Anticholinergic exposure and its association with dementia/Alzheimer's disease and mortality in older adults.

BACKGROUND: Use of anticholinergic (ACH) medications is associated with increased risk of cognitive decline in the elderly. However, little is known about this association from a health plan perspective. METHODS: This retrospective cohort study used the Humana Research Database to identify individuals with at least one ACH medication dispensed in 2015. Patients were followed until incidence of dementia/Alzheimer's disease, death, disenrollment or end of December 2019. Multivariate Cox regression models were used to assess the association between ACH exposure and study outcomes, adjusting for demographics and clinical characteristics. RESULTS: A total of 12,209 individuals with no prior ACH use or dementia/Alzheimer's disease diagnosis were included. As ACH polypharmacy increased (i.e., from no ACH exposure, to one, two, three, and four or more ACH medications), there was a stair-step increase in the incidence rate of dementia/Alzheimer's disease (15, 30, 46, 56 and 77 per 1,000 person-years of follow-up) and in the incidence of mortality (19, 37, 80, 115 and 159 per 1,000 person-years of follow-up). After adjusting for confounders, ACH exposure to one, two, three and four or more ACH medications was associated with a 1.6 (95% CI 1.4-1.9), 2.1 (95% CI 1.7-2.8), 2.6 (95% CI 1.5-4.4), and 2.6 (95% CI 1.1-6.3) times, respectively, increased risk of a dementia/Alzheimer's disease diagnosis compared to periods of no ACH exposure. ACH exposure to one, two, three and four or more medications was associated with a 1.4 (95% CI 1.2-1.6), 2.6 (95% CI 2.1-3.3), 3.8 (95% CI 2.6-5.4), and 3.4 (95% CI 1.8-6.4) times, respectively, increased risk of mortality compared to periods of no ACH exposure. CONCLUSIONS: Reducing ACH exposure may potentially minimize long-term adverse effects in older adults. Results suggest populations which may benefit from targeted interventions to reduce ACH polypharmacy.

Managing comorbidities in chronic kidney disease reduces utilization and costs.

BACKGROUND: Effective management of comorbid diabetes and hypertension in patients with chronic kidney disease (CKD) is important for optimal outcomes. However, little is known about this relationship from a health plan perspective. The objective of this study was to evaluate the association of effective management of comorbid diabetes and/or hypertension with healthcare resource utilization (HCRU) in patients with chronic kidney disease (CKD). METHODS: This retrospective cohort study used the Humana Research Database to identify patients with CKD Stage ≥ 3a in 2017. Eligible patients were enrolled in a Medicare Advantage Prescription Drug plan for ≥ 12 months before and after the index date (first observed evidence of CKD). Patients with end-stage renal disease, kidney transplant, or hospice election preindex were excluded. Recommended comorbid disease management included hemoglobin A1c monitoring; adherence to glucose-lowering, cardiovascular, and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker medications; and nephrologist/primary care provider (PCP) visits. HCRU was evaluated for 12 months postindex. RESULTS: The final cohort of 241,628 patients was 55% female and 77% White, with an average age of 75 years. Approximately 90% of patients had Stage 3 CKD. Half had both diabetes and hypertension, and most of the remaining half had hypertension without diabetes. Patients meeting the criteria for good disease management, compared with patients not meeting those criteria, were less likely to experience an inpatient hospitalization, by as much as 40% depending on the criterion and the comorbidities present, or an emergency department visit, by as much as 30%. Total monthly healthcare costs were as much as 17% lower. CONCLUSIONS: Management of comorbid diabetes and hypertension in patients with CKD was associated with lower HCRU and costs. Care coordination programs targeting patients with CKD must give careful attention to glucose and blood pressure control. TRIAL REGISTRATION: Not applicable.

Home versus outpatient hospital intravenous immunoglobulin infusion and health care resource utilization.

