The impact of health insurance status on the survival of patients with head and neck cancer

The association of hospital spending intensity and cancer outcomes: a population-based study in an Asian country

BACKGROUND

Different results are reported for the relationship between regional variation in medical spending and disease prognosis for acute illness and for cancer. Our objective was to investigate the association between hospital medical care spending intensity and mortality rates in cancer patients.

METHODS

A total of 80,597 patients with incident cancer diagnosed in 2002 were identified from the National Health Insurance Research Database of Taiwan, Republic of China. The Cox proportional hazards model was used to compare the 5-year survival rates of patients treated at hospitals with different spending intensities after adjusting for possible confounding and risk factors.

RESULTS

After adjustment for patient characteristics, treatment modality, and hospital volume, an association was found between lower hospital spending intensity and poorer survival rates. The 5-year survival rate expressed by hazard ratios was 1.36 (95% confidence interval [CI]: 1.30-1.43, p < .001) for colorectal cancer, 1.18 (95% CI: 1.08-1.29, p < .001) for lung cancer, 1.13 (95% CI: 1.05-1.22, p = .002) for hepatoma, 1.16 (95% CI: 1.07-1.26, p < .001) for breast cancer, and 1.23 (95% CI: 1.10-1.39, p = .001) for prostate cancer.

CONCLUSION

Our preliminary findings indicate that higher hospital spending intensity was associated with lower mortality rates in patients being treated for lung cancer, breast cancer, colorectal cancer, prostate cancer, hepatoma, or head and neck cancer. The cancer stages were unavailable in this series, and more research linked with the primary data may be necessary to clearly address this issue.

Squamous cell carcinoma of the parotid gland: a population-based analysis of 2545 cases

PURPOSE

Squamous cell carcinoma (SCC) of the parotid gland is an uncommon tumor, which generally affects older patients. In this study, we explore various aspects of this entity using a national population-based database.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) registry was used to extract data on frequency, incidence, and disease-specific survival (DSS) from 1973 to 2009. Variables analyzed included age, gender, race, histologic grade, stage and treatment. Cox proportional hazards analysis was conducted.

RESULTS

A total of 2545 cases were identified. Parotid SCC was most common in males (79.8%), whites (92.9%), and patients aged ≥75 years (51.4%). Incidence increased slightly over the past three decades (annual percent change 1.90%, p<0.05). Overall 5-year DSS was 54.4%. Statistically significant poor prognostic factors included black race, age ≥75 years, tumor T3 or greater, and higher clinical stage at diagnosis. Elective neck dissection (END) in patients staged N0 was associated with higher DSS (78.3% versus 51.1%, p<0.0001). The omission of END was associated with a three-fold greater hazard of death (hazard ratio 3.19, 95% confidence interval 1.53-7.26, p=0.0016), regardless of whether or not radiotherapy was given.

CONCLUSION

Parotid SCC is uncommon, and data on treatment decisions are limited. Our study profiles the demographic, clinicopathologic, incidence, and survival features of this entity. Perhaps most notably, our results support the practice of END of the N0 neck.

Is laparoscopy a risk factor for bile duct injury during cholecystectomy?

Laparoscopic cholecystectomy, obesity, insurance status, and hospital volume were not associated with an increased risk of bile duct injury.

Background and Objectives:

Previously, risk factors for bile duct injury have been identified as acute cholecystitis, male gender, older age, aberrant biliary anatomy, and laparoscopic cholecystectomy.

Methods:

A retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2006 was performed with an inclusion criterion of cholecystectomy performed on hospital day 0 or 1. Patient- and hospital-level factors potentially associated with bile duct injury were examined by logistic regression.

Results:

A total of 377,424 cholecystectomy patients were identified. There were 1124 bile duct injuries (0.30%), with 177 (0.06%) in the laparoscopic cholecystectomy group and 947 (1.46%) in the open cholecystectomy group (P < .001). On multivariate analysis, significant risk factors for bile duct injury were male gender (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.06–1.38; P = .006), age >60 years (OR, 2.23; 95% CI, 1.61–3.09; P < .001), and academic hospital status (OR, 1.37; 95% CI, 1.05–1.79; P = .02). Acute cholecystitis was associated with a lower risk of bile duct injury (OR, 0.67; 95% CI, 0.46–0.99; P = .044).

Conclusion:

Independent risk factors for bile duct injury included male gender, age >60 years, and academic hospital status. Laparoscopic cholecystectomy, obesity, insurance status, or hospital volume was not associated with an increased risk of bile duct injury.

The effect of individual and neighborhood socioeconomic status on gastric cancer survival

PURPOSE

Gastric cancer is a leading cause of death, particularly in the developing world. The literature reports individual socioeconomic status (SES) or neighborhood SES as related to survival, but the effect of both has not been studied. This study investigated the effect of individual and neighborhood SES simultaneously on mortality in gastric cancer patients in Taiwan.

MATERIALS AND METHODS

A study was conducted of 3,396 patients diagnosed with gastric cancer between 2002 and 2006. Each patient was followed for five years or until death. Individual SES was defined by income-related insurance premium (low, moderate, and high). Neighborhood SES was based on household income dichotomized into advantaged and disadvantaged areas. Multilevel logistic regression model was used to compare survival rates by SES group after adjusting for possible confounding factors.

RESULTS

In patients younger than 65 years, 5-year overall survival rates were lowest for those with low individual SES. After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score), gastric cancer patients with high individual SES had 68% risk reduction of mortality (adjusted odds ratio [OR] of mortality, 0.32; 95% confidence interval [CI], 0.17-0.61). Patients aged 65 and above had no statistically significant difference in mortality rates by individual SES group. Different neighborhood SES did not statistically differ in the survival rates.

