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ImportanceRobust quality measures to benchmark end-of-life care for children with cancer do not currently exist; 28 candidate patient-centered quality measures were previously developed.ObjectiveTo prioritize quality measures among parents who lost a child to cancer.Design, Setting, and ParticipantsThis survey study was conducted using an electronic, cross-sectional discrete choice experiment (DCE) with maximum difference scaling from January to June 2021 in the US. In each of 21 questions in the DCE, participants were presented with a set of 4 quality measures and were asked to select the most and least important measures within each set. All 28 quality measures were presented an equal number of times in different permutations. In the volunteer sample, 69 eligible bereaved parents enrolled in the study; 61 parents completed the DCE (participation rate, 88.4%).Main Outcomes and MeasuresUsing choices participants made, a hierarchical bayesian multinomial logistic regression was fit to derive mean importance scores with 95% credible intervals (95% Crs) for each quality measure, representing the overall probability of a quality measure being selected as most important. Importance scores were rescaled proportionally from 0 to 100, with the sum of scores for all quality measures adding up to 100. This enabled interpretation of scores as the relative importance of quality measures.ResultsParticipants included 61 bereaved parents (median [range] age, 48 [24-74] years; 55 individuals self-identified as women [90.2%]; 1 American Indian or Alaska Native [1.6%], 1 Asian [1.6%], 2 Black or African American [3.3%], 1 Native Hawaiian or Pacific Islander, and 58 White [91.8%]; 58 not Hispanic or Latinx [95.1%]). Highest-priority quality measures by mean importance score included having a child’s symptoms treated well (9.25 [95% Cr, 9.06-9.45]), feeling that a child’s needs were heard by the health care team (8.39 [95% Cr, 8.05-8.73]), and having a goal-concordant end-of-life experience (7.45 [95% Cr, 6.84-8.05]). Lowest-priority quality measures included avoiding chemotherapy (0.33 [95% Cr, 0.21-0.45]), provision of psychosocial support for parents (1.01 [95% Cr, 0.57-1.45]), and avoiding the intensive care unit (1.09 [95% Cr, 0.74-1.43]). Rank-ordering measures by mean importance revealed that symptom management was 9 times more important to parents than psychosocial support for themselves.Conclusions and RelevanceThis study found that bereaved parents prioritized end-of-life quality measures focused on symptom management and goal-concordant care while characterizing quality measures assessing their own psychosocial support and their child’s hospital resource use as substantially less important. These findings suggest that future research should explore innovative strategies to measure care attributes that matter most to families of children with advanced cancer.

Key Points Question After accounting for individual socioeconomic disadvantage, is living in a deprived neighborhood associated with worse survival after cancer diagnosis? Findings In this cohort study of 96 978 older patients with nonmetastatic breast, prostate, lung, and colorectal cancers, neighborhood-level disadvantage was associated with worse survival even after adjusting for patient-level low income. Meaning These findings suggest that in order to improve cancer outcomes and reduce health disparities, policies for ongoing investments in low-resource neighborhoods and low-income households are needed., This cohort study examines the association of neighborhood and individual socioeconomic disadvantage with survival among older patients with nonmetastatic common cancers., Importance Disadvantaged neighborhood-level and individual-level socioeconomic status (SES) have each been associated with suboptimal cancer care and inferior outcomes. However, independent or synergistic associations between neighborhood and individual socioeconomic disadvantage have not been fully examined, and prior studies using simplistic neighborhood SES measures may not comprehensively assess multiple aspects of neighborhood SES. Objective To investigate the associations of neighborhood SES (using a validated comprehensive composite measure) and individual SES with survival among patients with nonmetastatic common cancers. Design, Setting, and Participants This prospective, population-based cohort study was derived from the Surveillance, Epidemiology, and End Results–Medicare database from January 1, 2008, through December 31, 2011, with follow-up ending on December 31, 2017. Participants included older patients (≥65 years) with breast, prostate, lung, or colorectal cancer. Exposures Neighborhood SES was measured using the area deprivation index (ADI; quintiles), a validated comprehensive composite measure of neighborhood SES. Individual SES was assessed by Medicare-Medicaid dual eligibility (yes vs no), a reliable indicator for patient-level low income. Main Outcomes and Measures The primary outcome was overall mortality, and the secondary