2.96) and survivors with public (OR = 6.61) or employer-sponsored insurance (ESI; OR = 14.37) were more likely to have mental health coverage. Most childhood cancer survivors value having mental healthcare benefits; however, coverage and use of mental health services remain suboptimal. The most vulnerable of survivors, specifically the uninsured and those with a history of distress, are at risk of experiencing challenges accessing mental health care. Childhood cancer survivors are at risk for experiencing high levels of daily life stress that is compounded by treatment-related sequelae. Integrative, system-based approaches that incorporate financial programs with patient education about insurance benefits can help reduce some of the financial barriers survivors face.

Cost-related medication nonadherence among adolescent and young adult cancer survivors.

This study investigated cost-related medication nonadherence among survivors of adolescent and young adult cancer and a comparison group in the United States. A cross-sectional analysis of the 2013 to 2015 National Health Interview Survey was performed. N=953 patients who were diagnosed with cancer between the ages of 15 and 39 years were identified, and a comparison group was created using propensity scores. Cost-related medication nonadherence was determined by individuals' report of skipping medication, taking less medication, or delaying filling medication to save money in the previous year. Covariates included demographics, insurance status, financial factors (eg, out-of-pocket health care expenditures), and health-related factors (eg, comorbidity and mental distress). Chi-square tests were used to compare nonadherence between survivors and the comparison group. Logistic regressions identified covariates associated with nonadherence. Survivors were more likely to report nonadherence than the comparison group (23.8% vs 14.3%; P < .001). Survivors were also more likely to report that they could not afford medication, asked their physician for lower cost medication, and used alternative therapies in the previous year to save money. Uninsured survivors were more likely to report nonadherence than those privately insured (odds ratio [OR], 3.19; 95% confidence interval [CI], 1.67-6.09). Non-Hispanic black survivors, those who reported greater mental distress, and those with greater comorbidities reported nonadherence more often than their counterparts. Survivors reporting a usual source of care were at a lower risk of nonadherence than those without it (OR, 0.39; 95% CI, 0.18-0.82). Cost-related communication with survivors may be needed to increase medication adherence. Uninsured and sicker survivors should receive regular screening to improve adherence. Future work should evaluate adherence for specific drugs. Cancer 2017;123:2726-34. © 2017 American Cancer Society.

Health care experiences of long-term survivors of adolescent and young adult cancer.

Evaluate health care access and experiences with care among long-term survivors of adolescent and young adult (AYA) cancer relative to a comparison group in the USA. The 2008 to 2012 Medical Expenditure Panel Surveys identified 1163 survivors of cancer, diagnosed ages 15-39, current ages 20-64, who were at least 5years after diagnosis. A comparison group without cancer was matched using age, sex, and other characteristics. Primary outcomes included having ≥1 visit to doctor's office/clinic in the previous year and perceived health care quality (0 = worst to 10 = best; categorized as low (0-4), intermediate (5-7), and high (8-10)). Other experience-related outcomes (e.g., having adequate time with providers and providers show respect) were also evaluated. Bivariate analyses compared these outcomes between survivors and the comparison group. Multivariable logistic regressions identified survivor-level factors associated with health care visits and quality. Survivors had ≥1 visit more often (82.1 vs. 75.8%, p = 0.005) yet rated their health care quality lower (low or intermediate 30.7 vs. 23.6%, p < 0.001) than the comparison group. Fewer survivors reported always having enough time with providers (41.7 vs. 54.6%, p < 0.001) and that providers always show respect (57.5 vs. 67.7%, p = 0.002). Uninsured survivors were less likely to have ≥1 visit (odds ratio (OR) = 0.26, 95% confidence interval (CI) 0.17-0.40, p < 0.001) and rated their health care quality lower (OR = 0.25, 95% CI 0.13-0.48, p < 0.001) than privately insured. Many other factors were associated with visits and quality. Survivors of AYA cancer reported more health care visits but worse health care experiences than individuals without cancer. Targeted interventions that may improve survivors' experiences with health care should be evaluated.

Dental Care for Survivors of Adolescent and Young Adult Cancer: Special Considerations.

Oral health is important for quality of life, but may be undermanaged for survivors of cancer. We examine dental care use and barriers among long-term survivors of adolescent and young adult (AYA) cancer in comparison to individuals without a history of cancer. The 2008-2012 Medical Expenditure Panel Survey (MEPS) identified 1216 individuals diagnosed with cancer at AYA ages (15-39 years), who were at least 5 years from diagnosis. A comparison group was matched using age, sex, and other factors. We evaluated self-reported dental visits in the previous 12 months, and inability and delay in receiving necessary dental care among survivors and the comparison group. Furthermore, individual factors associated with dental care use were identified using multivariable logistic regressions. Of survivors, 60.86% reported no dental visits in the previous year compared to 51.96% of the comparison individuals (p < 0.001). Survivors were more likely to report inability (10.71% vs. 6.29%, p = 0.001) and delay (8.12% vs. 4.45%, p = 0.001) in getting necessary dental care than the comparison group. Notably, survivors without dental insurance were more likely to report inability and delay. Female survivors were more likely to use dental care than males (odds ratio = 1.76, 95% confidence interval 1.15-2.71, p = 0.01). Hispanic survivors, those diagnosed at younger ages, and uninsured survivors were less likely to have at least one dental visit. Survivors of AYA cancer need timely surveillance to manage late effects, including dental complications. Yet, these survivors, particularly those who are uninsured, delay dental care more often than individuals from the general population. Survivor-specific interventions are needed to reduce dental care barriers.

