Clinical, sociodemographic, and service provider determinants of guideline concordant colorectal cancer care for Appalachian residents

BACKGROUND

Colorectal cancer represents a significant cause of morbidity and mortality, particularly in Appalachia where high mortality from colorectal cancer is more prevalent. Adherence to treatment guidelines leads to improved survival. This paper examines determinants of guideline concordance for colorectal cancer.

METHODS

Colorectal cancer patients diagnosed in 2006-2008 from 4 cancer registries (Kentucky, Ohio, Pennsylvania, and North Carolina) were linked to Medicare claims (2005-2009). Final sample size after exclusions was 2,932 stage I-III colon, and 184 stage III rectal cancer patients. The 3 measures of guideline concordance include adjuvant chemotherapy (stage III colon cancer, <80 years), ≥12 lymph nodes assessed (resected stage I-III colon cancer), and radiation therapy (stage III rectal cancer, <80 years). Bivariate and multivariate analyses with clinical, sociodemographic, and service provider covariates were estimated for each of the measures.

RESULTS

Rates of chemotherapy, lymph node assessment, and radiation were 62.9%, 66.3%, and 56.0%, respectively. Older patients had lower rates of chemotherapy and radiation. Five comorbidities were significantly associated with lower concordance in the bivariate analyses: myocardial infarction, congestive heart failure, respiratory diseases, dementia with chemotherapy, and diabetes with adequate lymph node assessment. Patients treated by hospitals with no Commission on Cancer (COC) designation or lower surgical volumes had lower odds of adequate lymph node assessment.

CONCLUSIONS

Clinical, sociodemographic, and service provider characteristics are significant determinants of the variation in guideline concordance rates of 3 colorectal cancer measures.

Predictors of care for early-stage breast cancer in Appalachia

6558

Background: We studied care for early-stage breast cancer in Appalachia, a region with health infrastructure, socioeconomic (SES) and geographic disparities. Methods: Cases of stage I-III breast cancer diagnosed 2006-2008 were identified from cancer registries of KY, NC, OH, and PA and linked to Medicare data. Guideline concordance was studied in eligible groups, as follows: endocrine therapy for hormone receptor positive cancer (n=1429); and radiation (RT) use after breast conserving surgery (BCS) divided into two groups - age 70 years and older with ER/PR+, <2 cm, node negative tumors where it may have been acceptable to forgo RT (OptRT, n=1108) and all other cases (IndRT, n=1422). Multivariate (MV) and univariate analyses were performed. Covariates included age, state, Appalachian Regional Commission (ARC) economic status, Commission of Cancer (CoC) status, state, access to care, number of beds, surgery facility ownership, volume, and chemotherapy/radiation offered, provider graduation year and volume, Charlson comorbidity, diagnosis year, Medicaid/Medicare dual status, histology, tumor size, tumor sequence, positive lymph nodes, ER/PR status, stage, herceptin use, and BCS/mastectomy indicator. Results: Mean age was 74 years and 97% were white. Guideline-concordance was 76% for endocrine therapy, 83% for IndRT, and 77% for OptRT. Younger age predicted higher concordance in all groups. Endocrine therapy use was lower in NC vs PA (OR 0.60; 95% CI 0.41-0.88) and greater for cases whose provider graduated in years 1984-1988, vs. 1989+ (1.55; 1.06-2.29). In IndRT, provider volume in the 3rdquartile vs. highest quartile predicted increased radiation use (2.36; 1.46-3.81). In OptRT, less receipt of radiation was predicted by residence in NC vs. PA (0.26; 0.18-0.48), and competitive ARC class vs. transitional (0.60; 0.36-0.99). Conclusions: Within Appalachia, there are SES and provider characteristics that are associated with use of guideline concordant care.

Disparities in breast cancer presentation and treatment of older women, by insurance status