BACKGROUND: Home health care delivery is projected to increase. Intravenous immunoglobulin (IVIG) therapy has high potential to move from the outpatient hospital (OPH) setting to home delivery. OBJECTIVE: This study examined the relationship between home and OPH IVIG infusions and health care utilization. METHODS: We used a retrospective cohort study design and the Humana Research Database to identify patients with 1 or more medical or pharmacy claims for an IVIG infusion agent from January 1, 2017, to December 31, 2018. Eligible patients were enrolled in a Medicare Advantage Prescription Drug (MAPD) or commercial health plan, with at least 12 months of continuous enrollment before and after their first infusion (i.e., index date) received in the home or OPH setting. We measured the odds of experiencing an inpatient (IP) stay or emergency department (ED) visit, adjusted for baseline differences in age, sex, race, region, population density, low-income, and dual eligibility status, MAPD or commercial health plan, plan type, treatment-naïve status, home health use, RxRisk-V comorbidity burden score, and indications for IVIG use. RESULTS: A total of 208 and 1079 patients received IVIG infusions in the home and OPH setting, respectively. The odds for an IP stay (odds ratio [OR] 0.56 [95% CI 0.38-0.82]) and ED visit (OR 0.62 [95% CI 0.41-0.93]) were significantly lower in patients who received IVIG infusion in the home than patients receiving infusion in the OPH setting. CONCLUSIONS: Our findings suggest there may be value to increasing referrals for IVIG home infusion. Decreased health care utilization provides value to the system in cost savings and to patients and families owing to less disruption and improved clinical outcomes. Further study can help inform health policy designed to maximize the benefits of IVIG home infusion while minimizing potential risks.

Examining guidelines and new evidence in oncology nutrition: a position paper on gaps and opportunities in multimodal approaches to improve patient care.

Malnutrition, muscle loss, and cachexia are prevalent in cancer and remain key challenges in oncology today. These conditions are frequently underrecognized and undertreated and have devastating consequences for patients. Early nutrition screening/assessment and intervention are associated with improved patient outcomes. As a multifaceted disease, cancer requires multimodal care that integrates supportive interventions, specifically nutrition and exercise, to improve nutrient intake, muscle mass, physical functioning, quality of life, and treatment outcomes. An integrated team of healthcare providers that incorporates societies' recommendations into clinical practice can help achieve the best possible outcomes. A multidisciplinary panel of experts in oncology, nutrition, exercise, and medicine participated in a 2-day virtual roundtable in October 2020 to discuss gaps and opportunities in oncology nutrition, alone and in combination with exercise, relative to current evidence and international societies' recommendations. The panel recommended five principles to optimize clinical oncology practice: (1) position oncology nutrition at the center of multidisciplinary care; (2) partner with colleagues and administrators to integrate a nutrition care process into the multidisciplinary cancer care approach; (3) screen all patients for malnutrition risk at diagnosis and regularly throughout treatment; (4) combine exercise and nutrition interventions before (e.g., prehabilitation), during, and after treatment as oncology standard of care to optimize nutrition status and muscle mass; and (5) incorporate a patient-centered approach into multidisciplinary care.

Use of common analgesic medications and ovarian cancer survival: results from a pooled analysis in the Ovarian Cancer Association Consortium.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with improved survival in some cancers, but evidence for ovarian cancer is limited. METHODS: Pooling individual-level data from 12 Ovarian Cancer Association Consortium studies, we evaluated the association between self-reported, pre-diagnosis use of common analgesics and overall/progression-free/disease-specific survival among 7694 women with invasive epithelial ovarian cancer (4273 deaths). RESULTS: Regular analgesic use (at least once per week) was not associated with overall survival (pooled hazard ratios, pHRs (95% confidence intervals): aspirin 0.96 (0.88-1.04); non-aspirin NSAIDs 0.97 (0.89-1.05); acetaminophen 1.01 (0.93-1.10)), nor with progression-free/disease-specific survival. There was however a survival advantage for users of any NSAIDs in studies clearly defining non-use as less than once per week (pHR=0.89 (0.82-0.98)). CONCLUSIONS: Although this study did not show a clear association between analgesic use and ovarian cancer survival, further investigation with clearer definitions of use and information about post-diagnosis use is warranted.

Lymphadenectomy in Early-Stage Intermediate-/High-Risk Endometrioid Endometrial Cancer: Clinical Characteristics and Outcomes in an Australian Cohort.

