Trends in Use of Next-Generation Sequencing in Patients With Solid Tumors by Race and Ethnicity After Implementation of the Medicare National Coverage Determination

Autor: Daniel M. Sheinson, William B. Wong, Craig S. Meyer, Stella Stergiopoulos, Katherine T. Lofgren, Carlos Flores, Devon V. Adams, Mark E. Fleury
Rok vydání: 2021
Předmět:
Zdroj: JAMA Network Open
ISSN: 2574-3805
Popis: Key Points Question Is the implementation of the Medicare national coverage determination (NCD) associated with use of next-generation sequencing by insurance and racial and ethnic categories? Findings In this cohort study of 92 687 patients with lung, breast, colon, and skin cancer, NCD implementation was associated with a slower rate of increase in next-generation sequencing use for patients with patient assistance programs compared with Medicare beneficiaries. Implementation of the NCD was not associated with narrowing of racial and ethnic disparities among Medicare beneficiaries alone or the overall insured population. Meaning These findings suggest that implementation of the Medicare NCD for next-generation sequencing did not result in equal increased use across insurance types or racial and ethnic groups.
Importance In March 2018, Medicare issued a national coverage determination (NCD) for next-generation sequencing (NGS) to facilitate access to NGS testing among Medicare beneficiaries. It is unknown whether the NCD affected health equity issues for Medicare beneficiaries and the overall population. Objective To examine the association between the Medicare NCD and NGS use by insurance types and race and ethnicity. Design, Setting, and Participants A retrospective cohort analysis was conducted using electronic health record data derived from a real-world database. Data originated from approximately 280 cancer clinics (approximately 800 sites of care) in the US. Patients with advanced non–small cell lung cancer (aNSCLC), metastatic colorectal cancer (mCRC), metastatic breast cancer (mBC), or advanced melanoma diagnosed from January 1, 2011, through March 31, 2020, were included. Exposure Pre- vs post-NCD period. Main Outcomes and Measures Patients were classified by insurance type and race and ethnicity to examine patterns in NGS testing less than or equal to 60 days after diagnosis. Difference-in-differences models examined changes in average NGS testing in the pre- and post-NCD periods by race and ethnicity, and interrupted time-series analysis examined whether trends over time varied by insurance type and race and ethnicity. Results Among 92 687 patients with aNSCLC, mCRC, mBC, or advanced melanoma, mean (SD) age was 66.6 (11.2) years, 51 582 (55.7%) were women, and 63 864 (68.9%) were Medicare beneficiaries. The largest racial and ethnic categories according to the database used and further classification were Black or African American (8605 [9.3%]) and non-Hispanic White (59 806 [64.5%]). Compared with Medicare beneficiaries, changes in pre- to post-NCD NGS testing trends were similar in commercially insured patients (odds ratio [OR], 1.03; 95% CI, 0.98-1.08; P = .25). Pre- to post-NCD NGS testing trends increased at a slower rate among patients in assistance programs (OR, 0.93; 95% CI, 0.87-0.99; P = .03) compared with Medicare beneficiaries. The rate of increase for patients receiving Medicaid was not statistically significantly different compared with those receiving Medicare (OR, 0.92; 95% CI, 0.84-1.01; P = .07). The NCD was not associated with statistically significant changes in NGS use trends by racial and ethnic groups within Medicare beneficiaries alone or across all insurance types. Compared with non-Hispanic White individuals, increases in average NGS use from the pre-NCD to post-NCD period were 14% lower (OR, 0.86; 95% CI, 0.74-0.99; P = .04) among African American and 23% lower (OR, 0.77; 95% CI, 0.62-0.96; P = .02) among Hispanic/Latino individuals; increases among Asian individuals and those with other races and ethnicities were similar. Conclusions and Relevance The findings of this study suggest that expansion of Medicare-covered benefits may not occur equally across insurance types, thereby further widening or maintaining disparities in NGS testing. Additional efforts beyond coverage policies are needed to ensure equitable access to the benefits of precision medicine.
This cohort study examines changes in next-generation sequencing among individuals of different races and ethnicities and different levels of insurance coverage following implementation of the Medicare national coverage determination.
Databáze: OpenAIRE
Externí odkaz: