Racialized economic segregation and inequities in treatment initiation and survival among patients with metastatic breast cancer.

PURPOSE: Racialized economic segregation, a form of structural racism, may drive persistent inequities among patients with breast cancer. We examined whether a composite area-level index of racialized economic segregation was associated with real-world treatment and survival in metastatic breast cancer (mBC). METHODS: We conducted a retrospective cohort study among adult women with mBC using a US nationwide electronic health record-derived de-identified database (2011-2022). Population-weighted quintiles of the index of concentration at the extremes were estimated using census tract data. To identify inequities in time to treatment initiation (TTI) and overall survival (OS), we employed Kaplan-Meier methods and estimated hazard ratios (HR) adjusted for clinical factors. RESULTS: The cohort included 27,459 patients. Compared with patients from the most privileged areas, those from the least privileged areas were disproportionately Black (36.9% vs. 2.6%) or Latinx (13.2% vs. 2.6%) and increasingly diagnosed with de novo mBC (33.6% vs. 28.9%). Those from the least privileged areas had longer median TTI than those from the most privileged areas (38 vs 31 days) and shorter median OS (29.7 vs 39.2 months). Multivariable-adjusted HR indicated less timely treatment initiation (HR 0.87, 95% CI 0.83, 0.91, p < 0.01) and worse OS (HR 1.19, 95% CI 1.13, 1.25, p < 0.01) among those from the least privileged areas compared to the most privileged areas. CONCLUSION: Racialized economic segregation is a social determinant of health associated with treatment and survival inequities in mBC. Public investments directly addressing racialized economic segregation and other forms of structural racism are needed to reduce inequities in cancer care and outcomes.

Risk of contralateral breast cancer among Asian/Pacific Islander women in the United States.

PURPOSE: While breast cancer studies often aggregate Asian/Pacific Islander (API) women, as a single group or exclude them, this population is heterogeneous in terms of genetic background, environmental exposures, and health-related behaviors, potentially resulting in different cancer outcomes. Our purpose was to evaluate risks of contralateral breast cancer (CBC) among subgroups of API women with breast cancer. METHODS: We conducted a retrospective cohort study of women ages 18 + years diagnosed with stage I-III breast cancer between 2000 and 2016 in the Surveillance, Epidemiology and End Results registries. API subgroups included Chinese, Japanese, Filipina, Native Hawaiian, Korean, Vietnamese, Indian/Pakistani, and other API women. Asynchronous CBC was defined as breast cancer diagnosed in the opposite breast 12 + months after first primary unilateral breast cancer. Multivariable-adjusted subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were estimated and stratified by API subgroups. RESULTS: From a cohort of 44,362 API women with breast cancer, 25% were Filipina, 18% were Chinese, 14% were Japanese, and 8% were Indian/Pakistani. API women as an aggregate group had increased risk of CBC (SHR 1.15, 95% CI 1.08-1.22) compared to NHW women, among whom Chinese (SHR 1.23, 95% CI 1.08-1.40), Filipina (SHR 1.37, 95% CI 1.23-1.52), and Native Hawaiian (SHR 1.69, 95% CI 1.37-2.08) women had greater risks. CONCLUSION: Aggregating or excluding API patients from breast cancer studies ignores their heterogeneous health outcomes. To advance cancer health equity among API women, future research should examine inequities within the API population to design interventions that can adequately address their unique differences.

Changes in HIV Pre-exposure Prophylaxis (PrEP) Coverage at State and County Level During the COVID-19 Pandemic in the United States.