CONCLUSION

Gastric cancer patients aged less than 65 years old with low individual SES have higher risk of mortality, even under an universal healthcare system. Public health strategies, education and welfare policies should seek to correct the inequality in gastric cancer survival, especially in those with lower individual SES.

The combined effects of hospital and surgeon volume on short-term survival after hepatic resection in a population-based study

Background

The influence of different hospital and surgeon volumes on short-term survival after hepatic resection is not clearly clarified. By taking the known prognostic factors into account, the purpose of this study is to assess the combined effects of hospital and surgeon volume on short-term survival after hepatic resection.

Methods

13,159 patients who underwent hepatic resection between 2002 and 2006 were identified in the Taiwan National Health Insurance Research Database. Data were extracted from it and short-term survivals were confirmed through 2006. The Cox proportional hazards model was used to assess the relationship between survival and different hospital, surgeon volume and caseload combinations.

Results

High-volume surgeons in high-volume hospitals had the highest short-term survivals, following by high-volume surgeons in low-volume hospitals, low-volume surgeons in high-volume hospitals and low-volume surgeons in low-volume hospitals. Based on Cox proportional hazard models, although high-volume hospitals and surgeons both showed significant lower risks of short-term mortality at hospital and surgeon level analysis, after combining hospital and surgeon volume into account, high-volume surgeons in high-volume hospitals had significantly better outcomes; the hazard ratio of other three caseload combinations ranging from 1.66 to 2.08 (p<0.001) in 3-month mortality, and 1.28 to 1.58 (p<0.01) in 1-year mortality.

Conclusions

The combined effects of hospital and surgeon volume influenced the short-term survival after hepatic resection largely. After adjusting for the prognostic factors in the case mix, high-volume surgeons in high-volume hospitals had better short-term survivals. Centralization of hepatic resection to few surgeons and hospitals might improve patients’ prognosis.

The association of socioeconomic status and access to low-volume service providers in breast cancer

Background

No large-scale study has explored the combined effect of patients’ individual and neighborhood socioeconomic status (SES) on their access to a low-volume provider for breast cancer surgery. The purpose of this study was to explore under a nationwide universal health insurance system whether breast cancer patients from a lower individual and neighborhood SES are disproportionately receiving breast cancer surgery from low-volume providers.

Methods

5,750 patients who underwent breast cancer surgery in 2006 were identified from the Taiwan National Health Insurance Research Database. The Cox proportional hazards model was used to compare the access to a low-volume provider between the different individual and neighborhood SES groups after adjusting for possible confounding and risk factors. Hosmer-Lemeshow goodness-of-fit statistic was used to determine how well the model fit the data.

Results

Univariate analysis data shows that patients in disadvantaged neighborhood were more likely to receive breast cancer surgery at low-volume hospitals; and lower-SES patients were more likely to receive surgery from low-volume surgeons. In multivariate analysis, after adjusting for patient characteristics, the odds ratios of moderate- and low-SES patients in disadvantaged neighborhood receiving surgery at low-volume hospitals was 1.47 (95% confidence interval=1.19-1.81) and 1.31 (95% confidence interval=1.05-1.64) respectively compared with high-SES patients in advantaged neighborhood. Moderate- and low-SES patients from either advantaged or disadvantaged neighborhood had an odds ratios ranging from 1.51 to 1.80 (p<0.001) to receiving surgery from low-volume surgeons. In Hosmer-Lemeshow goodness-of-fit test, p>0.05 that shows the model has a good fit.

Conclusions

In this population-based cross-sectional study, even under a nationwide universal health insurance system, disparities in access to healthcare existed. Breast cancer patients from a lower individual and neighborhood SES are more likely to receive breast cancer surgery from low-volume providers. The authorities and public health policies should keep focusing on these vulnerable groups.

Does payer status impact clinical outcomes after cardiac surgery? A propensity analysis

BACKGROUND

Medicaid patients bear proportionately greater financial responsibility for the cost of outpatient care and medication than non-Medicaid patients. We hypothesized that this difference in provision of continuing care would be associated with adverse clinical outcomes after cardiac surgery.

MATERIALS AND METHODS

In a retrospective cohort analysis, 5056 consecutive adult patients undergoing cardiac surgery at a single institution between 2005 and 2010 were divided according to payer status. Propensity scores were calculated using 16 preoperative and demographic variables for each patient, and 461 1:1 propensity score-matched pairs were analyzed. Patient socioeconomic position was determined using aggregate data derived from zip codes. The main outcome measures were early mortality, postoperative complications, and patient survival.

RESULTS

In multivariate analysis, Medicaid was found to be an independent predictor of worse survival after cardiac surgery (hazard ratio [HR], 2.1; 95% confidence interval [CI], 1.2-3.7; P = .01). No significant difference was observed in operative mortality in the 2 groups. After propensity score matching and controlling for socioeconomic position, the only independent predictors of worse midterm survival were an ejection fraction = 30% (HR, 1.7; 95% CI, 1.1-2.7; P = .02) and a higher logistic EuroSCORE (HR, 1.03; 95% CI, 1.0-1.1; P = .02).

CONCLUSIONS

Comorbidity and lower socioeconomic status appear to be more important predictors of late mortality after cardiac surgery than payer status, which does not have a significant impact on survival.

