Understanding and Improving Quality of Cancer Care in Diverse Underserved Populations

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1 Understanding and Improving Quality of Cancer Care in Diverse Underserved Populations Stephanie B Wheeler, PhD MPH Department of Health Policy & Management

2 Overview Research Interests CDC-Special Interest Project: Using Behavioral Economics to Improve Colorectal Cancer Screening in Disadvantaged Communities Health-e-NC study: Understanding the Role of Primary Care Medical Homes in Breast Cancer Survivorship ACS-Mentored Research Scholar Grant: Improving Endocrine Therapy Use in Racially Diverse Breast Cancer Populations

3 Research Interests Understanding access to and quality of cancer care Screening, treatment, and survivorship Breast, colorectal, H&N, and cervical cancers Reducing outcome disparities By race/ethnicity, age, SES, insurance status, and geography Using epidemiologic, econometric, and decision analytic modeling tools, complemented by qualitative analyses Ensuring accessible, affordable, sustainable cancer care

4 Summary of CDC-SIP Study: Using Behavioral Economics to Improve Colorectal Cancer Screening in Disadvantaged Communities (CDC-SIP ) CRC screening recommended for adults ages (USPSTF), but underutilized (63% of US adults up-to-date) Multiple CRC screening modalities available, and decision preferences for test modalities differ across sub-populations Community Guide recommendations for CRC screening interventions may not meet the needs of vulnerable sub-populations Behavioral economics can help us understand why sub-populations do or don t engage in healthy behaviors and how to intervene

5 Potential Implications of Behavioral Economics for CRC Screening Messenger Use community leaders/sports figures to provide message Incentives Norms Defaults Salience Priming Affect Commitment Ego Provide financial rewards or penalties Establish that the norm is to get screened (e.g., don t provide info on few numbers who get screened) Make people opt-out of screening Provide engaging, personal information about CRC Provide cues throughout waiting room that promote CRC Remove emotions from decision process Encourage pre-commitment of screening Emphasize impact of not being screened on family members/friends ** Our central question is how to best alter these inputs to the CRC screening decision making process to optimize healthy behaviors **

6 CDC-SIP CRC Specific Aims 1. Identify underserved communities in NC in terms of CRC testing rates (publicly insured populations only) 2. Understand preferences and barriers to CRC screening using focus groups and discrete choice experiments in regions identified in Aim 1 3. Develop a health system-focused decision model to prioritize potential intervention strategies to nudge vulnerable populations in NC to get screened for CRC

7 CRC Testing Rates by County (among publicly-insured people turning 50 in , N=27,178) - Map indicates county-specific predicted probabilities of CRC testing from multivariate models, organized into deciles

8 Summary of Health-e-NC Study: Understanding the Role of Primary Care Medical Homes in Breast Cancer Survivorship (UCRF initiative) Breast cancer survivors often fail to receive appropriate and coordinated health care after primary cancer treatment ends, even though clear guidelines exist for clinical management and follow-up (ASCO/NCCN) Medical Homes (MH) are innovative patient-centered care models led by a medical provider with the capacity to direct the provision of comprehensive, high quality, accessible, community-based care Shown to be successful at improving asthma, diabetes, and cardiovascular disease outcomes But had not been evaluated in the context of cancer care NC s innovative and well-regarded primary care MH program, known as Community Care of NC (CCNC), may provide clues as to how MH can improve survivorship care coordination

9 Health-e-NC Findings With input from an expert advisory committee, we compared patterns of breast cancer survivorship care and healthcare utilization for Medicaid beneficiaries enrolled in CCNC versus those not enrolled in CCNC Identified all women diagnosed with stage 0, 1, or 2 breast cancer in through NC Central Cancer Registry (NCCCR) Matched to Medicaid claims data through 2009 (ICISS) Identified cases enrolled in CCNC Examined receipt of mammography, physical exams, and endocrine therapy, within time intervals specified by ASCO/NCCN guidelines Examined ED, inpatient, and outpatient care use, including counts of visits, and expenditures

10 Health-e-NC Findings

11 Summary of ACS Study: Improving Endocrine Therapy Use in Racially Diverse Breast Cancer Populations (MSRG ) Taking endocrine therapy (ET) for at least 5 years after breast cancer diagnosis greatly reduces chance of recurrence (by 40%) and mortality (by one-third) in women with hormone receptor positive (HR+) tumors However, as many as 50% of women prescribed ET do not take it properly (never start or fail to adhere over time) Differential rates of ET use may contribute to higher breast cancer mortality among AA women The reasons why women fail to use ET properly may differ by race; interventions may need to be racially-specific To date, the lack of high quality, comprehensive data on ET use in racially diverse populations has prevented researchers from understanding this issue in detail

12 Overall Objective of Research To improve endocrine therapy use (and eventually breast cancer outcomes) in racially diverse populations Specific Aims 1. Understand in-depth the person-level, providerlevel, regimen-based, and social/structural barriers and facilitators to ET utilization as reported by HR+ AA and non-aa women and by oncology providers in interviews 2. Assess strength and magnitude of multilevel predictors of ET utilization in a racially diverse sample (Carolina Breast Cancer Study-III) 3. Design and test feasibility and acceptability of a culturally-sensitive, behavioral intervention to improve ET utilization among AA and non-aa women

13 Summary of Efforts Thus Far ET Questionnaire designed, piloted in clinic, revised, and finalized Jan-Aug 2011 Embedded in CBCS-III follow-up #2 (18 month) mail-in survey in early fall 2011 FACT-B-ES (Endocrine symptom) Self-reported assessment of ET use (16 questions) Recruited and interviewed 39/48 HR+ women for in-depth interviews about ET use Recruited and interviewed 6/20 breast cancer care providers about their experiences treating patients who are prescribed ET

14 THANK YOU!! UNC (CRC study) - Mike Pignone* - Carmen Lewis - Kristen Hassmiller Lich* - Anne-Marie Meyer - May Guo - Ravi Goyal* - Emily Gillen - Trisha Crutchfield - Jane Laping CDC - Florence Tangka - Lisa Richardson - Ingrid Hall - Judith Lee Smith U of California - Paul Brown UNC (Health-e-NC study) - Marisa Domino - Katie Reeder Hayes* - Hy Muss - Alexis Moore - Tim Smith - Kelly Kohler - Claire Lin MUSC - Cathy Melvin * Indicates multiple collaborations UNC (ACS study) - Jo Anne Earp - Lisa Carey - Carol Golin - Morris Weinberger - Bryan Weiner - Bill Carpenter - Mary Beth Bell - Diane Bloom - Megan Roberts - Seth Tyree* Duke - Jeff Peppercorn