This study quantifies the prevalence and trends in weekly PrEP coverage at the national, state and county-level, before and during the COVID-19 pandemic in the United States.We estimated weekly PrEP coverage using longitudinal individual-level pharmacy claims from IQVIA LRx for a cohort of PrEP users (N = 287,493) ages 16 to 85 years between December 29th, 2019 and November 8th, 2020. Weekly PrEP coverage was defined as PrEP use among individuals at high risk for HIV. We conducted an interrupted time series analysis to quantify changes in weekly PrEP coverage before (December 29th, 2019 - March 8th, 2020) and during (March 29th - November 8th, 2020) the COVID-19 pandemic at the national, state and county-level by county characteristics, specifically by EHE priority jurisdiction, racial/ethnic composition, and urbanity. Nationally, weekly PrEP coverage among individuals ages 16 to 85 at high risk for HIV declined by 11.5% (from 11.0% before to 9.5% during the pandemic; t = 8.02,p < 0.01). Weekly PrEP coverage declined in all states and most counties yet varied substantially across states and counties. Geographic disparities in weekly PrEP coverage were also observed between urban EHE priority counties with significantly lower rates in counties with ≥ 50% Black/Latinx population when compared to their counterparts (7.9% vs. 11.2%; t = 18.91,p < 0.01);these disparities were most pronounced in California and New York. Weekly PrEP coverage was much lower than the 25% annual coverage reported by the Centers for Disease Control and geographic disparities observed within states likely contribute to the persistent racial/ethnic disparities in new HIV diagnoses observed within those states.

Sociodemographic inequities in COVID-19 vaccination among adults in the United States, 2022.

BACKGROUND: Despite the availability of COVID-19 vaccines since December 2020, sociodemographic inequities in vaccination and preventable COVID-related deaths persist. To inform efforts for equitable COVID-19 vaccination campaigns, a comprehensive national evaluation of existing inequities is necessary. OBJECTIVE: To examine sociodemographic inequities in COVID-19 vaccination receipt using data from the 2022 National Health Interview Survey (NHIS). METHODS: This secondary data analysis used cross-sectional nationally-representative data from the 2022 NHIS to assess vaccination inequities among 27,126 adults. Separate Poisson regressions adjusted for clinical factors (e.g., age, sex, high-risk health conditions) were used to evaluate vaccination inequities across sociographic factors (e.g., race/ethnicity, poverty, health insurance). RESULTS: In 2022, 79.6% of adults received at ≥ 1 vaccine dose, 75.0% received ≥ 2 doses ("fully vaccinated"), 45.7% received ≥ 3 doses (≥ 1 booster), and 17.2% received ≥ 4 doses (≥ 2 boosters). Marked inequities were evident in COVID-19 vaccination across primary and booster doses, especially receipt of at least 1 booster dose (≥ 3 doses). Black (35.7%, prevalence ratio [PR] 0.78 [95% CI 0.74-0.83]) and Latinx (35.5%, PR 0.82 [CI 0.78-0.86]) adults were less likely to receive ≥ 3 doses than Asian (66.5%, PR 1.41 [CI 1.35-1.48]) and White (48.8%) adults. Poverty (31.1% [PR 0.65 {CI 0.61-0.69}] vs. 50.7%) and food insecurity (27.1% [PR 0.63 {CI 0.58-0.68}] vs. 47.3%) were negatively associated with receipt of ≥ 3 vaccine doses. Adults without usual source of care (24.9%, PR 0.61 [CI 0.57-0.65]) or health insurance (17.4%, PR 0.40 [CI 0.36-0.45]) had much lower rates of ≥ 3 doses than those with appropriate health care access (48.7% and 51.9%, respectively). CONCLUSION: As of 2022, 1-in-5 U.S. adults remain unvaccinated, and more than half have not received any recommended booster doses. Economically/socially marginalized populations-including Black and Latinx adults and those with structural barriers such as poverty, food insecurity, and poor health care access-were less likely to receive a booster. Addressing these vaccination inequities is crucial to achieve equitable COVID-19 protection and reduce preventable deaths among economically/socially marginalized populations.

Access to community pharmacies based on drive time and by rurality across the contiguous United States.