The combined effect of individual and neighborhood socioeconomic status on nasopharyngeal cancer survival

Background

The relationship between individual and neighborhood socioeconomic status (SES) and mortality rates in patients with nasopharyngeal carcinoma (NPC) is unknown. This population-based study aimed to examine the association between SES and survival of patients with NPC in Taiwan.

Materials and Methods

A population-based follow-up study was conducted of 4691 patients diagnosed with NPC between 2002 and 2006. Each patient was traced to death or for 5 years. Individual SES was defined by enrollee job category. Neighborhood SES was based on household income dichotomized into advantaged and disadvantaged areas. Cox proportional hazards model was used to compare the death-free survival rates between the different SES groups after adjusting for possible confounding factors and risk factors.

Results

In NPC patients below the age of 65 years, 5-year overall survival rates were worst for those with low individual SES living in disadvantaged neighborhoods. After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score), NPC patients with low individual SES residing in disadvantaged neighborhoods were found to have a 2-fold higher risk of mortality than patients with high individual SES residing in advantaged neighborhoods. We found no significant difference in mortality rates between different SES groups in NPC patients aged 65 and above.

Conclusions

Our findings indicate that NPC patients with low individual SES who live in disadvantaged neighborhoods have the higher risk of mortality than their more privileged counterparts. Public health strategies and welfare policies would be well advised to try to offset the inequalities in health care and pay more attention to addressing the needs of this vulnerable group.

Disparities in oral cancer survival among mentally ill patients

Background

Many studies have reported excess cancer mortality in patients with mental illness. However, scant studies evaluated the differences in cancer treatment and its impact on survival rates among mentally ill patients. Oral cancer is one of the ten most common cancers in the world. We investigated differences in treatment type and survival rates between oral cancer patients with mental illness and without mental illness.

Methods

Using the National Health Insurance (NHI) database, we compared the type of treatment and survival rates in 16687 oral cancer patients from 2002 to 2006. The utilization rate of surgery for oral cancer was compared between patients with mental illness and without mental illness using logistic regression. The Cox proportional hazards model was used for survival analysis.

Results

Oral cancer patients with mental disorder conferred a grave prognosis, compared with patients without mental illness (hazard ratios [HR] = 1.58; 95% confidence interval [CI] = 1.30–1.93; P<0.001). After adjusting for patients’ characteristics and hospital characteristics, patients with mental illness were less likely to receive surgery with or without adjuvant therapy (odds ratio [OR] = 0.47; 95% CI = 0.34–0.65; P<0.001). In multivariate analysis, oral cancer patients with mental illness carried a 1.58-times risk of death (95% CI = 1.30–1.93; P<0.001).

Conclusions

Oral cancer patients with mental illness were less likely to undergo surgery with or without adjuvant therapy than those without mental illness. Patients with mental illness have a poor prognosis compared to those without mental illness. To reduce disparities in physical health, public health strategies and welfare policies must continue to focus on this vulnerable group.

Medicaid status is associated with higher complication rates after spine surgery

STUDY DESIGN

Multivariate analysis of prospectively collected registry data.

OBJECTIVE

To determine the effect of payor status on complication rates after spine surgery.

SUMMARY OF BACKGROUND DATA

Understanding the risk of perioperative complications is an essential aspect in improving patient outcomes. Previous studies have looked at complication rates after spine surgery and factors related to increased perioperative complications. In other areas of medicine, there has been a growing body of evidence gathered to evaluate the role of payor status on outcomes and complications. Several studies have found increased complication rates and inferior outcomes in the uninsured and Medicaid insured.

METHODS

The Spine End Results Registry (2003-2004) is a collection of prospectively collected data on all patients who underwent spine surgery at our 2 institutions. Extensive demographic data, including payor status, and medical information were prospectively recorded as described previously by Mirza et al. Medical complications were defined in detail a priori and were prospectively recorded for at least 2 years after surgery. Using univariate and multivariate analysis, we determined risk of postoperative medical complications dependent on payor status.

RESULTS

A total of 1591 patients underwent spine surgery in 2003 and 2004 that met our criteria and were included in our analysis. With the multivariate analysis and by controlling for age, patients whose insurer was Medicaid had a 1.68 odds ratio (95% confidence interval: 1.23-2.29; P = 0.001) of having any adverse event when compared with the privately insured.

CONCLUSION

After univariate and multivariate analyses, Medicaid insurance status was found to be a risk factor for postoperative complications. This corresponds to an ever-growing body of medical literature that has shown similar trends and raises the concern of underinsurance.

Incurable recurrences in patients with oropharyngeal and hypopharyngeal carcinomas

BACKGROUND

Carcinomas of the oropharyngeal and hypopharynx are difficult to treat because of their aggressive tendency to metastasize and their high recurrence rate.

METHODS

A retrospective review of 79 patients with recurrences of oropharyngeal or hypopharyngeal carcinomas was performed. The courses of disease from recurrence diagnosis to the valuation date or death were analyzed.

RESULTS

The median survival for patients classified as incurable at recurrence diagnosis amounted to 8 months (95% confidence interval [CI], 5-10 months), patients initially classified as curable at the time of recurrence diagnosis survived an estimated 12 months (95% CI, 8-22 months). No significant differences regarding the survival after diagnosed recurrence could be observed depending on the tumor location or tumor stage.

CONCLUSION

The knowledge about the courses of disease and especially the remaining lifetime after diagnosed incurability could facilitate the planning of the remaining lifetime in order to achieve the best possible quality of life.

