Associations of State Supplemental Nutrition Assistance Program Eligibility Policies With Mammography.

PURPOSE: The Supplemental Nutrition Assistance Program (SNAP) addresses food insecurity for low-income households, which is associated with access to care. Many US states expanded SNAP access through policies eliminating the asset test (ie, restrictions based on SNAP applicant assets) and/or broadening income eligibility. The objective of this study was to determine whether state SNAP policies were associated with the use of mammography among women eligible for breast cancer screening. METHODS: Data for income-eligible women 40 to 79 years of age were obtained from the 2006 to 2019 Behavioral Risk Factor Surveillance System. Difference-in-differences analyses were conducted to compare changes in the percentage of mammography in the past year from pre- to post-SNAP policy adoption (asset test elimination or income eligibility increase) between states that and did not adopt policies expanding SNAP eligibility. RESULTS: In total, 171,684 and 294,647 income-eligible female respondents were included for the asset test elimination policy and income eligibility increase policy analyses, respectively. Mammography within 1 year was reported by 58.4%. Twenty-eight and 22 states adopted SNAP asset test elimination and income increase policies, respectively. Adoption of asset test elimination policies was associated with a 2.11 (95% confidence interval [CI], 0.07-4.15; P = .043) percentage point increase in mammography received within 1 year, particularly for nonmetropolitan residents (4.14 percentage points; 95% CI, 1.07-7.21 percentage points; P = .008), those with household incomes <$25,000 (2.82 percentage points; 95% CI, 0.68-4.97 percentage points; P = .01), and those residing in states in the South (3.08 percentage points; 95% CI, 0.17-5.99 percentage points; P = .038) or that did not expand Medicaid under the Patient Protection and Affordable Care Act (3.35 percentage points; 95% CI, 0.36-6.34; P = .028). There was no significant association between mammography and state-level policies broadening of SNAP income eligibility. CONCLUSIONS: State policies eliminating asset test requirements for SNAP eligibility were associated with increased mammography among low-income women eligible for breast cancer screening, particularly for those in the lowest income bracket or residing in nonmetropolitan areas or Medicaid nonexpansion states.

Geographic Disparities in Head and Neck Cancer Mortality and Place of Death.

This cross-sectional study evaluates rural-urban disparities in age-adjusted mortality rates and place of death (eg, at home or medical facility) for patients with head and neck cancer.

Association of Historical Housing Discrimination and Colon Cancer Treatment and Outcomes in the United States.

PURPOSE: In the 1930s, the federally sponsored Home Owners' Loan Corporation (HOLC) used racial composition in its assessment of areas worthy of receiving loans. Neighborhoods with large proportions of Black residents were mapped in red (ie, redlining) and flagged as hazardous for mortgage financing. Redlining created a platform for systemic disinvestment in these neighborhoods, leading to barriers in access to resources that persist today. We investigated the association between residing in areas with different HOLC ratings and receipt of quality cancer care and outcomes among individuals diagnosed with colon cancer-a leading cause of cancer deaths amenable to early detection and treatment. METHODS: Individuals who resided in zip code tabulation areas in 196 cities with HOLC rating and were diagnosed with colon cancer from 2007 to 2017 were identified from the National Cancer Database and assigned a HOLC grade (A, best; B, still desirable; C, definitely declining; and D, hazardous and mapped in red). Multivariable logistic regression models investigated association of area-level HOLC grade and late stage at diagnosis and receipt of guideline-concordant care. The product-limit method evaluated differences in time to adjuvant chemotherapy. Multivariable Cox proportional hazard models investigated differences in overall survival (OS). RESULTS: There were 149,917 patients newly diagnosed with colon cancer with a median age of 68 years. Compared with people living in HOLC A areas, people living in HOLC D areas were more likely to be diagnosed with late-stage disease (adjusted odds ratio, 1.06 [95% CI, 1.00 to 1.12]). In addition, people living in HOLC B, C, and D areas had 8%, 16%, and 24% higher odds of not receiving guideline-concordant care, including lower receipt of surgery, evaluation of ≥12 lymph nodes, and chemotherapy. People residing in HOLC B, C, or D areas also experienced delays in initiation of adjuvant chemotherapy after surgery. People residing in HOLC C (adjusted hazard ratio [aHR], 1.09 [95% CI, 1.05 to 1.13]) and D (aHR, 1.13 [95% CI, 1.09 to 1.18]) areas had worse OS, including 13% and 20% excess risk of death for individuals diagnosed with early- and 6% and 8% for late-stage disease for HOLC C and D, respectively. CONCLUSION: Historical housing discrimination is associated with worse contemporary access to colon cancer care and outcomes.