outcome was cancer-specific mortality. Hazard ratios (HRs) for the associations of ADI and dual eligibility with overall and cancer-specific mortality were estimated via Cox proportional hazards regression. Statistical analyses were conducted from January 23 to April 15, 2021. Results A total of 96 978 patients were analyzed, including 25 968 with breast, 35 150 with prostate, 16 684 with lung, and 19 176 with colorectal cancer. Median age at diagnosis was 76 years (IQR, 71-81 years) for breast cancer, 73 years (IQR, 70-77 years) for prostate cancer, 76 years (IQR, 71-81 years) for lung cancer, and 78 years (IQR, 72-84 years) for colorectal cancer. Among lung and colorectal cancer patients, 8412 (50.4%) and 10 486 (54.7%), respectively, were female. The proportion of non-Hispanic White individuals among breast cancer patients was 83.7% (n = 21 725); prostate cancer, 76.8% (n = 27 001); lung cancer, 83.5% (n = 13 926); and colorectal cancer, 81.1% (n = 15 557). Neighborhood-level and individual-level SES were independently associated with overall mortality, and no interactions were detected. Compared with the most affluent neighborhoods (ADI quintile 1), living in the most disadvantaged neighborhoods (ADI quintile 5) was associated with higher risk of overall mortality (breast: HR, 1.34; 95% CI, 1.26-1.43; prostate: HR, 1.51; 95% CI, 1.42-1.62; lung: HR, 1.21; 95% CI, 1.14-1.28; and colorectal: HR, 1.24; 95% CI, 1.17-1.32). Individual socioeconomic disadvantage (dual eligibility) was associated with higher risk of overall mortality (breast: HR, 1.22; 95% CI, 1.15-1.29; prostate: HR, 1.29; 95% CI, 1.21-1.38; lung: HR, 1.14; 95% CI, 1.09-1.20; and colorectal: HR, 1.23; 95% CI, 1.17-1.29). A similar pattern was observed for cancer-specific mortality. Conclusions and Relevance In this cohort study, neighborhood-level deprivation was associated with worse survival among patients with nonmetastatic breast, prostate, lung, and colorectal cancer, even after accounting for individual SES. These findings suggest that, in order to improve cancer outcomes and reduce health disparities, policies for ongoing investments in low-resource neighborhoods and low-income households are needed.

Key Points Question Is adoption of prostate magnetic resonance imaging (MRI) and genomic testing associated with increased use of observation rather than active treatment for prostate cancer? Findings In this cohort study of 65 530 commercially insured patients with prostate cancer, uptake of prostate MRI and genomic testing was associated with increased use of observation vs active treatment as initial management. Although prostate MRI, genomic testing, and observation increased overall, use was highly varied across hospital referral regions. Meaning The findings of this study suggest that adoption of technologies designed to improve decision-making may lead to perceivable reductions in overtreatment of prostate cancer, Importance The clinical decisions that arise from prostate magnetic resonance imaging (MRI) and genomic testing in patients with prostate cancer are not well understood. Objective To evaluate the association between regional uptake of prostate MRI and genomic testing and observation vs treatment for prostate cancer. Design, Setting, and Participants This retrospective cohort study of commercial insurance claims for prostate MRI and genomic testing included 65 530 patients 40 to 89 years of age newly diagnosed with prostate cancer from July 1, 2012, through June 30, 2019. Exposures Patient- and regional-level use of prostate MRI and genomic testing. Main Outcomes and Measures Observation vs definitive treatment for prostate cancer. Patient-level analyses examined the association between receipt of testing or residing in a hospital referral region (HRR) that adopted testing and observation. In regional-level analyses, the dependent variable was the change in the proportion of patients observed for prostate cancer at the HRR level between 2 periods: July 1, 2012, to June 30, 2014, and July 1, 2017, to June 20, 2019. The independent study variables included HRR-level changes in the proportion of men undergoing prostate MRI and genomic testing between these periods, and the models were adjusted for contextual factors associated with prostate cancer care and socioeconomic status. Results This study identified 65 530 patients, including 27 679 in the early period (mean [SD] age, 58.0 [5.9] years) and 37 851 in the late period (mean [SD] age, 59.0 [5.7] years). Use of prostate MRI increased significantly from 7.2% (95% CI, 6.9%-7.5%) to 16.7% (95% CI, 16.3%-17.1%) from the early to late period. Use of genomic testing increased significantly from 1.3% (95% CI, 1.1%-1.4%) to 12.7% (95% CI, 12.3%-13.0%) from the early to late period. Compared with the lowest, the highest HRR quartiles of prostate MRI and genomic testing uptake were associated with an adjusted 4.1% (SE, 1.1%; P, This cohort study assesses the association between the use of prostate magnetic resonance imaging and genomic testing and the initial management of prostate cancer.