BACKGROUND: Considering that mail-order pharmacy use remains low in the United States, geographic accessibility of community pharmacies (pharmacy access) can have an outsized impact on a community's access to services and care, especially among rural residents. However, previous measurements of pharmacy access rely on methods that do not capture all aspects of geographic access. OBJECTIVES: This study aimed to measure pharmacy access across the contiguous United States and by rural, suburban, and urban areas using drive-time analysis and an improved methodological approach. METHODS: The 2-step floating catchment area method was used to measure pharmacy access by considering the supply capacity of pharmacies, population demand for pharmacies, and the interaction between them within a reasonable travel time range. This method is a methodologically improved approach compared with previous methods for measuring geographic access. Network analysis was used to measure drive time from the population-weighted centroids of census tracts to the geocoded location of community pharmacies. Census tract-level pharmacy access was measured using a 10- and 20-minute drive time. Census tracts were also categorized based on population per square mile as rural (< 1000), suburban (1000-3000), and urban (> 3000). RESULTS: Across the contiguous United States, 79.9% and 91.1% of census tracts had access to at least 1 pharmacy per 10,000 people within a 10- and 20-minute drive time, respectively. Rural census tracts had the lowest share of access to at least 1 pharmacy per 10,000 people compared with suburban and urban tracts and for both drive times. CONCLUSION: Community pharmacies are highly accessible health care access points, specifically in urban and suburban areas. Pharmacies should be considered to expand access to services with limited geographic accessibility such as treatment programs for opioid use disorders, primary care, and healthy foods.

Impact of socioeconomic status and rurality on cancer-specific survival among women with de novo metastatic breast cancer by race/ethnicity.

PURPOSE: There are approximately 150,000 women living with metastatic breast cancer (mBC) in the United States. Disparities in de novo mBC incidence and mortality exist across race/ethnicity, socioeconomic status (SES), and rurality. However, how SES and rurality independently impact mBC outcomes across different racial/ethnic groups is not fully understood. The purpose of this study was to determine the impact of SES and rurality on cancer-specific mortality among women with mBC by race/ethnicity. METHODS: We conducted a large, population-based retrospective cohort study in women aged 18 + years diagnosed with de novo mBC using the Surveillance, Epidemiology and End Results Census Tract-level SES and Rurality Database (2000-2015). Associations between SES/rurality and cancer-specific mortality were determined using Fine and Gray regression models. Subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) by race/ethnicity and hormone receptor (HR) status were calculated. RESULTS: A cohort of 33,976 women were included with the majority being White (67%), 17% Black, 0.4% American Indian/Alaskan Native, 6% Asian/Pacific Islander, and 10% Latina/Hispanic. We observed the greatest increased risk of BC mortality among Black women with HR-negative mBC residing in neighborhoods with lower SES (lowest versus highest quintile: SHR 1.38, 95% CI 1.00-1.90) and in rural areas compared to urban areas (SHR 1.27, 95% CI 1.01-1.59). CONCLUSION: Overall, BC-specific survival among women with de novo mBC differs by race/ethnicity, with the greatest adverse impacts of SES and rurality affecting Black women with HR-negative disease.

Understanding Immigration as a Social Determinant of Health: Cardiovascular Disease in Hispanics/Latinos and South Asians in the United States.

PURPOSE OF REVIEW: The main purpose of this review is to summarize the epidemiology of cardiovascular disease and its risk factors among two of the largest and most diverse immigrant groups in the United States (Hispanics/Latinos and South Asians). RECENT FINDINGS: While the migration process generates unique challenges for individuals, there is a wide heterogeneity in the characteristics of immigrant populations, both between and within regions of origin. Hispanic/Latino immigrants to the United States have lower levels of cardiovascular risk factors, prevalence, and mortality, but this assessment is limited by issues related to the "salmon bias." South Asian immigrants to the United States generally have higher levels of risk factors and higher mortality. In both cases, levels of risk factors and mortality generally increase with time of living in the United States (US). While immigration acts as a social determinant of health, associations between immigration and cardiovascular disease and its risk factors are complex and vary across subpopulations.