e17516

Background: Disparities are known to exist in breast cancer outcomes by age and socioeconomic status (SES), but there is little data regarding these disparities in the elderly. We studied older women in North Carolina (NC) using insurance status as an indicator of SES. Methods: From the 1999-2002 NC Central Cancer Registry, we identified women age ≥65 years presenting with nonmetastatic breast cancer, having surgery within 60 days of diagnosis, no neoadjuvant therapy, and insured by Medicare only (M) or dual Medicaid/Medicare (dMM). Chi-square tests followed by Tukey Style Multiple Comparison of Proportions were used to compare baseline characteristics and treatment received. Multivariate analyses including age, race, Charlson comorbidity, tumor size, lymph node status (LN), ER/PR status, HER2 status, and relevant treatment components, were used to determine predictors of use of chemotherapy. Results: The study population, n=3088 with mean age 75 (SD 6.69) years, included 560 dMM and 2528 M insured women. In dMM, tumors were larger (23.5 mm vs 18.5 mm, p<0.001), more likely poorly differentiated (p=0.04), and node positive (p=0.004). dMM were significantly less likely to have breast conserving surgery (vs mastectomy, p<0.001), radiation therapy after surgery (<0.001), adjuvant chemotherapy (0.007), and adjuvant endocrine therapy (<0.001). Significant predictors of receipt of adjuvant chemotherapy were: for dMM, white race (OR 0.22, 95% CI 0.06-0.78), positive LN (vs negative LN; 6.00, 1.44-25.02); for M, age 65-69 (vs 75+; 7.43, 3.64-15.18), age 70-74 (vs 75+; 4.93, 95% CI 2.38-10.22), larger tumor size (1.73, 1.09-2.74), positive LN (9.25, 4.80-17.83), and ER/PR negative (4.98, 2.29-10.85). Conclusions: Breast cancers in low SES, older patients are higher grade, larger, and more advanced, yet they less often receive adjuvant chemotherapy. Future work should focus on interventions to increase receipt of standard of care treatment among this population.

Effects of integrated delivery system on cost and quality

OBJECTIVES

To perform a systematic review of the current literature to assess the association between integrated healthcare delivery systems and changes in cost and quality.

METHODS

Medline, Embase, Cochrane Reviews, Academic Search Premier, and reference lists were used to retrieve peer-reviewed articles reporting outcomes (cost and quality) related to integrated delivery systems. A general Internet search and reference lists were used to retrieve non-peer reviewed publications meeting the same criteria. Included peer and non-peer reviewed publications were based in the United States and were published between the years 2000 and 2011.

RESULTS

A total of 21 peer-reviewed articles and 4 non-peer reviewed manuscripts met the inclusion criteria. Twenty studies showed an association between increased integration in healthcare delivery and an increase in the quality of care. One study reported no changes in quality indicators associated with increased integration. None of these studies measured cost reduction directly, but used reduction in utilization of services instead. Four studies associated decreases in the utilization of services with increases in integration.

CONCLUSIONS

The vast majority of studies we reviewed have shown that integrated delivery systems have positive effects on quality of care. Few studies linked use of an integrated delivery system to lower health service utilization. Only 1 study reported some small cost savings.

Nutritional vitamin D use in chronic kidney disease: a survey of pediatric nephrologists

BACKGROUND

Vitamin D deficiency may contribute to risk of cardiovascular disease, diabetes, and infections, in addition to known effects on mineral metabolism. Controversy remains regarding the use of nutritional vitamin D supplementation in chronic kidney disease (CKD), and the supplementation practices of pediatric nephrologists are unknown.

METHODS

An electronic survey containing eight vignettes was sent to physician members of the International Pediatric Nephrology Association in 2011 to identify physician and patient characteristics that influence nephrologists to supplement CKD patients with nutritional vitamin D. Vignettes contained patient characteristics including light vs dark skin, CKD stage, cause of renal disease, parathyroid hormone (PTH), and 25(OH) vitamin D levels. Multivariate logistic generalized estimating equation regression was used to identify predictors of supplementation.

RESULTS

Of 1,084 eligible physicians, 504 (46%) completed the survey. Supplementation was recommended in 73% of cases overall (ranging from 91% of those with vitamin D levels <10 ng/mL to 35% with levels >30). Greater CKD severity was associated with greater recommendation of supplementation, especially for patients with higher vitamin D levels (test for interaction p < 0.0001). PTH level above target for CKD stage was associated with greater recommendation to supplement in pre-dialysis CKD, but did not have an impact on recommendations in dialysis patients (test for interaction p < 0.0001). Skin color, cause of CKD, and albumin levels were not associated with supplementation recommendation.

CONCLUSIONS

Recommending nutritional vitamin D is common worldwide, driven by CKD stage and vitamin D and PTH levels. Future studies are needed to establish the risks and benefits of supplementation.

Insight into the sharing of medical images: physician, other health care providers, and staff experience in a variety of medical settings

BACKGROUND

Scant knowledge exists describing health care providers' and staffs' experiences sharing imaging studies. Additional research is needed to determine the extent to which imaging studies are shared in diverse health care settings, and the extent to which provider or practice characteristics are associated with barriers to viewing external imaging studies on portable media.

