Biggers Alana, Shi Yushu, Charlson John, Smith Elizabeth C, Smallwood Alicia J, Nattinger Ann B, Laud Purushottam W, Neuner Joan M
Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI.
J Clin Oncol. 2016 Dec 20;34(36):4398-4404. doi: 10.1200/JCO.2016.67.3350. Epub 2016 Oct 24.
Purpose To investigate the role of out-of-pocket cost supports through the Medicare Part D Low-Income Subsidy on disparities in breast cancer hormonal therapy persistence and adherence by race or ethnicity. Methods A nationwide cohort of women age ≥ 65 years with a breast cancer operation between 2006 and 2007 and at least one prescription filled for oral breast cancer hormonal therapy was identified from all Medicare D enrollees. The association of race or ethnicity with nonpersistence (90 consecutive days with no claims for a hormonal therapy prescription) and nonadherence (medication possession rate < 80%) was examined. Survival analyses were used to account for potential differences in age, comorbidity, or intensity of other treatments. Results Among the 25,111 women in the study sample, 77% of the Hispanic and 70% of the black women received a subsidy compared with 21% of the white women. By 2 years, 69% of black and 70% of Hispanic patients were persistent compared with 61% of white patients. In adjusted analyses, patients in all three unsubsidized race or ethnicity groups had greater discontinuation than subsidized groups (white patients: hazard ratio [HR], 1.83; 95% CI, 1.70 to 1.95; black patients: HR, 2.09; 95% CI, 1.73 to 2.51; Hispanic patients: HR, 3.00; 95% CI, 2.37 to 3.89). Racial or ethnic persistence disparities that were present for unsubsidized patients were not present or reversed among subsidized patients. All three subsidized race or ethnicity groups also had higher adherence than all three unsubsidized groups, although with the smallest difference occurring in black women. Conclusion Receipt of a prescription subsidy was associated with substantially improved persistence to breast cancer hormonal therapy among white, black, and Hispanic women and lack of racial or ethnic disparities in persistence. Given high subsidy enrollment among black and Hispanic women, policies targeted at low-income patients have the potential to also substantially reduce racial and ethnic disparities.
目的 探讨通过医疗保险D部分低收入补贴提供的自付费用支持对不同种族或族裔乳腺癌激素治疗持续性和依从性差异的作用。方法 从所有医疗保险D参保者中确定一个全国性队列，该队列由2006年至2007年间接受乳腺癌手术且至少有一张口服乳腺癌激素治疗处方配药记录的65岁及以上女性组成。研究了种族或族裔与治疗不持续（连续90天无激素治疗处方报销记录）和不依从（药物持有率<80%）之间的关联。生存分析用于考虑年龄、合并症或其他治疗强度方面的潜在差异。结果 在研究样本的25111名女性中，77%的西班牙裔和70%的黑人女性获得了补贴，而白人女性中这一比例为21%。到2年时，69%的黑人患者和70%的西班牙裔患者治疗持续，而白人患者中这一比例为61%。在调整分析中，所有三个未获得补贴的种族或族裔组的患者停药率均高于获得补贴的组（白人患者：风险比[HR]，1.83；95%置信区间[CI]，1.70至1.95；黑人患者：HR，2.09；95%CI，1.73至2.51；西班牙裔患者：HR，3.00；95%CI，2.37至3.89）。未获得补贴的患者中存在的种族或族裔持续性差异在获得补贴的患者中不存在或相反。所有三个获得补贴的种族或族裔组的依从性也高于所有三个未获得补贴的组，尽管黑人女性中的差异最小。结论 获得处方补贴与白人、黑人和西班牙裔女性乳腺癌激素治疗持续性的显著改善以及持续性方面种族或族裔差异的消除相关。鉴于黑人和西班牙裔女性中补贴参保率较高，针对低收入患者的政策有可能大幅减少种族和族裔差异。