Association of area-level mortgage denial and guideline-concordant non-small-cell lung cancer care and outcomes in the United States.

BACKGROUND: Racial and socioeconomic disparities in receipt of care for non-small-cell lung cancer (NSCLC) are well described. However, no previous studies have evaluated the association between mortgage denial rates and receipt of timely and guideline-concordant care for NSCLC and patient outcomes. METHODS: We identified individuals ≥18 years diagnosed with NSCLC between 2014 and 2019 from the National Cancer Database. Using the Home Mortgage Disclosure Act database, we calculated the proportion of denied home loans to total loans at the zip-code level and categorized them into quintiles. Our outcomes included receipt of guideline-concordant care based on clinical and pathologic stage at diagnosis and the National Comprehensive Cancer Network guidelines, time from surgery to chemotherapy initiation, and overall survival. RESULTS: Of the 629,288 individuals diagnosed with NSCLC (median age 69; IQR 61-76 years, 49.1% female), 47.8% did not receive guideline-concordant care. Residing in areas with higher mortgage denial rates and lower income was associated with worse guideline-concordant care overall (aRR = 1.28; 95% CI = 1.25-1.32) and for each cancer treatment modality, worse receipt of timely chemotherapy (aHR = 1.14; 95% CI = 1.11-1.17) and worse overall survival (aHR = 1.21; 95% CI = 1.19-1.22), compared with residing in areas with the lowest mortgage denial rate and highest income. CONCLUSIONS: Area-level mortgage denial rate was associated with worse receipt of timely and guideline-concordant NSCLC care and survival. This highlights the critical need to understand and address systemic practices, such as mortgage denial, that limit access to resources and are associated with worse access to quality cancer care and outcomes.

Financial Toxicity and Quality of Life in Patients Undergoing Stem-Cell Transplant Evaluation: A Single-Center Analysis.

PURPOSE: We investigated the prevalence of financial toxicity in a population undergoing hematopoietic cell transplantation (HCT) evaluation and measured its impact on post-transplant clinical and health-related quality-of-life outcomes. MATERIALS AND METHODS: This was a prospective study in patients undergoing evaluation for allogeneic HCT between January 1, 2018, and September 23, 2020, at a large academic medical center. Financial health was measured via a baseline survey and the comprehensive score for financial toxicity-functional assessment of chronic illness therapy (COST-FACIT) survey. The cohort was divided into three groups: none (grade 0), mild (grade 1), and moderate-high financial toxicity (grades 2-3). Health-related quality of life outcomes were measured at multiple time points. Multivariate logistic regression analysis evaluated factors associated with financial toxicity. Kaplan-Meier curves and log-rank tests was used to evaluate overall survival (OS) and nonrelapse survival. RESULTS: Of 245 patients evaluated for transplant, 176 (71.8%) completed both questionnaires (median age was 57 years, 63.1% were male, 72.2% were White, and 39.2% had myelodysplastic syndrome, 38.1% leukemia, and 13.6% lymphoma). At initial evaluation, 83 (47.2%) patients reported no financial toxicity, 51 (29.0%) with mild, and 42 (23.9%) with moderate-high financial toxicity. Patients with financial toxicity reported significant cost-cutting behaviors, including reduced spending on food or clothing, using their savings, or not filling a prescription because of costs (P < .0001). Quality of life was lower in patients with moderate-high financial toxicity at 6 months (P = .0007) and 1 year (P = .0075) after transplant. Older age (>62; odds ratio [OR], 0.33 [95% CI, 0.13 to 0.79]; P = .04) and income ≥$60,000 in US dollars (USD) (OR, 0.17 [95% CI, 0.08 to 0.38]; P < .0001) were associated with lower odds of financial toxicity. No association was noted between financial toxicity and selection for transplant, OS, or nonrelapse mortality. CONCLUSION: Financial toxicity was highly correlated with patient-reported changes in compensatory behavior, with notable impact on patient quality of life after transplant.

