Impact of the elimination of cost sharing for mammographic breast cancer screening among rural US women: A natural experiment.

BACKGROUND: Rural US women experience disparities in breast cancer screening and outcomes. In 2006, a national rural health insurance provider, the National Rural Electric Cooperative Association (NRECA), eliminated out-of-pocket costs for screening mammography. METHODS: This study evaluated the elimination of cost sharing as a natural experiment: it compared trends in screening before and after the policy change. NRECA insurance claims data were used to identify all women aged 40 to 64 years who were eligible for breast cancer screening, and mammography utilization from 1998 through 2011 was evaluated. Repeated measures regression models were used to evaluate changes in utilization over time and the association between screening and sociodemographic factors. RESULTS: The analysis was based on 45,738 women enrolled in the NRECA membership database for an average of 6.1 years and included 279,940 person-years of enrollment. Between 1998 and 2011, the annual screening rate increased from 35% to a peak of 50% among women aged 40 to 49 years and from 49% to 58% among women aged 50 to 64 years. The biennial screening rate increased from 56% to 66% for women aged 40 to 49 years and from 68% to 73% for women aged 50 to 64 years. Screening rates increased significantly (P < .0001) after the elimination of cost sharing and then declined slightly after changes to government screening guidelines in 2009. Younger women experienced greater increases in both annual screening (6.2%) and biennial screening (5.6%) after the elimination of cost sharing in comparison with older women (3.0% and 2.6%, respectively). In a multivariate analysis, rural residence, lower population income, and lower population education were associated with modestly lower screening. CONCLUSIONS: In a national sample of predominantly rural working-age women, the elimination of cost sharing correlated with increased breast cancer screening. Cancer 2017;123:2506-15. © 2017 American Cancer Society.

Breast cancer screening utilization and understanding of current guidelines among rural U.S. women with private insurance.

Women living in rural areas of the U.S. face disparities in screening mammography and breast cancer outcomes. We sought to evaluate utilization of mammography, awareness of screening guidelines, and attitudes towards screening among rural insured U.S. women. We conducted a cross-sectional self-administered anonymous survey among 2000 women aged 40-64 insured by the National Rural Electric Cooperative Association, a non-profit insurer for electrical utility workers in predominantly rural areas across the U.S. Outcomes included mammographic screening in the past year, screening interval, awareness of guidelines, and perceived barriers to screening. 1588 women responded to the survey (response rate 79.4 %). 74 % of respondents lived in a rural area. Among women aged 40-49, 66.5 % reported mammographic screening in the past year. 46 % received annual screening, 32 % biennial screening, and 22 % rare/no screening. Among women aged 50-64, 77.1 % reported screening in the past year. 63 % received annual screening, 25 % biennial screening, and 12 % rare/no screening. The majority of women (98 %) believed that the mammography can find breast cancer early and save lives. Less than 1 % of younger women, and only 14 % of women over age 50 identified the recommendations of the U.S. Preventative Services Screening Task Force as the current expert recommendations for screening. Screening practices tended to follow perceived guideline recommendations. When rural U.S. women over age 40 have insurance, most receive breast cancer screening. The screening guidelines of cancer advocacy groups and specialty societies appear more influential and widely recognized than those of the U.S. preventative services taskforce.

Does comparative effectiveness research promote rationing of cancer care?

Comparative effectiveness research aims to inform health-care decisions by patients, clinicians, and policy makers. However, questions related to what information is relevant, and how to view the relative attributes of alternative interventions have political, social, and medical considerations. In particular, questions about whether cost is a relevant factor, and whether cost-effectiveness is a desirable or necessary component of such research, have become increasingly controversial as the area has gained prominence. Debate has emerged about whether comparative effectiveness research promotes rationing of cancer care. At the heart of this debate are questions related to the role and limits of patient autonomy, physician discretion in health-care decision making, and the nature of scientific knowledge as an objective good. In this article, we examine the role of comparative effectiveness research in the USA, UK, Canada, and other health-care systems, and the relation between research and policy. As we show, all health systems struggle to balance access to cancer care and control of costs; comparative effectiveness data can clarify choices, but does not itself determine policy or promote rationing of care.