ImportancePrevious studies have demonstrated racial and ethnic inequities in medical student assessments, awards, and faculty promotions at academic medical centers. Few data exist about similar racial and ethnic disparities at the level of graduate medical education.ObjectiveTo examine the association between race and ethnicity and performance assessments among a national cohort of internal medicine residents.Design, Setting, and ParticipantsThis retrospective cohort study evaluated assessments of performance for 9026 internal medicine residents from the graduating classes of 2016 and 2017 at Accreditation Council of Graduate Medical Education (ACGME)–accredited internal medicine residency programs in the US. Analyses were conducted between July 1, 2020, and June 31, 2022.Main Outcomes and MeasuresThe primary outcome was midyear and year-end total ACGME Milestone scores for underrepresented in medicine (URiM [Hispanic only; non-Hispanic American Indian, Alaska Native, or Native Hawaiian/Pacific Islander only; or non-Hispanic Black/African American]) and Asian residents compared with White residents as determined by their Clinical Competency Committees and residency program directors. Differences in scores between Asian and URiM residents compared with White residents were also compared for each of the 6 competency domains as supportive outcomes.ResultsThe study cohort included 9026 residents from 305 internal medicine residency programs. Of these residents, 3994 (44.2%) were female, 3258 (36.1%) were Asian, 1216 (13.5%) were URiM, and 4552 (50.4%) were White. In the fully adjusted model, no difference was found in the initial midyear total Milestone scores between URiM and White residents, but there was a difference between Asian and White residents, which favored White residents (mean [SD] difference in scores for Asian residents: −1.27 [0.38]; P P P Conclusions and RelevanceIn this cohort study, URiM and Asian internal medicine residents received lower ratings on performance assessments than their White peers during the first and second years of training, which may reflect racial bias in assessment. This disparity in assessment may limit opportunities for physicians from minoritized racial and ethnic groups and hinder physician workforce diversity.

This cross-sectional study examines the proportion of US nonprofit hospitals with community health needs assessments and implementation strategies as required by the Patient Protection and Affordable Care Act.

This cross-sectional study investigates demographic data reporting and demographic representation by sex, age, and race/ethnicity in premarketing and postmarketing studies of novel cancer therapeutics., Key Points Question Are the demographic characteristics of patients enrolled in premarketing and postmarketing studies used by the US Food and Drug Administration (FDA) to evaluate the safety and efficacy of novel cancer therapeutics clearly reported and representative of the US cancer population? Findings In this cross-sectional study of 77 premarketing studies and 56 postmarketing studies for FDA-approved cancer therapeutics, there was inconsistent reporting of demographic data and underrepresentation of older adults and Black patients in premarketing and postmarketing studies of cancer therapeutics. Meaning Premarketing and postmarketing studies used by the FDA to evaluate novel cancer therapeutics may not adequately represent the US cancer population., Importance Adequate representation of demographic subgroups in premarketing and postmarketing clinical studies is necessary for understanding the safety and efficacy associated with novel cancer therapeutics. Objective To characterize and compare the reporting of demographic data and the representation of individuals by sex, age, and race in premarketing and postmarketing studies used by the Food and Drug Administration (FDA) to evaluate novel cancer therapeutics. Design, Setting, and Participants In this cross-sectional study, premarketing and postmarketing studies for novel cancer therapeutics approved by the FDA from 2012 through 2016 were identified. Study demographic information was abstracted from publicly available sources, and US cancer population demographic data was abstracted from US Cancer Statistics. Analyses were conducted from February 25 through September 21, 2020. Main Outcomes and Measures The percentages of trials reporting sex, age, and race/ethnicity were calculated, and participation to prevalence ratios (PPRs) were calculated by dividing the percentage of study participants in each demographic group by the percentage of the US cancer population in each group. PPRs were constructed for premarketing and postmarketing studies and by cancer type. Underrepresentation was defined as PPR less than 0.8. Results From 2012 through 2016, the FDA approved 45 cancer therapeutics. The study sample included 77 premarketing studies and 56 postmarketing studies. Postmarketing studies, compared with premarketing studies, were less likely to report patient sex (42 studies reporting [75.0%] vs 77 studies reporting [100%]; P

