Policy-relevant mechanisms of socioeconomic disparities in adherence to oral hormonal therapy for breast cancer

项目摘要 不良的药物依从性是可预防的发病率和死亡率的主要原因，并且低血糖的患者 社会经济地位（SES）的人不遵守的可能性高达65%。乳腺癌患者生活在高 SES地区的五年生存率为84%，而低SES地区为68%， 乳腺癌治疗的差异，特别是使用和坚持激素治疗（HT），可能 造成了这些生存差异。在这个建议中，我们试图调查差异的机制， 在HT依从性方面，重点关注潜在的可补救的健康交付问题。具体而言，我们的目标是：1）检查 SES在坚持口服激素乳腺癌治疗方面的差异程度，以及它们与 所有年龄段的全国乳腺癌发病妇女队列中的死亡率差异，2）分解 依从性的潜在机制（支付能力、药物复杂性和药房可及性） 差异和3）模拟替代护理策略和政策对HT依从性，乳腺癌， 癌症死亡率和SES差异。这些目标将通过分析当代 从Optum美国数据集中确定的乳腺癌发病女性队列，其中包含 超过3500万人的社会人口、经济（包括净资产）、医疗和药物信息 由私人和公共保险覆盖的患者，我们将与药房距离措施联系起来。我们将 开始检查SES、依从性和死亡率之间的关系，然后寻求 根据每个潜在因素（或一组因素）的贡献， 因素），使用基于Oaxaca-Blinder回归的分解方法。最后，在量化了 每个因素对SES特定依从性的净贡献及其差异，我们将使用参数 目标1中产生的估计数，以模拟替代政策或干预措施的预期效果（改变 补贴阈值，改善补充同步），以减少乳腺癌治疗的差异， 结果。我们的目标是为政策制定者、计划管理者、研究人员和倡导社会提供 更好地理解可能解释乳腺癌SES差异的健康提供因素 我们将继续努力，以取得成果，并着眼于制定有效的战略来消除这些现象。通过专注于一个 在所有年龄段的乳腺癌患者中，这项研究将解决一个重要而及时的问题。 问题，并直接告知努力，以确定如何最好地分配资源，在癌症以及其他慢性 条件，以获得最大的价值和公平。

PROJECT SUMMARY-ABSTRACT Poor medication adherence is a leading cause of preventable morbidity and mortality, and patients of low socioeconomic status (SES) are up to 65% more likely to be non-adherent. Breast cancer patients living in high SES areas have 84% five-year survival compared with 68% for low SES, and there are large SES-based differences in breast cancer treatment, particularly use and adherence to hormonal therapy (HT), that likely contribute to these survival differences. In this proposal, we seek to investigate mechanisms for the differences in HT adherence, focusing on potentially remediable health delivery issues. Specifically, we aim to 1) Examine the extent of SES disparities in adherence to oral hormonal breast cancer therapies, and their association with mortality disparities among an all-age, national cohort of women with incident breast cancer, 2) Decompose potential mechanisms (ability to pay, medication complexity, and pharmacy accessibility) of adherence disparities and 3) Simulate the effect of alternative care strategies and policies on HT adherence, breast cancer mortality and SES disparities therein. These aims will be carried out by analyzing a contemporary cohort of women with incident breast cancer identified from the Optum U.S. dataset, which contains sociodemographic, economic (including net worth), medical, and pharmaceutical information for over 35 million patients covered by private and public insurance, which we will link to pharmacy distance measures. We will begin by examining the relationship between measures of SES, adherence and mortality, and then seek to apportion the SES disparities in adherence according to the contribution of each potential factor (or set of factors), using the Oaxaca-Blinder regression-based decomposition approach. Finally, having quantified the net contribution of each factor on SES-specific adherence and differentials therein, we will use parameter estimates generated in Aim 1 to simulate the anticipated effect of alternative policies or interventions (changing subsidy thresholds, improving refill synchronization) in reducing disparities in breast cancer treatment and outcomes. Our goal is to provide policymakers, plan administrators, researchers and advocacy societies with an improved understanding of the health delivery factors that might explain SES disparities in breast cancer outcomes, with an eye to developing effective strategies to eliminate them. By focusing on the experience of a large and diverse cohort of breast cancer patients of all ages, this study will address an important and timely issue, and directly inform efforts to determine how best to allocate resources in cancer as well as other chronic conditions in order to obtain the greatest value and equity.