IntroductionAntibiotic resistance is a growing public health threat, resulting in challenges in effectively treating bacterial infections. Primary care providers account for the majority of antibiotic prescriptions, highlighting their critical role in antimicrobial stewardship. As telemedicine becomes more prevalent in primary care, there is limited data on how this shift has influenced antibiotic prescribing behavior. Our objective was to examine differences in antibiotic prescription rates for upper respiratory infections (URIs) between in-person and telemedicine appointments in a large primary care health system.MethodsIn this retrospective cohort study, we included patients 18 years and older treated in primary care clinics in the Greater Atlanta area from May 2020 to September 2023. Eligible encounters were billed with a diagnostic code related to URI. The main measures included patient demographics, insurance status, and visit modality. A multivariable logistic regression model evaluated differences in antibiotic prescriptions by visit type.ResultsThere were 33,008 (66%) in-person visits and 16,965 (33.9%) telemedicine visits, totaling 49,973 encounters. The average age of patients was 56.8 (SD 17.5) years, 67.1% patients were female, and 37.6% were Black. There were no significant differences in antibiotic prescribing between telemedicine and in-person appointments (adjusted odds ratio 1.00, 95% CI 0.14-4.86, P > 0.5).DiscussionRates of antibiotic prescribing did not differ significantly between in-person and telemedicine primary care visits for URI. As a healthcare quality indicator, this result provides evidence that in-person and telemedicine appointments are comparable modalities of patient care.

OBJECTIVES:To estimate the prevalence of ambient artificial intelligence (AI) documentation tool adoption among US hospitals using Epic electronic health record (EHR) systems and to identify hospital characteristics associated with adoption.​ Study Design: Cross-sectional observational study of US hospitals using Epic.​ Methods: Among a national sample of US hospitals using Epic, we assessed ambient AI adoption using Epic Showroom (June 2025) to identify eligible ambient applications and health systems that had implemented or were implementing these applications. We linked adoption data to hospital characteristics from the American Hospital Association Annual Survey (2012-2023; most recent response per hospital) and estimated multivariable logistic regression models with robust SEs clustered at the domain level, reporting adjusted predicted probabilities (margins).​ Results: Among 6561 US hospitals, 2784 (42.4%) were Epic users. Among Epic hospitals, 62.6% adopted ambient AI. In adjusted analyses, adoption was higher across workload quartiles (61.7% in quartile [Q] 1 vs 73.1% in Q4; P = .003) and among hospitals in the top operating margin quartiles (58.0% in Q1 vs 67.6% in Q4; P = .001 vs Q1). Adoption was higher among metropolitan hospitals (64.7% vs 54.3% in nonmetropolitan hospitals; P = .012) and nonprofit hospitals (70.2% vs 28.8% in for-profit hospitals; P < .001).​ Conclusions: Ambient AI documentation tools were widely adopted among US hospitals using Epic EHR systems, with adoption associated with workload, financial performance, ownership, and select structural characteristics. These patterns suggest potential for uneven diffusion across hospitals and underscore the need for research on impacts on clinician outcomes, care quality, and equity.

OBJECTIVES:To examine whether self-efficacy in managing symptoms is associated with symptom burden and adjuvant endocrine therapy (AET) adherence among women with early-stage breast cancer and whether self-efficacy modifies the effects of a remote monitoring intervention. STUDY DESIGN:Post hoc analysis of a randomized trial evaluating app-based remote monitoring of self-reported symptoms and adherence for women prescribed AET. METHODS:Participants were randomly assigned to enhanced usual care (EUC), app only (weekly remote monitoring), or app plus feedback (with weekly tailored supportive text messages). Outcomes included 12-month symptom burden (Functional Assessment of Cancer Therapy-Endocrine Subscale [FACT-ES]) and adherence (≥ 80% of expected doses recorded using a connected pillbox). Multivariable regression evaluated associations of the PROMIS (Patient-Reported Outcomes Measurement Information System) Self-Efficacy for Managing Symptoms T score with symptom burden and adherence as well as differential intervention effects by self-efficacy level. RESULTS:Among 264 participants (mean age, 58.5 years; 64% White, 32% Black), mean (SD) baseline self-efficacy exceeded the normative mean of 50 (54.2 [9.9]). Higher self-efficacy was associated with lower symptom burden (eg, higher FACT-ES score: 0.6; 95% CI, 0.3-0.8) and greater odds of adherence (OR, 1.1; 95% CI, 1.0-1.1). Adherence benefits were greater at lower self-efficacy levels (eg, at a score of 30, 52.7% were adherent in app + feedback vs 17.8% in EUC; +34.9 percentage points; 95% CI, 1.0-68.9; P  = .04), with effects diminishing and becoming nonsignificant at higher self-efficacy levels. CONCLUSIONS:Without additional support, breast cancer survivors with low self-efficacy had poorer symptom control and lower adherence. Remote symptom monitoring with tailored messaging was most effective among women with lower self-efficacy levels, highlighting the need for screening and targeted interventions for patients most likely to benefit.