Key Points Question Is there an association between sexual orientation and burnout among US medical students, and is this association mediated by experiences of mistreatment? Findings Cross-sectional surveys of 2016 and 2017 graduating US medical students showed significantly higher rates of perceived mistreatment and burnout symptoms among lesbian, gay, or bisexual (LGB) medical students compared with heterosexual students. Perceived experiences of mistreatment mediated the association between LGB sexual orientation and burnout but did not completely account for excess burnout reported by LGB students. Meaning The findings of this study suggest that medical students in sexual minority groups report increased symptoms of burnout regardless of their perceived experiences of mistreatment., Importance Medical trainee burnout is associated with poor quality care and attrition. Medical students in sexual minority groups report fear of discrimination and increased mistreatment, but the association between sexual orientation, burnout, and mistreatment is unknown. Objective To evaluate whether medical student burnout differs by sexual orientation and whether this association is mediated by experiences of mistreatment. Design, Setting, and Participants This cross-sectional study surveyed US medical students graduating from Association of American Medical Colleges (AAMC)–accredited US allopathic medical schools who responded to the AAMC graduation questionnaire in 2016 and 2017. Statistical analyses were performed from March 15, 2019, to July 2, 2020, and from November 20 to December 9, 2020. Main Outcomes and Measures Burnout was measured using the Oldenburg Burnout Inventory for Medical Students, and sexual orientation was categorized as either heterosexual or lesbian, gay, or bisexual (LGB). Logistic regression models were constructed to evaluate the association between sexual orientation and experiencing burnout (defined as being in the top quartile of exhaustion and disengagement burnout dimensions) and to test the mediating association of mistreatment. Results From 2016 to 2017, 30 651 students completed the AAMC Graduation Questionnaire, and 26 123 responses were analyzed. Most respondents were younger than 30 years (82.9%) and White (60.3%). A total of 13 470 respondents (51.6%) were male, and 5.4% identified as LGB. Compared with heterosexual students, a greater proportion of LGB students reported experiencing mistreatment in all categories, including humiliation (27.0% LGB students vs 20.7% heterosexual students; P, This cross-sectional study evaluates whether medical student burnout differs by sexual orientation and whether this association is mediated by experiences of mistreatment.

Key Points Question Are National Institutes of Health (NIH) funding levels associated with changes in burden of disease? Findings This cohort study of 46 diseases found that NIH funding levels for a specific disease in 2019 were most highly associated with such levels in 2008. Burden of disease and changes in burden of disease were not statistically significantly associated with NIH funding levels once the prior level of funding was included in the model. Meaning In this study, NIH spending appeared to be based primarily on the level of spending for that disease in prior years, despite changes in burden of disease., Importance Prior research suggests an association between burden of disease and National Institutes of Health (NIH) funding. The allocation of NIH funding should reflect, to some extent, the health needs of the population, along with other factors. Objective To examine the factors associated with NIH funding in 2019 for 46 diseases. Design, Setting, and Participants This cohort study used disability-adjusted life-years to measure the 2008 and 2019 US burden of disease and compared them with NIH categoric funding for 46 diseases. Exposures Disability-adjusted life-years to measure the 2008 and 2019 US burden of disease, 2016 health spending, and 2008 NIH funding levels for 46 diseases. Main Outcomes and Measures 2019 NIH funding levels for 46 diseases. Results The 46 diseases accounted for 62 392 713 of 94 399 784 disability-adjusted life-years (66.1%) in 2008 and 75 706 718 of 111 074 472 disability-adjusted life-years (68.2%) in 2019, representing more than 66% of all disability-adjusted life-years in both years. By dollar volume, Alzheimer and dementia increased the most, with approximately $1.8 billion more funding in 2019 than 2008 (from $530 million in 2008 to $2398 million in 2019, a 352% increase), whereas interpersonal violence had the greatest decrease, $95 million, in 2019 NIH funding (from $236 million in 2008 to $141 million in 2019, a 40% decrease). For the 46 diseases in this study, the variable with the greatest association with NIH funding in 2019 was the level of NIH funding in 2008, with a simple correlation of 0.88. Burden of disease and changes in burden of disease were not statistically significantly associated with NIH funding levels once the prior level of funding was included in the model. The models suggested that a 1% higher level of NIH funding in 2008 was associated with a 0.91% higher level of NIH funding in 2019. Conclusions and Relevance In this study, NIH spending for most diseases seemed to be based primarily on the level of NIH spending more than 10 years earlier, despite changes in burden of disease. Congress and the NIH should examine the allocation process to ensure NIH investments are responsive to changes in the health of the population., This cohort study examines the factors associated with National Institutes of Health funding in 2019 for 46 diseases.