Telepharmacy and medication adherence in urban areas.

BACKGROUND: Telepharmacies, which dispense medications on-site under the supervision of an off-site pharmacist using telecommunication technologies, have been proposed as a means to ameliorate the impact of pharmacy closures and improve access to medications. OBJECTIVES: To examine whether adherence varies among individuals filling prescription medications through a telepharmacy versus a traditional pharmacy in an urban neighborhood. METHODS: We conducted a retrospective cohort study using dispensing records of a traditional pharmacy and a telepharmacy, located in the same low-income Chicago neighborhood, from January 2016 to December 2018. We focused on individuals using statins (n = 1044), angiotensin-converting enzyme inhibitors (ACEs)/angiotensin II receptor blockers (ARBs) (n = 1003), or noninsulin diabetes medications (NIDMs) (n = 692). We defined adherence as a proportion of days covered greater than 80% over 12-months. We examined the association between telepharmacy use and medication adherence using logistic regressions adjusted for demographics (age and sex) and index prescription characteristics (method of payment, e-prescription, 90-day supply). RESULTS: Telepharmacy users were less adherent to statins (37.6% vs. 54.3%, adjusted odds ratio 0.54 [95% CI 0.38-0.76], P < 0.01) and ACEs/ARBs (41.4% vs, 56.5%, 0.61 [0.44-0.84], P < 0.01) than users of the traditional pharmacy. However, adherence to NIDMs was similar among users of the tele- and traditional pharmacies (65.5% vs. 60.1%, 1.47 [0.92-2.35], P = 0.11). Our findings were similar when we conducted a series of sensitivity analyses, including restricting our cohorts to those who only used their index pharmacy and analyzing cohorts of new rather than continuing users of these medications. CONCLUSION: In this analysis, medication adherence was lower among users of telepharmacy than users of a traditional pharmacy in some but not all drug classes examined. Further research is needed to identify whether other interventions to improve adherence, such as longer hours of operation, at-home delivery, or 90-day supply, may be coupled with telepharmacies to increase their use in urban areas.

Statin nonadherence in Latino and noncitizen neighborhoods in New York City, Los Angeles, and Chicago, 2012-2016.

BACKGROUND: Latino adults, especially immigrants without citizenship (i.e., noncitizens), experience considerable barriers to health care, including medications. Inequitable access to medications, especially statins, may exacerbate disparities in cardiovascular disease. Despite this, little is known about medication nonadherence in Latino neighborhoods, especially those with large noncitizen populations. OBJECTIVES: To estimate nonadherence to statins in Latino neighborhoods and evaluate differences on the basis of their noncitizen population. METHODS: We conducted a retrospective cohort study among 48,161 adults who lived in predominately Latino neighborhoods in New York City, Los Angeles, and Chicago and who initiated statin therapy from January 2012 to December 2015 using IQVIA LifeLink. Statin nonadherence was defined as a proportion of days covered amounting to less than 80% over 12 months. We focused on differences between neighborhoods with high noncitizen concentrations (areas where noncitizens are at least 35% of the adult population) and other Latino neighborhoods. We examined associations using logistic regressions adjusted for individual (e.g., payment method) and neighborhood characteristics (e.g., poverty). RESULTS: Individuals living in neighborhoods with high noncitizen concentrations were more nonadherent to statins than those in Latino neighborhoods with fewer noncitizens (75.0% vs. 70.0%, adjusted odds ratio [aOR] 1.18, [95% CI 1.06-1.33]). These disparities were worse in New York City (77.7% vs. 69.1%, aOR 1.37, [95% CI 1.23-1.53]) and Chicago (76.1% vs. 68.8%, aOR 1.38, [95% CI 1.14-1.67]) than in Los Angeles (73.8% vs. 71.3%, aOR 1.10, [95% CI 1.01-1.20]). CONCLUSION: Neighborhoods with large noncitizen populations have much higher rates of statin nonadherence than Latino neighborhoods with fewer noncitizens. These disparities were least pronounced in Los Angeles, where the county provides health care to all uninsured residents, including noncitizens without documentation to reside in the United States. Efforts to improve medication access in Latino neighborhoods should be multifocal and start by implementing state and local health care options for low-income residents, regardless of citizenship status.

