Socioeconomic status and modification of atherosclerotic cardiovascular disease risk prediction: epidemiological analysis using data from the atherosclerosis risk in communities study

OBJECTIVE

Examine whether the relationship between the pooled cohort equations (PCE) predicted 10-year risk for atherosclerotic cardiovascular disease (ASCVD) and absolute risk for ASCVD is modified by socioeconomic status (SES).

DESIGN

Population-based longitudinal cohort study-Atherosclerosis Risk in Communities (ARIC)-investigating the development of cardiovascular disease across demographic subgroups.

SETTING

Four communities in the USA-Forsyth County, North Carolina, Jackson, Mississippi, suburbs of Minneapolis, Minnesota and Washington County, Maryland.

PARTICIPANTS

We identified 9782 ARIC men and women aged 54-73 without ASCVD at study visit 4 (1996-1998).

PRIMARY OUTCOME MEASURES

Risk ratio (RR) differences in 10-year incident hospitalisations or death for ASCVD by SES and PCE predicted 10-year ASCVD risk categories to assess for risk modification. SES measures included educational attainment and census-tract neighbourhood deprivation using the Area Deprivation Index. PCE risk categories were 0%-5%, >5%-10%, >10%-15% and >15%. SES as a prognostic factor to estimate ASCVD absolute risk categories was further investigated as an interaction term with the PCE.

RESULTS

ASCVD RRs for participants without a high school education (referent college educated) increased at higher PCE estimated risk categories and was consistently >1. Results indicate education is both a risk modifier and delineates populations at higher ASCVD risk independent of PCE. Neighbourhood deprivation did modify association but was less consistent in direction of effect. However, for participants residing in the most deprived neighbourhoods (referent least deprived neighbourhoods) with a PCE estimated risk >10%-15%, risk was significantly elevated (RR 1.65, 95% CI 1.05 to 2.59). Education and neighbourhood deprivation inclusion as an interaction term on the PCE risk score was statistically significant (likelihood ratio p≤0.0001).

CONCLUSIONS

SES modifies the association between PCE estimated risk and absolute risk of ASCVD. SES added into ASCVD risk prediction models as an interaction term may improve our ability to predict absolute ASCVD risk among socially disadvantaged populations.

The Role of Primary Care in the Initiation of Opioid Use Disorder Treatment in Statewide Public and Private Insurance

OBJECTIVE

To determine if individuals newly diagnosed with opioid use disorder (OUD) who saw a primary care provider (PCP) before or on the date of diagnosis had higher rates of medication treatment for OUD (MOUD).

METHODS

Observational study using logistic regression with claims data from Medicaid and a large private insurer in North Carolina from January 2014 to July 2017.

KEY RESULTS

Between 2014 and 2017, the prevalence of diagnosed OUD increased by 47% among Medicaid enrollees and by 76% among the privately insured. Over the same time period, the percent of people with an OUD who received MOUD fell among both groups, while PCP involvement in treatment increased. Of Medicaid enrollees receiving buprenorphine, the percent receiving buprenorphine from a PCP increased from 32% in 2014 to 39% in 2017. Approximately 82% of people newly diagnosed with OUD had a PCP visit in the 12 months before diagnosis in Medicaid and private insurance. Those with a prior PCP visit were not more likely to receive MOUD. Seeing a PCP at diagnosis was associated with a higher probability of receiving MOUD than seeing an emergency provider but a lower probability than seeing a behavioral health specialist or other provider type.

CONCLUSIONS

People newly diagnosed with OUD had high rates of contact with PCPs before diagnosis, supporting the importance of PCPs in diagnosing OUD and connecting people to MOUD. Policies and programs to increase access to MOUD and improve PCPs' ability to connect people to evidence-based treatment are needed.

Cost-effectiveness of endocrine therapy versus radiotherapy versus combined endocrine and radiotherapy for older women with early-stage breast cancer

PURPOSE

To evaluate the cost-effectiveness of endocrine therapy (ET), radiation therapy (XRT), and combination ET + XRT as post-surgical treatment for older women with early-stage breast cancer from the societal perspective.

METHODS

We constructed a Markov state-transition model consisting of three mutually exclusive health-states: Disease-Free, Recurrence, or Death. Osteoporotic fracture, radiation-induced breast fibrosis, and radiation pneumonitis were modeled as treatment-related adverse events (AEs). Cancer registry-linked-Medicare data were used to assess probability of recurrence and total costs, after propensity adjustment to account for treatment selection, among women aged >65 years diagnosed with estrogen receptor positive or progesterone receptor positive (ER+/PR+) breast cancer receiving ET, XRT, or ET + XRT in 2007-2011. Following randomized controlled trials, overall survival was assumed equivalent, but locoregional recurrence varied. Indirect costs and health-state utilities were literature-driven and varied in sensitivity analyses. Costs and outcomes were discounted at 3% annually.