This cohort study evaluates the association between programmed cell death ligand 1 testing and first-line immune checkpoint inhibitor use in patients with advanced non–small cell lung cancer., Key Points Question How was programmed cell death ligand 1 (PD-L1) testing used to select immune checkpoint inhibitor treatment for patients with advanced non–small cell lung cancer (NSCLC)? Findings In this cohort study of 45 631 patients with advanced NSCLC, substantial increases occurred in the use of first-line immune checkpoint inhibitor treatment among patients with low or negative PD-L1 expression and those without documented PD-L1 testing. These increases were consistent with the dissemination of new evidence supporting benefit in these groups. Meaning The findings suggest that use and interpretation of the PD-L1 biomarker to guide first-line treatment for advanced NSCLC was rapidly responsive to new clinical evidence., Importance Initial approval for immune checkpoint inhibitors (ICIs) for treatment of advanced non–small cell lung cancer (NSCLC) was limited to patients with high levels of programmed cell death ligand 1 (PD-L1) expression. However, in the period after approval, it is not known how new evidence supporting efficacy of these treatments in patients with low or negative PD-L1 expression was incorporated into real-world practice. Objective To evaluate the association between PD-L1 testing and first-line ICI use. Design, Setting, and Participants This retrospective cohort study (January 1, 2011, to December 31, 2018) used a deidentified nationwide electronic health record–derived database reflecting real-world care at more than 280 US community and academic cancer clinics (approximately 800 sites of care). Patients included those with advanced NSCLC without other identifiable variations diagnosed in the period after the US Food and Drug Administration’s initial first-line approval of ICIs for patients with high PD-L1 expression (≥50%). Exposure First-line ICI treatment. Main Outcomes and Measures Patterns of PD-L1 testing and first-line ICI treatment among all patients and patients stratified by tumor histologic type (squamous vs nonsquamous). Results A total of 45 631 patients (mean [SD] age, 68.4 [9.6] years; 21 614 [47.4%] female) with advanced NSCLC were included in the study. PD-L1 testing increased from 468 (7.2%) in 2015 to 4202 (73.2%) in 2018. Within a subset of 7785 patients receiving first-line treatment in the period after first-line approval of pembrolizumab, those who received PD-L1 testing had a greater odds of receiving an ICI (odds ratio, 2.11; 95% CI, 1.89-2.36). Among patients with high PD-L1 expression (≥50%), 1541 (83.5%) received first-line ICI treatment; 776 patients (40.3%) with low PD-L1 expression (1%-49%) and 348 (32.3%) with negative PD-L1 expression (0%) also received ICIs. In addition, 755 untested patients (32.8%) were treated with a first-line ICI. The proportion of patients who received ICIs without PD-L1 testing increased during the study period (59 [17%] in quarter 4 of 2016 to 141 [53.8%] in quarter 4 of 2018). Conclusions and Relevance In this study, use of first-line ICI treatment increased among patients with advanced NSCLC with negative, low, or untested PD-L1 expression status in 2016 through 2018. These findings suggest that national practice was rapidly responsive to new clinical evidence rather than adhering to regulatory guidance in place at the time.

