bluuebunny/crossref_metadata_2025_split huggingface dataset:
End-of-life spending analysis of randomized trial of machine learning nudges to prompt serious illness communication among patients with cancer.
Authors: Parikh Ravi Bharat , Chen Jinbo , Heintz Jonathan , LaPergola Marc , Bilker Warren , Patel Mitesh S , Bekelman Justin E. , Manz Christopher 
Published: June 2023

6515 Background: Early serious illness conversations (SICs) between oncology clinicians and patients in the outpatient setting may improve mood and quality-of-life among patients with cancer. However, the impact of early SIC “nudges” on end-of-life spending is unknown. Methods: This was a secondary analysis of a stepped-wedge randomized trial (NCT03984773) that randomized 9 medical oncology practices and their high-risk patients at a large academic institution to a behavioral intervention to increase SICs (performance reports and peer comparisons; precommitments for high-risk patients; weekly opt-out text prompts before high-risk encounters) vs. standard of care, between June 2019 and April 2020. We identified high-risk patients using a machine learning (ML) algorithm predicting 180-day mortality. This secondary analysis included 1187 (957 intervention, 230 control) patients with complete data who died by December 2020. We abstracted spending (defined as inflation-adjusted reimbursements for acute care [inpatient + ED], office/outpatient care, intravenous chemotherapy, other therapy [e.g. radiation], long-term care, and hospice) from the institution’s accounting system; we captured spending at University of Pennsylvania inpatient, outpatient, and pharmacy settings. To evaluate intervention impacts on spending, we used a two-part model: first, logistic regression to model zero versus nonzero spending, and second, generalized linear models with gamma distribution and log-link function to model daily mean spending in the last 180 days of life. Models were adjusted for clinic and wedge fixed effects and clustered at the oncologist level. Results: Median age at death was 68 years (IQR 15.5), 317 (27%) patients were non-White, and 448 (38%) patients had a SIC prior to death. The intervention was associated with lower mean spending in the last 180 days of life (mean daily spending $377.96 [intervention] vs. $449.92 [control]; adjusted mean difference -$75.33, 95% CI -$136.42, -$14.23 , p = 0.016) (Table), translating to $13,559 total adjusted savings. Intervention patients incurred lower mean daily spending for chemotherapy (adjusted difference -$51.35, p < 0.001), office/outpatient care (-$14.59, p < 0.001), and other therapy (-$10.35, p = 0.043). The intervention was not associated with differences in end-of-life spending for acute care utilization, long-term care, and hospice. Results were consistent for spending in the last 30 and 90 days of life and after adjusting for age, race, and ethnicity. Conclusions: A ML intervention to prompt SICs led to end-of-life savings, driven by decreased chemotherapy and outpatient spending. Clinical trial information: NCT03984773 . [Table: see text]
Biosimilar uptake and cost savings analysis before and after implementation of a pharmacist-driven substitution program within a National Community Oncology Network: One-year follow-up.