OBJECTIVE

This analysis uses qualitative data to 1) examine how providers and their staff accessed outside medical imaging studies, 2) examine whether use or the desire to use imaging studies conducted at outside facilities varied by provider specialty or location (urban, suburban, and small town) and 3) delineate difficulties experienced by providers or staff as they attempted to view and use imaging studies available on portable media.

METHODS

Semi-structured interviews were conducted with 85 health care providers and medical facility staff from urban, suburban, and small town medical practices in North Carolina and Virginia. The interviews were audio recorded, transcribed, then systematically analyzed using ATLAS.ti.

RESULTS

Physicians at family and pediatric medicine practices rely primarily on written reports for medical studies other than X-rays; and thus do not report difficulties accessing outside imaging studies. Subspecialists in urban, suburban, and small towns view imaging studies through internal communication systems, internet portals, or portable media. Many subspecialists and their staff report experiencing difficulty and time delays in accessing and using imaging studies on portable media.

CONCLUSION

Subspecialists have distinct needs for viewing imaging studies that are not shared by typical primary care providers. As development and implementation of technical strategies to share medical records continue, this variation in need and use should be noted. The sharing and viewing of medical imaging studies on portable media is often inefficient and fails to meet the needs of many subspeciality physicians, and can lead to repeated imaging studies.

Defining care provided for breast cancer based on medical record review or Medicare claims: information from the Centers for Disease Control and Prevention Patterns of Care Study

BACKGROUND

Description of care patterns is important as evidence-based guidelines increasingly dictate care. We explore the level of agreement between claims and record abstraction for guideline concordant multidisciplinary breast cancer care.

METHODS

From the U.S. Centers for Disease Control and Prevention's National Program of Cancer Registries Patterns of Care study, in which medical record abstraction of breast cancer and treatment was accomplished, cases include breast cancer where Medicare claims were available. Components of care were breast-conserving surgery (BCS), mastectomy, node assessment, radiation (RT), and chemotherapy (CTX), including specific chemotherapeutic agents, and combinations. We compared Medicare claims with record abstraction, and measured concordance using the kappa statistic and sensitivity.

RESULTS

The study sample consisted of 1762 women with stage 0 to 4 breast cancer. Level of agreement was excellent for surgery type (kappa = 0.84) and CTX (kappa = 0.89); agreement for RT therapy was slightly lower (kappa = 0.79). For standard multicomponent strategies, sensitivities and specificities were high; for example, 88.8%/93.5% for mastectomy plus nodes and 86.6%/95.4% for BCS plus nodes and RT. For selected, standard, multi-agent, adjuvant CTX regimens, sensitivities ranged from 66.3% to 68.8% (kappa 0.63-0.73).

CONCLUSIONS

Medicare claims, compared with chart abstraction, is a reliable method for determining patterns of multicomponent care for breast cancer.

The cost of Medicaid coverage for the uninsured: evidence from Buncombe County, North Carolina

BACKGROUND

The Affordable Care Act gives states the option to expand state Medicaid programs to cover many who are currently uninsured. The potential financial impact has not been thoroughly examined. We characterized the health risk of uninsured adults in Buncombe County, North Carolina, relative to that of local Medicaid recipients, to estimate the cost of expanding Medicaid coverage to include the uninsured.

METHODS

We obtained de-identified patient enrollment and claims data for 2008 from the Division of Medical Assistance, North Carolina Department of Health and Human Services and from the 3 safety-net providers who care for most of the county's low-income uninsured adults. We used the Chronic Illness and Disability Payment System (CDPS) risk-adjustment tool to measure the relative health risk of the two populations. Based on actual spending in the Medicaid group and its health risk relative to that of the uninsured, we then projected how much it would have cost to provide Medicaid coverage for these uninsured in 2008.

RESULTS

We estimated, based on CDPS adjustment for demographics and diagnoses, that these uninsured adults would have incurred costs 13% greater than those of the actual nondisabled adult Medicaid population. The projected cost of providing Medicaid coverage to these uninsured would have been $4,320 per person.

LIMITATIONS

Data were drawn from only the 3 major safety-net organizations and therefore excluded care obtained from other safety-net providers. Also, this sample of uninsured people included some who are ineligible for Medicaid because of their citizenship status. Furthermore, Medicaid enrollment might lead to increased utilization, revealing a greater burden of illness than we detected.