Digital breast tomosynthesis (DBT) is a breast cancer screening modality that has gained popularity in recent years. Although insurance coverage for DBT is not mandated under the Patient Protection and Affordable Care Act, several states have required coverage without cost sharing for private insurers.To evaluate the association between state-level insurance coverage mandates for DBT and changes in DBT use, price, and out-of-pocket payments.This cohort study used an event-study design with repeated cross-sectional observations of US states. Data were obtained from the Blue Cross Blue Shield Axis database for commercially insured women aged 40 to 64 years who underwent screening mammography between January 1, 2015, and June 30, 2019. Data were analyzed between January 14, 2021, and January 20, 2022.Passage of state-level legislation requiring insurance coverage of DBT.Change in DBT use among women screened for breast cancer, overall DBT price, and out-of-pocket payments for DBT in states with mandates for coverage of DBT compared with states that did not pass legislation.This study included 9 604 084 screening mammograms from 5 754 123 women (mean [SD] age, of 53 [6.7] years). During the study period, 15 states enacted DBT coverage mandates and 34 states did not. In states with coverage mandates, DBT use increased by 9.0 percentage points (95% CI, 1.8-16.3 percentage points; P = .02) 2 years after the mandate compared with states without coverage mandates. Coverage mandates were also associated with a net $38.7 (95% CI, $13.4-$63.9; P = .003) decrease in the mean price of DBT compared with no coverage mandates. There was no association between coverage mandates and out-of-pocket payments 2 years after mandate passage ($-2.1; 95% CI, $-5.3 to $1.0; P = .18).In this cohort study, DBT coverage mandates were associated with an increase in DBT use but not with any change in out-of-pocket payments. The findings suggest that coverage mandates for DBT may have been associated with broader use but were not associated with changes in direct costs to patients.

While increased adherence to colorectal cancer (CRC) screening guidelines in the US has been associated with significant reductions in cancer incidence in US individuals aged 50 years and older, the incidence of CRC among those aged younger than 50 years has been steadily increasing. Understanding the survival among individuals with early-onset CRC compared with those aged 50 years and older is fundamental to informing treatment approaches and understanding the unique biological distinctiveness within early-onset CRC.To characterize the overall survival for individuals with early-onset CRC.This cohort study used data from the National Cancer Database. Included individuals were ages 0 to 90 years and diagnosed with primary CRC from January 1, 2004, through December 31, 2015. Individuals diagnosed at ages 51 through 55 years were selected as the reference group and defined as later-onset CRC for this study. Individuals diagnosed at age 50 years were excluded to minimize an apparent screening detection bias at that age in our population, given that these individuals disproportionately presented with earlier stage. All statistical analyses were conducted from January 4, 2020, through December 26, 2020.Early-onset CRC was defined as age younger than 50 years at diagnosis.Overall survival was assessed by Kaplan-Meier analysis and Cox proportional hazards regression.Among 769 871 individuals with CRC (377 890 [49.1%] women; 636 791 White individuals [82.7%]), 353 989 individuals (46.0%) died (median [range] follow-up: 2.9 [0-14.0] years), 102 168 individuals (13.3%) had early-onset CRC, and 78 812 individuals (10.2%) had later-onset CRC. Individuals with early-onset CRC, compared with those diagnosed with CRC at ages 51 through 55 years, had a lower 10-year survival rate (53.6% [95% CI, 53.2%-54.0%] vs 54.3% [95% CI, 53.8%-54.8%]; P .001) in unadjusted analysis. However, after adjustment for other factors associated with mortality, most notably stage, individuals with early-onset CRC had a lower risk of death compared with individuals diagnosed from ages 51 through 55 years (adjusted hazard ratio [HR], 0.95 [95% CI, 0.93-0.96]; P .001). In the model adjusted for stage, the HR for individuals with early-onset CRC was 0.89 (95% CI, 0.88-0.90; P .001). The survival advantage was greatest for individuals diagnosed at ages 35 through 39 years (adjusted HR, 0.88 [95% CI, 0.84-0.92]; P .001) and stages I (adjusted HR, 0.87 [95% CI, 0.81-0.93]; P .001) and II (adjusted HR, 0.86 [95% CI, 0.82-0.90]; P .001) and was absent among those diagnosed at ages 25 years or younger and stages III through IV.These findings suggest that there is a survival benefit for individuals with early-onset CRC compared with those diagnosed with CRC at later ages. Further study is needed to understand the underlying heterogeneity of survival among individuals with early-onset CRC by age and stage.