Access to pharmacies and pharmacy services in New York City, Los Angeles, Chicago, and Houston, 2015-2020.

BACKGROUND: Despite the importance of pharmacies in ensuring medications and health care needs are met, there is limited up-to-date information regarding access to pharmacies or their services in the United States. OBJECTIVES: To evaluate trends and disparities in access to pharmacies in 4 largest cities in the United States, New York City, Los Angeles, Houston, and Chicago, by neighborhood racial and ethnic composition from 2015 to 2020. METHODS: Data from the National Council for Prescription Drug Programs (2015-2020) and the American Community Survey (2015-2019) were used. We examined neighborhoods (i.e., census tracts) and evaluated disparities in "pharmacy deserts" (low-income neighborhoods (1) whose average distance to the nearest pharmacy was at least 1 mile or (2) whose average distance to the nearest pharmacy was at least 0.5 mile and at least 100 households had no vehicle access). We also evaluated the differences in pharmacy closures and the availability of pharmacy services. RESULTS: From 2015 to 2020, the percent of neighborhoods with pharmacy deserts declined in New York City (from 1.6% to 0.9% of neighborhoods, P < 0.01), remained stable in Los Angeles (13.7% to 13.4%, P = 0.58) and Houston (27.0% to 28.5%, P = 0.18), and increased in Chicago (15.0% to 19.9%, P < 0.01). Pharmacy deserts were persistently more common in Black and Latino neighborhoods in all 4 cities. As of 2020, pharmacies in Black and Latino neighborhoods were also more likely to close and less likely to offer immunization, 24-hour, and drive-through services than pharmacies in other neighborhoods. CONCLUSION: To reduce disparities in access to medications and health care services, including those in response to the coronavirus disease 2019 pandemic (e.g., testing and vaccinations), policies that improve pharmacy access and expand the provision of pharmacy services in minority neighborhoods are critical.

Immigration Status and Disparities in the Treatment of Cardiovascular Disease Risk Factors in the Hispanic Community Health Study/Study of Latinos (Visit 2, 2014-2017).

Objectives. To estimate treatment rates of high cholesterol, hypertension, and diabetes among Hispanic/Latino immigrants by immigration status (i.e., naturalized citizens, documented immigrants, or undocumented immigrants).Methods. We performed a cross-sectional analyses of the Hispanic Community Health Study/Study of Latinos (visit 2, 2014-2017). We restricted our analysis to Hispanic/Latino immigrants with high cholesterol (n = 3974), hypertension (n = 3353), or diabetes (n = 2406); treatment was defined as use of statins, antihypertensives, and antidiabetics, respectively.Results. When compared with naturalized citizens, undocumented and documented immigrants were less likely to receive treatment for high cholesterol (38.4% vs 14.1%; prevalence ratio [PR] = 0.37 [95% confidence interval [CI] = 0.27, 0.51] and 25.7%; PR = 0.67 [95% CI = 0.58, 0.76]), hypertension (77.7% vs 57.7%; PR = 0.74 [95% CI = 0.62, 0.89] and 68.1%; PR = 0.88 [95% CI = 0.82, 0.94]), and diabetes (60.3% vs. 50.4%; PR = 0.84 [95% CI = 0.68, 1.02] and 55.8%; PR = 0.93 [95% CI = 0.83, 1.03]); the latter did not reach statistical significance. Undocumented and documented immigrants had less access to health care, including insurance coverage or a usual health care provider, than naturalized citizens. Therefore, adjusting for health care access largely explained treatment disparities across immigration status.Conclusions. Preventing cardiovascular disease among Hispanic/Latino immigrants should focus on undertreatment of high cholesterol, hypertension, and diabetes by increasing health care access, especially among undocumented immigrants.

