Maria Pisu

Health-care access dimensions and ovarian cancer survival: SEER-Medicare analysis of the ORCHiD study

AbstractBackgroundRacial and ethnic disparities in ovarian cancer (OC) survival are well-documented. However, few studies have investigated how health-care access (HCA) contributes to these disparities.MethodsTo evaluate the influence of HCA on OC mortality, we analyzed 2008-2015 Surveillance, Epidemiology, and End Results-Medicare data. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between HCA dimensions (affordability, availability, accessibility) and OC-specific and all-cause mortality, adjusting for patient characteristics and treatment receipt.ResultsThe study cohort included 7590 OC patients: 454 (6.0%) Hispanic, 501 (6.6%) Non-Hispanic (NH) Black, and 6635 (87.4%) NH White. Higher affordability (HR = 0.90, 95% CI = 0.87 to 0.94), availability (HR = 0.95, 95% CI = 0.92 to 0.99), and accessibility scores (HR = 0.93, 95% CI = 0.87 to 0.99) were associated with lower risk of OC mortality after adjusting for demographic and clinical factors. Racial disparities were observed after additional adjustment for these HCA dimensions: NH Black patients experienced a 26% higher risk of OC mortality compared with NH White patients (HR = 1.26, 95% CI = 1.11 to 1.43) and a 45% higher risk among patients who survived at least 12 months (HR = 1.45, 95% CI = 1.16 to 1.81).ConclusionsHCA dimensions are statistically significantly associated with mortality after OC and explain some, but not all, of the observed racial disparity in survival of patients with OC. Although equalizing access to quality health care remains critical, research on other HCA dimensions is needed to determine additional factors contributing to disparate OC outcomes by race and ethnicity and advance the field toward health equity.

Associations of Healthcare Affordability, Availability, and Accessibility with Quality Treatment Metrics in Patients with Ovarian Cancer

Abstract Background: Differential access to quality care is associated with racial disparities in ovarian cancer survival. Few studies have examined the association of multiple healthcare access (HCA) dimensions with racial disparities in quality treatment metrics, that is, primary debulking surgery performed by a gynecologic oncologist and initiation of guideline-recommended systemic therapy. Methods: We analyzed data for patients with ovarian cancer diagnosed from 2008 to 2015 in the Surveillance, Epidemiology, and End Results–Medicare database. We defined HCA dimensions as affordability, availability, and accessibility. Modified Poisson regressions with sandwich error estimation were used to estimate the relative risk (RR) for quality treatment. Results: The study cohort was 7% NH-Black, 6% Hispanic, and 87% NH-White. Overall, 29% of patients received surgery and 68% initiated systemic therapy. After adjusting for clinical variables, NH-Black patients were less likely to receive surgery [RR, 0.83; 95% confidence interval (CI), 0.70–0.98]; the observed association was attenuated after adjusting for healthcare affordability, accessibility, and availability (RR, 0.91; 95% CI, 0.77–1.08). Dual enrollment in Medicaid and Medicare compared with Medicare only was associated with lower likelihood of receiving surgery (RR, 0.86; 95% CI, 0.76–0.97) and systemic therapy (RR, 0.94; 95% CI, 0.92–0.97). Receiving treatment at a facility in the highest quartile of ovarian cancer surgical volume was associated with higher likelihood of surgery (RR, 1.12; 95% CI, 1.04–1.21). Conclusions: Racial differences were observed in ovarian cancer treatment quality and were partly explained by multiple HCA dimensions. Impact: Strategies to mitigate racial disparities in ovarian cancer treatment quality must focus on multiple HCA dimensions. Additional dimensions, acceptability and accommodation, may also be key to addressing disparities.

Health Care Access Dimensions and Racial Disparities in End-of-Life Care Quality among Patients with Ovarian Cancer

Abstract This study investigated the association between health care access (HCA) dimensions and racial disparities in end-of-life (EOL) care quality among non-Hispanic Black (NHB), non-Hispanic White (NHW), and Hispanic patients with ovarian cancer. This retrospective cohort study used the Surveillance, Epidemiology, and End Results–linked Medicare data for women diagnosed with ovarian cancer from 2008 to 2015, ages 65 years and older. Health care affordability, accessibility, and availability measures were assessed at the census tract or regional levels, and associations between these measures and quality of EOL care were examined using multivariable-adjusted regression models, as appropriate. The final sample included 4,646 women [mean age (SD), 77.5 (7.0) years]; 87.4% NHW, 6.9% NHB, and 5.7% Hispanic. In the multivariable-adjusted models, affordability was associated with a decreased risk of intensive care unit stay [adjusted relative risk (aRR) 0.90, 95% confidence interval (CI): 0.83–0.98] and in-hospital death (aRR 0.91, 95% CI: 0.84–0.98). After adjustment for HCA dimensions, NHB patients had lower-quality EOL care compared with NHW patients, defined as: increased risk of hospitalization in the last 30 days of life (aRR 1.16, 95% CI: 1.03–1.30), no hospice care (aRR 1.23, 95% CI: 1.04–1.44), in-hospital death (aRR 1.27, 95% CI: 1.03–1.57), and higher counts of poor-quality EOL care outcomes (count ratio:1.19, 95% CI: 1.04–1.36). HCA dimensions were strong predictors of EOL care quality; however, racial disparities persisted, suggesting that additional drivers of these disparities remain to be identified. Significance: Among patients with ovarian cancer, Black patients had lower-quality EOL care, even after adjusting for three structural barriers to HCA, namely affordability, availability, and accessibility. This suggests an important need to investigate the roles of yet unexplored barriers to HCA such as accommodation and acceptability, as drivers of poor-quality EOL care among Black patients with ovarian cancer.