Patient experience and attitudes toward addressing the cost of breast cancer care.

BACKGROUND: The American Society of Clinical Oncology views patient-physician discussion of costs as a component of high-quality care. Few data exist on patients' views regarding how cost should be addressed in the clinic. METHODS: We distributed a self-administered, anonymous, paper survey to consecutive patients with breast cancer presenting for a routine visit within 5 years of diagnosis at an academic cancer center. Survey questions addressed experience and preferences concerning discussions of cost and views on cost control. Results are primarily descriptive, with comparison among participants on the basis of disease stage, using chi-square and Fisher's exact tests. All p values are two-sided. RESULTS: We surveyed 134 participants (response rate 86%). Median age was 61 years, and 28% had stage IV disease. Although 44% of participants reported at least a moderate level of financial distress, only 14% discussed costs with their doctor; 94% agreed doctors should talk to patients about costs of care. Regarding the impact of costs on decision making, 53% felt doctors should consider direct costs to the patient, but only 38% felt doctors should consider costs to society. Moreover, 88% reported concern about costs of care, but there was no consensus on how to control costs. CONCLUSION: Most breast cancer patients want to discuss costs of care, but there is little consensus on the desired content or goal of these discussions. Further research is needed to define the role of cost discussions at the bedside and how they will contribute to the goal of high-quality and sustainable cancer care.

Age- and treatment-related associations with health behavior change among breast cancer survivors.

OBJECTIVE: The aim of this study was to identify demographic and treatment-related factors associated with health-promoting behavior changes after a breast cancer diagnosis. Changes in health behaviors were also evaluated according to weight, exercise, diet and alcohol consumption patterns before breast cancer diagnosis. MATERIALS AND METHODS: We examined self-reported behavior changes among 1415 women diagnosed with breast cancer in the NIEHS Sister Study cohort. Women reported changes in exercising, eating healthy foods, maintaining a healthy body weight, drinking alcohol, smoking, getting enough sleep, spending time with family and friends, and participating in breast cancer awareness events. RESULTS: On average, women were 3.7 years from their breast cancer diagnosis. Overall, 20-36% reported positive changes in exercise, eating healthy foods, maintaining a healthy weight, or alcohol consumption. However, 17% exercised less. With each 5-year increase in diagnosis age, women were 11-16% less likely to report positive change in each of these behaviors (OR = 0.84-0.89; p < 0.05), except alcohol consumption (OR = 0.97; CI: 0.81, 1.17). Women who underwent chemotherapy were more likely to report eating more healthy foods (OR = 1.47; 95% CI 1.16-1.86), drinking less alcohol (OR = 2.01; 95% CI: 1.01, 4.06), and sleeping enough (OR = 1.41; 95% CI: 1.04, 1.91). The majority of women (50-84%) reported no change in exercise, eating healthy foods, efforts to maintain a healthy weight, alcohol consumption, sleep patterns, or time spent with family or friends. CONCLUSIONS: Many women reported no change in cancer survivorship guideline-supported behaviors after diagnosis. Positive changes were more common among younger women or those who underwent chemotherapy.

Cost Implications of an Evidence-Based Approach to Radiation Treatment After Lumpectomy for Early-Stage Breast Cancer.

INTRODUCTION: Breast cancer treatment costs are rising, and identification of high-value oncology treatment strategies is increasingly needed. We sought to determine the potential cost savings associated with an evidence-based radiation treatment (RT) approach among women with early-stage breast cancer treated in the United States. PATIENTS AND METHODS: Using the National Cancer Database, we identified women with T1-T2 N0 invasive breast cancers treated with lumpectomy during 2011. Adjuvant RT regimens were categorized as conventionally fractionated whole-breast irradiation, hypofractionated whole-breast irradiation, and omission of RT. National RT patterns were determined, and RT costs were estimated using the Medicare Physician Fee Schedule. RESULTS: Within the 43,247 patient cohort, 64% (n = 27,697) received conventional RT, 13.3% (n = 5,724) received hypofractionated RT, 1.1% (n = 477) received accelerated partial-breast irradiation, and 21.6% (n = 9,349) received no RT. Among patients who were eligible for shorter RT or omission of RT, 57% underwent treatment with longer, more costly regimens. Estimated RT expenditures of the national cohort approximated $420.2 million during 2011, compared with $256.2 million had women been treated with the least expensive regimens for which they were safely eligible. This demonstrated a potential annual savings of $164.0 million, a 39% reduction in associated treatment costs. CONCLUSION: Among women with early-stage breast cancer after lumpectomy, use of an evidence-based approach illustrates an example of high-value care within oncology. Identification of high-value cancer treatment strategies is critically important to maintaining excellence in cancer care while reducing health care expenditures.