Changes in Emergency Contraceptive Fills After Massachusetts' Statewide Standing Order.

This study examines whether policies that reduce prescribing barriers may improve access to emergency contraceptives, particularly ulipristal.

Use of Oral and Emergency Contraceptives After the US Supreme Court's Dobbs Decision.

Importance: The US Supreme Court Dobbs v Jackson Women's Health Organization decision allowed states to strengthen restrictions on abortion access, triggering the closure of family planning clinics and leading to confusion about the legality of emergency contraceptives (ECs). Objectives: To evaluate the association between the Dobbs decision and fills for oral and emergency contraceptives in states that enacted the most restrictive abortion policies after Dobbs. Design, Setting, and Participants: This cohort study used data on contraceptive fills for women of reproductive age (15-49 years) in the US from IQVIA's National Prescription Audit PayerTrak and data from the Guttmacher Institute were used to categorize changes in abortion restrictions in each state. A difference-in-differences analysis compared changes in monthly fill rates for daily oral contraceptive pills (OCPs) and ECs in states that became most restrictive (implemented a full abortion ban after Dobbs) and comparison states (kept a medium level of abortion restrictions after Dobbs) before (March 2021 to November 2021) and after (July 2022 to October 2023) the Dobbs decision. Exposure: State-level abortion restrictions. Main Outcomes and Measures: Monthly fills of OCPs and ECs per 100 000 women of reproductive age. Results: Between March 2021 and October 2023, 142.8 million prescriptions for OCPs and 904 269 prescriptions for ECs were dispensed at US retail pharmacies. Before Dobbs, trends in monthly fill rates were similar for OCPs and ECs between the most restrictive and comparison states. After the Dobbs decision, states that became the most restrictive experienced an additional 4.1% decline in OCP fills with 285.9 fewer fills per 100 000 (95% CI, -495.8 to -6.8; P = .04). In contrast to OCPs, fills for ECs increased during the first year after Dobbs (July 2022 to June 2023) in both groups of states. However, 1 year after Dobbs (July 2023 to October 2023), the most restrictive states experienced an additional 65% decrease in emergency contraceptive fills with 13.2 fewer fills per 100 000 (95% CI, -27.2 to -4.1; P = .01). Conclusions and Relevance: In this cohort study of prescriptions filled at US pharmacies, the Dobbs decision was associated with declines in oral contraceptives, particularly ECs, in states enacting the most restrictive abortion policies. Given the important role of OCPs and ECs in preventing pregnancy and the need for abortion, efforts to improve access may be needed, especially in states where legal abortion is no longer an option.

Are community oncology practices with/without clinical research programs different? A comparison of patient and practice characteristics.

PURPOSE: Expanding access to clinical trials in community settings is a potential approach to addressing disparities in accrual of historically underrepresented populations. However, little is known about the characteristics of practices that do not participate in research. We investigated differences in patient and practice characteristics of US community oncology practices with high vs low engagement in clinical research. METHODS: We included patients from a real-world, nationwide electronic health record-derived, de-identified database who received active treatment for cancer at community oncology practices between 11/1/17 and 10/31/22. We assessed patient and practice characteristics and their associations with high vs low research engagement using descriptive analyses and logistic regression models. RESULTS: Seventy (39.3%) of 178 practices had high research engagement, treated 57.8% of the overall 568,540 patient cohort, and enrolled 3.25% of their patients on cancer treatment trials during the five-year observation period (v 0.27% enrollment among low engagement practices). Practices with low vs high research engagement treated higher proportions of the following patient groups: ages > =75 (24.2% v 21.8%), non-Latinx Black (12.6% v10.3%) or Latinx (11.6% v 6.1%), were within the lowest socioeconomic status quintile (21.9% v 16.5%), and were uninsured or had no documented insurance (22.2% v 13.6%). CONCLUSION: Patient groups historically underrepresented in oncology clinical trials are more likely to be treated at community practices with limited or no access to trials. These results suggest that investments to expand the clinical research footprint among practices with low research engagement could help address persistent inequities in trial representation.

