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，社会经济地位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。尽管贫困人群的乳腺癌发病率比富裕人群低10-20%，但到20世纪90年代末，生活在贫困社区的乳腺癌患者的存活率比生活在富裕社区的乳腺癌患者低20-30%。较低社会经济地位人群较差的生存经历可能至少部分归因于较少使用有效但昂贵的口服药物，这些药物已成为治疗绝经后乳腺癌的可用药物。2006年医疗保险受益人的D部分（药品）保险的出现提供了一个检验假设的机会，即药品保险的可获得性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)在符合医疗保险条件的乳腺癌患者队列中，确定参加医疗保险D部分计划的患者的特征，特别关注社区社会经济状况和合并症。2)确定老年乳腺癌幸存者队列中SES、D部分入组、合并症和死亡率的关系。3)检查乳腺癌D部分受试者中辅助激素治疗的使用情况，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系列队列的分析来实现。将采用一种经过验证和发表的算法来确定2001-2008年接受过初始治疗的医疗保险乳腺癌幸存者的国家样本。对人口普查区的地址进行地理编码，可以确定社区的社会经济地位。使用医疗保险索赔和国家死亡指数数据确定3年和5年总体死亡率和疾病特异性死亡率的结果。分析将采用不同的方法（工具变量和倾向分数）来控制选择参加医疗保险D部分计划的内生性。针对具体目标3的分析将利用医疗保险D部分药物数据，这是一种新的数据源。该项目将对乳腺癌幸存者领域以及对减少该疾病结果差异感兴趣的人具有重大意义。它还将为政策制定者提供有关刚刚起步的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，因为它研究了不同社会经济地位的乳腺癌预后差异。此外，该项目通过审查新的医疗保险D部分制药计划在潜在减少这些差距方面的影响，与卫生政策有关。

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.