Authors: Chang Melody , Li Jenny , Peters Brooke , Winegar Bradley , Carr Robert , Rodriguez Camilo , Kohler-Gerber Ashley , Connor Darell , Freeman Taqyra , Brown Kyle 
Published: June 2023

6516 Background: As of December 2022, 22 of the 40 biosimilar approvals in the United States, are used for the treatment of cancer or for the supportive care of patients with cancer. Our organization is a network of community oncology practices, representing 107 oncologists at 76 locations across 17 states. Because our network faces formulary selection and reimbursement challenges related to a diverse payor mix across multiple states, we sought to see the impact of utilizing regional clinical pharmacists (RCPs) to assist with selection of the most cost-effective biosimilar products. Methods: In October 2021, our network initiated an RCP-driven biosimilar substitution program, whereby the RCP acts as a liaison between providers and financial teams to evaluate existing drug orders and their financial impact. We previously presented data on the financial impact to payors and providers before and after implementation of the program from 4/1/2021 to 4/1/2022. This study evaluates the one-year results following program implementation. Additionally, outcomes related to biosimilar utilization as well as financial impacts to payors, patients, and providers were assessed. Payor savings is defined as the difference of the calculated 80% Medicare ASP+6 for the administered biosimilar compared to the originator; patient savings is defined as the difference of the calculated 20% Medicare ASP+6 co-insurance for the administered biosimilar compared to the originator; provider savings is defined as the difference between the invoiced cost of the biosimilar compared to the originator. Results: By the end of 2022, preferred product utilization was achieved for >90% of bevacizumab, trastuzumab, and rituximab orders. Use of the preferred pegfilgrastim product increased from <20% in 4/2021 to >60% by 12/2022. Use of filgrastim biosimilar product increased from <75% in 4/2021 to >90% by 4/2022, then decreased to 55% by 12/2022 due to trending ASP. Payor preference prevented biosimilar switching in approximately 34% of cases. Conclusions: Use of institution-preferred biosimilar products increased across all agents in this study after implementation of the RCP-driven biosimilar substitution program, except for filgrastim. Significant cost savings were noted for payors, patients, and providers. Barriers to switching to institution-preferred products included non-medical switching requirements by payors, patient assistance and compassionate use programs, and patient and/or provider preferences. [Table: see text]
The impact of adverse financial events on healthcare utilization and treatment costs at the end of life.
Authors: Kwendakwema Chipo Natasha , Li Li , Yu Kaiyue , Khan Hiba , Kestner Shannon , Fedorenko Catherine R. , Kreizenbeck Karma L. , Ramsey Scott David , Shankaran Veena 
Published: June 2023

6517 Background: Patients with cancer are at higher risk of bankruptcy and other adverse financial events (AFEs) compared to similar individuals without cancer. However, little is known about how AFEs affect cancer care, particularly at the end of life (EOL). We investigated the association between AFEs, healthcare utilization, and healthcare costs at the EOL among patients with cancer. Methods: Western Washington Surveillance Epidemiology and End Results (SEER) cancer registry cases were linked to credit records from TransUnion and to claims from commercial payers and Medicare. Patients with AJCC Stage I-IV solid tumors who died between January 2013 and December 2019 and who had continuous enrollment in commercial or Medicare insurance for the 6 months prior to death were included. Emergency department (ED) and inpatient (IP) visits in the last 3 months of life, place of death, and mean healthcare costs per patient (paid by insurer) were compared between patients with versus without AFEs (charge-offs, third-party collections, tax liens, delinquent mortgage payments, foreclosures, or repossessions). A multivariate logistic regression analysis was used to evaluate the association between AFEs, ED or IP visits (>1 of either), and inpatient death, adjusting for sociodemographic factors, comorbidities, payer type, and cancer stage. Two-sample t tests were used to compare mean per-patient costs in the last 6 and 3 months of life among patients with versus without an AFE. Results: A total of 13,545 patients (median age 75, 54% male) were included, of which 15.6% experienced an AFE. Patients with AFEs were more likely to have multiple ED or IP visits (OR 1.19, CI 1.07-1.34) and die in a hospital (OR 1.37, CI 1.22-1.55) (Table). Younger age, higher Carlson Comorbidity Index (CCI), and being partnered were also associated with greater EOL healthcare utilization while race, sex, payer type, and cancer stage were not. Mean total healthcare costs were higher in patients with AFEs than those without in the last 6 months ($66,232, vs. $55,831, p<0.0001) and 3 months ($39,664 vs. $33,638, p<0.0001) of life. Conclusions: We demonstrated an independent association between AFEs as measured in credit records, increased EOL healthcare utilization, and greater per-patient costs in the months before death. These findings suggest that addressing patient financial hardship could improve their EOL experience and decrease healthcare costs. [Table: see text]
Guideline-concordant use of olanzapine as part of a 4-drug antiemetic regimen for high emetic risk chemotherapy across the state of Michigan.
Authors: Bowen Ashley , Mackler Emily R. , DeVries Kelly , Liu Manlan , Griggs Jennifer J. 