Objective:This study explored how administering an innovation contest was associated with work experiences among nurses, providers, and staff in primary care.Background:Innovation contests offer structured ways for employees to share ideas and engage in organizational problem-solving. Given high burnout and turnover in US primary care, such interventions may foster a more supportive work environment.Methods:All 778 employees across a health system's primary care network were invited to submit and vote on ideas to improve recruitment, retention, and workflow. Senior leaders implemented ideas selected through voting. A follow-up survey measured feeling heard, organizational identification, job satisfaction, and burnout.Results:Employees aware of the contest reported greater organizational identification. Those who observed winning ideas being implemented reported higher levels of feeling heard, identification, and job satisfaction. Simply submitting or voting was not associated with differences.Conclusions:Acting on employee-generated ideas may improve workplace engagement and satisfaction in primary care.

Purpose: To examine the associations between Medicaid expansion and stage at diagnosis, timely initiation and receipt of guideline-concordant treatment, and 5-year overall survival (OS) among people with non-small cell lung cancer (NSCLC). Methods: Individuals newly diagnosed with stage I to IV NSCLC at age 18-64 years between January 1, 2004, and December 31, 2023, in 50 states and Washington, DC, were identified from the National Cancer Database. We examined the association of Medicaid expansion and (1) early-stage diagnosis (I and II); (2) timely initiation of guideline-concordant treatment within 30 days after diagnosis; (3) receipt of all first-course guideline-concordant treatment; and (4) 5-year OS. We applied conventional and updated (Sun and Abraham) difference-in-differences (DID) approaches to examine the changes in study outcomes associated with Medicaid expansion using multivariable linear probability models to estimate stage and treatment and multivariable flexible parametric survival models to investigate survival overall and by key factors. Results: Compared with people in nonexpansion states (n = 164,228), people in expansion states (n = 350,290) were more likely to be female, non-Hispanic White, or living in areas with higher family income or in nonmetropolitan areas. Medicaid expansion was associated with increases in early-stage NSCLC diagnosis (DID: 1.02 percentage points [ppt; 95% CI, 0.52 to 1.52]), timely treatment initiation (2.10 ppt [95% CI, 0.05 to 4.15]), and higher 5-year OS (1.79 ppt [95% CI, 1.32 to 2.26]). In stratified analyses, people living in areas with lower household income were more likely to benefit from Medicaid expansion. Conclusion: Medicaid expansion was associated with improvements in early detection, timeliness of guideline-concordant treatment, and survival for people with NSCLC. Anticipated Medicaid coverage losses may jeopardize these gains.