Cancer survival disparities by health insurance status

Previous studies found that uninsured and Medicaid insured cancer patients have poorer outcomes than cancer patients with private insurance. We examined the association between health insurance status and survival of New Jersey patients 18–64 diagnosed with seven common cancers during 1999–2004. Hazard ratios (HRs) with 95% confidence intervals for 5-year cause-specific survival were calculated from Cox proportional hazards regression models; health insurance status was the primary predictor with adjustment for other significant factors in univariate chi-square or Kaplan–Meier survival log-rank tests. Two diagnosis periods by health insurance status were compared using Kaplan–Meier survival log-rank tests. For breast, colorectal, lung, non-Hodgkin lymphoma (NHL), and prostate cancer, uninsured and Medicaid insured patients had significantly higher risks of death than privately insured patients. For bladder cancer, uninsured patients had a significantly higher risk of death than privately insured patients. Survival improved between the two diagnosis periods for privately insured patients with breast, colorectal, or lung cancer and NHL, for Medicaid insured patients with NHL, and not at all for uninsured patients. Survival from cancer appears to be related to a complex set of demographic and clinical factors of which insurance status is a part. While ensuring that everyone has adequate health insurance is an important step, additional measures must be taken to address cancer survival disparities.

A faith- and community-based approach to identifying the individual at risk for head and neck cancer in an inner city

OBJECTIVES/HYPOTHESIS

To perform a subset analysis of faith- and community-based screening events to further identify at-risk populations for head and neck cancer in hopes of further focusing screening efforts.

STUDY DESIGN

Prospective cohort study.

METHODS

Three hundred fifty-three individuals (n=353) presented to community events and self-selected for head and neck cancer screenings. A subgroup analysis focusing on risk factors for the development of head and neck cancer and for poor overall prognosis was performed. Subgroups analyzed were individuals screened at church-affiliated events, social events, or community outreach events at homeless shelters. Statistical analysis was performed using one-tailed analysis of variance test.

RESULTS

The outreach group had more risk factors for development of cancer, and a significantly higher proportion who used tobacco (P<.05) and consumed >1 drink/day (P<.05). Those in the outreach and church groups had a greater number of risk factors for a poor prognosis with and neck cancer in comparison with the social group: number of uninsured subjects (P<.05), fewer subjects with private insurance (P<.05), fewer subjects with a primary care provider (P<.05), and more subjects with a reported barrier to care (P<.05).

CONCLUSIONS

Inhabitants of homeless shelters represent a particularly vulnerable population for both the development and poor prognosis of head and neck cancer. Members of urban church groups are also an at-risk subpopulation due to the prevalence of poor prognostic risk factors. These groups may benefit from future targeted screenings for head and neck cancer.

Health systems performance and cancer outcomes

Do the characteristics of health systems influence cancer outcomes? Although caveats are required when undertaking international comparisons of both health systems and cancer outcomes, observed differences cannot solely be explained by data problems or economic development. Health systems can influence cancer outcomes through three mechanisms: coverage, innovation, and quality of care. First, in countries where population coverage is incomplete, patients may find certain services excluded or face substantial copayments or deductibles. Second, there are variations in the rate at which innovative treatments are introduced, reflecting in particular the need for publicly funded health systems to compare costs and benefits of increasingly expensive treatments given demands for other treatments. Third, systematic differences in quality of care (early diagnosis, timely and equitable access to specialist care, and existence of systematic coordination between these activities) may lead to variations in cancer outcomes.

Long-term survival in young women: hazards and competing risks after thyroid cancer

Background. Differentiated thyroid cancers (DTCs) are one of the most common and survivable cancers diagnosed in women. We examine factors associated with long-term survival and competing risks of death in women diagnosed with DTC under the age of 40 (<40) and aged 40 and older (40+). Methods. SEER data was used to identify DTCs diagnosed in women from 1975 to 2009. We examined overall (OS), disease-specific (DSS), other cancer (OCS), and non-cancer-related (NCS) survival using multivariate Cox proportional hazards modeling. Results. Observed survival was 97.2% for <40 (n = 14,540) and 82.5% for 40+ (n = 20,513). Distant stage (HR = 1.96, 95% CI 1.23–3.07), non-Hispanic Black (HR = 2.04, 95% CI 1.45–2.87), being unmarried (HR = 1.26, 95% 1.03–1.54), and subsequent primary cancers (HR = 4.63, 95% CI 3.76–5.71) were significant for OS in women <40. Age was an effect modifier for all survival outcomes. Racial disparities in NCS were most pronounced for young non-Hispanic black women (HR = 3.36, 95% CI 2.17–5.22). Women in both age groups were more likely to die from other causes. Conclusions. Age at diagnosis remains one of the strongest prognostic factors for thyroid cancer survival. More directed efforts to ensure effective care for comorbid conditions are needed to reduce mortality from other causes.

Mortality and access to care among adults after state Medicaid expansions

BACKGROUND

Several states have expanded Medicaid eligibility for adults in the past decade, and the Affordable Care Act allows states to expand Medicaid dramatically in 2014. Yet the effect of such changes on adults' health remains unclear. We examined whether Medicaid expansions were associated with changes in mortality and other health-related measures.

METHODS

We compared three states that substantially expanded adult Medicaid eligibility since 2000 (New York, Maine, and Arizona) with neighboring states without expansions. The sample consisted of adults between the ages of 20 and 64 years who were observed 5 years before and after the expansions, from 1997 through 2007. The primary outcome was all-cause county-level mortality among 68,012 year- and county-specific observations in the Compressed Mortality File of the Centers for Disease Control and Prevention. Secondary outcomes were rates of insurance coverage, delayed care because of costs, and self-reported health among 169,124 persons in the Current Population Survey and 192,148 persons in the Behavioral Risk Factor Surveillance System.

