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

项目摘要-摘要 服药依从性差是可预防的发病率和死亡率的主要原因， 社会经济地位(SES)不符合的可能性要高出65%。乳腺癌患者生活在高位 SES地区的五年存活率为84%，而低SES地区的五年存活率为68%，而且有大型SES 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。在这项提案中，我们试图调查这些差异的机制 在坚持HT方面，专注于潜在的可补救的健康提供问题。具体地说，我们的目标是1)检查 SES在坚持口服荷尔蒙乳腺癌治疗方面的差异程度及其与 全国所有年龄段的乳腺癌患者队列中的死亡率差异，2)分解 遵守的潜在机制(支付能力、用药复杂性和药房可获得性) 差异和3)模拟替代护理策略和政策对HT依从性、乳房的影响 癌症死亡率和SES在其中的差异。这些目标将通过分析当代的 从Optom美国数据集中确定的女性乳腺癌发病队列，该数据集包含 超过3500万人的社会人口、经济(包括净资产)、医疗和药品信息 由私人和公共保险承保的患者，我们将与药房距离措施联系起来。我们会 首先检查SES、依从性和死亡率的测量之间的关系，然后寻求 根据每个潜在因素(或一组)的贡献来分摊SES遵守方面的差异 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特定依附性的净贡献和其中的差异，我们将使用参数 在目标1中生成的估计数，用于模拟替代政策或干预措施的预期效果(不断变化 补贴门槛，改善再灌装同步性)，以减少乳腺癌治疗和 结果。我们的目标是为政策制定者、计划管理员、研究人员和倡导团体提供 对可能解释乳腺癌患者SES差异的健康提供因素的更好理解 结果，并着眼于制定有效的战略来消除这些结果。通过将重点放在 在各个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，并直接为确定如何最好地分配资源用于癌症和其他慢性疾病的努力提供信息 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.