Published: June 2023

6519 Background: Chemotherapy-induced nausea and vomiting (CINV) is a feared side effect of cancer treatment. If not adequately controlled, CINV can negatively affect both quality of life and increase the costs of care. Clinical practice guidelines from both ASCO and NCCN recommend inclusion of olanzapine as part of a 4-drug antiemetic regimen in patients receiving high emetic risk chemotherapy (HEC). Uptake of olanzapine has been low, however, in part due to oncologists’ lack of familiarity with the medication, lack of awareness or agreement with the guidelines, and lack of olanzapine inclusion on prepopulated order sets. Current labeling of olanzapine as an antipsychotic poses an additional barrier. The purpose of this project was to increase guideline-concordant prescribing of olanzapine as part of a 4-drug antiemetic regimen in patients receiving HEC in practices that are part of the Michigan Oncology Quality Consortium (MOQC), a physician-led consortium of nearly 90% of oncologists in Michigan. Methods: In 2019, MOQC began measuring guideline-concordant HEC prophylaxis with a 4-drug regimen of olanzapine added to corticosteroids, a 5HT3RA, and an NK1RA as part of its measure set. A quality improvement intervention was initiated that consisted of 1) dissemination of baseline measure performance and regular reporting of practice and state-level performance to MOQC practices, 2) information support through sharing of guidelines at biannual meetings (2019, 2022) and state-wide CINV education to improve prescriber knowledge and beliefs and support the practices in updating prepopulated antiemetic order sets, and 3) addition of value-based reimbursement in 2021 to encourage practice change. Measure performance was assessed using ASCO’s Quality Oncology Practice Initiative (QOPI) program. Results: The patient sample included 5,703 patients. MOQC practices increased the guideline-concordant prescribing of olanzapine as part of a 4-drug antiemetic regimen in patients receiving HEC round over round from R1 2019 to R1 2022 (p<0.0001). Conclusions: MOQC has facilitated increased use of olanzapine as part of a 4-drug antiemetic regimen in patients receiving HEC through practice education, reporting, and value-based reimbursement. Ongoing work will focus on practices with low uptake and on demonstrating the impact of this important practice change on patient outcomes. [Table: see text]
Curating clinical trials: Helping patients find hope by exploring clinical trial opportunities.
Authors: Abdel-Nabi Rhonda , Hossami Mahmoud , Touma Kayla , Nassar Renee , Paunic Milica , Hilal Olla , Zaib Farwa , Rim Claire , Hirmiz Roaa , Hamm Caroline M. 
Published: June 2023

6521 Background: Clinical trials are essential to the advancement of clinical therapies. However, only 5% of cancer patients enroll in clinical trials (CTs) due to limited accessibility. Given that greater participation in CTs is associated with better patient outcomes, patients from smaller centres are at a disadvantage. The Clinical Trials Navigators (CTN) program was established by Hamm (2022) to help patients in smaller communities navigate and enrol in CTs, resulting in clinical trial enrolment of 7% of patients. This study will provide updated results on the impact of the CTN program as it has expanded. Methods: Between March 2019 to September 2022, 241 patients were enrolled in the CTN program. Five Clinical Trials Navigators (CTNs) receive referrals from various sources: physicians, patients, and patient support groups. CTNs review medical information submitted and search five CT registries. Eligibility criteria is scrutinized. A second review of the CT list is conducted by two physicians to ensure accuracy. The number of potential trials is recorded at each step of review. Data collected includes: patient disease, stage, and number of prior therapies, time from referral to death, number of potential trials, number of trials that were phase I or phase II / III / IV, number of outgoing referrals, locations of the identified trials, and successful enrolment onto CTs. Patient information and results were inputted and analysed using REDCap. REB Category A approval has been granted on August 31, 2022. REB approval number is 22-439. Results: 41 Canadian cancer patients used the CTN program. The updated study found that 75.9% of patients were in stage IV of their disease, and 51% had at least two prior lines of therapy. 61.4% of patients deceased at last follow up, with a range of 0.3-37.5 months from CTN program referral to death, and a median of 5.9 months. CTNs identified a range of zero to 26 trials for each patient with a median of three trials: a range of zero to 10 phase I trials were found, and a range of one to eight phase II / III / IV trials were found. 25.5% of patients referred to a CT enrolled onto the recommended trial. The expanded CTN program resulted in CT enrolment of 8.5% of patients that follow-up information is available for. Conclusions: One quarter of patients referred to a CT by the CTN program were successfully enrolled, highlighting the CTN program as a successful tool to identify CTs for cancer patients and improve CT accrual. 8.5% of all patients with available follow-up information that participated in the CTN program were enrolled onto clinical trials. Further investigation into reasoning for early high mortality rates should be assessed. New initiatives to improve uptake of the CTN program are ongoing.