RESULTS

Medicaid expansions were associated with a significant reduction in adjusted all-cause mortality (by 19.6 deaths per 100,000 adults, for a relative reduction of 6.1%; P=0.001). Mortality reductions were greatest among older adults, nonwhites, and residents of poorer counties. Expansions increased Medicaid coverage (by 2.2 percentage points, for a relative increase of 24.7%; P=0.01), decreased rates of uninsurance (by 3.2 percentage points, for a relative reduction of 14.7%; P<0.001), decreased rates of delayed care because of costs (by 2.9 percentage points, for a relative reduction of 21.3%; P=0.002), and increased rates of self-reported health status of "excellent" or "very good" (by 2.2 percentage points, for a relative increase of 3.4%; P=0.04).

CONCLUSIONS

State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health.

Regular dental visits are associated with earlier stage at diagnosis for oral and pharyngeal cancer

PURPOSE

Oral and pharyngeal cancer patients diagnosed at an advanced stage experience increased morbidity and mortality relative to those with localized disease. The aim of this study was to assess the impact of dental insurance status and regularity of dental visits on early detection of oral and pharyngeal cancer.

METHODS

We examined the relationship of dental insurance and frequency of dental visits with stage at diagnosis among 441 oral and pharyngeal cancer cases from a population-based study of head and neck cancer. Ordinal logistic regression models were used to assess the association with stage, and tumor (T) and nodal (N) classification.

RESULTS

Never or rarely going to the dentist was associated with being diagnosed at higher stage for oral and pharyngeal cancer (cumulative OR = 2.28, 95 % CI: 1.02-5.10) and oral cancer (cumulative OR = 9.17, 95 % CI: 2.70-31.15) compared to those going to the dentist at least annually. Oral and pharyngeal cancer patients who went to the dentist infrequently (cumulative OR = 1.82, 95 % CI: 1.09-3.05) or rarely/never (cumulative OR = 3.24, 95 % CI: 1.59-6.57) were diagnosed with a higher T classification compared with those who went at least annually.

CONCLUSIONS

Receipt of regular dental examinations at least annually may reduce the public health burden of oral and pharyngeal cancer by facilitating earlier detection of the disease.

The combined effect of individual and neighborhood socioeconomic status on cancer survival rates

Background

This population-based study investigated the relationship between individual and neighborhood socioeconomic status (SES) and mortality rates for major cancers in Taiwan.

Methods

A population-based follow-up study was conducted with 20,488 cancer patients diagnosed in 2002. Each patient was traced to death or for 5 years. The individual income-related insurance payment amount was used as a proxy measure of individual SES for patients. Neighborhood SES was defined by income, and neighborhoods were grouped as living in advantaged or disadvantaged areas. The Cox proportional hazards model was used to compare the death-free survival rates between the different SES groups after adjusting for possible confounding and risk factors.

Results

After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score, urbanization, and area of residence), tumor extent, treatment modalities (operation and adjuvant therapy), and hospital characteristics (ownership and teaching level), colorectal cancer, and head and neck cancer patients under 65 years old with low individual SES in disadvantaged neighborhoods conferred a 1.5 to 2-fold higher risk of mortality, compared with patients with high individual SES in advantaged neighborhoods. A cross-level interaction effect was found in lung cancer and breast cancer. Lung cancer and breast cancer patients less than 65 years old with low SES in advantaged neighborhoods carried the highest risk of mortality. Prostate cancer patients aged 65 and above with low SES in disadvantaged neighborhoods incurred the highest risk of mortality. There was no association between SES and mortality for cervical cancer and pancreatic cancer.

Conclusions

Our findings indicate that cancer patients with low individual SES have the highest risk of mortality even under a universal health-care system. Public health strategies and welfare policies must continue to focus on this vulnerable group.

Multivariate analyses to assess the effects of surgeon and hospital volume on cancer survival rates: a nationwide population-based study in Taiwan

Background

Positive results between caseloads and outcomes have been validated in several procedures and cancer treatments. However, there is limited information available on the combined effects of surgeon and hospital caseloads. We used nationwide population-based data to explore the association between surgeon and hospital caseloads and survival rates for major cancers.

Methodology

A total of 11677 patients with incident cancer diagnosed in 2002 were identified from the Taiwan National Health Insurance Research Database. Survival analysis, the Cox proportional hazards model, and propensity scores were used to assess the relationship between 5-year survival rates and different caseload combinations.

Results

Based on the Cox proportional hazard model, cancer patients treated by low-volume surgeons in low-volume hospitals had poorer survival rates, and hazard ratios ranged from 1.3 in head and neck cancer to 1.8 in lung cancer after adjusting for patients’ demographic variables, co-morbidities, and treatment modality. When analyzed using the propensity scores, the adjusted 5-year survival rates were poorer for patients treated by low-volume surgeons in low-volume hospitals, compared to those treated by high-volume surgeons in high-volume hospitals (P<0.005).

Conclusions

After adjusting for differences in the case mix, cancer patients treated by low-volume surgeons in low-volume hospitals had poorer 5-year survival rates. Payers may implement quality care improvement in low-volume surgeons.

Trends in the use of cytoreductive nephrectomy in the United States

BACKGROUND

Two randomized trials published in 2001 established CyNx for patients with metastatic renal carcinoma (mRCC) as a treatment standard in the cytokine era. However, first-line systemic therapy for mRCC changed in 2005 with FDA approval of VEGFR TKIs. We evaluated the patterns of use of CyNx from 2000 to 2008.