Diagnoses and Treatment of Behavioral and Psychological Symptoms of Dementia Among Racially and Ethnically Diverse Persons Living with Dementia.

Background: Behavioral and psychological symptoms of dementia (BPSD) and prescribed central nervous system (CNS) active drugs to treat them are prevalent among persons living with Alzheimer's disease and related dementias (PLWD) and lead to negative outcomes for PLWD and their caregivers. Yet, little is known about racial/ethnic disparities in diagnosis and use of drugs to treat BPSD. Objective: Quantify racial/ethnic disparities in BPSD diagnoses and CNS-active drug use among community-dwelling PLWD. Methods: We used a retrospective cohort of community-dwelling Medicare Fee-for-Service beneficiaries with dementia, continuously enrolled in Parts A, B and D, 2017-2019. Multivariate logistic models estimated rates of BPSD diagnosis and, conditional on diagnosis, CNS-active drug use. Results: Among PLWD, 67.1% had diagnoses of an affective, psychosis or hyperactivity symptom. White (68.3%) and Hispanic (63.9%) PLWD were most likely, Blacks (56.6%) and Asians (52.7%) least likely, to have diagnoses. Among PLWD with BPSD diagnoses, 78.6% took a CNS-active drug. Use was highest among whites (79.3%) and Hispanics (76.2%) and lowest among Blacks (70.8%) and Asians (69.3%). Racial/ethnic differences in affective disorders were pronounced, 56.8% of white PLWD diagnosed; Asians had the lowest rates (37.8%). Similar differences were found in use of antidepressants. Conclusions: BPSD diagnoses and CNS-active drug use were common in our study. Lower rates of BPSD diagnoses in non-white compared to white populations may indicate underdiagnosis in clinical settings of treatable conditions. Clinicians' review of prescriptions in this population to reduce poor outcomes is important as is informing care partners on the risks/benefits of using CNS-active drugs.

Association Between Pharmacy Proximity With Cardiovascular Medication Use and Risk Factor Control in the United States.

BACKGROUND: Poor neighborhood-level access to health care, including community pharmacies, contributes to cardiovascular disparities in the United States. The authors quantified the association between pharmacy proximity, antihypertensive and statin use, and blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) among a large, diverse US cohort. METHODS AND RESULTS: A cross-sectional analysis of Black and White participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study during 2013 to 2016 was conducted. The authors designated pharmacy proximity by census tract using road network analysis with population-weighted centroids within a 10-minute drive time, with 5- and 20-minute sensitivity analyses. Pill bottle review measured medication use, and BP and LDL-C were assessed using standard methods. Poisson regression was used to quantify the association between pharmacy proximity with medication use and BP control, and linear regression for LDL-C. Among 16 150 REGARDS participants between 2013 and 2016, 8319 (51.5%) and 8569 (53.1%) had an indication for antihypertensive and statin medication, respectively, and pharmacy proximity data. The authors did not find a consistent association between living in a census tract with higher pharmacy proximity and antihypertensive medication use, BP control, or statin medication use and LDL-C levels, regardless of whether the area was rural, suburban, or urban. Results were similar among the 5- and 20-minute drive-time analyses. CONCLUSIONS: Living in a low pharmacy proximity census tract may be associated with antihypertensive and statin medication use, or with BP control and LDL-C levels. Although, in this US cohort, outcomes were similar for adults living in high or low pharmacy proximity census tracts.

Broadening Eligibility Criteria and Diversity among Patients for Cancer Clinical Trials.