Key Points Question How commonly are drugs commercially available in the countries where they were tested? Findings This cross-sectional study found that 5 years after their approval in the US, 15% of novel drugs (5 of 34 drugs) were approved in all countries where they were tested; among 70 countries contributing research participants, 7% (5 countries) received market access to the drugs they helped test within 1 year of US approval and 31% (22 countries) did so within 5 years. Approvals were faster in high-income countries, and access was lowest in African countries. Meaning These findings suggest that substantial gaps exist between where drugs are tested and where they become available to patients, raising concerns about the equitable distribution of research benefits., This cross-sectional study examines where drugs were tested for US Food and Drug Administration approval and determines how commonly and quickly these drugs received marketing approval in the countries where they were tested, both overall and by country income level and geographical region., Importance Clinical research supporting US Food and Drug Administration (FDA) drug approvals is largely conducted outside the US. Objective To characterize where drugs were tested for FDA approval and to determine how commonly and quickly these drugs received marketing approval in the countries where they were tested, both overall and by country income level and geographical region. Design, Setting, and Participants This cross-sectional analysis of trials supporting FDA approval of novel drugs in 2012 and 2014, sponsored by large drug companies, did not involve human participants. The settings were the countries hosting trials supporting US drug approval. Data sources included Drugs@FDA, ClinicalTrials.gov, PubMed, Google Scholar, EMBASE, and drug regulatory agency websites. Data analysis was completed March through September 2020. Main Outcomes and Measures The primary outcomes were the proportion of drugs approved for marketing in the countries where they were tested for FDA approval within 1, 2, 3, 4, and 5 years of FDA approval and the proportion of countries contributing participants to trials supporting FDA approvals receiving market access to the drugs they helped test within 1, 2, 3, 4, and 5 years of FDA approval. Results In 2012 and 2014, the FDA approved 34 novel drugs sponsored by large companies, on the basis of a total of 898 trials, 563 of which had location information available. Each drug was tested in a median (interquartile range [IQR]) of 25 (18-37) unique countries, including a median (IQR) of 20 (13-25) high-income countries, 6 (4-11) upper-middle-income countries, and 1 (0-2) low-middle-income country. One drug was approved for marketing in all testing countries within 1 year of FDA approval and 15% (5 of 34 drugs) were approved in all testing countries within 5 years of FDA approval. Of the 70 countries contributing research participants for FDA drug approvals, 7% (5 countries) received market access to drugs they helped test within 1 year of FDA approval and 31% (22 countries) did so within 5 years. Access within 1 year occurred in 13% (5 of 39) of high-income countries, 0 of 22 upper-middle-income countries (0%), and 0 of 9 lower-middle-income countries (0%), whereas at 5 years access rates were 46% (18 of 39 countries), 9% (2 of 22 countries), and 22% (2 of 9 countries), respectively. Approvals were faster in high-income countries (median [IQR], 8 [0-11] months) than in upper-middle-income countries (median [IQR], 11 [5-29] months) or lower-middle-income countries (median [IQR], 17 [11-27] months) after FDA approval. Access was lowest in African countries. Conclusions and Relevance These findings suggest that substantial gaps exist between where FDA-approved drugs are tested and where they ultimately become available to patients, raising concerns about the equitable distribution of research benefits at the population level.

This survey study uses data from the Medical Group Management Association’s voluntary physician compensation survey from 2008 to 2017 to examine trends in compensation for primary care and specialist physicians after passage of the Affordable Care Act.