MATERIALS AND METHODS

The National Cancer Database was queried for patients diagnosed with mRCC. Patients who underwent CyNx were identified and were further categorized by pre-VEGFR versus VEGFR TKI era, race, insurance status, and hospital. For these subcategories, prevalence ratios (PRs) were generated using the proportion of patients with mRCC undergoing CyNx versus those not undergoing CyNx.

RESULTS

Of the 47,417 patients (pts) identified with mRCC, the prevalence of cytoreductive nephrectomy increased 3% each year from 2000 to 2005 (P < .0001), then decreased 3% each year from 2005 to 2008 (P = .0048), with a significant difference between the eras (0.97 vs. 1.025; P < .0001). Black and Hispanic pts were less likely than Caucasian pts to undergo CyNx. Pts with Medicaid, Medicare, and no insurance were less likely than pts with private insurance to undergo CyNx. Pts diagnosed at community hospitals were significantly less likely than pts at teaching hospitals to undergo CyNx.

CONCLUSION

The use of CyNx has declined in the VEGFR-TKI era. In addition, racial and socioeconomic disparities exist in the use of CyNx. The results of pending randomized trials evaluating the role of CyNx in the VEGFR-TKI era are awaited to optimize use of this modality and address potential disparities.

Paths to success: optimal and equitable health outcomes for all

Abstract:U.S. health disparities are real, pervasive, and persistent, despite dramatic improvements in civil rights and economic opportunity for racial and ethnic minority and lower socioeconomic groups in the United States. Change is possible, however. Disparities vary widely from one community to another, suggesting that they are not inevitable. Some communities even show paradoxically good outcomes and relative health equity despite significant social inequities. A few communities have even improved from high disparities to more equitable and optimal health outcomes. These positive-deviance communities show that disparities can be overcome and that health equity is achievable. Research must shift from defining the problem (including causes and risk factors) to testing effective interventions, informed by the natural experiments of what has worked in communities that are already moving toward health equity. At the local level, we need multi-dimensional interventions designed in partnership with communities and continuously improved by rapid-cycle surveillance feedback loops of community-level disparities metrics. Similarly coordinated strategies are needed at state and national levels to take success to scale. We propose ten specific steps to follow on a health equity path toward optimal and equitable health outcomes for all Americans.

The Patient Protection and Affordable Care Act of 2010: impact on otolaryngology practice and research

The Patient Protection and Affordable Care Act (PPACA) was signed into law by President Barack Obama on March 23, 2010. Since its passage, the PPACA has led to increased health insurance coverage for millions more Americans, and it includes provisions leading to new avenues for clinical and health services research funding. The legislation also favors development of the primary care specialties and general surgery, increased training of midlevel health care providers, and medical training and service in underserved areas of the United States. However, the PPACA does not effectively engage otolaryngologists in quality improvement, despite modifications to the Physician Quality Reporting System. The legislation also levies a tax on cosmetic procedures, affecting both clinicians and patients. This article reviews the sections of the PPACA that are most pertinent to otolaryngologists and explains how these components of the bill will affect otolaryngologic practice and research over the coming decade.

Human papillomavirus outcomes in an access-to-care laryngeal cancer cohort

OBJECTIVE

Human papillomavirus (HPV), particularly HPV16, is a causative agent for 25% of head and neck squamous cell cancer, including laryngeal squamous cell cancer (LSCC). HPV-positive (HPV+ve) patients, particularly those with oropharyngeal SCC, have improved prognosis. For LSCC patients, this remains to be established. The goal was to determine stage and survival outcomes in LSCC in the context of HPV infection.

STUDY DESIGN

Historical cohort study.

SETTING

Primary care academic health system.

SUBJECTS AND METHODS

In 79 patients with primary LSCC, HPV was determined using real-time quantitative polymerase chain reaction. χ(2) or Fisher exact test was used to test the association of HPV+ve with 21 risk factors including race, stage, gender, age, smoking, alcohol, treatment, and health insurance. Kaplan-Meier and log-rank tests were used to study the association of HPV and LSCC survival outcome.

RESULTS

HPV16 was detected in 27% of LSCC patients. Caucasian American (CA) patients had higher HPV prevalence (33%) than did African American (AA) LSCC patients (16%; P = .058). HPV was significantly associated with gender (P = .016) and insurance type (P = .001). There were no differences in survival between HPV+ve and HPV-negative (HPV-ve) patients. There was no association with HPV and other risk factors including stage (early vs late).

CONCLUSION

We found a high prevalence of HPV in men and a lower prevalence of HPV infection in AA compared with CA. Despite the strikingly better survival of patients with HPV+ve oropharyngeal tumors, even when adjusted for smoking, this correlation does not seem to hold true in the larynx. Larger multiethnic LSCC cohorts are needed to more clearly delineate HPV-related survival across ethnicities.

Just give me hope: lived experiences of Medicaid patients with advanced cancer

The purpose of this phenomenological exploration was to describe the lived experiences of persons diagnosed with advanced cancer who receive Medicaid. Themes emerged from the transcribed interviews of 10 participants in accordance with the cancer trajectory. Before diagnosis, participants were uninsured or underinsured and had more severe symptoms prior to late diagnosis. Upon diagnosis, they desired hopeful, respectful communication and experienced strong emotional reactions. There was also an abrupt change in the use of health care resources. During cancer treatment, they experienced social isolation from family and friends while receiving strong psychosocial support from the health care team. Throughout the cancer trajectory, they focused on living, reclaiming normalcy, and expressed resiliency and spirituality. Findings support the need to recognize the "fighting spirit" of patients regardless of prognosis or socioeconomic status; the impact of hopeful, respectful communication; and the value of oncology social work assistance when navigating the cancer experience. Lack of health care coverage prior to severe symptoms prevented earlier diagnosis and contributed to poor physical outcomes. Medicaid eligibility enabled these patients to receive quality health care and focus on living beyond cancer.