Abstract WP163: One in Three Stroke Survivors has Uncontrolled Blood Pressure 90 Days After Stroke

Background and Objectives: High blood pressure (BP) is a major modifiable cause of recurrent stroke. The prevalence of uncontrolled BP 90 days after stroke in contemporary populations of unselected stroke patients is unclear. We measured the prevalence and predictors of uncontrolled BP 90 days after stroke in a population-based stroke surveillance project. Methods: Prospective cohort study of 214 Mexican American or non-Hispanic white adults aged ≥45 years with ischemic or hemorrhagic stroke and completed outcome assessments 90 day after stroke in the Brain Attack Surveillance in Corpus Christi (BASIC) project from March 2011 through June 2012. Trained personnel conducted in-home examinations following a standardized protocol to measure BP 90 days after stroke using an automated arm monitor (OmROn model 700 series). BP was measured in triplicate and the third BP reading was used. BP control was defined as BP&lt;140/90 mm Hg. We investigated risk factors for uncontrolled BP 90 days after stroke using logistic regression and adjusting for ethnicity, age, sex, education, and insurance status as well as variables that were associated with uncontrolled BP. Results: Median age was 66 years (interquartile range [IQR], 58-77 years), and 93% of strokes were ischemic. Median systolic BP was 128.5 mm Hg (IQR, 114-145) and diastolic BP was 76 mm Hg (IQR, 68 to 84). Overall, BP was uncontrolled in 35.1% (95% CI, 29.9% to 41.7%) of stroke survivors 90 days after stroke, and this did not differ by ethnicity (Mexican American, 34.3% [95% CI, 26.8% to 42.7%] vs. non-Hispanic white, 36.3%; [95% CI, 26.6% to 47.2%]; Wald P=0.58). Uncontrolled BP 90 days after stroke was more likely in stroke survivors with older age (adjusted odds ratio [aOR], 1.03 per 1 year increase; 95% CI, 1.00 to 1.06; P=0.03), no health insurance (aOR, 3.08; 95% CI, 1.19 to 7.96; P=0.02, and hypertension (aOR, 2.24; 95% CI, 0.96 to 5.26; P=0.06). Conclusion: More than one third of stroke survivors has uncontrolled BP 90 days after stroke in this population-based study. Interventions designed to improve BP control and targeting older and uninsured stroke survivors are needed.

Impact of health care costs on utilization of needed health care in the Childhood Cancer Survivor Study (CCSS).

20 Background: Survivors of childhood cancer face increased risks for morbidity and premature mortality due to the sequelae of their primary disease and its treatment. Survivors may be socioeconomically vulnerable, which could negatively impact their healthcare utilization. We investigated sociodemographic factors associated with forgoing needed healthcare due to cost among long-term survivors within the CCSS. Methods: From a survey of insured and uninsured survivors conducted in 2011-12, forgoing needed healthcare due to cost was determined by the question “In the past year, was there a time when you did any of the following because you were worried about the cost? (Yes/No)” with 10 response categories (e.g., skipping a test/treatment, postponing medical care, taking a smaller cost of a prescription). ‘Yes’ responses were summarized using a categorical outcome variable of 0, 1-2, or ≥ 3 instances of forgoing healthcare. Ordinal logistic regression models assessed the association of sociodemographic factors with increased instances of forgoing healthcare due to cost, including survey weights to account for stratified sampling. Results: Of 1,110 mailed surveys, we received 698 (64%) responses. Mean age at time of survey was 39.6 (range 24-60) years and average time since diagnosis was 31.3 (SD = 4.6) years. 23% of survivors reported 1-2 instances of foregoing needed healthcare and 31% reported 3 or more. Odds of more forgone needed healthcare due to costs were increased for those who were uninsured, female, and had a chronic medical condition. [Table: see text]

Health behaviors, quality of life, and psychosocial health among survivors of adolescent and young adult cancers.