OBJECTIVE: The role of lymphadenectomy (LND) in early-stage endometrial cancer (EC) remains controversial. Previous studies have included low-risk patients and nonendometrioid histologies for which LND may not be beneficial, whereas long-term morbidity after LND is unclear. In a large Australian cohort of women with clinical early-stage intermediate-/high-risk endometrioid EC, we analyzed the association of LND with clinicopathological characteristics, adjuvant treatment, survival, patterns of disease recurrence, and morbidity. MATERIALS AND METHODS: From a larger prospective study (Australian National Endometrial Cancer Study), we analyzed data from 328 women with stage IA grade 3 (n = 63), stage IB grade 1 to 3 (n = 160), stage II grade 1 to 3 (n = 71), and stage IIIC1/2 grade 1 to 3 (n = 31/3) endometrioid EC. Overall survival (OS) was estimated using Kaplan-Meier methods. The association of LND with OS was assessed using Cox regression analysis adjusted for age, stage, grade, and adjuvant treatment. The association with risk of recurrent disease was analyzed using logistic regression adjusted for age, stage, and grade. Morbidity data were analyzed using χ2 tests. RESULTS: Median follow-up was 45.8 months. Overall survival at 3 years was 93%. Lymphadenectomy was performed in 217 women (66%), 16% of this group having positive nodes. Median node count was 12. There were no significant differences in OS between LND and no LND groups, or by number of nodes removed. After excluding stage IB grade 1/2 tumors, there was no association between LND and OS among a "high-risk" group of 190 women with a positive node rate of 24%. However, a similar cohort (n = 71) of serous EC in the Australian National Endometrial Cancer Study had improved survival after LND. Women who underwent LND had significantly higher rates of critical events (5% vs 0%, P = 0.02) and lymphoedema (23% vs 4%, P < 0.0001). CONCLUSIONS: In this cohort with early-stage intermediate-/high-risk endometrioid EC, LND did not improve survival but was associated with significantly increased morbidity.

Assessing the genetic architecture of epithelial ovarian cancer histological subtypes.

Epithelial ovarian cancer (EOC) is one of the deadliest common cancers. The five most common types of disease are high-grade and low-grade serous, endometrioid, mucinous and clear cell carcinoma. Each of these subtypes present distinct molecular pathogeneses and sensitivities to treatments. Recent studies show that certain genetic variants confer susceptibility to all subtypes while other variants are subtype-specific. Here, we perform an extensive analysis of the genetic architecture of EOC subtypes. To this end, we used data of 10,014 invasive EOC patients and 21,233 controls from the Ovarian Cancer Association Consortium genotyped in the iCOGS array (211,155 SNPs). We estimate the array heritability (attributable to variants tagged on arrays) of each subtype and their genetic correlations. We also look for genetic overlaps with factors such as obesity, smoking behaviors, diabetes, age at menarche and height. We estimated the array heritabilities of high-grade serous disease ([Formula: see text] = 8.8 ± 1.1 %), endometrioid ([Formula: see text] = 3.2 ± 1.6 %), clear cell ([Formula: see text] = 6.7 ± 3.3 %) and all EOC ([Formula: see text] = 5.6 ± 0.6 %). Known associated loci contributed approximately 40 % of the total array heritability for each subtype. The contribution of each chromosome to the total heritability was not proportional to chromosome size. Through bivariate and cross-trait LD score regression, we found evidence of shared genetic backgrounds between the three high-grade subtypes: serous, endometrioid and undifferentiated. Finally, we found significant genetic correlations of all EOC with diabetes and obesity using a polygenic prediction approach.

'As many options as there are, there are just not enough for me': contraceptive use and barriers to access among Australian women.

OBJECTIVE: A comprehensive life course perspective of women's experiences in obtaining and using contraception in Australia is lacking. This paper explores free-text comments about contraception provided by women born between 1973 and 1978 who participated in the Australian Longitudinal Study on Women's Health (ALSWH). METHODS: The ALSWH is a national population-based cohort study involving over 40,000 women from three age groups, who are surveyed every three years. An initial search identified 1600 comments from 690 women across five surveys from 1996 (when they were aged 18-23 years) to 2009 (31-36 years). The analysis included 305 comments from 289 participants. Factors relating to experiences of barriers to access and optimal contraceptive use were identified and explored using thematic analysis. RESULTS: Five themes recurred across the five surveys as women aged: (i) side effects affecting physical and mental health; (ii) lack of information about contraception; (iii) negative experiences with health services; (iv) contraceptive failure; and (v) difficulty with accessing contraception. CONCLUSION: Side effects of hormonal contraception and concerns about contraceptive failure influence women's mental and physical health. Many barriers to effective contraception persist throughout women's reproductive lives. Further research is needed into reducing barriers and minimising negative experiences, to ensure optimal contraceptive access for Australian women.