CONCLUSION

In Buncombe County, uninsured adults who enroll in expanded Medicaid are likely to have somewhat more costly health problems than do currently enrolled nondisabled adults.

Evaluation of serum creatinine concentration-based glomerular filtration rate equations in pediatric patients with chronic kidney disease

STUDY OBJECTIVE

To evaluate the accuracy of four equations based on serum creatinine concentration-the original Schwartz equation and the Leger, Bedside Chronic Kidney Disease in Children (CKiD), and Counahan-Barratt equations-for determining glomerular filtration rate (GFR) in pediatric patients with chronic kidney disease.

DESIGN

Retrospective, observational, cross-sectional study.

SETTING

Single-center, academic, outpatient pediatric nephrology clinic.

PATIENTS

Fifty-three pediatric patients with stages 2-5 chronic kidney disease who completed GFR assessment with (125) I-iothalamate between January 2002 and January 2005.

MEASUREMENT AND MAIN RESULTS

Data were collected from each patient's medical record. Glomerular filtration rate data were analyzed using 59 evaluations from the 53 pediatric patients. (125) I-iothalamate clearance was used as the index GFR. The Bedside CKiD and Counahan-Barratt equations outperformed the Schwartz and Leger equations when the index GFR was less than 60 ml/minute/1.73 m(2) ; the Schwartz and Counahan-Barratt equations performed best for index GFRs of 60 ml/minute/1.73 m(2) or greater. Overestimation was highest with the Schwartz and Leger equations (> 20% index GFR in 57.6% and 62.7% of patients, respectively). Underestimation was highest with the Bedside CKiD and Counahan-Barratt equations (> 20% index GFR in 30.5% and 28.8%, respectively).

CONCLUSION

The new Bedside CKiD equation performed well for pediatric patients with moderate-to-severe chronic kidney disease, but less well for pediatric patients with mild disease. Additional studies are needed to develop more precise GFR equations using serum creatinine concentration.

Influence of comorbidity on guideline concordant care for breast cancer: Findings from the Center for Disease Control and Prevention National Program of Cancer Registry (NPCR) patterns of care study

6052

Background: Comorbidity burden predicts cancer treatment and may influence outcome. We explore the relationship of specific comorbid illnesses with receipt of guideline concordant care for early stage breast cancer. Methods: The NPCR’s Patterns of Care study reabstracted the medical records of breast cancer cases diagnosed in 2004 from 7 cancer registries. We included women with nonmetastatic in situ and invasive breast cancer, known hormone receptor status, node status, and tumor size. Guideline-concordant management, including surgery, radiation, chemotherapy and endocrine components, was based on NCCN guidelines using tumor size, nodal and hormone receptor status. Comorbidity was measured according to the Adult Comorbidity Evaluation Index (ACE). Multivariate logistic regression models were used to determine factors associated with guideline-concordant care, and included overall ACE scores and 26 separate ACE comorbidity categories, as well as age, race, hormone receptor status, and HER2 status. Results: The study sample included 6904 women (mean age 58.7 and range 20-99 years, 76% white, 45% with ACE comorbidity score of 0, 70% ER and/or PR+, 13% HER2+). Overall, 64% received guideline-concordant care. Receipt of guideline-concordant care varied by overall comorbidity burden (71% for none; 65% for minor; 63% for moderate; 50% for severe; p<0.05). The presence of hypertension (OR 1.26, 95% CI 1.08-1.48) predicted receipt of guideline concordant care, whereas, peripheral artery disease (OR 0.44, 95% CI 0.21-0.93), diabetes (OR 0.78, 95% CI 0.63-0.97) and dementia (OR 0.31, 95% CI 0.13-0.74) predicted lack of guideline concordant care. Older age, black race, and hormone receptor positivity were associated with less, and HER2 positivity with receipt of more guideline-concordant care. Conclusions: Overall those with more comorbidity burden received less guideline-concordant care. However, the effects vary by specific conditions. The odds of receiving guideline-concordant care was greater in those with hypertension and less in those with peripheral arterial disease, diabetes, and dementia.

