Navigating financial toxicity in patients with cancer: A multidisciplinary management approach.

Approximately one-half of individuals with cancer face personal economic burdens associated with the disease and its treatment, a problem known as financial toxicity (FT). FT more frequently affects socioeconomically vulnerable individuals and leads to subsequent adverse economic and health outcomes. Whereas multilevel systemic factors at the policy, payer, and provider levels drive FT, there are also accompanying intervenable patient-level factors that exacerbate FT in the setting of clinical care delivery. The primary strategy to intervene on FT at the patient level is financial navigation. Financial navigation uses comprehensive assessment of patients' risk factors for FT, guidance toward support resources, and referrals to assist patient financial needs during cancer care. Social workers or nurse navigators most frequently lead financial navigation. Oncologists and clinical provider teams are multidisciplinary partners who can support optimal FT management in the context of their clinical roles. Oncologists and clinical provider teams can proactively assess patient concerns about the financial hardship and employment effects of disease and treatment. They can respond by streamlining clinical treatment and care delivery planning and incorporating FT concerns into comprehensive goals of care discussions and coordinated symptom and psychosocial care. By understanding how age and life stage, socioeconomic, and cultural factors modify FT trajectory, oncologists and multidisciplinary health care teams can be engaged and informative in patient-centered, tailored FT management. The case presentations in this report provide a practical context to summarize authors' recommendations for patient-level FT management, supported by a review of key supporting evidence and a discussion of challenges to mitigating FT in oncology care. CA Cancer J Clin. 2022;72:437-453.

Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis.

BACKGROUND: The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid. METHODS: We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest. RESULTS: Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91). CONCLUSIONS: State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.

Medicaid expansion and 2-year survival in women with gynecologic cancer: a difference-in-difference analysis.

BACKGROUND: The Affordable Care Act implemented optional Medicaid expansion starting in 2014, but the association between Medicaid expansion and gynecologic cancer survival is unknown. OBJECTIVE: To evaluate the impact of Medicaid expansion by comparing 2-year survival among gynecologic cancers before and after 2014 in states that did and did not expand Medicaid using a difference-in-difference analysis. STUDY DESIGN: We searched the National Cancer Database for women aged 40 to 64 years, diagnosed with a primary gynecologic malignancy (endometrial, ovarian, cervical, vulvar, and vaginal) between 2010 and 2016. We used a quasiexperimental difference-in-difference multivariable Cox regression analysis to compare 2-year survival between states that expanded Medicaid in January 2014 and states that did not expand Medicaid as of 2016. We performed univariable subgroup difference-in-difference Cox regression analyses on the basis of stage, income, race, ethnicity, and geographic location. Adjusted linear difference-in-difference regressions evaluated the proportion of uninsured patients on the basis of expansion status after 2014. We evaluated adjusted Kaplan-Meier curves to examine differences on the basis of study period and expansion status. RESULTS: Our sample included 169,731 women, including 78,669 (46.3%) in expansion states and 91,062 (53.7%) in nonexpansion states. There was improved 2-year survival on adjusted difference-in-difference Cox regressions for women with ovarian cancer in expansion than in nonexpansion states after 2014 (hazard ratio, 0.88; 95% confidence interval, 0.82-0.94; P<.001) with no differences in endometrial, cervical, vaginal, vulvar, or combined gynecologic cancer sites on the basis of expansion status. On univariable subgroup difference-in-difference Cox analyses, women with ovarian cancer with stage III-IV disease (P=.008), non-Hispanic ethnicity (P=.042), those in the South (P=.016), and women with vulvar cancer in the Northeast (P=.022), had improved 2-year survival in expansion than in nonexpansion states after 2014. In contrast, women with cervical cancer in the South (P=.018) had worse 2-year survival in expansion than in nonexpansion states after 2014. All cancer sites had lower proportions of uninsured patients in expansion than in nonexpansion states after 2014. CONCLUSION: There was a significant association between Medicaid expansion and improved 2-year survival for women with ovarian cancer in states that expanded Medicaid after 2014. Despite improved insurance coverage, racial, ethnic, and regional survival differences exist between expansion and nonexpansion states.