A comparison of clinical, utilization, and cost outcomes between oral treatments for multiple sclerosis.

BACKGROUND: Multiple sclerosis (MS) affects nearly 1 million people in the United States and causes significant disability and economic loss. Among the first available oral MS treatment options, clinical outcome comparisons and associated health care resource utilization are not clearly defined. OBJECTIVE: To compare MS outcomes, health care resource utilization, and relative costs across treatment with dimethyl fumarate (DMF), fingolimod (FG), or teriflunomide (TERI) among Medicare Advantage Prescription Drug (MAPD) plan and commercially insured beneficiaries. METHODS: This retrospective cohort study used the Humana Research Database. Eligible study patients had their first MS medication claim for oral DMG, FG, or TERI between January 1, 2013, and December 31, 2018. Patients were followed for a minimum of 12 months (mean follow-up = 3.8 years), until the earliest of the following occurred: health plan disenrollment, the end of the study period, or death. Study cohorts were balanced with inverse probability of treatment weighting. All-cause and MS-related health care resource utilization, time on therapy, and time after therapy were compared using inverse probability of treatment-adjusted multivariate generalized linear models across treatment groups. Relative costs were compared using a generalized linear model with a gamma distribution and log link. RESULTS: We identified 1,442 patients in 3 medication groups: DMF (n = 843), FG (n = 213), and TERI (n = 386). After weighting, there were no significant differences between the medication groups on demographic and clinical characteristics. Time on therapy (days) was significantly different across medication groups (P < 0.001). Time on therapy was longest for FG compared with the DM and TERI groups (644 vs 462 vs 521). The number discontinuing the index medication was significantly different for FG vs DMF vs TERI (74.7% vs 85.3% vs 80.7%; P < 0.001). FG had the lowest discontinuation rate. The mean (SD) annualized relapse rates (ARRs) were 0.47 (0.80), 0.42 (1.3), and 0.53 (1.3) (P = 0.037) for DMF, FG, and TERI, respectively. The percentage of those experiencing inpatient stays and the number of stays (mean [SD]) were significantly different among the FG group vs DMF vs TERI (29.9% vs 34.1% vs 40.9%; P < 0.001) and (0.57 [2.9] vs 0.74 [1.9] vs 0.91 [3.5]; P = 0.007), respectively. All-cause emergency department visits and the number of visits (mean [SD]) were significantly different for the FG cohort vs DMF vs TERI (46% vs 54.3% vs 61%; P < 0.001) and (1.84 [7.7] vs 2.38 [5.9] vs 2.87 [8.8]; P = 0.002), respectively. FG had the lowest impatient stays and emergency department visits of the 3 groups. CONCLUSIONS: Patients with MS initiated on FG used fewer health care resources and experienced lower ARR compared with patients on DMF and TERI.

Medication adherence star ratings measures, health care resource utilization, and cost.

OBJECTIVE: To examine the association between missed CMS Star Ratings quality measures for medication adherence over 3 years for diabetes, hypertension, and hyperlipidemia medications (9 measures) and health care utilization and relative costs. STUDY DESIGN: Retrospective cohort study. METHODS: The study examined eligible patients who qualified for the diabetes, statin, and renin-angiotensin system antagonist medication adherence measures in 2018, 2019, and 2020 and were continuously enrolled in a Medicare Advantage prescription drug plan from 2017 through 2021. A total of 103,900 patients were divided into 4 groups based on the number of adherence measures missed (3 medication classes over 3 years): (1) missed 0 measures, (2) missed 1 measure, (3) missed 2 or 3 measures, and (4) missed 4 or more measures. To achieve a quality measure, patients had to meet the Pharmacy Quality Alliance 80% threshold of proportion of days covered during the calendar year. RESULTS: The mean age of the cohort was 71.1 years, and 49.9% were female. Compared with patients who missed 0 of 9 adherence measures, those who missed 1 measure, 2 or 3 measures, and 4 or more measures experienced 12% to 26%, 22% to 42%, and 24% to 50% increased risks, respectively, of all-cause and diabetes-related inpatient stays and all-cause and diabetes-related emergency department visits (all  P  values < .01). Additionally, patients who missed 1, 2 or 3, and 4 or more adherence measures experienced 14%, 19%, and 20% higher monthly medical costs, respectively. CONCLUSIONS: Missing Star Ratings quality measures for medication adherence was associated with an increased likelihood of health care resource utilization and increased costs for patients taking medications to treat diabetes, hypertension, and hyperlipidemia.