11012 Background: Telehealth has become an increasingly important care modality following the COVID-19 pandemic. For patients with cancer approaching end of life (EOL), telehealth may be particularly relevant given their substantial symptom burden, need for frequent healthcare services, and declining functional status. Telehealth may facilitate convenient access to care and enhance EOL care quality. However, limited research has examined associations between telehealth use and EOL care among patients with cancer. Methods: We conducted a retrospective, population-based cohort study of EOL telehealth use using 100% Medicare Traditional Medicare (TM) and Medicare Advantage (MA) claims. We included beneficiaries aged 66+ years with cancer who died in 2020-2023 with continuous enrollment in TM or MA during the 12 months preceding death. Patients with cancer were identified by at least 1 inpatient or 2 outpatient claims with relevant diagnosis codes. Telehealth use during the first 6 months of the last year of life was identified using procedure codes and modifiers. We examined validated claims-based EOL care outcomes, including hospice use and place of hospice care, and indicators of potentially burdensome transitions (e.g., late hospice enrollment ≤3 days of death, multiple hospitalizations and emergency department visits ≤30 days of death). Separate multivariable logistic regression models assessed associations between telehealth use and EOL outcomes. Results: Among a total of 2,897,720 Medicare beneficiaries with cancer who died in 2020-2023, mean age was 79.8 years; 44.9% were female, 9.4% were non-Hispanic Black, and 1.7% were Hispanic. Telehealth use in the first 6 months of last year of life was 30.0% in 2020-2023, with utilization peaking in 2021 (47.1%). Among all decedents, 60.7% enrolled in hospice; among hospice users, 73.1% received hospice care at home and 18.6% enrolled ≤3 days of death. In the last 30 days, 11.2% and 13.4% experienced multiple hospitalizations and ER visits respectively. In adjusted analyses, telehealth use was associated with 2.38 percentage points (ppts, 95%CI=2.25 to 2.50) higher likelihood of any hospice use. Among hospice recipients, telehealth use was associated with 5.45 ppts (95%CI=5.31 to 5.60) higher likelihood of home hospice use. Telehealth use was also associated with 2.18 ppts (95%CI=-2.31 to -2.05) lower likelihood of late hospice enrollment. Associations with multiple hospitalizations and ER visits were small and statistically non-significant. Conclusions: Telehealth use among Medicare decedents with cancer was associated with higher hospice use, particularly home hospice, and a lower likelihood of late hospice enrollment, suggesting potential improvements in EOL care transitions. These associations may reflect enhanced care coordination and continuity facilitated by telehealth during the EOL.

Abstract Background Febrile illness remains a leading cause of morbidity and mortality among children under five in sub-Saharan Africa. In Kenya, pharmacies are a common first point of care for childhood fevers, yet important questions remain about the quality of care provided in these settings and how consistently it aligns with national malaria treatment guidelines. This study examines the care received and outcomes for pediatric suspected malaria illness episodes managed in private pharmacies in malaria-endemic regions of Kenya. Methods A longitudinal cohort study was conducted at 39 private stand-alone pharmacies. Caregivers of children under five presenting with fever were surveyed at the point of care and followed up via phone two weeks later. The study assessed whether children received malaria diagnostic testing, whether treatment was guideline-concordant (i.e., antimalarial treatment for confirmed malaria), and whether the child had recovered at follow-up. Logistic regression models using Lasso-selected covariates identified predictors of diagnostic testing and appropriate treatment. Results Among 239 febrile children treated at an included pharmacy, 69% received a malaria diagnostic test. Of those tested, 59% were malaria-positive, and 78% of these received appropriate antimalarial treatment. Only 3% of malaria-negative children received antimalarials. Among malaria-positive children treated with antimalarials, 88% had fully recovered at follow-up. Predictors of diagnostic testing included caregiver education, younger child age, and provider malaria knowledge. Appropriate treatment was more likely for older children, male children, and when providers had more years of experience. Conclusions Pharmacies in this sample demonstrate high adherence to malaria diagnostic and treatment guidelines for pediatric febrile illness, with strong alignment between diagnosis and treatment and high rates of illness resolution. However, heterogeneity in care quality based on caregiver, child, and provider characteristics suggests opportunities to improve equity and consistency in pharmacy-based care. These findings underscore the importance of pharmacies in malaria case management and highlight the need for further research and policy attention to this critical access point in the healthcare system. Trial registration Not applicable.

