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- Title
Socioeconomic Deprivation and Health Care Use in Patients Enrolled in SWOG Cancer Clinical Trials.
- Authors
Hershman, Dawn L.; Vaidya, Riha; Till, Cathee; Barlow, William; LeBlanc, Mike; Ramsey, Scott; Unger, Joseph M.
- Abstract
Key Points: Question: What is the association between socioeconomic factors and emergency department (ED) visits and hospital stays (HS) among individuals enrolled in Medicare who participate in cancer clinical trials? Findings: In this cohort study of 3027 patients aged 65 years or older who participated in a cancer clinical trial and had Medicare, 36.1% had an ED visit and 32.4% had an HS. Patients who lived in areas with the most socioeconomic deprivation had a 62% increase in risk of either an ED visit or HS; patients eligible for both Medicare and Medicaid were 96% more likely to have an ED visit. Meaning: These findings suggest that despite participation in cancer clinical trials, older patients living in areas with higher socioeconomic deprivation and those who are dual eligible for Medicaid and Medicare, which is a marker of economic disadvantage, have an increased risk of unplanned emergency care use. This cohort study examines whether emergency department visits and hospital stays within 12 months of trial enrollment are more common among Medicare enrollees who live in areas of socioeconomic deprivation or have Medicaid insurance. Importance: Reducing acute care use is an important strategy for improving value. Patients with cancer are at risk for unplanned emergency department (ED) visits and hospital stays (HS). Clinical trial patients have homogeneous treatment; despite this, structural barriers to care may independently impact acute care use. Objective: To examine whether ED visits and HS within 12 months of trial enrollment are more common among Medicare enrollees who live in areas of socioeconomic deprivation or have Medicaid insurance. Design, Setting, and Participants: This cohort study included patients with cancer who were 65 years or older and treated in SWOG Cancer Research Network trials from 1999 to 2018 using data linked to Medicare claims. Data were collected from 1999 to 2019 and analyzed from 2022 to 2024. Main Outcomes and Measures: Outcomes were ED visits, HS, and costs in the first year following enrollment. Neighborhood socioeconomic deprivation was measured using patients' zip code linked to the Area Deprivation Index (ADI), measured on a 0 to 100 scale for increasing deprivation and categorized into tertiles (T1 to T3). Type of insurance was classified as Medicare with or without commercial insurance vs dual Medicare and Medicaid. Demographic, clinical, and prognostic factors were captured from trial records. Multivariable regression was used, and the association of ADI and insurance with each outcome was considered separately. Results: In total, 3027 trial participants were analyzed. The median (range) age was 71 (65-98) years, 1280 (32.3%) were female, 221 (7.3%) were Black patients, 2717 (89.8%) were White patients, 90 (3.0%) had Medicare and Medicaid insurance, and 660 (22.3%) were in the areas of highest deprivation (ADI-T3). In all, 1094 patients (36.1%) had an ED visit and 983 patients (32.4%) had an HS. In multivariable generalized estimating equation, patients living in areas categorized as ADI-T3 were more likely to have an ED visit (OR, 1.34; 95% CI, 1.10-1.62; P =.004). A similar but nonsignificant pattern was observed for HS (OR, 1.36; 95% CI, 0.96-1.93; P =.08). Patients from areas with the highest deprivation had a 62% increase in risk of either an ED visit or HS (OR, 1.62; 95% CI, 1.25-2.09; P <.001). Patients with Medicare and Medicaid were 96% more likely to have an ED visit (OR, 1.96; 95% CI, 1.56-2.46; P <.001). Conclusions and Relevance: In this cohort of older patients enrolled in clinical trials, neighborhood deprivation and economic disadvantage were associated with an increase in ED visits and HS. Efforts are needed to ensure adequate resources to prevent unplanned use of acute care in socioeconomically vulnerable populations.
- Subjects
RESEARCH funding; SOCIOECONOMIC factors; PRIMARY health care; CLINICAL trials; MULTIVARIATE analysis; LONGITUDINAL method; ODDS ratio; CONFIDENCE intervals; DATA analysis software; REGRESSION analysis
- Publication
JAMA Network Open, 2024, Vol 7, Issue 3, pe244008
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.4008