Transition-to-dialysis planning, health care use, and mortality in end-stage renal disease.

OBJECTIVES: To evaluate the association of dialysis transition planning factors (eg, nephrologist care, vascular access placement, place of dialysis) with inpatient (IP) stays, emergency department (ED) visits, and mortality. STUDY DESIGN: Retrospective cohort study. METHODS: We used the Humana Research Database to identify 7026 patients with a diagnosis of end-stage renal disease (ESRD) in 2017 who were enrolled in a Medicare Advantage Prescription Drug plan with at least 12 months preindex enrollment, with first ESRD evidence as the index date. Patients with kidney transplant, hospice election, or dialysis preindex were excluded. Transition-to-dialysis planning was defined as optimal (vascular access placed), suboptimal (nephrologist care, but no vascular access), or unplanned (first dialysis in IP stay or ED visit). RESULTS: The cohort was 41% female and 66% White, with a mean age of 70 years. Optimally planned, suboptimally planned, and unplanned transition to dialysis occurred for 15%, 34%, and 44% of the cohort, respectively. Among patients with preindex chronic kidney disease (CKD) stages 3a and 3b, 64% and 55%, respectively, had an unplanned dialysis transition. For patients with preindex CKD stages 4 and 5, 68% and 84%, respectively, had a planned transition. In adjusted models, patients with a suboptimally or optimally planned transition were 57% to 72% less likely to die, 20% to 37% less likely to experience an IP stay, and 80% to 100% more likely to experience an ED visit than patients with an unplanned dialysis transition. CONCLUSIONS: A planned transition to dialysis was associated with reduced odds of IP stays and lower mortality.

Early vs late filling of new heart failure prescription and its association with avoidable hospital admissions.

BACKGROUND: Individuals with heart failure (HF) are at increased risk for hospitalization and readmission after discharge. The impact of timing to new prescription filling on avoidable HF hospitalization is understudied in HF management. The Agency of Healthcare Research and Quality identifies HF-related inpatient admissions as potentially avoidable if they could be managed successfully in outpatient settings. OBJECTIVE: To compare avoidable HF hospitalization rate and all-cause and HF-related costs in patients who were early fillers (≤30 days) vs late fillers (>30 days) of newly prescribed HF medications following an HF-related inpatient stay or emergency department visit. METHODS: This retrospective cohort study used the Humana Research Database to identify patients with at least 1 claim for a new HF medication from January 1, 2018, to June 30, 2019. Eligible patients were enrolled in a Medicare Advantage Prescription Drug plan for at least 12 months pre-index and 6-months post-index (ie, first new HF prescription). Individuals who were early (n = 794) vs late fillers (n = 397) were propensity-score matched in a 2:1 ratio to balance baseline characteristics. A logistic regression model was fitted to compare avoidable HF hospitalization in those who were late fillers vs early fillers. Mean cost differences were compared using paired t-test. Outcomes were measured 6-months post-index. RESULTS: Late fillers had greater odds of experiencing an avoidable HF hospitalization compared with early fillers (odds ratio = 1.65; P = 0.001). Late filling was associated with a 49.5% increase in average all-cause medical costs (P < 0.0001), a 13.6% decrease in average all-cause pharmacy costs (P = 0.0929), and a 39.4% increase in average all-cause total costs (P < 0.0001). HF-related costs showed similar trends. CONCLUSION: Compared with patients who filled their prescription within 30 days of discharge following an HF admission, those who delayed the filling of a new HF prescription experienced increased likelihood of an avoidable readmission, and late filling was associated with increased 6-month total and medical costs. DISCLOSURES: Humana Healthcare Research, Inc., funded the research and article development. No external funds were used in the creation of this work. All authors are/were employees of Humana Inc. and/or Humana Healthcare Research, Inc., at the time of the work.