Impact of gender, partner status, and race on locoregional failure and overall survival in head and neck cancer patients in three radiation therapy oncology group trials

PURPOSE

We investigated the impact of race, in conjunction with gender and partner status, on locoregional control (LRC) and overall survival (OS) in three head and neck trials conducted by the Radiation Therapy Oncology Group (RTOG).

METHODS AND MATERIALS

Patients from RTOG studies 9003, 9111, and 9703 were included. Patients were stratified by treatment arms. Covariates of interest were partner status (partnered vs. non-partnered), race (white vs. non-white), and sex (female vs. male). Chi-square testing demonstrated homogeneity across treatment arms. Hazards ratio (HR) was used to estimate time to event outcome. Unadjusted and adjusted HRs were calculated for all covariates with associated 95% confidence intervals (CIs) and p values.

RESULTS

A total of 1,736 patients were analyzed. Unpartnered males had inferior OS rates compared to partnered females (adjusted HR = 1.22, 95% CI, 1.09-1.36), partnered males (adjusted HR = 1.20, 95% CI, 1.09-1.28), and unpartnered females (adjusted HR = 1.20, 95% CI, 1.09-1.32). White females had superior OS compared with white males, non-white females, and non-white males. Non-white males had inferior OS compared to white males. Partnered whites had improved OS relative to partnered non-white, unpartnered white, and unpartnered non-white patients. Unpartnered males had inferior LRC compared to partnered males (adjusted HR = 1.26, 95% CI, 1.09-1.46) and unpartnered females (adjusted HR = 1.30, 95% CI, 1.05-1.62). White females had LRC superior to non-white males and females. White males had improved LRC compared to non-white males. Partnered whites had improved LRC compared to partnered and unpartnered non-white patients. Unpartnered whites had improved LRC compared to unpartnered non-whites.

CONCLUSIONS

Race, gender, and partner status had impacts on both OS and locoregional failure, both singly and in combination.

Effect of individual and neighborhood socioeconomic status on oral cancer survival

This population-based study investigated the relationship between individual and neighborhood socioeconomic status (SES) and oral cancer mortality. A population-based follow-up study was conducted of 3607 oral cancer patients (predominantly male) who were diagnosed between 2004 and 2005. Each patient was traced to death or for 2 years. Individual SES was defined by enrollee category. Neighborhood SES was defined by income, and numbers of doctors, and neighborhoods were grouped into advantaged and disadvantaged areas. The Cox proportional hazards model was used to compare the death-free survival rate between the different SES groups after adjusting for possible confounding and risk factors. In oral cancer patients aged below 65 years, death rates among those with low SES were highest in disadvantaged neighborhoods. After adjusting for patient characteristics (age, gender, Charlson Comorbidity Index Score, urbanization, and area of residence), tumor extent, treatment modalities (operation, adjuvant therapy), hospital characteristics (ownership, teaching level, caseload), and year of diagnosis, oral cancer patients with low individual SES in disadvantaged neighborhoods conferred a 1.46- to 1.64-fold higher risk for death, compared with patients with high individual SES in advantaged neighborhoods. No statistically significant difference was found in risk of death between different SES groups in patients aged 65 and above. Our findings indicate that oral cancer patients with low individual SES have the highest risk of mortality even under a universal health-care system. Public health strategies and welfare policies must continue to focus on this vulnerable group.

Survival rate in nasopharyngeal carcinoma improved by high caseload volume: a nationwide population-based study in Taiwan

BACKGROUND

Positive correlation between caseload and outcome has previously been validated for several procedures and cancer treatments. However, there is no information linking caseload and outcome of nasopharyngeal carcinoma (NPC) treatment. We used nationwide population-based data to examine the association between physician case volume and survival rates of patients with NPC.

METHODS

Between 1998 and 2000, a total of 1225 patients were identified from the Taiwan National Health Insurance Research Database. Survival analysis, the Cox proportional hazards model, and propensity score were used to assess the relationship between 10-year survival rates and physician caseloads.

RESULTS

As the caseload of individual physicians increased, unadjusted 10-year survival rates increased (p < 0.001). Using a Cox proportional hazard model, patients with NPC treated by high-volume physicians (caseload ≥ 35) had better survival rates (p = 0.001) after adjusting for comorbidities, hospital, and treatment modality. When analyzed by propensity score, the adjusted 10-year survival rate differed significantly between patients treated by high-volume physicians and patients treated by low/medium-volume physicians (75% vs. 61%; p < 0.001).

CONCLUSIONS

Our data confirm a positive volume-outcome relationship for NPC. After adjusting for differences in the case mix, our analysis found treatment of NPC by high-volume physicians improved 10-year survival rate.

