Disparities in Erythropoiesis-Stimulating Agent Use after Changes in Medicare Reimbursement and Implementation of a Risk Evaluation and Mitigation Strategy

The use of erythropoiesis-stimulating agents (ESAs) for treatment of chemotherapy-induced anemia (CIA) has been linked to potential negative health effects. Additionally, research has identified disparities in ESA utilization for CIA treatment. This study examines (1) health disparities in ESA use and (2) whether reimbursement (Medicare National Coverage Determination [NCD]) or regulatory (Risk Evaluation and Mitigation Strategy [REMS]) policies impacted disparities. In a retrospective cohort study (2006–2018) among 1,747,889 patients with cancer in the United States receiving myelosuppressive chemotherapy at age ≥ 65 years, differences in ESA use for CIA were estimated using generalized estimating equation models, adjusting for policy periods, demographic characteristics, and clinical factors extracted from Medicare claims data. After controlling for covariates, ESA use was higher among Black, female, and urban patients in all policy periods, but these disparities decreased significantly following the NCD. The gap continued to close through the REMS period. Disparities in ESA use across geographic regions were modest, and ESA use disparities across socioeconomic characteristics (area deprivation index or dual Medicare/Medicaid eligibility) were not observed. Being female, Black, or an urban resident was associated with higher ESA use for CIA in older patients with cancer. Both NCD and REMS implementation helped reduce disparities. REMS release was not observed to contribute to racial, sex, and rural–urban disparities in ESA use for CIA.