RESULTS

In a cohort of 10,000 women over ten years, we estimated 1620 total recurrences in the ET-only group, 1296 in the XRT-only group, and 1076 with ET + XRT. Compared to ET-only, the base-case incremental cost-effectiveness ratio (ICER) was $10,826 per quality-adjusted life-year (QALY)-gained for XRT-only and $26,834/QALY-gained for ET + XRT. Similarities in cost and effectiveness between treatments led to highly sensitive results. We also present clinically-relevant patient preference scenarios for recurrence risk-averse patients and near-term AE risk-averse patients.

CONCLUSIONS

The cost-effectiveness of regimens including ET and/or XRT in older women with early-stage breast cancer is sensitive to small differences in costs, as well as risk of, and utilities associated with, locoregional recurrence, suggesting that patient preferences concerning treatment benefits and risks should be considered by physicians.

Opioid Prescribing Laws Are Not Associated with Short-term Declines in Prescription Opioid Distribution

OBJECTIVE

To determine whether the adoption of laws that limit opioid prescribing or dispensing is associated with changes in the volume of opioids distributed in states.

METHODS

State-level data on total prescription opioid distribution for 2015-2017 were obtained from the US Drug Enforcement Administration. We included in our analysis states that enacted an opioid prescribing law in either 2016 or 2017. We used as control states those that did not have an opioid prescribing law during the study period. To avoid confounding, we excluded from our analysis states that enacted or modified mandates to use prescription drug monitoring programs (PDMPs) during the study period. To estimate the effect of opioid prescription laws on opioid distribution, we ran ordinary least squares models with indicators for whether an opioid prescription law was in effect in a state-quarter. We included state and quarter fixed effects to control for time trends and time-invariant differences between states.

RESULTS

With the exception of methadone and buprenorphine, the amount of opioids distributed in states fell during the study period. The adoption of opioid prescribing laws was not associated with additional decreases in opioids distributed.

CONCLUSIONS

We did not detect an association between adoption of opioid prescribing laws and opioids distributed. States may instead wish to pursue evidence-based efforts to reduce opioid-related harm, with a particular focus on treatment access and harm reduction interventions.

Employment Changes Following Breast Cancer Diagnosis: The Effects of Race and Place

The financial implications of breast cancer diagnosis may be greater among rural and black women. Women with incident breast cancer were recruited as part of the Carolina Breast Cancer Study. We compared unadjusted and adjusted prevalence of cancer-related job or income loss, and a composite measure of either outcome, by rural residence and stratified by race. We included 2435 women: 11.7% were rural; 48.5% were black; and 38.0% reported employment changes after diagnosis. Rural women more often reported employment effects, including reduced household income (43.6% vs 35.4%, two-sided χ2 test P = .04). Rural white, rural black, and urban black women each more often reported income reduction (statistically significant vs. urban white women), although these groups did not meaningfully differ from each other. In multivariable regression, rural differences were mediated by socioeconomic factors, but racial differences remained. Programs and policies to reduce financial toxicity in vulnerable patients should address indirect costs of cancer, including lost wages and employment.

Association Between Reimbursement Incentives and Physician Practice in Oncology: A Systematic Review

Importance

Significant controversy exists regarding whether physicians factor personal financial considerations into their clinical decision making. Within oncology, several reimbursement policies may incentivize physicians to increase health care use.

Objective

To evaluate whether the financial incentives presented by oncology reimbursement policies affect physician practice patterns.

Evidence Review

Studies evaluating an association between reimbursement incentives and changes in reimbursement policy on oncology care delivery were reviewed. Articles were identified systematically by searching PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier. English-language articles focused on the US health care system that made empirical estimates of the association between a measurement of physician reimbursement/compensation and a measurement of delivery of cancer treatment services were included. The Risk of Bias in Non-Randomized Studies of Interventions tool was used to assess risk of bias. There were no date restrictions on the publications, and literature searches were finalized on February 14, 2018.

Findings

Eighteen studies were included. All were observational cohort studies, and most had a moderate risk of bias. Heterogeneity of reimbursement policies and outcomes precluded meta-analysis; therefore, a qualitative synthesis was performed. Most studies (15 of 18 [83%]) reported an association between reimbursement and care delivery consistent with physician responsiveness to financial incentives, although such an association was not identified in all studies. Findings consistently suggested that self-referral arrangements may increase use of radiotherapy and that profitability of systemic anticancer agents may affect physicians' choice of drug. Findings were less conclusive as to whether profitability of systemic anticancer therapy affects the decision of whether to use any systemic therapy.