Temporal trends of healthcare system use between symptomatic presentation and ovarian cancer diagnosis in the United States.

OBJECTIVE: To describe trends in healthcare system use over time between onset of classic ovarian cancer symptoms and ovarian cancer diagnosis in the United States. METHODS: A population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted on patients aged ≥66 years with stage II-IV epithelial ovarian cancer between 1992 and 2015 with at least one of the following diagnosis codes: abdominal pain, bloating, difficulty eating, and/or urinary symptoms. The outcomes were frequency of visit type, frequency of diagnostic modality, and Medicare reimbursement between first symptomatic claim and cancer diagnosis. Jonckheere-Terpstra and Cochran-Armitage tests were used to evaluate trends over time. RESULTS: Among 13 872 women, 13 541 (97.6%) had outpatient, 6466 (46.6%) had inpatient, and 4906 (35.4%) had emergency room visits. The frequency of outpatient (p<0.001) and emergency room visits (p<0.001) increased while the frequency of inpatient visits (p<0.001) decreased between 1992 and 2015. The median number of outpatient visits (p<0.001) and physician specialties seen (p<0.001) increased over time. The median hospital length of stay decreased from 10 days in 1992 to 5 days in 2015 (p<0.001). Between 1992 and 2015, the frequency of ultrasound decreased (p<0.001) while the frequency of computed tomography, magnetic resonance imaging, positron emission tomography imaging, and cancer antigen 125 tumor immunoassay increased (p<0.001). Median monthly total (p<0.001), inpatient (p<0.001), and outpatient (p=0.006) reimbursements decreased while emergency room reimbursements increased (p<0.001) over time. CONCLUSION: Healthcare reimbursement between symptomatic presentation and ovarian cancer diagnosis has decreased over time and may reflect the trends in fewer and shorter hospitalizations and increased use of emergency and outpatient management during the evaluation of symptoms of women with ovarian cancer.

Association between time to diagnosis, time to treatment, and ovarian cancer survival in the United States.

OBJECTIVE: Evaluate the association between time to diagnosis and treatment of advanced ovarian cancer with overall and ovarian cancer specific mortality using a retrospective cross sectional study of a population based cancer registry database. METHODS: The Surveillance, Epidemiology, and End Results-Medicare database was searched from 1992 to 2015 for women aged ≥66 years with epithelial ovarian cancer and abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of cancer diagnosis. Time from presentation to diagnosis and treatment were evaluated as outcomes and covariables. Cox regression models and adjusted Kaplan-Meier curves evaluated 5 year overall and cancer-specific survival. RESULTS: Among 13 872 women, better survival was associated with longer time from presentation to diagnosis (overall survival hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.94 to 0.95; cancer specific survival HR 0.95, 95% CI 0.94 to 0.96) and diagnosis to treatment (overall survival HR 0.94, 95% CI 0.92 to 0.96; cancer specific survival HR 0.93, 95% CI 0.91 to 0.96). There was longer time from presentation to diagnosis in Hispanic women (relative risk (RR) 1.21, 95% CI 1.12 to 1.32) and from diagnosis to treatment in non-Hispanic black women (RR 1.36, 95% CI 1.21 to 1.54), with lower likelihood of survival at 5 years after adjustment for time to diagnosis and treatment among non-Hispanic black women (HR 1.15, 95% CI 1.05 to 1.26) compared with non-Hispanic white women. Gynecologic oncology visit was associated with improved overall (p<0.001) and cancer specific (p<0.001) survival despite a longer time from presentation to treatment (p<0.001). CONCLUSION: Longer time to diagnosis and treatment were associated with improved survival, suggesting that tumor specific features are more important prognostic factors than the time interval of workup and treatment. Significant sociodemographic disparities indicate social determinants of health influencing workup and care. Gynecologic oncologist visits were associated with improved survival, highlighting the importance of appropriate referral for suspected ovarian cancer.

Factors impacting the time to ovarian cancer diagnosis based on classic symptom presentation in the United States.