HIV preexposure prophylaxis treatment patterns in a national health plan population.

BACKGROUND: Medication nonadherence diminishes the benefits of preexposure prophylaxis (PrEP) for the 1.2 million Americans at risk for HIV exposure. OBJECTIVE: To describe HIV PrEP treatment patterns among Medicare Advantage Prescription Drug (MAPD) plan and commercially insured beneficiaries. METHODS: This retrospective cohort study identified patients aged 16 to 89 years with at least 1 dispensing of emtricitabine-tenofovir disoproxil fumarate from July 2012, through December 2020, or emtricitabine-tenofovir alafenamide from October 2019 through December 2020, and who were continuously enrolled at least 12 months prior to and following the earliest PrEP claim. Outcomes were HIV PrEP adherence measured by proportion of days covered (PDC) using 2 binary thresholds of 0.60 (4 doses/week) and 0.80 (5-6 doses/week) and duration of index treatment episode, total time on treatment, and total number of prescription fills. RESULTS: The study cohort of 707 (292 MAPD plan, 415 commercial) was predominantly made up of male patients (90.0%) and resided in the South (78.9%) with a mean age of 46.2 years (MAPD plan: 54.5, commercial: 40.4). Both populations engaged in high-risk sexual behavior (All: 18.7%, MAPD plan: 16.8%, commercial: 20.0%) and experienced sexually transmitted infections (All: 3.3%, MAPD plan: 2.1%, commercial: 4.1%). The mean index treatment episode length was 297.0 days (MAPD plan: 283.6, commercial: 306.5). Total time on treatment was 477.3 days (MAPD plan: 450.7, commercial 496.0). At 3 months, 84.9% (MAPD plan: 83.6%, commercial: 85.8%) and at 12 months, 58.7% (MAPD plan: 57.2, commercial: 59.8) of patients achieved a PDC of at least 0.80. At 3 months, 100.0% (MAPD plan: 100.0%, commercial: 100.0%), and at 12 months, 74.3% (MAPD plan: 70.2%, commercial: 76.9%) of patients achieved a PDC of at least 0.60. The cohort had a mean of 16.4 fills of 30 days (MAPD plan: 16.4, commercial: 16.3) supply. CONCLUSIONS: There is an opportunity for clinical programs to focus on improving longer-term PrEP adherence among individuals at risk for HIV exposure.

Association of medication adherence quality measures for diabetes, hypertension, and hyperlipidemia with cognitive decline.

Background: While diabetes, hypertension, and hyperlipidemia each are associated with increased risk of cognitive decline, little is known regarding how nonadherence to medications for these conditions is associated with cognitive decline risk. Methods: We identified patients enrolled in a Medicare Advantage Prescription Drug plan who were eligible for inclusion in the CMS Star Medication Adherence quality measures for diabetes, hypertension, and hyperlipidemia in 2018, 2019, and 2020. To achieve an adherence quality measure, patients had to meet 80% of the proportion of days for the medication. We used propensity score with inverse probability of treatment weighting to balance outcomes for baseline characteristics and logistic regression models to compare odds of cognitive decline outcomes across patient groups. Results: The study population of 99,774 individuals had a mean age of 71.0 years and was 49.1% female, 73.9% White, and 17.8% Black, with 62.0% living in an urban setting. Compared with patients who missed zero adherence measures, those who missed one measure had 23%-33% increased odds of cognitive decline (any decline OR = 1.23; dementia OR = 1.33; Alzheimer's disease OR = 1.27; all P values <0.01). Patients who missed 2-3 measures had 37%-96% increased odds of cognitive decline (any decline OR = 1.37; dementia OR = 1.58; Alzheimer's disease OR = 1.96; all P values <0.01). Patients who missed ≥4 adherence measures had the greatest odds of cognitive decline (any decline OR = 1.64; dementia OR = 2.05; Alzheimer's disease OR = 2.48; all P values <0.01). Conclusion: Not achieving CMS Star Medication Adherence quality measures for diabetes, hypertension, and hyperlipidemia therapies was associated with increased risk of cognitive decline outcomes.