Association of Neighborhood-Level Environmental Injustice With Health Status in the US.

This cross-sectional study uses the Environmental Justice Index to assess the association between environmental injustice and health status at the neighborhood level.

Local Social Vulnerability as a Predictor for Cancer-Related Mortality Among US Counties.

Substantial gaps in national healthcare spending and disparities in cancer mortality rates are noted across counties in the US. In this cross-sectional analysis, we investigated whether differences in local county-level social vulnerability impacts cancer-related mortality. We linked county-level age-adjusted mortality rates (AAMR) from the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research database, to county-level Social Vulnerability Index (SVI) from the CDC Agency for Toxic Substances and Disease Registry. SVI is a metric comprising 15 social factors including socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. AAMRs were compared between least and most vulnerable counties using robust linear regression models. There were 4 107 273 deaths with an overall AAMR of 173 per 100 000 individuals. Highest AAMRs were noted in older adults, men, non-Hispanic Black individuals, and rural and Southern counties. Highest mortality risk increases between least and most vulnerable counties were noted in Southern and rural counties, individuals aged 45-65, and lung and colorectal cancers, suggesting that these groups may face highest risk for health inequity. These findings inform ongoing deliberations in public health policy at the state and federal level and encourage increased investment into socially disadvantaged counties.

Trends in the Prevalence of Functional Limitations Among US Cancer Survivors, 1999-2018.

This cross-sectional study examines trends in the prevalence of functional limitation in cancer survivors using data from the National Health Interview Survey.

Incorporating Cost Measures Into the Merit-Based Incentive Payment System: Implications for Oncologists.

PURPOSE: The Merit-Based Incentive Payment System (MIPS) is currently the only federally mandated value-based payment model for oncologists. The weight of cost measures in MIPS has increased from 0% in 2017 to 30% in 2022. Given that cost measures are specialty-agnostic, specialties with greater costs of care such as oncology may be unfairly affected. We investigated the implications of incorporating cost measures into MIPS on physician reimbursements for oncologists and other physicians. METHODS: We evaluated physicians scored on cost and quality in the 2018 MIPS using the Doctors and Clinicians database. We used multivariable Tobit regression to identify physician-level factors associated with cost and quality scores. We simulated composite MIPS scores and payment adjustments by applying the 2022 cost-quality weights to the 2018 category scores and compared changes across specialties. RESULTS: Of 168,098 identified MIPS-participating physicians, 5,942 (3.5%) were oncologists. Oncologists had the lowest cost scores compared with other specialties (adjusted mean score, 58.4 for oncologists v 71.0 for nononcologists; difference, -12.66 [95% CI, -13.34 to -11.99]), while quality scores were similar (82.9 v 84.2; difference, -1.31 [95% CI, -2.65 to 0.03]). After the 2022 cost-quality reweighting, oncologists would receive a 4.3-point (95% CI, 4.58 to 4.04) reduction in composite MIPS scores, corresponding to a four-fold increase in magnitude of physician penalties ($4,233.41 US dollars [USD] in 2018 v $18,531.06 USD in 2022) and greater reduction in exceptional payment bonuses compared with physicians in other specialties (-42.8% [95% CI, -44.1 to -41.5] for oncologists v -23.6% [95% CI, -23.8 to -23.4] for others). CONCLUSION: Oncologists will likely be disproportionally penalized after the incorporation of cost measures into MIPS. Specialty-specific recalibration of cost measures is needed to ensure that policy efforts to promote value-based care do not compromise health care quality and outcomes.