BACKGROUND: Patients with ovarian cancer often present with late-stage disease and nonspecific symptoms, but little is known about factors affecting the time to diagnosis (TTD) in the United States. METHODS: A retrospective, population-based study of the Surveillance, Epidemiology, and End Results-Medicare database was conducted. It included women 66 years old or older with stage II to IV epithelial ovarian cancer with at least 1 code for abdominal/pelvic pain, bloating, difficulty eating, or urinary symptoms within 1 year of the cancer diagnosis. TTD was defined from the first claim with a prespecified symptom to the ovarian cancer diagnosis. Kruskal-Wallis tests were used to assess for differences in TTD by group medians. Univariate and generalized linear models with a log-link function evaluated TTD by covariables. RESULTS: For the 13,872 women analyzed, the mean and median times to diagnosis were 2.9 and 1.1 months, respectively. The median TTD differed significantly by first symptom (P < .001), number of symptoms (P < .001), and first physician specialty seen (P < .001). In a multivariable analysis, TTD differed significantly according to race/ethnicity (P < .001), geographic region (P = .001), urban-rural location (P = .031), emergency room presentation (P < .001), and number of specialties seen (P < .001). A shorter TTD was associated with a diagnosis in 2006-2010 (relative risk [RR], 0.92; 95% confidence interval [CI], 0.87-0.98) or 2011-2015 (RR, 0.87; 95% CI, 0.81-0.93) in comparison with 1992-1999. CONCLUSIONS: The time from a symptomatic presentation to care to a diagnosis of ovarian cancer is influenced by clinical and demographic variables. This study's findings reinforce the importance of educating all physicians on ovarian cancer symptoms to aid in diagnosis. LAY SUMMARY: Ovarian cancer is often diagnosed once disease has spread because the classic symptoms of ovarian cancer-abdominal or pelvic pain, bloating, difficulty eating, and urinary issues-can be mistaken for other problems. This study examined the time between when women with classic ovarian cancer symptoms went to a physician and when they received a cancer diagnosis in a large database population. The authors found that the time to diagnosis differed according to the type and number of symptoms and what type of physician a woman saw as well as factors such as race, geographic location, and year of diagnosis.

Characteristics and Effectiveness of Alcohol Website Age Gates Preventing Underage User Access.

AIMS: Examine and evaluate the overall effectiveness of age gates preventing access of underage users to alcohol websites. METHODS: Assess the characteristics of digital age gates among the top 25 alcohol brands among American adolescents, including type of age gate employed and resulting actions of repeated access requests indicating the user was under the legal drinking age. RESULTS: All official alcohol brand websites examined included an age gate, requiring either entering one's date of birth (DOB, 91%) or clicking a yes/no box indicating they were of legal drinking age (9%). Only one out of every five alcohol websites blocked futures attempts to gain access after entering a response indicating the user was under the legal drinking age. Users were allowed indefinite attempts to enter a DOB that was of legal drinking age, with the majority of websites subsequently granting access even after multiple underage entries. CONCLUSIONS: Alcohol website visitors with minimal arithmetic abilities, such as very young youth, are able to employ 'trial and error' to eventually enter an acceptable legal drinking DOB and gain access. Alcohol brand age gates are weak, at best, and likely an inconsequential barrier that someone with limited math abilities can easily overcome.

Use of Emergency Departments for Preventative Care Among Adults in the United States: Estimates From the 2017 National Health Interview Survey.

BACKGROUND: Use of the emergency department (ED) for routine or preventative care has been an abiding concern for policy makers and public health practitioners. OBJECTIVES: We utilized recent data to examine health-related, socioeconomic, and demographic factors associated with use of the ED for routine or preventative care using a national sample of adults. METHODS: Data from the 2017 National Health Interview Survey, a nationally representative sample of 26,742 adults ≥18 years of age was used for this investigation. Bivariate and multivariate analyses were used to assess the association between reported use of EDs as a usual source of preventative care and health-related, socioeconomic, and demographic factors. RESULTS: In 2017, approximately 2 million adults nationwide reported the ED as their usual source of preventative health care. Individuals experiencing ≥2 health care-related barriers were more likely to use the ED as a source of usual preventative care (odds ratio = 2.78 [95% confidence interval 1.64-4.72]). Individuals without insurance had higher odds (odds ratio = 9.52 [95% confidence interval 5.60-16.19]) of using the ED for care compared with those who were privately insured. In addition, those using the ED for preventative care were more likely to be younger, poorer, less educated, to identify as Asian or African American, and to reside in the Northeast United States. CONCLUSION: This study provides a current perspective into characteristics and factors contributing to use of the ED for preventative care. Overall, our findings suggest that the ED continues to provide crucial safety net services to a small subset of the population experiencing significant barriers to timely medical care.

