Use of Single-Item Self-Rated Health Measure to Identify Frailty and Geriatric Assessment-Identified Impairments Among Older Adults with Cancer.

BACKGROUND: Poor self-rated health (SRH) is a known predictor of frailty and mortality in the general population; however, its role among older adults with cancer is unknown. We evaluated the role of SRH as a potential screening tool to identify frailty and geriatric assessment (GA)-identified impairments. MATERIALS AND METHODS: Adults ≥60 years diagnosed with cancer in the UAB Cancer & Aging Resilience Evaluation (CARE) registry underwent a GA at the time of initial consultation. We measured SRH using a single-item from the Patient-Reported Outcomes Measurement Information System global health scale and dichotomized responses as poor (poor, fair) and good (good, very good, and excellent). We evaluated the diagnostic performance of SRH in measuring frailty, and GA impairment (≥2 deficits among a set of seven GA domains). We examined the impact of SRH with survival using a Cox model adjusting for confounders, exploring the mediating role of frailty. RESULTS: Six hundred and three older adults with cancer were included, with a median age of 69 years. Overall, 45% (n = 274) reported poor SRH. Poor SRH demonstrated high sensitivity and specificity for identifying frailty (85% and 78%, respectively) and GA impairment (75% and 78%, respectively). In a Cox regression model, poor SRH was associated with inferior survival (HR = 2.26; 95% CI 1.60-3.18) after adjusting for confounders; frailty mediated 69% of this observed relationship. CONCLUSION: Self-rated health may be used as a screening tool to identify older adults with cancer with frailty and GA impairments. Poor SRH is associated with inferior survival, which is mediated by frailty.

Association Between Chronologic Age and Geriatric Assessment-Identified Impairments: Findings From the CARE Registry.

BACKGROUND: The NCCN Guidelines for Older Adult Oncology recommend that, when possible, older adults with cancer undergo a geriatric assessment (GA) to provide a comprehensive health appraisal to guide interventions and appropriate treatment selection. However, the association of age with GA-identified impairments (GA impairments) remains understudied and the appropriate age cutoff for using the GA remains unknown. PATIENTS AND METHODS: We designed a cross-sectional study using the Cancer and Aging Resilience Evaluation (CARE) registry of older adults with cancer. We included adults aged ≥60 years diagnosed with gastrointestinal malignancy who underwent a patient-reported GA prior to their initial consultation at the gastrointestinal oncology clinic. We noted the presence of GA impairments and frailty using Rockwood's deficit accumulation approach. We studied the relation between chronologic age and GA impairments/frailty using Spearman rank correlation and chi-square tests of trend. RESULTS: We identified 455 eligible older adults aged ≥60 years with gastrointestinal malignancies; the median age was 68 years (range, 64-74 years) and colorectal (33%) and pancreatic (24%) cancers were the most common cancer type. The correlation between chronologic age and number of geriatric impairments was weak and did not reach statistical significance (Spearman ρ, 0.07; P=.16). Furthermore, the prevalence of domain-specific impairments or frailty was comparable across the 3 age groups (60-64 years, 65-74 years, ≥75 years) with the exception of comorbidity burden. Notably, 61% of patients aged 60 to 64 years had ≥2 GA impairments and 35% had evidence of frailty, which was comparable to patients aged 65 to 74 years (66% and 36%, respectively) and ≥75 years (70% and 40%, respectively). CONCLUSIONS: Using chronologic age alone to identify which patients may benefit from GA is problematic. Future studies should identify screening tools that may identify patients at high risk of frailty and GA impairments.

Patient-reported geriatric assessment-based frailty index among older adults with gastrointestinal malignancies.

BACKGROUND: Older adults with cancer are at increased risk of treatment-related toxicities and excess mortality. We evaluated whether a patient-reported geriatric assessment (GA) based frailty index can identify those at risk of adverse outcomes. METHODS: Older adults (≥60 years) enrolled in a single-institutional prospective registry underwent patient-reported GA at initial evaluation in our medical oncology clinic. Using deficit accumulation method, we constructed a 44-item frailty index (CARE-FI), categorizing patients as robust, pre-frail, and frail. The primary outcome was overall survival (OS). Secondary outcomes included (a) functional decline at 3 months post-therapy (b) incident grade ≥3 treatment-related toxicities at six-month post-treatment. We used multivariate Cox and logistic regression models respectively to study the impact of frailty on primary and secondary outcomes. RESULTS: We identified 589 older adults with a median age of 69 years; 55% males and 73% Whites. Overall, 168 (29%) were pre-frail and 230 (39%) frail. Being frail (vs. robust) was associated with worse OS (Hazards Ratio, HR 1.83, 95% Confidence Interval, CI 1.34-2.49, p < 0.001) after adjusting for age, sex, race/ethnicity, cancer type, cancer stage, and line of therapy. Similarly, frailty was associated with increased risk of functional decline (OR 3.01; 95% CI 1.33-6.81; p = 0.008) and grade ≥3 non-hematologic toxicities (OR 3.65; 95% CI 1.54-8.69; p = 0.003) but not hematologic toxicities (OR 1.01; 95% CI 0.46-2.22; p = 0.97). CONCLUSIONS: Our frailty index using a patient-reported GA is a robust predictor of survival, functional decline, and treatment related toxicity among older adults with GI malignancies.