Healthcare coverage, access, and affordability among adult immigrant cancer survivors in the United States.
Authors: Santos Patricia Mae Garcia , Barnes Justin Michael , Shah Kanan , Nogueira Leticia M , Yabroff Robin , Chino Fumiko 
Published: June 2023

6529 Background: Cancer is a leading cause of morbidity and mortality among US immigrants; however, barriers to care remain understudied. This study assessed disparities in health insurance, health care access, and affordability among immigrant cancer survivors in the United States. Methods: Adult cancer survivors aged ≥18 years who participated in the 2019-2022 National Health Interview Survey were classified as 1) natives 2) foreign-born (FB) citizens or 3) noncitizens. Logistic regression tested for associations between nativity/citizenship and insurance, access (i.e., urgent care, emergency room [ER], hospital admissions), and affordability (assessed by social determinants of health [SDoH]: financial hardship, food insecurity, housing assistance). Separate models adjusted for demographics, socioeconomic status, and comorbidities. Results: A total of 8,923 adults (90% natives, 7% FB citizens, 3% noncitizens) were included in the study. There were baseline differences in age <65 (42% natives vs 61% FB citizens vs 76% noncitizens), female sex (57% vs 59% vs 73%), non-White race (15% vs 64% vs 77%), and Hispanic ethnicity (31% vs 62% vs 5%) between groups (all p<0.05). More noncitizens had household incomes <125% of the federal poverty line (12% vs 18% vs 35%). On adjusted analysis, noncitizens were 3x as likely as natives to be uninsured (2.99 [1.36-6.53]; p=0.006) and FB citizens were 2x as likely to have Medicaid (2.10 [1.35-2.35]; p=0.001). Financial hardship was 1.5x more common among FB citizens (1.50 [1.18-1.91]; p<0.001) while receipt of housing assistance was >2x more common among FB citizens (2.98 [1.82-4.88]; p<0.001) and noncitizens (2.37 [1.08-5.22]; p=0.03). While more FB citizens (18%) and noncitizens (33%) were food insecure (vs. 11%), there were no associations with nativity/citizenship (Table). There were no significant differences in health care access across groups. Conclusions: In this nationwide analysis of adult cancer survivors, although there were no differences in health care access/utilization, immigrants and foreign-born citizens had higher rates of uninsurance and affordability concerns—suggestive of barriers to care. This may portend worse health outcomes in cancer survivorship. [Table: see text]
Associations of loneliness and mortality risk among cancer survivors in the United States.