BACKGROUND:Adjuvant endocrine therapy reduces breast cancer recurrence, but symptom burden contributes to nonadherence, particularly among Black women. We examined how patient sociodemographic factors and perceived discrimination are associated with symptoms and Black-White differences in symptoms during early treatment course of adjuvant endocrine therapy. METHODS:We conducted a post hoc analysis using survey data collected at study enrollment in the THRIVE trial from November 15, 2018, to June 11, 2021, among women with early-stage breast cancer. Symptom burden was assessed by the Functional Assessment of Cancer Therapy-Endocrine Subscale within 8 weeks of adjuvant endocrine therapy initiation. Covariates included sociodemographic and clinical information and perceived discrimination. Multivariable regressions and Kitagawa-Oaxaca-Blinder decomposition evaluated how these patient characteristics are associated with Black-White differences in symptoms. RESULTS:Among 272 participants, 35.7% self-identified as Black and 64.3% as White. Black women reported more symptoms (lower Functional Assessment of Cancer Therapy-Endocrine Subscale scores) than White women (60.7 vs 64.3, P = .004) and similar discrimination scores (5.44 vs 5.54, P = .17). Experiencing less discrimination (ie, each unit increase in discrimination score, 1.93, 95% confidence interval [CI] = 0.08 to 3.78), older age groups (65-83 vs 30-49 years: 4.84, 95% CI = 1.15 to 8.54), and higher income (≥400% vs <200% federal poverty level = 5.72, 95% CI = 2.12 to 9.33) was associated with lower symptom burden. Decomposition analyses attributed 84.6% of Black-White symptom differences to patient characteristics, with income explaining the largest proportion, while perceived discrimination did not explain symptom burden differences. CONCLUSIONS:Black women experienced higher early symptoms during adjuvant endocrine therapy. Although perceived discrimination was associated with greater symptom burden, it did not clinically or statistically significantly explain Black-White differences in symptoms. Income explained the largest portion of Black-White symptom differences. Addressing income inequality is essential for equitable symptom management.

Oral adjuvant endocrine therapy (AET) improves survival in hormone receptor-positive breast cancer, but younger, premenopausal women often struggle with adherence. In a post hoc analysis of a randomized trial (N = 304), app-based remote symptom monitoring improved 12-month AET adherence among premenopausal women (App-only: 53.9% vs. EUC: 25.0%), with no benefit for postmenopausal women. Findings suggest remote monitoring may help close adherence gaps in younger patients. Prospectively registered on ClinicalTrials.gov: NCT03592771.

Diabetes distress, the negative emotional impact of living with diabetes, is associated with suboptimal outcomes, including higher HbA1c, poorer self-management, and reduced quality of life, and contributes to disparities between Black and White patients with type 1 diabetes (T1D). Young adults may be particularly vulnerable to diabetes distress. Young Black adults therefore may benefit from tailored, representative, and inclusive interventions. Yet, few interventions have been designed to center the experiences of diabetes distress among Black young adults with T1D. OnTrack, an evidence-based diabetes distress group intervention, was adapted with input from an advisory board comprised of Black young adults to be culturally appropriate for Black young adults (ages 18–30 years) with T1D. The adapted intervention, called Type 1 Diabetes Education and Support (T1DES), will be tested in this pilot randomized trial to assess the feasibility of T1DES in two distinct healthcare systems: an integrated care system and a safety net care system. Participants will be stratified by site and randomized into the intervention condition (T1DES, n = 40, 20 per site) or an attention control condition providing a traditional diabetes education program not focused on distress (StreamLine, n = 40, 20 per site). Both conditions will include five workshop sessions over 3 months. Feasibility outcomes will include an assessment of intervention acceptability, demand, practicality, fidelity, and economic feasibility. Signals of efficacy will be assessed by changes in diabetes distress (self-reported), diabetes management skills (self-reported), and glycemic control (HbA1c) between study arms, which will be collected at baseline and 3 months post intervention and 6 months post intervention. Black young adults with T1D face unique needs and challenges that need to be considered when providing diabetes support. Interventions that tailor content to represent the experiences of Black young adults have the potential to reduce diabetes distress and HbA1c and improve diabetes management. If successful, the T1DES intervention could be disseminated to support the long-term goal of improving diabetes outcomes and reducing healthcare disparities in this population. ClinicalTrials.gov NCT05735340. Registered on 2023-2-9. ClinicalTrials.gov NCT06494722. Registered on 2024-7-9.

BACKGROUND:The objective of this study was to examine the associations between federal and state short-term limited-duration (STLD) insurance plan regulations and timely cancer treatment initiation. METHODS:Adults aged 18-64 years newly diagnosed with female breast, colorectal, or non-small cell lung cancers in 2017-2019 were identified from the National Cancer Database. Patients were categorized into five groups on the basis of their state of residence at diagnosis: (1) the state continuously prohibited STLD plans; (2) the state stopped offering STLD plans after the 2018 federal rule; (3) the state kept the same 3-month limit on STLD plans before and after the 2018 federal rule; (4) the state expanded the sale of STLD plans but imposed more stringent regulation of STLD plans; and (5) the state expanded the sale of STLD plans and did not impose additional regulation. A difference-in-differences (DID) approach examined the changes in the percentages of patients initiating treatment within 30 days of their cancer diagnosis before and after the 2018 federal rule. RESULTS:For all cancers combined, compared to patients living in states continuously prohibiting STLD plans, a net decrease was observed in the percentages receiving timely treatment among patients living in states continuously limiting STLD plans to 3 months (DID, -1.61 percentage points [ppts]; 95% confidence interval [CI], -2.86 to -0.37 ppts), in states with less stringent regulations (DID, -2.09 ppts; 95% CI, -3.33 to -0.84 ppts), and in states with the least stringent regulations (DID, -2.48 ppts; 95% CI, -3.52 to -1.44 ppts). CONCLUSIONS:Limited or no state regulation of STLD plans after the 2018 federal expansion of plan coverage duration was associated with decreases in timely cancer treatment initiation.