BACKGROUND: Certain populations have been historically underrepresented in clinical trials. Broadening eligibility criteria is one approach to inclusive clinical research and achieving enrollment goals. How broadened trial eligibility criteria affect the diversity of eligible participants is unknown. METHODS: Using a nationwide electronic health record-derived deidentified database, we identified a retrospective cohort of patients diagnosed with 22 cancer types between April 1, 2013 and December 31, 2022 who received systemic therapy (N=235,234) for cancer. We evaluated strict versus broadened eligibility criteria using performance status and liver, kidney, and hematologic function around first line of therapy. We performed logistic regression to estimate odds ratios for exclusion by strict criteria and their association with measures of patient diversity, including sex, age, race or ethnicity, and area-level socioeconomic status (SES); estimated the impact of broadening criteria on the number and distribution of eligible patients; and performed Cox regression to estimate hazard ratios for real-world overall survival (rwOS) comparing patients meeting strict versus broadened criteria. RESULTS: When applying common strict cutoffs for eligibility criteria to patients with complete data and weighting each cancer type equally, 48% of patients were eligible for clinical trials. Female (odds ratio, 1.30; 95% confidence interval [CI], 1.25 to 1.35), older (age 75+ vs. 18 to 49 years old: odds ratio, 3.04; 95% CI, 2.85 to 3.24), Latinx (odds ratio, 1.46; 95% CI, 1.39 to 1.54), non-Latinx Black (odds ratio, 1.11; 95% CI, 1.06 to 1.16), and lower-SES patients were more likely to be excluded using strict eligibility criteria. Broadening criteria increased the number of eligible patients by 78%, with the strongest impact for older, female, non-Latinx Black, and lower-SES patients. Patients who met only broadened criteria had worse rwOS versus those with strict criteria (hazard ratio, 1.31; 95% CI, 1.27 to 1.34). CONCLUSIONS: Data-driven evaluation of clinical trial eligibility criteria may optimize the eligibility of certain historically underrepresented groups and promote access to more inclusive trials. (Sponsored by Flatiron Health.).

Citizenship status and cost-related nonadherence in the United States, 2017-2021.

OBJECTIVE: To assess inequities in prescription medication use and subsequent cost-related nonadherence (CRN) and cost-saving strategies by citizenship status in the United States. DATA SOURCES/STUDY SETTING: National Health Interview Survey (2017-2021). STUDY DESIGN: This cross-sectional study examined noncitizen (n = 8596), naturalized citizen (n = 12,800), and US-born citizen (n = 120,195) adults. We also examined older adults (≥65 years) separately, including noncitizens without Medicare (a group of importance given their immigration-related barriers to health care access). Multiple mediation analysis was used to examine differences in CRN and determine whether economic, health care, and immigration factors explain observed inequities. PRINCIPAL FINDINGS: Noncitizens (41.9%) were less likely to use prescription medications than naturalized (60.5%) and US-born citizens (68.2%). Among prescription medication users, noncitizens (13.8%) were more likely to report CRN than naturalized (9.5%) and US-born citizens (11.0%). CRN differences between noncitizens and naturalized citizens (OR 1.38, 95% CI 1.21-1.44) and between noncitizens and US-born citizens (OR 1.23, 95% CI 1.07-1.35) were explained by insurance status and food insecurity. Only 4.9% of medication users turned to alternative therapies to lower their drug costs, but there were no substantial differences across citizenship status. More medication users requested lower-cost prescriptions (19.0%); however, noncitizens were less likely to make these requests. Older noncitizens without Medicare, of whom 23.9% requested lower-cost drugs, were an exception. Noncitizens (5.8%), particularly older noncitizens without Medicare (21.8%), were more likely to import their drugs than naturalized (3.5%) and US-born citizens (1.2%). CONCLUSIONS: Noncitizens experience a high burden of cost-related barriers to prescription medications. Efforts to reduce these inequities should focus on dismantling health care and food access barriers, regardless of citizenship status.