Financial Distress Among Older Adults With Cancer.

PURPOSE: Financial distress (FD) among older adults with cancer is not well studied. We sought to characterize prevalence and factors associated with FD among older adults with cancer and the association of FD with geriatric assessment (GA) -identified deficits. PATIENTS AND METHODS: We included adults age ≥ 60 years with cancer in the University of Alabama at Birmingham Cancer and Aging Resilience Evaluation Registry who underwent GA during initial consultation with a medical oncologist before starting systemic therapy. We captured FD using a single-item question: "Do you have to pay for more medical care than you can afford?" We built multivariable models to study the impact of sociodemographic/clinical factors on FD as well as the association of FD with GA impairments. RESULTS: We identified 447 older adults with a median age of 69 years; 60% were men, 75% were White, and colorectal (26%) and pancreatic (19%) cancers were the most common. Overall, 27% (n = 121) reported having FD. Factors associated with FD included being Black (v White; odds ratio [OR], 2.26; 95% CI, 1.35 to 3.81; P = .002), being disabled/unemployed (v employed; OR, 2.60; 95% CI, 1.17 to 5.76; P = .019), and having an advanced degree (v less than high school; OR, 0.13; 95% CI, 0.03 to 0.65; P = .012). Patients with FD were more likely to report several GA impairments, including depression (OR, 2.10; 95% CI, 1.06 to 4.18; P = .034) and impaired health-related quality of life in physical (ß = -2.82; P = .014) and mental health domains (ß = -3.31; P = .002). CONCLUSION: More than a quarter of older adults with cancer reported FD at the time of initial presentation to an oncologist. Several demographic factors and GA impairments were associated with FD.

A systematic literature review assessing the directional impact of managed care formulary restrictions on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization.

BACKGROUND: There is extensive literature demonstrating that formulary restrictions reduce the pharmacy costs and utilization of restricted drugs. However, some research suggests that there may be unintended consequences of formulary restrictions on other patient outcomes. While several literature reviews have assessed the relationship between formulary restrictions and medication adherence, clinical outcomes, economic outcomes, or health care resource utilization, these reviews were either not systematic, were conducted more than 5 years ago, or did not assess the aggregate directional impact of the relationships. OBJECTIVE: To conduct a systematic literature review assessing the direction (positive, negative, or neutral) of the relationship between managed care formulary restrictions (including step therapy, cost sharing, prior authorization, preferred drug lists, and quantity limits) on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization.  METHODS: Articles published in 1993 or later were identified from PubMed using 2 lists of search terms. List A included 12 formulary restriction terms and List B included 12 patient outcomes terms, resulting in 144 unique search term combinations. Each article was evaluated by 2 investigators against the following exclusion criteria using a stepwise approach: (a) the article was a commentary or review article; (b) the article did not assess the impact of managed care formulary restrictions on outcomes; and (c) the study was conducted outside the United States. The total number of studies was reported by formulary restriction type. Next, the total number of outcomes reported in each study was summed to conduct an outcomes-level analysis. The outcomes were categorized by type of outcome (medication adherence, clinical, economic, or health care resource utilization) and direction of association (positive, negative, or neutral/not significant) based on the relationship reported in each study. The frequencies of each type of outcome were stratified by direction of association.  RESULTS: A total of 93 studies were included from 811 reviewed articles. Cost sharing was the most commonly assessed type of formulary restriction (60.2% of included articles), followed by prior authorization (21.5%). Of the 262 patient outcomes assessed, medication adherence was the most common (120 outcomes, 45.8%). Overall, formulary restrictions were most frequently negatively correlated with outcomes (130 outcomes, 49.6%). When outcome type was stratified by direction of association, 68.3% (82/120) of medication adherence outcomes were negative. The direction of association of economic outcomes (n = 59) with formulary restrictions was split between neutral (37.3%), positive (33.9%), and negative (28.8%). Health care resource utilization outcomes (n = 72) had no association with formulary restrictions in 50.0% of the outcomes assessed. There were 11 clinical outcomes identified in the literature review. CONCLUSIONS: There is a strong evidence base demonstrating a negative correlation between formulary restrictions on medication adherence outcomes. Additional research on commonly used formulary restrictions, specifically prior authorization and step therapy, as well as on the association between formulary restrictions and clinical outcomes, is warranted.