Adjuvant Radiation and Outcomes After Breast Conserving Surgery in Publicly Insured Patients

OBJECTIVES: Epidemiologic studies report that lack of adjuvant radiation (RT) after breast conserving surgery (BCS) is associated with higher short-term mortality. It is generally accepted that adjuvant RT decreases risk of breast cancer recurrence and thereby lowers long-term mortality; here, we explore reasons for its relationship to short-term mortality. MATERIALS AND METHODS: We studied 1,583 publically insured women who had BCS between 1998 and 2002 (mean 71.8 years, range 27-101), of whom 1,346 (85%) received RT. Multivariate analyses with Cox Proportional Hazards and Logistic Regression models included: age; race; comorbidity; insurance status; tumor size; number of nodes positive; hormone receptor status; receipt of radiation; adjuvant chemotherapy; preventive care - including mammography, Pap smear and primary care visits; and hospitalization. RESULTS: At a mean follow-up of 52.8 months, overall mortality was significantly lower in those who received RT (HR 0.45, p<0.0001) and higher with older age (HR 1.05, p<0.0001) and greater comorbidity (HR 1.16, p=0.0007). Local recurrence was less with receipt of optimal radiation (HR 0.47; p=0.03). Breast cancer event, as determined by a clinically logical algorithm to detect breast cancer recurrence and death, however, was not significantly associated with receipt of RT (OR 1.32, p=0.2). CONCLUSION: These results imply that the higher short-term mortality in women not receiving RT after BCS is related to factors other than breast cancer recurrence.

The anti-tumour activity of allogeneic cytokine-induced killer cells in patients who relapse after allogeneic transplant for haematological malignancies

We performed a Phase I/II clinical trial to study the feasibility, toxicity and efficacy of allogeneic cytokine-induced killer (CIK) cell expansion, and treatment for patients with haematological malignancies who relapsed after allogeneic haemopoietic SCT (allo-HSCT). Allogeneic CIK cells were successfully generated for a total of 24 patients, including those from patients' own leukapheresis products in 5 patients who had no access to further donor cells. The median CD3(+) T-cell expansion was 9.33 (1.3-38.97) fold, and CD3(+)CD56(+) natural killer (NK)-like T-cell expansion was 27.77 (2.59-438.93) fold. A total of 55 infusions were done for 16 patients who had either failed or progressed after initial response to various individualized chemotherapy regimens and donor lymphocyte infusion (DLI), at doses ranging from 10 to 200 million CD3(+) cells/kg. Response attributable to CIK cell infusion was observed in five patients. These included two with ALL, two with Hodgkin's disease (HD) and one with AML, and two of whom had a response sustained for more than 2 years. Acute GVHD occurred in three and was easily treatable. This study provides some evidence suggestive of the efficacy of allogeneic CIK cells even after failure of DLI in some cases.

Stress CMR imaging observation unit in the emergency department reduces 1-year medical care costs in patients with acute chest pain: a randomized study for comparison with inpatient care

OBJECTIVES

This study sought to compare the direct cost of medical care and clinical events during the first year after patients with intermediate risk acute chest pain were randomized to stress cardiac magnetic resonance (CMR) observation unit (OU) testing versus inpatient care.

BACKGROUND

In a recent study, randomization to OU-CMR reduced median index hospitalization cost compared with the cost of inpatient care in patients presenting to the emergency department with intermediate risk acute chest pain.

METHODS

Emergency department patients with intermediate risk chest pain were randomized to OU-CMR (OU care, cardiac markers, stress CMR) or inpatient care (admission, care per admitting provider). This analysis reports the direct cost of cardiac-related care and clinical outcomes (myocardial infarction, revascularization, cardiovascular death) during the first year of follow-up subsequent to discharge. Consistent with health economics literature, provider cost was calculated from work-related relative value units using the Medicare conversion factor; facility charges were converted to cost using departmental-specific cost-to-charge ratios. Linear models were used to compare cost accumulation among study groups.

RESULTS

We included 109 randomized subjects in this analysis (52 OU-CMR, 57 inpatient care). The median age was 56 years; baseline characteristics were similar in both groups. At 1 year, 6% of OU-CMR and 9% of inpatient care participants experienced a major cardiac event (p = 0.72) with 1 patient in each group experiencing a cardiac event after discharge. First-year cardiac-related costs were significantly lower for participants randomized to OU-CMR than for participants receiving inpatient care (geometric mean = $3,101 vs. $4,742 including the index visit [p = 0.004] and $29 vs. $152 following discharge [p = 0.012]). During the year following randomization, 6% of OU-CMR and 9% of inpatient care participants experienced a major cardiac event (p = 0.72).

CONCLUSIONS

An OU-CMR strategy reduces cardiac-related costs of medical care during the index visit and over the first year subsequent to discharge, without an observed increase in major cardiac events. (Cost Comparison of Cardiac Magnetic Resonance Imaging [MRI] Use in Emergency Department [ED] Patients With Chest Pain; NCT00678639).