e23120 Background: Telehealth use has surged since the COVID-19 pandemic. For individuals with cancer approaching end-of-life (EOL) facing high symptom burden, declining mobility, and increasing reliance on caregivers, telehealth may enhance access to specialty and palliative care services. National evidence comparing EOL telehealth use between cancer and non-cancer populations remains limited. Methods: We conducted a retrospective, population-based cohort study of telehealth use using 100% Traditional Medicare (TM) and Medicare Advantage (MA) claims. We included Medicare beneficiaries died in 2019-2023 with continuous TM or MA enrollment in the 12 months preceding death. Patients with cancer were identified by 1 inpatient or 2 outpatient visits with cancer diagnosis codes in the last year of life. Telehealth use in the last year of life was identified using procedure codes and modifiers and classified into synchronous patient–provider (audio-only and audio–video), asynchronous, and remote physiologic or therapeutic monitoring (RPM/RTM) encounters. Telehealth use, overall and by service type, was compared between Medicare decedents with and without cancer; multivariable logistic regression examined patient characteristics associated with telehealth use after COVID-19 onset. Results: Among a total of 10,767,407 Medicare decedents, average age was 81.56, with 51.8% female, 9.7% Non-Hispanic Black, 2.3% Hispanic, and 33.1% with cancer diagnosis. Telehealth use among decedents with cancer increased from 2.7% to 47.8% in 2019-2023, peaking in 2021 (70.0%), which was persistently higher than those without cancer (2.4% to 34.4% in 2019-2023). Synchronous video encounters (1.2% to 41.2%) were most common, followed by synchronous audio only encounters (1.6% to 20.9%) in 2019-2023. RTM/RPM was limited but increased from 0.1% to 2.0% in 2019-2023. Decedents with cancer were consistently more likely to use all telehealth modalities than those without cancer. In adjusted analysis, older (85+ vs. 66-74 years: -6.10 percentage points [ppts]), Non-Hispanic Black (vs. Non-Hispanic White: -3.27 ppts), and beneficiaries in counties with a higher social vulnerability index (Q4 vs. Q1: -0.92 ppts, p-values<.001) were less likely to use telehealth. More comorbidities (14.70 ppts), multiple hospitalizations in the prior year (5.18 ppts), and counties with better broadband internet access (80%+ households with 25+ Mbps internet connection vs. ≤40%: 13.98 ppts, p-values<.001) were associated with higher likelihood of telehealth use. Conclusions: EOL telehealth use differs meaningfully between cancer and non-cancer decedents, which may reflect greater care intensity and more frequent clinical contact. Telehealth use was lower among older, racial and ethnic minority beneficiaries, and those living in more socially vulnerable areas, and higher among patients with greater medical complexity and better broadband access.