Qualitative Analysis of Partnerships' Effect on Implementation of a Nationally Led Community-Based Initiative.

INTRODUCTION: The American Heart Association (AHA) was funded to implement a nationally led initiative to implement policy, systems, and environment (PSE) interventions in communities across the United States. In Cohort 1, 15 communities were tasked with working with local community partners to plan and implement initiatives. METHOD: Engaged as the evaluators, Texas A&M researchers conducted telephone interviews with project managers (employed by AHA) and community partners representing the 15 communities. Interviewees were asked questions pertaining to partnership planning and involvement in initiatives and overall perceptions of the impact of the program. Interviews were analyzed qualitatively using the Consolidated Framework for Implementation Research as the guiding framework. RESULTS: Thematic analysis revealed that partners were used in planning and implementing initiatives and felt that initiatives were successful in building community engagement. Some noted success in PSE changes, although this was not a major focus of respondents, regardless of it being a main indicator for the funder. DISCUSSION: Themes reveal several recommendations for those embarking on community-level work. Those recommendations include (1) build on existing priorities, (2) focus on incremental steps that build toward the bigger goal, (3) use national organizations to move more quickly, and (4) leverage resources through collaborative efforts.

Evaluation of Community-Based Policy, Systems, and Environment Interventions Targeting the Vending Machines.

The American Heart Association conducted policy, systems, and environmental (PSE) focused interventions to increase healthy vending in 8 communities. PSE interventions were assessed using the Nutrition Environment Measures Survey Vending Assessment to see changes in the food environment. Baseline and follow-up assessments were conducted with 3 settings and a total of 19 machines. PSE changes resulted in increased availability of healthy options and decreased unhealthy options. Implementation of PSE interventions targeting the food environment can be an effective method of providing increased access to healthy foods and beverages with the goal of increasing consumption to decrease chronic diseases.

Travel for medical or dental care by race/ethnicity and rurality in the U.S.: Findings from the 2001, 2009 and 2017 National Household Travel Surveys.

The travel burden for medical or dental care is a well-documented barrier to healthcare access, particularly in rural areas. There is limited research providing national estimates of the travel trends for medical/dental care, particularly among racial/ethnic groups, and among rural and urban populations. We analyzed data from the 2001, 2009, and 2017 National Household Travel Surveys. Main outcomes were the average travel distance (in miles), average travel time (in minutes), and travel burden, characterized as the percentage of trips lasting ≥ 30 miles or minutes for medical/dental care. We used ordinary least squares and multivariable logistic regressions to examine trends in the travel time/distance and travel burden, controlling for socio-demographic and travel dynamics. Among rural residents, the average travel distance for medical/dental care increased by 17.8% between 2001 and 2017, while no increase was observed among urban residents. Thirty-six percent of trips among rural residents lasted ≥ 30 minutes in 2001 but increased to 47.4% in 2017. Logistic regression estimates show that though Blacks experienced higher odds of a travel time burden compared to Whites, the burden lessened over time. In 2017, urban Blacks (OR = 0.41, 95% C.I. = 0.26,0.66), and rural Blacks (OR = 0.16, 95% C.I. = 0.05,0.55) were less likely to spend ≥ 30 minutes traveling for medical/dental care compared to Whites, using the year 2001 as the baseline. The travel distance and time for medical/dental care have increased in rural areas. However, the travel burden among rural and urban Black residents has decreased. Continuing to alleviate excess burdens of transportation may be beneficial.

Who, where, when: Colorectal cancer disparities by race and ethnicity, subsite, and stage.

BACKGROUND: There are well-established disparities in colorectal cancer (CRC) outcomes between White and Black patients; however, assessments of CRC disparities for other racial/ethnic groups are limited. METHODS: The Surveillance, Epidemiology, and End Results database identified patients aged 50-74 years with CRC adenocarcinoma from 2000 to 2019. Trends in age-adjusted incidence rates were computed by stage at diagnosis and subsite across five broad race/ethnic groups (White, Black, Asian/Pacific Islander [API], American Indian/Alaskan Native [AIAN], and Hispanic) and four API subgroups (East Asian, Southeast Asian, South Asian, and Pacific Islander) Multivariable logistic regression evaluated associations between race/ethnicity and diagnosis stage. Multivariable Cox proportional hazards models assessed differences in cause-specific survival (CSS). RESULTS: Hispanic, AIAN, Southeast Asian, Pacific Islander, and Black patients were 3% to 28% more likely than Whites to be diagnosed with distant stage CRC, whereas East Asian and South Asians had similar or lower risk of distant stage CRC. From Cox regression analysis, Black, AIAN, and Pacific Islanders also experienced worse CSS, while East Asian and South Asian patient groups experienced better CSS. No significant differences in CSS were observed among Hispanic, Southeast Asian, and White patients. When stratified by stage, Black patients had worse CSS across all stages (early, hazard ratio (HR) = 1.38; regional, HR = 1.22; distant, HR: 1.07, p < 0.05 for all). CONCLUSION: Despite advances in CRC screening, treatment and early detection efforts, marked racial/ethnic disparities in incidence, stage at diagnosis, and survival persist. Findings demonstrate the extent to which aggregating heterogenous populations masks significant variability in CRC outcomes within race/ethnic subgroups.

Factors associated with hospitalizations for co-occurring HIV and opioid-related diagnoses: Evidence from the national inpatient sample, 2009-2017.

There has been evidence of rising HIV incidence attributable to opioid misuse within some areas of the U.S. The purpose of our study was to explore national trends in co-occurring HIV and opioid-related hospitalizations and to identify their risk factors. We used the 2009-2017 National Inpatient Sample to indicate hospitalizations with co-occurring HIV and opioid misuse diagnoses. We estimated the frequency of such hospitalizations per year. We fitted a linear regression to the annual HIV-opioid co-occurrences with year as a predictor. The resulting regression did not reveal any significant temporal changes. We used multivariable logistic regression to determine the adjusted odds (AOR) of hospitalization for co-occurring HIV and opioid-related diagnoses. The odds of hospitalization were lower for rural residents (AOR = 0.28; CI = 0.24-0.32) than urban. Females (AOR = 0.95, CI = 0.89-0.99) had lower odds of hospitalization than males. Patients identifying as White (AOR = 1.23, CI = 1.00-1.50) and Black (AOR = 1.27, CI = 1.02-1.57) had higher odds of hospitalization than other races. When compared to co-occuring hospitalizations in the Midwest, the odds were higher in the Northeast. (AOR = 2.56, CI = 2.07-3.17) Future research should explore the extent to which similar findings occur in the context of mortality and targeted interventions should intesify for subpopulations at highest risk of co-occuring HIV and opioid misuse diagnoses.

Racial and Ethnic Trends and Disparities in NSCLC.