Physician Experience and Attitudes Toward Addressing the Cost of Cancer Care.

PURPOSE: We surveyed US cancer doctors to examine current attitudes toward cost discussions and how they influence decision making and practice management. METHODS: We conducted a self-administered, anonymous, electronic survey of randomly selected physician ASCO members to evaluate the frequency and nature of cost discussions reported by physicians, attitudes toward discussions of cost in clinics, and potential barriers. RESULTS: A total of 333 of 2,290 physicians responded (response rate [RR], 15%; adjusted RR after omitting nonpracticing physician ASCO members, 25%), Respondent practice settings were 45% academic and 55% community/private practice. Overall, 60% reported addressing costs frequently/always in clinic, whereas 40% addressed costs rarely/never. The largest reported barrier was lack of resources to guide discussions. Those who reported frequent discussions were significantly more likely to prioritize treatments in terms of cost and believed doctors should explain patient and societal costs. A total of 36%did not believe that doctors should discuss costs with patients. Academic practitioners were significantly less likely to discuss costs (odds ratio [OR], 0.41; P = .001) and felt less prepared for such discussions (OR, 0.492; P = .005) but were more likely to consider costs to the patient (OR, 2.68; P = .02) and society (OR, 1.822; P = .02). CONCLUSION: Although the majority of respondents believe it is important to consider out-of-pocket costs to patients, a substantial proportion do not discuss or consider costs of cancer care. Lack of consensus on the importance of such discussions and uncertainty regarding the optimal timing and content appear to be barriers to addressing costs of care with patients.

Overweight among children younger than 3 years in a low-income patient population: prevalence in 2010.

OBJECTIVES: To examine the prevalence and correlates of overweight and obesity among patients aged 0 to 2 years, and to compare 3 measures of early childhood weight status, weight-for-age, weight-for-length, and body mass index-for-age. SETTING: Well-child visits in the Philadelphia Health Centers, public community health centers providing primary health care to predominantly low-income residents. STUDY DESIGN: Cross-sectional. RESULTS: Using the 3 measures, 13% to 16% of boys and 10% to 13% of girls seen during 2010 were classified as high in weight. No consistent associations with feeding method were identified. "Other/unknown" race was consistently associated with higher rates of overweight than the African American reference group. Hispanic girls had higher rates of high weight-for-age and weight-for-length than African American girls. CONCLUSION: Elevated weight status emerges in a significant proportion of very young children, by all of the commonly used weight measures. There is an urgent need for appropriate clinical strategies to prevent and respond to overweight in this age group.

Severe obesity and high blood pressure among children, Philadelphia health centers, 2010.

BACKGROUND: Child obesity is a major health problem particularly affecting disadvantaged population groups. Severe obesity carries additional health risks for children. In the context of the childhood obesity epidemic, high blood pressure among children is of increasing concern. METHODS: Chart reviews were carried out to examine the prevalence of severe obesity and its association with high blood pressure measurements among randomly selected patients aged 3 to 17 years who had well-child care visits at 8 public community health centers during 2010. RESULTS: A majority of the 691 patients reviewed were African American (58%); an additional 16% were Hispanic. The prevalence of severe obesity was 7.7% (95% confidence interval = 5.8% to 9.9%) and the prevalence of high blood pressure measurements was 17.5% (95% confidence interval = 14.8% to 20.6%). Patients who were severely obese were more than twice as likely as other children to have high blood pressure values. CONCLUSIONS: Severe obesity is associated with substantially increased frequency of high blood pressure measurements in children, and should be investigated further as a potential marker for hypertension in children. Primary care providers should be prepared to diagnose and treat hypertension in severely obese children.