11093 Background: Advance care planning (ACP) allows individuals to discuss and document preferences for future medical care under serious illness, yet engagement among older adults remains limited. Experiences of a health shock, such as a diagnosis of cancer, major illnesses, or hospitalization, may prompt participation in ACP. This study aimed to examine the association between health shocks and subsequent ACP engagement and variation by key sociodemographic characteristics. Methods: We conducted a longitudinal cohort study using data from the Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged ≥65 years. Adults from 2012–2022 HRS with no baseline ACP who completed at least one follow-up wave were included. The exposure was a new health shock, defined as a new diagnosis of cancer, stroke, heart disease, or hospitalization. The outcome was new ACP engagement in subsequent waves. Generalized estimating equation models estimated adjusted odds ratios (ORs) of experiencing a health shock due to cancer diagnosis and due to other causes (vs. no health shock) on new ACP; and how such associations varied by respondents’ characteristics. Results: Among 8,553 person-wave observations (4,426 unique respondents), median age was 74 years (IQR 69–79); 52.9% were women, 24.3% lived alone, 27.6% experienced a health shock, and 3.11% reported a health shock from new cancer diagnosis. Health shocks were associated with higher odds of ACP engagement (OR = 1.41; 95% CI, 1.28–1.56). In the three-level shock model, both non-cancer shock (OR = 1.43; 95% CI, 1.28–1.59) and cancer shock (OR = 1.31; 95% CI, 1.01–1.70) were associated with higher odds of ACP compared with no shock. Older age, female gender, and higher education were associated with greater ACP engagement overall. Compared with non-Hispanic Whites, non-Hispanic Black (OR = 0.73; 95% CI, 0.64–0.84) and Hispanic (OR = 0.55; 95% CI, 0.47–0.65) had lower odds of ACP. Living alone was associated with higher ACP engagement (OR = 1.29; 95% CI, 1.14–1.45). However, when stratified by patient sociodemographic characteristics, the associations between health shock and ACP were similar across groups, except that for those living alone who showed larger odds of initiating a new ACP following health shock (OR = 1.76; 95% CI, 1.45-2.14) than those not living alone (OR = 1.31; 95% CI, 1.16-1.47). Conclusions: Health shocks were associated with new ACP engagement among older adults, with similar associations observed for cancer-specific and non-cancer health shocks. Alhtought disparities in ACP by sociodemographic characteristics persisted, health shocks were associated with similarly odds of initiating ACP across population subgroups. This highlights the importance of leveraging health shocks as clinical touchpoints for ACP discussions, and the need for targeted strategies to reduce inequities in ACP engagement outside of acute health events.

11181 Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly used in cancer survivors with Type 2 Diabetes (T2D) given its efficacy, yet concerns regarding treatment tolerance, weight loss, and limited oncology-specific guidance during active treatment and survivorship may influence prescribing patterns. To date, little evidence exists regarding the trends and factors associated with GLP-1RA use in cancer populations with T2D. Methods: We conducted a retrospective cohort study using SEER–Medicare data to identify patients newly diagnosed with seven most common cancers in 2010-2021 with pre-existing T2D. Pre-existing T2D was defined by relevant diagnosis codes within 12 months prior to cancer diagnosis. Patients with continuous Medicare Parts A & B and Part D enrollment were followed annually from diagnosis until death or end of follow-up (12/31/2022) to assess GLP-1RA use. A non-cancer cohort with T2D was identified using a 5% random sample of Medicare beneficiaries without cancer. We calculated annual proportions of beneficiaries with any GLP-1RA use, stratified by Traditional Medicare (TM) and Medicare Advantage (MA, data available in 2016-2021). Multivariable logistic regression models evaluated patient sociodemographic and clinical characteristics associated with GLP-1RA use in 2021. Results: We included 482,878 and 542,285 Medicare beneficiaries with T2D in the cancer and non-cancer cohort respectively (1,927,771 and 3,265,774 person-years in 2010-2022). Among TM beneficiaries, GLP-1RA use in the cancer cohort increased from 0.5% to 8.2% in 2010-2022, compared to an increase from 0.4% to 6.4% among non-cancer cohort; similarly higher GLP-1RA use was observed in cancer than non-cancer cohort among MA beneficiaries in 2016-2021 (1.8% to 6.8% vs. 1.3% to 5.7%; unadjusted p-values < 0.001). Rapid uptake was observed for dulaglutide and semaglutide from 2015, while liraglutide use declined modestly after peaking in 2018. In adjusted analyses within the cancer cohort, patients with breast (0.87 percentage points [ppts], p < 0.001), female genital (1.08 ppts, p < 0.001), and prostate cancers (0.62 ppts, p = 0.001) were more likely to receive GLP-1RAs than those with colorectal cancer. More advanced cancer stage was associated with lower likelihoods of GLP-1RA use; Non-Hispanic White, higher socioeconomic neighborhoods, and dual eligibility were associated with higher likelihoods of GLP-1RAs use. Conclusions: GLP-1RA use increased substantially among Medicare beneficiaries with cancer and T2D, and was consistently higher than those without cancer, which may reflect greater clinical engagement and cardiometabolic risk burden following a cancer diagnosis. Variation by cancer site, stage, and socioeconomic factors suggest that both clinical complexity and structural determinants shape GLP-1RA use in cancer survivors.

