A Randomized Controlled Trial to Improve Health Insurance Literacy and Surveillance among Young Adult Cancer Survivors

摘要 癌症治疗结束后的第一年是为年轻人建立生存护理的关键时期 年龄在26到39岁之间的癌症幸存者接受循证生存护理，包括癌症监测 根据国家指南，复发率在YA幸存者中仍然很低。与此同时，26岁至 39岁是美国成年人中没有保险和保险不足的比例最高的。我们团队的前期工作 表明，YA癌症幸存者报告对他们的健康保险及其服务的了解程度较低， 覆盖，这影响了他们导航护理的能力。这些问题加在一起可能会导致大量获得护理的机会 这对这一人群造成了严重的医疗费用障碍和后果。这一建议解决了迫切需要 提高YA癌症幸存者的健康保险知识，减少财务毒性，从而提高他们的 接受推荐的生存护理的能力。以Andersen和Aday的健康行为模型为指导 服务使用，我们开发并试点测试了YA癌症的4节虚拟患者导航干预 这是一个针对儿童癌症幸存者的试点项目。初步结果支持可行性， 这两个试点试验的可接受性和初步疗效与YA幸存者年龄26至39岁。我们现在 建议进行一项随机对照试验，以测试该计划（“CHAT-S”）改善健康的功效 保险知识，由于医疗费用造成的财务毒性，以及治疗后复发监测， 癌症幸存者年龄在26到39岁之间。我们计划随机分配N=300例（N=200例干预; N=100例常规治疗）YA 乳腺癌、睾丸癌、淋巴瘤、肉瘤和结直肠癌患者， 在过去的一年里，来自犹他州大学医疗保健（UUHC）和山间医疗保健（IH）的14个地点 系统. UUHC和IH有许多农村（20%）和西班牙裔/拉丁裔（18%）YA癌症幸存者;我们将 对这些重要的亚组进行过抽样。我们将确定CHAT-S是否提高了健康保险知识 6个月随访时的财务毒性（主要结局）。此外，UUHC和IH具有综合数据 基础设施，使我们能够捕获电子健康记录和索赔数据，以调查是否 CHAT-S改善了18个月随访时复发的监测护理（次要结局）。我们将 探索版主（例如，农村，种族）的干预效果。最后，为了告知未来的传播， 我们将进行预算影响分析和短期及长期的成本效益分析 分析CHAT-S。该提案涉及国家癌症研究所的目标，即改善对 癌症幸存者和减轻财务毒性。我们将证明，一个虚拟的健康保险素养 干预可以改善YA癌症患者的保险知识、财务毒性和监测护理 幸存者，并提供指导，以改善美国各地的幸存者护理。

ABSTRACT The first year after cancer treatment ends is a critical time to establish survivorship care for young adult (YA) cancer survivors ages 26 to 39. Receipt of evidence-based survivorship care, including surveillance for cancer recurrence based on national guidelines, remain low among YA survivors. At the same time, YAs ages 26 to 39 have the highest rate of both uninsurance and underinsurance among US adults. Our team’s prior work demonstrated that YA cancer survivors report low understanding of their health insurance and the services it covers, which affects their ability to navigate care. Together, these issues can lead to significant access to care barriers and severe medical cost consequences for this population. This proposal addresses the urgent need to improve YA cancer survivors’ health insurance literacy and decrease financial toxicity, thus improving their ability to receive recommended survivorship care. Guided by Andersen and Aday’s Behavioral Model of Health Services Use, we developed and pilot-tested a 4-session virtual patient navigation intervention for YA cancer survivors that was adapted from a pilot program for childhood cancer survivors. Initial results support feasibility, acceptability, and preliminary efficacy of both of these pilot trials with YA survivors ages 26 to 39. We now propose a randomized controlled trial to test the efficacy of this program (“CHAT-S”) to improve health insurance literacy, financial toxicity due to medical costs, and post-treatment surveillance for recurrence among YA cancer survivors ages 26 to 39. We plan to randomize N=300 (N=200 intervention; N=100 usual care) YAs with breast, testicular, lymphoma, sarcoma, and colorectal cancer who have completed initial treatment within the past year from 14 locations in the University of Utah Healthcare (UUHC) and Intermountain Healthcare (IH) systems. UUHC and IH have many rural (20%) and Hispanic/Latinx (18%) YA cancer survivors; we will oversample these important subgroups. We will determine whether CHAT-S improves health insurance literacy and financial toxicity at 6-month follow-up (primary outcomes). Further, UUHC and IH have an integrated data infrastructure which allows us to capture electronic health records and claims data to investigate whether CHAT-S improves surveillance care for recurrence at 18-month follow-up (secondary outcome). We will explore moderators (e.g., rurality, ethnicity) of the intervention effects. Finally, to inform future dissemination, we will conduct a budget impact analysis and a short-term and long-term time horizon cost-effectiveness analysis of CHAT-S. This proposal addresses the National Cancer Institute’s goal of improving the care of cancer survivors and mitigating financial toxicity. We will demonstrate that a virtual health insurance literacy intervention can improve insurance literacy, financial toxicity, and surveillance care among YA cancer survivors, and provide guidance to improving survivorship care across the United States.