Conclusions and Relevance

To date, this study is the first systematic review of reimbursement policy and clinical care delivery in oncology. The findings suggest that some oncologists may, in certain circumstances, alter treatment recommendations based on personal revenue considerations. An implication of this finding is that value-based reimbursement policies may be a useful tool to better align physician incentives with patient need and increase the value of oncology care.

Association Between State Minimum Wages and Suicide Rates in the U.S

INTRODUCTION

The suicide rate in the U.S. has been increasing in recent years. Previous studies have consistently identified financial stress as a contributing factor in suicides. Nevertheless, there has been little research on the effect of economic policies that can alleviate financial stress on suicide rates. The purpose of this study is to determine whether increases in state minimum wages have been associated with changes in state suicide rates.

METHODS

A retrospective panel data study was conducted. In 2018, linear regression models with state fixed effects were used to estimate the relationship between changes in state minimum wages and suicide rates for all 50U.S. states between 2006 and 2016. Models controlled for time-varying state characteristics that could be associated with changes in minimum wages and suicide rates.

RESULTS

There were approximately 432,000 deaths by suicide in the study period. A one-dollar increase in the real minimum wage was associated on average with a 1.9% decrease in the annual state suicide rate in adjusted analyses. This negative association was most consistent in years since 2011. An annual decrease of 1.9% in the suicide rate during the study period would have resulted in roughly 8,000 fewer deaths by suicide. Analyses by race and sex did not reveal substantial variation in the association between minimum wages and suicides.

CONCLUSIONS

Increases in real minimum wages have been associated with slower growth in state suicide rates in recent years. Increasing the minimum wage could represent a strategy for addressing increases in suicide rates.

An updated systematic review of the cost-effectiveness of therapies for metastatic breast cancer

PURPOSE

The goal of this systematic review is to provide an update to the review by Pouwels et al. by conducting a systematic review and an assessment of the reporting quality of the economic analyses conducted since 2014.

METHODS

This systematic review identified published articles focused on metastatic breast cancer treatment using the Medline/PubMed and Scopus databases and the following search criteria: (((cost effectiveness[MeSH Terms]) OR (cost effectiveness) OR (cost-effectiveness) OR (cost utility) OR (cost-utility) OR (economic evaluation)) AND (("metastatic breast cancer") OR ("advanced breast cancer"))). The reporting quality of the included articles was evaluated using the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

Of the 256 identified articles, 67 of the articles were published after October 2014 when the prior systematic review stopped its assessment (Pouwels et al. in Breast Cancer Res Treat 165:485-498, 2017). From the 67 articles, we narrowed down to include 17 original health economic analyses specific to metastatic or advanced breast cancer. These articles were diverse with respect to methods employed and interventions included.

CONCLUSION

Although each of the articles contributed their own analytic strengths and limitations, the overall quality of the studies was moderate. The review demonstrated that the vast majority of the reported incremental cost-effectiveness ratios exceeded the typically employed willingness to pay thresholds used in each country of analysis. Only three of the reviewed articles studied chemotherapies rather than treatments targeting either HER2 or hormone receptors, demonstrating a gap in the literature.

Decomposing Mortality Disparities in Urban and Rural U.S. Counties

OBJECTIVE

To understand the role of county characteristics in the growing divide between rural and urban mortality from 1980 to 2010.

DATA SOURCE

Age-adjusted mortality rates for all U.S. counties from 1980 to 2010 were obtained from the CDC Compressed Mortality File and combined with county characteristics from the U.S. Census Bureau, the Area Health Resources File, and the Inter-University Consortium for Political and Social research.

STUDY DESIGN

We used Oaxaca-Blinder decomposition to assess the extent to which rural-urban mortality disparities are explained by observed county characteristics at each decade.

PRINCIPAL FINDINGS

Decomposition shows that, at each decade, differences in rural/urban characteristics are sufficient to explain differences in mortality. Furthermore, starting in 1990, rural counties have significantly lower predicted mortality than urban counties when given identical county characteristics. We find changes in the effect of characteristics on mortality, not the characteristics themselves, drive the growing mortality divide.

CONCLUSIONS

Differences in economic and demographic characteristics between rural and urban counties largely explain the differences in age-adjusted mortality in any given year. Over time, the role these characteristics play in improving mortality has increased differentially for urban counties. As characteristics continue changing in importance as determinants of health, this divide may continue to widen.