Association of prenatal stress with distance to delivery for pregnant women in Western North Carolina.

PURPOSE: Rural areas throughout the US continue to see closures of maternity wards and decreasing access to prenatal and intrapartum care. Studies examining closure's impacts have demonstrated both positive and negative effects on maternal and neonatal outcomes of mortality and morbidity. Our study aims to build on growing evidence from Canada and Scandinavia that suggests increased travel time to give birth is associated with increased emotional and financial stress for rural pregnant women. METHODS: Pregnant patients at 7 clinic sites in western North Carolina were invited to complete the Rural Pregnancy Experience Scale (RPES) while waiting for their prenatal appointments. Results were analyzed using adjusted linear regressions to examine the correlation between RPES scores and self-reported distance to anticipated birth location as well as RPES scores with recent local labor and delivery closure. FINDINGS: A total of 174 participants completed the survey and met inclusion criteria. For every 10 min increase in travel distance to the patient's anticipated place of delivery, RPES scores increased by an average of 0.72 points. Participants who reported a recent labor and delivery unit closure near them saw average increases of 2.52 on the RPES. CONCLUSIONS: Our findings are consistent with the growing body of literature internationally that demonstrates the distance required to travel to delivery location is associated with increased stress among rural pregnant women.

The role of integrated medical and prescription drug plans in addressing racial and ethnic disparities in medication adherence.

Medication nonadherence in the United States contributes to 125,000 deaths and 10% of hospitalizations annually. The pain of preventable deaths and the personal costs of nonadherence are borne disproportionately by Black, Latino, and other minority groups because nonadherence is higher in these groups due to a variety of factors. These factors include socioeconomic challenges, issues with prescription affordability and convenience of filling and refilling them, lack of access to pharmacies and primary care services, difficulty taking advantage of patient engagement opportunities, health literacy limitations, and lack of trust due to historical and structural discrimination outside of and within the medical system. Solutions to address the drivers of lower medication adherence, specifically in minority populations, are needed to improve population outcomes and reduce inequities. While various solutions have shown some traction, these solutions have tended to be challenging to scale for wider impact. We propose that integrated medical and pharmacy plans are well positioned to address racial and ethnic health disparities related to medication adherence. DISCLOSURES: This study was not supported by any funding sources other than employment of all authors by Humana Inc. Humana products and programs are referred to in this article.

Exploration of the Effects of Rural Obstetric Unit Closures on Birth Outcomes in North Carolina.

PURPOSE: Closures of rural labor and delivery (L/D) units have prompted national and state-based efforts to assess the impact on birth outcomes. This study explores local effects of L/D closures in rural areas of North Carolina (NC). METHODS: This is a retrospective cohort study of birth outcomes of 4,065 women in 5 rural areas of NC with L/D unit closures between 2013 and 2017. Outcomes were abstracted from birth certificate data from the NC Vital Statistics Reporting System. Localized outcomes 1 year prior to L/D unit closure were compared with outcomes 1 and 2 years post closure, including: (1) birth location and demographics, (2) change in travel patterns for birth, and (3) birth outcomes, including rates of labor induction, cesarean deliveries, maternal morbidity, and neonatal outcomes. FINDINGS: Before closures, 25%-56% of deliveries occurred outside county of residence. Commercially insured and college-educated women were more likely to deliver out-of-area. Closures increased travel distance to delivery hospital an average of 7-27 miles. In 2 areas, cesarean delivery rates decreased despite an increase in labor inductions. There was also variability between areas in prenatal care adequacy and breastfeeding. CONCLUSIONS: We found that L/D unit closures in rural NC disproportionately affected women on Medicaid. The impact showed area-specific variability, highlighting effects potentially masked by statewide or national analyses. Implications for future L/D closures would be eased by regional coordination and planning to mitigate negative effects, and state and national policies should address the excess burden placed on vulnerable populations.

Management of Cancer Cachexia: ASCO Guideline.

