Summary
Previous studies show that SDOH play an important role in BC stage, treatment, and outcomes. Disparities in BC overall survival (OS) by SDOH are well documented. Z codes were introduced into International Classification of Diseases, 10th edition in 2015 to identify reasons for clinical encounters when circumstances other than a disease or injury are recorded as diagnoses, but uptake has been slow. Herein we report Z codes Z55 – Z65, which specifically identify SDOH impacting health care utilization, for BC patients (pts) in CancerLinQ (CLQ).
Methods
CLQ is a health data platform representing ∼7M pts across 100+ US oncology practices and cancer centers. In this retrospective cross-sectional analysis, CLQ pts diagnosed (dx) with BC actively managed in 2021 were identified and pt diagnosis codes (PDC) evaluated. Descriptive statistics and multi-variate logistic regression analysis were performed, estimating statistically significant proportions (%) and adjusted odds ratios with corresponding 95% confidence intervals [aOR (95% CI)] for associations between independent demographic variables and Z code reporting. BC pts with >1 Z code reported were compared to BC pts with no Z codes.
Results
We evaluated 8,134,071 BC PDC representing 236,115 BC pts actively managed in 2021. BC pts were 77% Non-Hispanic White (NHW), 16% Non-Hispanic Black (NHB), with Asian and Hispanic/Latino BC pts comprising <6%. BC pts dx age <40 were 3%, 12% dx age 40-49, 29% dx age 50-59, 25% dx age 70-79, with 10% dx age ≥ 80. 52% of BC pts were married, 33% divorced/widowed, with 15% single. BC pts were largely female (99%) and urban (86%). Of the BC PDC assessed, 7,069 were Z code PDC representing 7,624 BC pts, 3.2% of CLQ BC pts actively managed in 2021. Among BC pts represented, 50.9% had 1, 13.4% had 2, 6.3% had 3, 14.6% had 4, and 14.7% had 5+ Z codes reported. The 5 most frequently reported Z code groups were: Z63 (35%) - Support group & family circumstances Z59 (27%) - Housing & economic circumstances Z65 (16%) - Other psychological circumstance Z60 (11%) - Social environment Z56 (5%) - Employment NHB, Asian, and Hispanic/Latino BC PDC had greater odds of Z code reporting compared to NHW, with Hispanic/Latino BC PDC having almost 2x greater odds of Z code reporting [1.8 (1.64, 1.94)]. An inverse relationship was observed between dx age and aOR of Z code reporting, with BC PDC of pts dx age <40 having the greatest odds [1.4 (1.24, 1.58)] and BC PDC of pts dx ≥80 having the lowest [0.8 (0.76, 0.92)]. Divorced/widowed PDC [1.7 (1.60, 1.78)] and single PDC [1.6 (1.53, 1.75)] BC PDC had greater odds of Z code reporting compared to married BC PDC. Rural BC PDC [0.9 (0.81, 0.94) had lesser odds of Z code reporting compared to urban BC PDC.
Conclusions
CLQ BC Z code utilization in 2021 (3.2%) exceeded previously reported disease-agnostic studies (1.3% - 1.9%). Z codes indicative of factors related to socioeconomic status (SES), employment, and social isolation represent 94% of all Z codes reported among BC PDC in this analysis. This finding is consistent with previous studies of SDOH among BC pts. Hispanic/Latino, divorced/widowed, and single BC PDC had the greatest odds of Z code reporting, with rural BC PDC among the lowest odds. The association of poorer quality care and survival among rural pts is well-known. Similarly, previous studies of women dx age <40 experiencing negative SDOH were more likely to receive chemotherapy, less likely to take endocrine therapy if indicated, and suffered worse OS. Thus, the inverse relationship observed between dx age and Z code reporting as well as low odds of reporting in rural settings should be further studied in future analyses which include BC stage, treatment patterns, and outcomes. Greater Z code reporting by providers could uncover SDOH trends impacting BC diagnosis, healthcare utilization, treatment, and outcomes.