Prevalence of Delayed or Forgone Care Due to Patient-Clinician Identity Discordance Among US Cancer Survivors.

This case-control study assesses the prevalence of patient-reported delayed or forgone care due to patient-clinician identity discordance among cancer survivors and factors associated with this barrier to care.

Oncologist Participation and Performance in the Merit-Based Incentive Payment System.

The merit-based incentive payment system (MIPS) is a value-based payment model created by the Centers for Medicare & Medicaid Services (CMS) to promote high-value care through performance-based adjustments of Medicare reimbursements. In this cross-sectional study, we examined the participation and performance of oncologists in the 2019 MIPS. Oncologist participation was low (86%) compared to all-specialty participation (97%). After adjusting for practice characteristics, higher MIPS scores were observed among oncologists with alternative payment models (APMs) as their filing source (mean score, 91 for APMs vs. 77.6 for individuals; difference, 13.41 [95% CI, 12.21, 14.6]), indicating the importance of greater organizational resources for participants. Lower scores were associated with greater patient complexity (mean score, 83.4 for highest quintile vs. 84.9 for lowest quintile, difference, -1.43 [95% CI, -2.48, -0.37]), suggesting the need for better risk-adjustment by CMS. Our findings may guide future efforts to improve oncologist engagement in MIPS.

Housing and Cancer Care and Outcomes: A Systematic Review.

BACKGROUND: Access to stable and affordable housing is an important social determinant of health in the United States. However, research addressing housing and cancer care, diagnosis, and outcomes has not been synthesized. METHODS: We conducted a systematic review of studies examining associations of housing and cancer care and outcomes using PubMed, Embase, Scopus, and CINAHL. Included studies were conducted in the United States and published in English between 1980 and 2021. Study characteristics and key findings were abstracted and qualitatively synthesized. RESULTS: A total of 31 studies were identified. Housing-related measures were reported at the individual level in 20 studies (65%) and area level in 11 studies (35%). Study populations and housing measures were heterogeneous. The most common housing measures were area-level housing discrimination (8 studies, 26%), individual-level housing status (8 studies, 26%), and individual-level housing concerns (7 studies, 23%). The most common cancer outcomes were screening (12 studies, 39%) and mortality (9 studies, 29%). Few studies assessed multiple dimensions of housing. Most studies found that exposure to housing insecurity was statistically significantly associated with worse cancer care (11 studies) or outcomes (10 studies). CONCLUSIONS: Housing insecurity is adversely associated with cancer care and outcomes, underscoring the importance of screening for housing needs and supporting systemic changes to advance equitable access to care. Additional research is needed to develop and test provider- and policy-level housing interventions that can effectively address the needs of individuals throughout the cancer care continuum.

Intermediate Strengths and Inflated Prices: The Story of Transdermal Fentanyl Patches.

In 2015, Mylan pharmaceuticals received final approval from the Food and Drug Administration for its Supplemental Abbreviated New Drug Application and introduced three new intermediate strengths of transdermal fentanyl patches to the U.S. drug market.1 With this approval, Mylan added 37.5 , 62.5, and 87.5 mcg/hr strength patches to existing 12, 25, 50, 75, and 100 mcg/hr strength patches. Today, these intermediate strength patches cost many times more than older strengths. In this commentary, we discuss the clinical implications of intermediate strengths of the fentanyl patch, explore mechanisms for price differences, and offer practice-based and policy solutions to address these differences.