Survivors of adolescent and young adult (AYA) cancer may engage in unhealthy lifestyles (e.g., smoking), potentially heightening their risk for long-term health problems. We assessed health behaviors and constructs including quality of life (QOL) and psychosocial well-being among survivors of AYA cancer compared to the general population. We used 2009 Behavioral Risk Factor Surveillance System data to evaluate health behaviors for survivors of AYA cancer compared to AYAs without cancer. Multivariable regressions assessed health behaviors (smoking, binge drinking, physical inactivity, and low fruit/vegetable intake) by sex and age between AYA survivors and controls, and among survivors to determine the effects of demographic, QOL, psychosocial, and cancer factors on behaviors. A greater proportion of female survivors of AYA cancer smoked than controls (currently aged 20-39: 27 vs. 14.3%, respectively; currently aged 40-64: 29.3 vs. 18.4%, respectively). Generally, survivors and controls were non-adherent to national health behavior guidelines. Uninsured survivors were at greater risk of smoking vs. insured (females, Relative Risk (RR) = 1.64, 95% confidence interval (CI) 1.43-1.90; males, RR = 2.62, 95% CI 1.71-4.02). Poor social/emotional support was associated with smoking (RR = 1.26, 95% CI 1.07-1.48) among female survivors and was associated with low fruit/vegetable intake among male (RR = 1.12, 95% CI 1.01-1.23) and female (RR= 1.12, 95% CI 1.05-1.19) survivors. Female survivors >10 years from diagnosis had higher risk of smoking (RR = 1.26-1.91, all p < 0.01) than survivors 5-10 years from diagnosis. Unhealthy lifestyle behaviors are common in survivors of AYA cancer. AYA survivors require health behavior support.

Childhood Cancer Survivor Study participants' perceptions and understanding of the Affordable Care Act.

The Patient Protection and Affordable Care Act (ACA) established provisions intended to increase access to affordable health insurance and thus increase access to medical care and long-term surveillance for populations with pre-existing conditions. However, childhood cancer survivors' coverage priorities and familiarity with the ACA are unknown. Between May 2011 and April 2012, we surveyed a randomly selected, age-stratified sample of 698 survivors and 210 siblings from the Childhood Cancer Survivor Study. Overall, 89.8% of survivors and 92.1% of siblings were insured. Many features of insurance coverage that survivors considered "very important" are addressed by the ACA, including increased availability of primary care (94.6%), no waiting period before coverage initiation (79.0%), and affordable premiums (88.1%). Survivors were more likely than siblings to deem primary care physician coverage and choice, protections from costs due to pre-existing conditions, and no start-up period as "very important" (P < .05 for all). Only 27.3% of survivors and 26.2% of siblings reported familiarity with the ACA (12.1% of uninsured v 29.0% of insured survivors; odds ratio, 2.86; 95% CI, 1.28 to 6.36). Only 21.3% of survivors and 18.9% of siblings believed the ACA would make it more likely that they would get quality coverage. Survivors' and siblings' concerns about the ACA included increased costs, decreased access to and quality of care, and negative impact on employers and employees. Although survivors' coverage preferences match many ACA provisions, survivors, particularly uninsured survivors, were not familiar with the ACA. Education and assistance, perhaps through cancer survivor navigation, are critically needed to ensure that survivors access coverage and benefits.

Abstract WP418: Insurance Status Influences Blood Pressure Control among Stroke Survivors in the United States

BACKGROUND: Hypertension is the premier modifiable risk factor for stroke. After a stroke, poorly controlled blood pressure (BP) is associated with a higher risk of recurrent vascular events; however, less than half of stroke survivors in the US have BP in the normal range. Uninsured and under-insured adults generally have less access to recommended care and receive poorer quality of care, but it is unclear to what extent insurance status affects BP control after stroke. METHODS: We assessed BP control among adults (≥20 years) with a history of stroke who participated in the National Health and Nutrition Examination Surveys from 1999 through 2010. The relationship between insurance type and BP control (ideal: &lt;120/80 mm Hg and good: &lt;140/90 mm Hg) was evaluated using logistic regression before and after adjusting for age, sex, race, body mass index, household income, history of hypertension and major comorbidities, and NHANES cycle. RESULTS: Of an estimated 2,253,394 stroke survivors &lt;65 years, 47% had private insurance, 19% were uninsured, 10% had Medicaid, 10% had Medicare, 8% had other government insurance, and 4% had Medicare and Medicaid. Among an estimated 2,927,596 stroke survivors aged ≥65 years, 38% had Medicare, 44% had Medicare and Medicaid, 8% had private insurance, and the remainder had Medicaid, other government insurance, or were uninsured. Overall, 28% of stroke survivors exhibited ideal BP control and 61% of stroke survivors had good BP control. Insurance type was not associated with ideal BP control. However, among stroke survivors &lt;65 years, those with Medicaid were more likely than those who were uninsured to have good BP control (HR 2.41, 95% CI 0.87-6.68; p=0.09). Among stroke survivors ≥65 years, those with a combination of Medicare and private insurance had greater odds of good BP control compared to persons with Medicare insurance alone (HR 1.39, 95% CI 0.97-2.00, p=0.07). CONCLUSIONS: Depending on age and insurance type, uninsured or underinsured stroke survivors in the US tend to have lower odds of good BP control. Recent legislation to expand insurance coverage may help bridge these disparities, but intensified efforts aimed at enhancing clinician communication and promoting self-management among these patients may also be warranted.