PURPOSE: To provide evidence-based guidance on the clinical management of cancer cachexia in adult patients with advanced cancer. METHODS: A systematic review of the literature collected evidence regarding nutritional, pharmacologic, and other interventions, such as exercise, for cancer cachexia. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and systematic reviews of RCTs published from 1966 through October 17, 2019. ASCO convened an Expert Panel to review the evidence and formulate recommendations. RESULTS: The review included 20 systematic reviews and 13 additional RCTs. Dietary counseling, with or without oral nutritional supplements, was reported to increase body weight in some trials, but evidence remains limited. Pharmacologic interventions associated with improvements in appetite and/or body weight include progesterone analogs and corticosteroids. The other evaluated interventions either had no benefit or insufficient evidence of benefit to draw conclusions on efficacy. Limitations of the evidence include high drop-out rates, consistent with advanced cancer, as well as variability across studies in outcomes of interest and methods for outcome assessment. RECOMMENDATIONS: Dietary counseling may be offered with the goals of providing patients and caregivers with advice for the management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely. In the absence of more robust evidence, no specific pharmacological intervention can be recommended as the standard of care; therefore, clinicians may choose not to prescribe medications specifically for the treatment of cancer cachexia. Nonetheless, when it is decided to trial a drug to improve appetite and/or improve weight gain, currently available pharmacologic interventions that may be used include progesterone analogs and short-term (weeks) corticosteroids.

Inadequate Nutrition Coverage in Outpatient Cancer Centers: Results of a National Survey.

Cancer-related malnutrition is associated with poor health outcomes, including decreased tolerance to cancer therapy, greater treatment toxicities, and increased mortality. Medical nutrition therapy (MNT) optimizes clinical outcomes, yet registered dietitian nutritionists (RDNs), the healthcare professionals specifically trained in MNT, are not routinely employed in outpatient cancer centers where over 90% of all cancer patients are treated. The objective of this study was to evaluate RDN staffing patterns, nutrition services provided in ambulatory oncology settings, malnutrition screening practices, and referral and reimbursement practices across the nation in outpatient cancer centers. An online questionnaire was developed by the Oncology Nutrition Dietetic Practice Group (ON DPG) of the Academy of Nutrition and Dietetics and distributed via the ON DPG electronic mailing list. Complete data were summarized for 215 cancer centers. The mean RDN full-time equivalent (FTE) for all centers was 1.7 ± 2.0. After stratifying by type of center, National Cancer Institute-Designated Cancer Centers (NCI CCs) employed a mean of 3.1 ± 3.0 RDN FTEs compared to 1.3 ± 1.4 amongst non-NCI CCs. The RDN-to-patient ratio, based on reported analytic cases, was 1 : 2,308. Per day, RDNs evaluated and counseled an average of 7.4 ± 4.3 oncology patients. Approximately half (53.1%) of the centers screened for malnutrition, and 64.9% of these facilities used a validated malnutrition screening tool. The majority (76.8%) of centers do not bill for nutrition services. This is the first national study to evaluate RDN staffing patterns, provider-to-patient ratios, and reimbursement practices in outpatient cancer centers. These data indicate there is a significant gap in RDN access for oncology patients in need of nutritional care.

American Society of Clinical Oncology Summit on Addressing Obesity Through Multidisciplinary Provider Collaboration: Key Findings and Recommendations for Action.

OBJECTIVE: Given the increasing evidence that obesity increases the risk of developing and dying from malignancy, the American Society of Clinical Oncology (ASCO) launched an Obesity Initiative in 2013 that was designed to increase awareness among oncology providers and the general public of the relationship between obesity and cancer and to promote research in this area. Recognizing that the type of societal change required to impact the obesity epidemic will require a broad-based effort, ASCO hosted the "Summit on Addressing Obesity through Multidisciplinary Collaboration" in 2016. METHODS: This meeting was held to review current challenges in addressing obesity within the respective health care provider communities and to identify priorities that would most benefit from a collective and cross-disciplinary approach. RESULTS: Efforts focused on four key areas: provider education and training; public education and activation; research; and policy and advocacy. Summit attendees discussed current challenges in addressing obesity within their provider communities and identified priorities that would most benefit from multidisciplinary collaboration. CONCLUSIONS: A synopsis of recommendations to facilitate future collaboration, as well as examples of ongoing cooperative efforts, provides a blueprint for multidisciplinary provider collaboration focused on obesity prevention and treatment.