Authors: Zhao Jingxuan , Reese Jennifer B. , Han Xuesong , Yabroff Robin 
Published: June 2023

6531 Background: Loneliness (i.e., the subjective feeling of being isolated from others), has been linked to multiple adverse health outcomes, including chronic conditions such as heart disease, mental health disorders, and higher risk for early mortality. However, associations between loneliness and worse health outcomes have not been thoroughly examined in cancer survivors. This study examined associations between loneliness and mortality risk among cancer survivors in the U.S. Methods: Cancer survivors were identified from the 2008-2018 Health and Retirement Study, a nationally representative longitudinal survey conducted biannually among individuals aged ≥50 years, with follow-up was through December 31, 2020. Loneliness was measured at every 4 years using an abbreviated 11-item version of the UCLA Loneliness Scale Version 3. Example items include feelings of lacking companionship and isolation from others. Items were summed to create total loneliness scores, which were categorized into four levels: 11-12 (low/no loneliness), 13-15 (mild loneliness), 16-19 (moderate loneliness), and 20-33 (high loneliness). Time-varying Cox proportional hazard models were used to examine the association of loneliness and mortality risk among cancer survivors, while accounting for measurements at multiple time points. Sex, marital status, educational attainment, number of health conditions other than cancer, and year since cancer diagnosis were included in multivariable models. Results: Among 5808 person-years, there were 724 deaths during the study period. Compared to the low/no loneliness group, survivors reporting greater loneliness had higher hazard ratios (HR), indicating higher mortality risks; the highest HR observed was among the high loneliness group (HR:1.90, 95%CI:1.58-2.29), following a dose-response association (Table). HRs were attenuated after adjusting for sociodemographic characteristics, but findings were largely unchanged, and HRs remained highest for the high loneliness group (HR:1.71, 95%CI:1.39-2.12). Conclusions: Any elevated loneliness was associated with higher mortality risks among cancer survivors. Programs to screen for loneliness among cancer survivors and to provide social support to those in need are warranted. [Table: see text]
The association between continuity of Medicaid enrollment and cancer survival in young adults diagnosed with cancer.
Authors: Johnson Kimberly J. , Brown Derek J , King Allison A. , Thompson Tess 
Published: June 2023

6538 Background: Disparities in young adult cancer survival between individuals with Medicaid and private insurance have been reported. To further understand the association between insurance-related access to healthcare and young adult cancer survival, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to test two hypotheses: 1) Those linked to Medicaid have lower cancer survival than those not linked, and 2) those with discontinuous enrollment in Medicaid around the time of diagnosis have lower survival than those with continuous enrollment. Methods: SEER-Medicaid linked data from 2006 to 2013 were obtained. Follow-up for vital status was through 2018. We included individuals diagnosed with a first malignant primary cancer diagnosed between 20 to 39 years. We excluded individuals who were linked to Medicaid enrollment records in multiple states during the same year. Individuals were defined as Medicaid-linked if they were linked to Medicaid in any U.S. state or the District of Columbia from 2006 to 2013. Medicaid enrollment was classified as continuous (enrolled within both the three months before and after diagnosis) and discontinuous (enrolled only within the 3 months before or after diagnosis or only at diagnosis). We used survival analysis methods including Kaplan-Meier (KM) curves and Cox Proportional Hazards (PH) regression models to evaluate survival differences in association with Medicaid linkage and enrollment timing after adjusting for race and a measure of census tract poverty. Results: Our analytic dataset included 137,259 young adults, among which there were 22,955 cancer deaths. KM curves showed consistently lower survival probabilities over time in young adults who linked vs. those not linked to Medicaid and in those with discontinuous vs. continuous enrollment (p < .0001). Adjusted Cox PH regression models indicated that those who linked to Medicaid had a 2.19 (95% CI 2.14-2.25) times higher hazard of death vs. those who did not link. Those with continuous and discontinuous Medicaid enrollment had a 1.91 (95% CI 1.84 to 1.99) and 3.32 (95% CI 3.19 to 3.45) times higher hazard of death, respectively, vs. those not linked to Medicaid. Similar patterns were consistently observed for specific cancer types. Conclusions: These results confirm an insurance-associated disparity in a national sample of young adult cancer patients and provide additional information on risks in association with Medicaid enrollment continuity. These results further support the critical need for consistent health insurance coverage in young adults and for additional research to understand social, economic, and access-related factors leading to lower survival in the Medicaid population. Lowering administrative burdens for Medicaid enrollment, eligibility, and renewal are potentially important strategies for improving cancer outcomes.