Key Points Question How substantial are cancer disparities on the basis of county levels of income, and what are the factors that may mediate the disparities? Findings In this cross-sectional study of 3135 US counties, cancer death rates varied significantly in counties of different income levels, with a mean cancer death rate per 100 000 person-years of 185.9 in high-income counties, 204.9 in medium-income counties, and 229.7 in low-income counties. The strongest possible mediators were health risk behaviors, cost and quality of clinical care, and food insecurity. Meaning There are multiple county-level factors that may serve as mediators of cancer disparities and that may be targeted by future efforts to achieve equity in cancer outcomes., This cross-sectional study uses death records from the US National Center for Health Statistics to investigate the association between cancer death rates and county-level median household income and identifies potential mediating factors of this association., Background There are concerns about the degree to which county income level might underlie the stark disparities in cancer death rates among US counties; at the same time, there is uncertainty about the factors that may mediate the disparities. Objectives To assess county-level cancer death rates and to identify possible mediators of the association between county-level median incomes and cancer death rates. Design, Setting, and Participants Cross-sectional study using death records from the National Center for Health Statistics in 2014, with data collected and analyzed between October 1, 2016, and July 31, 2017. All US counties and county equivalents were included. Exposures County-level median household income. Main Outcomes and Measures County-level age-standardized cancer death rate. Results In 3135 counties, median incomes ranged from $22 126 to $121 250 per year. Low-income counties (median income, $33 445) vs high-income counties (median income, $55 780) had higher proportions of residents who were non-Hispanic black, lived in rural areas, or reported poor or fair health. The mean (SD) cancer death rate was 185.9 (24.4) per 100 000 person-years in high-income counties, compared with 204.9 (26.3) and 229.7 (32.9) per 100 000 person-years in medium- and low-income counties, respectively. In mediation models, health risk behaviors (smoking, obesity, and physical inactivity); clinical care factors (unaffordable care and low-quality care); health environments (food insecurity); and health policies (state smoke-free laws and Medicaid payment rates) in aggregate accounted for more than 80% of the income-related disparity. The strongest possible mediators were food insecurity (explaining 19.1% [95% CI, 12.5%-26.5%] of the association between county incomes and cancer deaths), low-quality care (17.9%; 95% CI, 14.0%-21.8%), smoking (12.7%; 95% CI, 9.4%-15.6%), and physical inactivity (12.2%; 95% CI, 9.4%-15.6%). Conclusions and Relevance There are wide gaps in cancer death rates between low-, medium-, and high-income counties. Future studies are needed to assess whether targeting the possible mediators might ameliorate the substantial socioeconomic cancer disparities.

This cohort study compares receipt of National Comprehensive Cancer Network (NCCN) guideline–discordant prostate cancer imaging (radionuclide, CT, or MRI) to stage incident prostate cancer among men being treated in the Veterans Health Administration system vs those receiving Medicare-covered services vs a combination of the two., Key Points Question What is the association between the type of health care delivery system and guideline-discordant prostate cancer imaging rates? Findings In this cohort study that included data from 98 867 US men with a diagnosis of prostate cancer, Medicare beneficiaries were significantly more likely to receive guideline-discordant prostate cancer imaging than men treated only at the Veterans Health Administration. Meaning Increased reliance on fee-for-service Medicare vs the Veterans Health Administration health system for prostate cancer treatment could be associated with the receipt of more unnecessary and potentially harmful tests., Importance Prostate cancer imaging rates appear to vary by health care setting. With the recent extension of the Veterans Access, Choice, and Accountability Act, the government has provided funds for veterans to seek care outside the Veterans Health Administration (VA). It is important to understand the difference in imaging rates and subsequent differences in patterns of care in the VA vs a traditional fee-for-service setting such as Medicare. Objective To assess the association between prostate cancer imaging rates and a VA vs fee-for-service health care setting. Design, Setting, and Participants This cohort study included data for men who received a diagnosis of prostate cancer from January 1, 2004, through March 31, 2008, that were collected from the VA Central Cancer Registry, linked to administrate claims and Medicare utilization records, and the Surveillance, Epidemiology, and End Results Program database. Three distinct nationally representative cohorts were constructed (use of VA only, use of Medicare only, and dual use of VA and Medicare). Men older than 85 years at diagnosis and men without high-risk features but missing any tumor risk characteristic (prostate-specific antigen, Gleason grade, or clinical stage) were excluded. Analysis of the data was completed from March 2016 to February 2018. Exposures Patient utilization of different health care delivery systems. Main Outcomes and Measures Rates of prostate cancer imaging were analyzed by health care setting (Medicare only, VA and Medicare, and VA only) among patients with low-risk prostate cancer and patients with high-risk prostate cancer. Results Of 98 867 men with prostate cancer (77.4% white; mean [SD] age, 70.26 [7.48] years) in the study cohort, 57.3% were in the Medicare-only group, 14.5% in the VA and Medicare group, and 28.1% in the VA-only group. Among men with low-risk prostate cancer, the Medicare-only group had the highest rate of guideline-discordant imaging (52.5%), followed by the VA and Medicare group (50.9%) and the VA-only group (45.9%) (P