Introduction: Detailed evaluations of racial and ethnic trends and disparities in NSCLC outcomes are lacking, and it remains unclear whether recent advances in screening and targeted therapies for NSCLC have benefited all population groups equally. Methods: Using the Surveillance, Epidemiology, and End Results 18-registry data, we evaluated trends in overall and stage-specific NSCLC incidence (2007-2018) among patients aged 55 to 79 years by sex and race and ethnicity. Overall and stage-specific 2-year cause-specific survival rates were calculated by sex and race and ethnicity. Health Disparities software calculated absolute (difference) and relative (ratio) disparity measures comparing racial and ethnic groups with the highest and lowest rates (range measures) and comparing white patients (reference group) with other groups (pairwise rate measures). Joinpoint software assessed changes in rates and disparities. Results: Both men and women experienced substantial declines in NSCLC incidence from 2007 to 2018, largely due to significant declines in the incidence of distant-stage NSCLC over the study period (p < 0.05). During the same time period, the incidence of local-stage NSCLC significantly increased among black and Hispanic women (p < 0.05) and remained stable among all other groups. Overall, 2-year cause-specific survival rates improved across most racial and ethnic groups, especially among those diagnosed in regional and distant stages. For both sexes, absolute disparities in overall and stage-specific incidence of NSCLC significantly decreased over time (p < 0.05), whereas relative disparities remained unchanged. Pairwise comparison revealed persistent disparities in NSCLC burden between black and white men. Conclusion: We found evidence of narrowing racial and ethnic disparities in NSCLC incidence over time; however, important disparities persist. More work is needed to ensure consistent and equitable access to high-quality screening, diagnosis, and treatment to reduce and eliminate cancer disparities.

A Contemporary Analysis of Racial and Ethnic Disparities in Diagnosis of Early-Stage Breast Cancer and Stage-Specific Survival by Molecular Subtype.

BACKGROUND: Prior studies of breast cancer disparities have focused primarily on differences between Black and White women, yet contemporary patterns of disparity for other groups are not well understood. We examine breast cancer disparities by stage at diagnosis across nine racial and ethnic groups. METHODS: The SEER 18 registries identified 841,975 women diagnosed with breast cancer from 2000 to 2017. Joinpoint models assessed trends in diagnosis stage and survival. Multivariable logistic regression evaluated associations between race/ethnicity and diagnosis stage. Multivariable Cox models compared survival of groups by stage and molecular subtype. RESULTS: Black, American Indian, Southeast Asian, South Asian, Pacific Islander, and Hispanic women were less likely than white women to be diagnosed with early stage breast cancer. Among those diagnosed at early stage, Hispanic, American Indian, Pacific Islander and Black women were 9%, 14%, 22%, and 39% (respectively) more likely than White women to die from breast cancer, whereas Asian subgroups had lower risk of death. Among those diagnosed at late stage, Black women were 18% more likely than White counterparts to die from breast cancer, and survival disparities for Black women persisted across all subtypes and stages, (except late stage HR-/HER2-). East Asian women with early stage HR+/HER2- tumors had better survival than White women. CONCLUSIONS: Persistent disparities in early detection and survival of breast cancer demand further work to address and reduce disparities across the cancer continuum. IMPACT: Results have implications for efforts to reduce entrenched racial and ethnic disparities in breast cancer early detection and survival.

Evaluating community-driven cardiovascular health policy changes in the United States using agent-based modeling.

Comprehensive smoke-free policy is a strategy to prevent cardiovascular disease (CVD) at a population-level; however, evaluating their long-term outcomes is difficult. This study used an agent-based model to estimate long-term impacts of a comprehensive smoke-free policy, as it was implemented in two communities, Arlington and Mesquite, Texas. The model predicted the percentage of myocardial infarction (MI), stroke, and diabetes in the population 10 and 20 years following policy adoption. In Arlington, the percentage of the population with these conditions each decreased by approximately 0.5% over 20 years; in Mesquite, the percentage of the population with diabetes, myocardial infarction (MI), and stroke decreased by 1.1%, 0.6%, and 0.3%, respectively, after 20 years. The results were statistically significant (p < 0.001). As an evaluation strategy, agent-based modeling can help researchers and practitioners estimate the potential long-term effects of policies and garner intervention support for implementation.

Impacts of Medicaid Expansion on Stage at Cancer Diagnosis by Patient Insurance Type.