Functional outcome in patients with advanced head and neck cancer: surgery and reconstruction with free flaps versus primary radiochemotherapy

The objective was to compare functional outcome in patients with advanced head and neck cancer (HNC) treated with (a) surgical resection and reconstruction with microvascular free flaps (MVFF) followed by radiochemotherapy versus (b) primary radiochemotherapy (RCT) on the basis of the International Classification of Functioning, Disability and Health (ICF) from WHO. This was a cross-sectional, multi-institutional study. The outcome measures included ICF Core Sets for HNC, the EORTC-QLQ, modules c30 + hn35 and the University of Washington-Quality of life Questionnaire (UW-QOL). Analyses included descriptive statistics, ranking exercises, and regression analyses in a cumulative logit model; 27 patients were treated with MVFF and 22 with RCT. Global Quality of life scores suggested a slightly better functional outcome for the surgical approach. The majority of ICF categories (81/93, 87%) did not show a difference in functional outcome between the two treatment approaches. In the remaining 12 ICF categories, n = 3 body structures were more affected in the MVFF group, while n = 3 body functions, and n = 6 activities/participations were more problematic in the RCT group. This included oral swallowing and weight maintenance functions as well as social relationships, acquiring a job, and economic self-sufficiency. In addition, nine contextual environmental factors were more relevant to the RCT group. Both treatment approaches seemed appropriate to advanced HNC from the perspective of functional outcome. The influence of treatment modalities on the social and economic lives of cancer survivors needs to be explored further. In order to guide rehabilitation according to patients' needs, the ICF offers a multidimensional view comprising body structures, body functions, and activities and participation in life.

The impact of insurance status on actuarial survival in hospitalized trauma patients: when do they die?

BACKGROUND

Previous work has suggested that insurance status, gender, and ethnicity all have an independent association with mortality after trauma. The purpose of this study is to investigate whether these factors exerted survival impact that could be observed throughout the hospital stay.

METHODS

Using the National Trauma Data Bank (version 7.0), a Cox proportional hazards survival analysis was performed on young (19-30 years old) trauma patients to mitigate the impact of comorbid confounders. Variables included in the model were age, gender, ethnicity, Injury Severity Score, presence of shock at presentation, mechanism of injury, insurance status, year of admission, teaching status of the hospital, diagnosis of substance abuse or psychotic disorders, and complications after admission. Rate ratios (RRs) comparing the slopes of the adjusted survival curves were calculated using the Mantel-Cox method.

RESULTS

A total of 192,488 young trauma patients were identified with complete data. Increased hazard of death was seen in patients who were uninsured (hazard ratio [HR]=1.69, 95% confidence interval [CI]=1.59-1.80, p<0.001), of a minority ethnicity (HR=1.08, 95% CI=1.01-1.15, p=0.025) or men (HR=1.14, 95% CI=1.04-1.23, p=0.004). RRs were significantly larger between insurance status (RR=1.75, 95% CI=1.58-1.94, p<0.001) than between race (RR=1.23, 95% CI=1.10-1.37, p<0.001) or between gender (RR=1.16, 95% CI=1.01-1.32, p=0.030).

CONCLUSION

Risk of death on the first hospital day after injury differs by insurance status, and this disparity becomes more pronounced throughout the hospital stay. Further study is necessary to determine whether this is a result of additional unmeasured patient covariates with insurance status or a difference in provider behavior in response to patient insurance status.

Head and neck cancer-specific survival based on socioeconomic status in Asians and Pacific Islanders

BACKGROUND

Lower socioeconomic status (SES) has been linked to higher incidence of head and neck cancer (HNC) and lower survival. However, little is known about the effect of SES on HNC survival in Asians and Pacific Islanders (APIs). This study's purpose was to examine the effect of SES on disease-specific survival (DSS) and overall survival (OS) in APIs with HNC using population-based data.

METHODS

A total of 53,544 HNC patients (4,711 = APIs) were identified from the California Cancer Registry from 1988 to 2007. Neighborhood (block-group-level) SES, based on composite Census 1990 and 2000 data, was calculated for each patient based on address at diagnosis, categorized into statewide quintiles, and collapsed into 2 groups for comparison (low SES = quintiles 1-3; high SES = quintiles 4-5). DSS and OS were computed by the Kaplan-Meier method. Adjusted hazards ratios (HR) were estimated using Cox proportional hazards regression models.

RESULTS

Among APIs, lower neighborhood SES was significantly associated with poorer DSS (HR range for oral cavity, oropharynx, or larynx/hypopharynx cancer, 1.07-1.34) and OS (HR, 1.13-1.37) after adjusting for patient and tumor characteristics. Lower SES was significantly associated with poorer survival in API with all HNC sites combined: DSS HR: 1.26 (95% confidence interval [CI], 1.08-1.48) and OS HR, 1.30 (95% CI, 1.16-1.45).

CONCLUSIONS

Neighborhood SES was associated with longer DSS and OS in API with HNC. The effect of SES on HNC survival should be considered in future studies, and particular attention should be paid to clinical care of lower-SES HNC patients.

Determinants of head and neck cancer survival by race

BACKGROUND

Several factors contribute to the documented racial disparity in head and neck cancer, among which are socioeconomic status, access to care, and biologic factors.

METHODS

Clinical characteristics of 87 African-American patients with head and neck cancer and a random sample of 261 white patients matched on age and smoking dose were associated with outcome.

RESULTS

Black patients with cancers of the oral cavity and larynx were more likely diagnosed with advanced stages than whites, after adjusting for socioeconomic and insurance status and other confounding factors. There was a significant difference in relapse-free survival between blacks and whites with tumors of the larynx (hazard ratio [HR] = 3.36, 95% confidence interval [CI]: 1.62-7.00), but not with tumors of the oral cavity or pharynx.

CONCLUSIONS

Differences in disease outcome may be attributed to a combination of tumor stage, socioeconomic status, and access to health care. The inclusion of biologic markers such as human papillomavirus (HPV) status is needed in future studies to further evaluate racial disparities in head and neck cancer outcomes.