BACKGROUND:Cyclin-dependent kinase 4/6 inhibitors (CDKIs) improves survival when added to endocrine therapy in hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) breast cancer. However, their complex schedule, side effects, and cost contribute to non-adherence. METHODS:The EAQ221CD is a two-arm randomized controlled trial that evaluates the effectiveness of the CONnected CUstomized Treatment Platform (CONCURxP), a mobile health intervention, versus enhanced usual care (EUC) on CDKI adherence among 390 patients with breast cancer and a new CDKI prescription. Participants use a smart pouch (Wisebag) to monitor real-time adherence. CONCURxP arm patients: (1) receive text reminders for missed or extra doses; (2) receive text message surveys inquiring reasons for missed or extra doses; and (3) have access to their adherence history on a study web portal. Missed or double doses trigger alerts to the oncology team. Patients citing cost as a barrier are referred to a national non-profit financial navigation program. EUC arm patients receive educational materials on side effect management. Patients complete surveys at baseline, 3, 6, and 12 months after randomization. Our objectives are to: (1) compare 12-month CDKI adherence measured using Wisebag (primary outcome) between the two arms; (2) compare patient-reported outcomes at 12-months between the two arms, including symptom burden, quality of life, patient-provider communication, self-efficacy for managing symptoms, and financial worry; and (3) use mixed methods to describe patients' experience with the CONCURxP intervention. Our multilevel intervention will provide actionable results to improve adherence, health outcomes, and patients' experience. TRIAL REGISTRATION:NCT06112613.

Breast cancer survivors often face numerous challenges during and after treatment, including chemotherapy-induced peripheral neuropathy (CIPN) from neurotoxic antineoplastic treatments. Delayed or underreported CIPN may resul.

Importance:The introduction of immune checkpoint inhibitors (ICIs) has been associated with substantial improvement in median survival among individuals with cancer; however, people without health insurance coverage may be unable to afford ICIs due to their high costs. Objective:To examine the association between the introduction of ICIs and changes in survival disparities by health insurance coverage among people with a new diagnosis of advanced-stage cancer. Design, Setting, and Participants:This cross-sectional study was conducted among individuals who received a new diagnosis at age 18 to 64 years of stage IV melanoma (n = 12 048), non-small cell lung cancer (NSCLC; n = 152 610), or renal cell carcinoma (RCC; n = 18 782) who were identified from the National Cancer Database before and after US Food and Drug Administration approval of ICIs (January 1, 2002, to December 31, 2019, for melanoma and January 1, 2010, to December 31, 2019, for other cancers). Statistical analysis was conducted from December 2023 to April 2025. Exposure:Health insurance coverage at the time of diagnosis (private, Medicaid, or uninsured). Main Outcomes and Measures:The primary study outcome was 2-year overall survival. For each type of cancer, a 6-group propensity score weighting difference-in-differences (DID) approach was applied to examine the changes in 2-year survival before and after the ICI approval date among individuals without insurance or with Medicaid compared with those with private insurance. Results:Among the 183 440 individuals included, the mean (SD) age was 55.5 (7.0) years, and 56.5% were male. Two-year overall survival rates increased post-ICI approval among uninsured individuals (from 16.2% to 28.3%) and individuals with private insurance (from 28.7% to 46.0%) for those with a diagnosis of melanoma, resulting in a widening disparity of 6.1 percentage points (pp) (95% CI, 1.7-10.6 pp) after adjusting for sociodemographic characteristics. Similarly, among people with a diagnosis of NSCLC, the survival disparity between people without insurance and people with private insurance widened to 1.3 pp (95% CI, 0.2-2.3 pp). Survival differences between people with Medicaid and those with private insurance did not change significantly with the introduction of ICIs (DID for melanoma, -1.9 pp [95% CI, -5.6 to 1.8 pp]; DID for NSCLC, 0.4 pp [95% CI, -0.4 to 1.2 pp]; and DID for RCC, -3.8 pp [95% CI, -9.4 to 1.9 pp]). Conclusions and Relevance:This serial cross-sectional study found that the introduction of ICIs was associated with widening survival disparity between people without health insurance and those with private insurance. Policies expanding access to health insurance coverage options and making new treatments more affordable are needed.