PURPOSE: High-intensity care with undue suffering among patients with cancer at the end of life (EoL) is associated with poor quality of life. We examined the pattern and predictors of high-intensity care among patients with GI cancer in Puerto Rico. METHODS: This population-based study of data from the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database examined patients with GI cancer who died between 2009 and 2017. EoL care intensity indicators include the following services in the last month before death: emergency room (ER) visits, hospitalizations, intensive care unit (ICU) admissions, life-extending procedures, death in an acute care setting, and the use of chemotherapy in the last 14 days. We used logistic regression models to examine factors associated with EoL care. RESULTS: Four thousand six hundred twenty-nine patients with GI cancer were included in the analysis. We found that 11.0% of patients received chemotherapy, 17.3% had > 1 hospitalization, 9.3% were in the ICU, 18.0% had > 1 ER visit, 39.3% died in an acute care setting, and 8.6% received life-extending procedures. A compound indicator of the aggressiveness of care showed that 54.5% of patients had at least one of the selected aggressive indicators. The multivariable model showed that female patients, patients ≥ 60 years of age, patients enrolled in Medicaid, patients dually eligible for both Medicare and Medicaid, and patients who survived > 1 year were less likely to receive aggressive EoL care. CONCLUSION: Our findings support the urgent need to improve EoL care in Puerto Rico. Further studies are warranted to fully understand EoL care in patients with cancer in Puerto Rico.
Background: Squamous cell carcinoma of the anus (SCCA), caused by human papillomavirus infection (HPV), is the most frequently diagnosed form of anal cancer (85%-90%). SCCA incidence has increased dramatically among the general population in Puerto Rico (nearly 5% annually) and the risk is disproportionately elevated among patients living with HIV. SCCA is preventable through HPV vaccination and screening. Therefore, the study of the cost of anal cancer care could have significant implications for understanding preventable economic burden in Puerto Rico. Objective: Determine the lifetime and phase-specific cost of SCCA cases aged ≥21 diagnosed during 2009-2016 in Puerto Rico. Method: This population-based study used the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database (PRCCR-HILD), which links PRCCR data with health insurance claim data from the principal health insurance companies and the government health plan. PRCCR-HILD has information for almost 90% of Puerto Rico's cancer cases from 2008. We matched SCCA cases and non-cancer control (1:1) by age and sex for each phase of care (initial, continuation, and terminal). SCCA-related costs were calculated by subtracting the costs between SCCA patients and the control group. We used the phase-specific monthly cost estimates combined with survival data, stratified by age and cancer stage (localized, regional, and distance), to calculate the lifetime and average annual cost (discount at 3%) for SCCA. The cost was adjusted to 2019 US dollars using the consumer price index. We used the number of SCCA incident cases for 2019, stratified by age group and multiplied by the lifetime SCCA cost estimates, to calculate the SCCA-related lifetime economic burden for Puerto Rico. Results: Of the 351 patients with SCCA included in this study, the mean age at diagnosis was 64 years, 66.4% were women, 57.6% were diagnosed at a localized stage, and 23.1% were enrolled in private insurance. The overall survival after cancer diagnosis was 18 years. Meanwhile, the average monthly costs per patient were higher in the initial phase ($4,755), followed by the terminal phase ($3,499). The main cost driver in all phases was the outpatient costs. However, inpatient costs increased substantially at the terminal phase of care. The average lifetime cost for patient with SCCA was $137,343 (95% CI: $130,873-$145,241) (2019 US dollars). The average SCCA per year cost was $9,193 (95% CI: $8,744-$9,895), while the SCCA-related lifetime economic burden for 2018 in Puerto Rico was nearly $8.7 million. Conclusion: To our knowledge, this is the first study to describe the cost of SCCA management in Puerto Rico. Although SCCA continues to be relatively rare among the general population, our study shows that the SCCA-related lifetime economic burden is substantial and could continue to rise due to the rising SCCA burden in Puerto Rico. These findings could support the evaluation of the impact of strategies to reduce the SCCA burden through HPV vaccination and anal cancer screening for high-risk populations. Citation Format: Karen J. Ortiz-Ortiz, Axel Gierbolini-Bermúdez, Ana P. Ortiz, Karen Pabón-Cruz, Chi-Fang Wu, Jeslie Ramos-Cartagena, Reydi Morales-Martínez, Ashish A. Deshmukh. Lifetime cost of care associated with squamous cell carcinoma of the anus in Puerto Rico [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A052.
Introduction: Among jurisdictions of the United States, Puerto Rico (PR) has the highest incidence of cervical cancer, and cervical cancer screening (CCS) is below 80%. Public health emergencies have an impact on people's access to health care services. We examined the impact of the public policy implemented by the government of Puerto Rico during the first 5 months of the COVID-19 pandemic in the utilization of CCS for participants of the Government's Public Health Plan. Methodology: This was a retrospective cohort study. A total of 40 government executive orders (issued between March 15 to July 31, 2020) were analyzed according to the level of restrictions they imposed on the population. Three periods with the greatest restrictions were identified: two of them in the government's initial response phase (March 15-30th & March 31st-April 12th) and one in the re-opening phase (July 17-July 31st). We examined the utilization of all modalities of CCS (pap test only and pap + HPV contesting). Rate ratios (RRs) were estimated to compare to CCS rates during periods of 2020 and compared to 2018-2019. Results: In comparison to 2019, CCS decreased during the most restricted period (March 31st-April 12th) of the response phase (RR= 0.19, 95% CI=0.15-0.24 for women 21-29 years; RR= 0.04 95% CI= 0.03-0.05 for women 30-65 years). During the re-opening phase, screening services started to rebound. However, an increase in COVID-19 cases led to another restriction (July 17-July31st), which led to a second phase of decrease in utilization of CCS (RR=0.17, 95% CI=0.13-0.21 for women 21-29 years (RR= 0.09, 95% CI=0.08-0.10 for women 30-65 years). Conclusion: Our results evidence how the public policy implemented as a result of the COVID-19 pandemic in Puerto Rico had a direct impact on the utilization of CCS services in this Hispanic population. Future studies should examine screening patterns and social barriers of service utilization after July 2020 in Puerto Rico. Citation Format: Axel Gierbolini-Bermúdez, Karen Ortiz-Ortiz, Jeslie M Ramos- Cartagena, Kalyani Sonawane, Vivian Colón-Lopez, Ashish Deshmukh, Ana P Ortiz. Impact of COVID-19 public policies on utilization on cervical cancer screening in Puerto Rico during March 15, 2020 to July 31, 2020 [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-252.
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