SES Disparities in Breast Cancer: Effect of Pharmaceutical Coverage

描述（由申请人提供）：传统上，乳腺癌被认为是一种基于社会经济地位（SES）的反向差异的疾病;也就是说，社会经济水平较低的妇女的发病率和死亡率较低。然而，在过去二十年中，这种情况发生了变化。尽管与富裕人群相比，贫困人群的乳腺癌发病率仍低10-20%，但到20世纪90年代末，居住在贫困社区的乳腺癌患者的生存率比居住在富裕社区的患者低20-30%。SES较低人群的生存率较低可能至少部分归因于较少使用有效但昂贵的口服药物，这些药物可用于治疗绝经后乳腺癌。2006年医疗保险受益人D部分（药品）保险的出现提供了一个机会来检验这一假设，即药品保险的提供将减少在使用辅助激素和其他口服药物治疗方面的社会经济差异，因此将减少生存方面的社会经济差异。该项目的具体目标是：1）在符合Medicare资格的乳腺癌患者队列中，确定参加Medicare Part D计划的患者的特征，特别关注社区社会经济地位和共病状况。2)确定老年乳腺癌幸存者队列中SES、D部分入组、合并症和死亡率之间的关系。3)检查辅助激素治疗在乳腺癌D部分入组者中的使用，并通过SES评估其与死亡率差异的关系。这些目标将通过对医疗保险乳腺癌患者的系列队列进行分析来实现。将采用一种经过验证和公布的算法来确定2001-2008年接受初步治疗的医疗保险乳腺癌幸存者的国家样本。对人口普查区域的地址进行地理编码将允许确定社区SES。总体死亡率和疾病特异性死亡率的三年和五年结果将使用医疗保险索赔和国家死亡指数数据来确定。分析将采用不同的方法（工具变量和倾向评分）来控制选择参加Medicare Part D计划的内分泌。针对具体目标3的分析将利用医疗保险D部分制药数据，这是一种新的数据源。该项目将对乳腺癌生存领域以及那些有兴趣减少该疾病结果差异的人具有重大意义。它还将为政策制定者提供有关初出茅庐的D部分计划的关键信息。公共卫生相关性：该项目与公共卫生直接相关，因为它研究了社会经济地位对乳腺癌结果的差异。此外，该项目涉及到卫生政策，通过检查新的医疗保险D部分药物计划的影响，在这些差距的潜在减少。

DESCRIPTION (provided by applicant): Traditionally breast cancer has been thought of as an illness subject to reverse disparities based on socioeconomic status (SES); that is, incidence and mortality rates were lower for women of lower socioeconomic levels. However, during the past two decades this situation changed. Despite breast cancer incidence rates which remained 10-20% lower for poorer populations compared to more affluent populations, breast cancer patients residing in poorer neighborhoods had 20-30% lower survival than those residing in wealthier neighborhoods by the late 1990s. It is likely that the worse survival experience of lower SES populations is attributable at least in part to lesser use of the effective but expensive oral medications that have become available for treating postmenopausal breast cancer. The advent of Part D (pharmaceutical) coverage for Medicare beneficiaries in 2006 provides an opportunity to examine the hypothesis that the availability of pharmaceutical insurance coverage will reduce socioeconomic disparities with respect to the use of adjuvant hormonal and other oral medication therapies, and therefore will reduce socioeconomic disparities in survival. The specific aims of this project are: 1) Determine, among a cohort of Medicare-eligible breast cancer patients, the characteristics of those enrolling in the Medicare Part D program, with special attention to neighborhood socioeconomic status and comorbid conditions. 2) Determine the relationship of SES, Part D enrollment, comorbidity, and mortality among a cohort of older breast cancer survivors. 3) Examine the use of adjuvant hormone therapy among breast cancer Part D enrollees and evaluate its relationship to mortality disparities by SES. These aims will be carried out by analysis of serial cohorts of Medicare breast cancer patients. A validated and published algorithm will be employed to identify national samples of Medicare breast cancer survivors with initial treatment in 2001-2008. Geocoding of addresses to census tracts will permit determination of neighborhood SES. Three-year and five-year outcomes of overall mortality and disease-specific mortality will be ascertained using Medicare claims and National Death Index data. Analyses will employ different approaches (instrumental variables and propensity scores) to controlling for endogeneity in the choice to enroll in the Medicare Part D program. Analyses to address Specific Aim 3 will utilize Medicare Part D pharmaceutical data, a novel data source. This project will have major significance for the field of breast cancer survivorship, and for those interested in reducing disparities in outcomes for that disease. It will also provide critical information to policy-makers regarding the fledgling Part D program. Public Health Relevance: This project is directly relevant to public health, as it examines disparities in breast cancer outcomes by socioeconomic status. In addition, the project relates to health policy by examining the effect of the new Medicare Part D pharmaceutical program with respect to a potential reduction in those disparities.