INTRODUCTION: The expansion of Medicaid under the Affordable Care Act increased access to health care for millions of low-income Americans. However, the longer-term impacts of the policy on cancer outcomes remain unknown. This study examined the impact of Medicaid expansion on early- and late-stage diagnosis for 4 common cancers (breast, cervical, colorectal, and lung) using 4 full years of postpolicy data. METHODS: Patients aged 40-64 years diagnosed with breast, cervical, colorectal, or lung cancer from 2010 to 2017 were identified using the National Cancer Database. Difference-in-difference analyses compared changes in early-stage and late-stage diagnoses among expansion states with those among nonexpansion states. Subgroup analyses explored potential effect modification by insurance type. Data analysis was performed from June to October 2021. RESULTS: The proportion of early stage diagnosis of breast (difference in difference=1.58, 95% CI=0.89, 2.27), cervical (difference in difference=3.20; 95% CI=0.44, 5.95), colorectal (difference in difference=1.98; 95% CI=1.18, 2.78), and lung (difference in difference=1.74; 95% CI=0.98, 2.50) cancers increased more in expansion states than in nonexpansion states, whereas late-stage diagnosis of colorectal (difference in difference= -2.12; 95% CI= -2.98, -1.27) and lung (difference in difference= -1.87; 95% CI= -2.89, -0.84) cancers decreased more in expansion states following implementation of the Affordable Care Act. In subgroup analyses, difference-in-difference estimates for all sites and stages (except late-stage cervical cancer) were significant and larger in magnitude among Medicaid-insured than among privately insured patients. CONCLUSIONS: Study results highlight the positive impacts of Medicaid expansion on earlier diagnosis of several cancers for which screening and early detection exist, and subgroup analyses revealed greater positive effects among Medicaid-insured patients most targeted by the policy.

Racial, Rural, and Regional Disparities in Diabetes-Related Lower-Extremity Amputation Rates, 2009-2017.

OBJECTIVE: To examine the racial/ethnic, rural-urban, and regional variations in the trends of diabetes-related lower-extremity amputations (LEAs) among hospitalized U.S. adults from 2009 to 2017. RESEARCH DESIGN AND METHODS: We used the National Inpatient Sample (NIS) (2009-2017) to identify trends in LEA rates among those primarily hospitalized for diabetes in the U.S. We conducted multivariable logistic regressions to identify individuals at risk for LEA based on race/ethnicity, census region location (North, Midwest, South, and West), and rurality of residence. RESULTS: From 2009 to 2017, the rates of minor LEAs increased across all racial/ethnic, rural/urban, and census region categories. The increase in minor LEAs was driven by Native Americans (annual percent change [APC] 7.1%, P < 0.001) and Asians/Pacific Islanders (APC 7.8%, P < 0.001). Residents of non-core (APC 5.4%, P < 0.001) and large central metropolitan areas (APC 5.5%, P < 0.001) experienced the highest increases over time in minor LEA rates. Among Whites and residents of the Midwest and non-core and small metropolitan areas there was a significant increase in major LEAs. Regression findings showed that Native Americans and Hispanics were more likely to have a minor or major LEA compared with Whites. The odds of a major LEA increased with rurality and was also higher among residents of the South than among those of the Northeast. A steep decline in major-to-minor amputation ratios was observed, especially among Native Americans. CONCLUSIONS: Despite increased risk of diabetes-related lower-limb amputations in underserved groups, our findings are promising when the major-to-minor amputation ratio is considered.

Children's Health Insurance Status and Emergency Room Utilization: An Examination of Complex Survey Data.

Since the Children's Health Insurance Program's passage into law in 1997, the program has increased in cost to over $15 billion in recent years. Emergency room usage has also increased throughout the United States, leading to nationwide issues in overcrowding and surges in service costs. This study seeks to examine emergency room utilization of children insured under Children's Health Insurance Program to determine if Children's Health Insurance Program enrollees use the emergency room more or less frequently than their privately insured counterparts. The data used in this study were from the 2017 National Health Interview Survey. SAS statistical software was used to conduct a multinomial regression assessing the relationship between insurance type (private v. Children's Health Insurance Program) and frequency of emergency room utilization over the last 12 months. The analysis results indicate no statistically significant difference between Children's Health Insurance Program insured and privately insured children in terms of frequency of emergency room utilization and suggest a need to explore other factors that more directly influence Children's Health Insurance Program costs.