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DeMari JA, Madeka I, Evans JK, Bailey C, Bartucci K, Bottsford-Miller J, Bradford L, Burnett B, Kelly R, Rowland M, Wallbillich JJ, Shalowitz DI. Multi-Institutional Study of Referral Patterns for Gynecologic Oncology Consultation. JCO Oncol Pract 2024:OP2300729. [PMID: 38776512 DOI: 10.1200/op.23.00729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/24/2024] [Accepted: 04/03/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE Evaluation by a gynecologic oncologist (GO) is associated with improved clinical outcomes for patients with gynecologic cancers, yet little is known about health care factors that influence patients' referrals to GO. METHODS Medical records of 50 consecutive new patients seen in GO clinics at each of six referral centers across the United States were reviewed. Patient and disease characteristics were collected along with referral indication, evaluation and referral dates, diagnostic procedures, provider specialties, and zone improvement plan (ZIP) code of up to three referring providers per patient. The primary outcome was interval between first evaluation and referral. Univariate associations were evaluated with Chi-square and Wilcoxon rank-sum tests and multivariable associations with negative binomial regression models. Secondary outcome was prolonged time to GO referral, defined as greater than the 75th percentile. Logistic regression was used for multivariable modeling. RESULTS Three hundred patient records were analyzed. The median time from first health care encounter to referral was 15 days (IQR, 5-43). The mean distance from residence to GO was 39.8 miles (standard deviation, 53.8). Seventy-one percent of GO referrals were initiated by obstetrician-gynecologists, 9% by family physicians, and 6% internists. Presentation-to-referral interval was 76% shorter for patients evaluated by an emergency medicine clinician (exp(Beta), 0.24; 95% CI, 0.11 to 0.53; P < .001). Public insurance was associated with 1.47 times longer time to referral compared with private insurance (exp(Beta), 1.47; 95% CI, 1.05 to 2.04; P = .001). Residents of nonmetropolitan ZIP codes were less likely to have prolonged time to referral (odds ratio [OR], 0.288; P = .017). Distance from residence to GO (per 10 miles) increased the likelihood of prolonged time to referral (OR, 1.10; P = .010). CONCLUSION Interventions are needed to improve recognition and referral of patients for gynecologic oncology evaluation. Community outreach and engagement with obstetrician-gynecologists should be prioritized to improve times to referral.
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Affiliation(s)
- Joseph A DeMari
- Section on Gynecologic Oncology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Isheeta Madeka
- Section on Gynecologic Oncology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Joni K Evans
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston Salem, NC
| | - Courtney Bailey
- Division of Gynecological Oncology, Medical College of Georgia, Augusta, GA
| | - Kristen Bartucci
- Division of Gynecologic Oncology, University of Missouri-Kansas City, Kansas City, MO
| | | | | | - Brian Burnett
- Section on Gynecologic Oncology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Rebeca Kelly
- Division of Gynecologic Oncology, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI
| | - Michelle Rowland
- Division of Gynecologic Oncology, University of Missouri-Kansas City, Kansas City, MO
| | - John J Wallbillich
- Division of Gynecologic Oncology, Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI
| | - David I Shalowitz
- West Michigan Cancer Center, Kalamazoo, MI
- Collaborative on Equity in Rural Cancer Care, Kalamazoo, MI
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Rimel BJ, Kunos CA, Macioce N, Temkin SM. Current gaps and opportunities in screening, prevention, and treatment of cervical cancer. Cancer 2022; 128:4063-4073. [PMID: 36239009 DOI: 10.1002/cncr.34487] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/15/2022] [Accepted: 04/27/2022] [Indexed: 11/07/2022]
Abstract
In their fiscal year 2021 reports, the US House and Senate Appropriations Committees requested that the National Institutes of Health (NIH) evaluate current research related to women's health and topics that include stagnant cervical cancer survival. In response, the NIH Office of Research on Women's Health, with input from women's health experts; members of the public; representatives from NIH institutes, centers, and offices; and members of the NIH Advisory Committee on Research on Women's Health, reviewed the public health needs and current NIH activities on cervical cancer. The Advancing NIH Research on the Health of Women: A 2021 Conference held in October 2021 reviewed these findings and allowed the identification of opportunities to strengthen research. In this review, the authors summarize public health needs related to cervical cancer and NIH activities in this realm. Cervical cancer has become a rare disease in the United States, yet significant portions of the US population remain under screened or unscreened for cervical cancer, human papillomavirus vaccination rates remain low, access to high-quality treatment remains a challenge for many, and large inequities by race and ethnicity persist. Novel, inclusive, and intentional research is needed to produce improvements in cervical cancer survival within the United States.
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Affiliation(s)
- Bobbie J Rimel
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Charles A Kunos
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Nikeya Macioce
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Sarah M Temkin
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland, USA
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Cherston C, Yoh K, Huang Y, Melamed A, Gamble CR, Prabhu VS, Li Y, Hershman DL, Wright JD. Relative importance of individual insurance status and hospital payer mix on survival for women with cervical cancer. Gynecol Oncol 2022; 166:552-560. [PMID: 35787803 DOI: 10.1016/j.ygyno.2022.06.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the relative contributions of individual insurance status and hospital payer mix (safety net status) to quality of care and survival for patients with cervical cancer. METHODS We used the National Cancer Database to identify patients with cervical cancer diagnosed from 2004 to 2017. Patients were classified by insurance (uninsured/Medicaid/private/Medicare/other) and hospitals were grouped into quartiles based on the proportion of uninsured/Medicaid patients (payer mix) (top quartile defined as safety-net hospital (SNHs) and lowest as Q1 hospitals). Quality-of-care was assessed by adherence to evidence-based metrics. Individual contributions of insurance status and payer mix to survival was assessed with a proportional hazards Cox model. RESULTS A total of 124,339 patients including 11,338 uninsured (9.1%) and 27,281 Medicaid (21.9%) recipients treated at 1156 hospitals were identified. Quality-of-care was not significantly different across hospital quartiles. Adjusting for patients' clinical/demographic characteristics, treatment at a SNH was associated with a 14% higher mortality (HR = 1.14; 95% CL, 1.08-1.20) than at Q1 hospitals. Testing for individual insurance, uninsured patients had 32% increased mortality (HR = 1.32; 95% CI,1.26-1.38) and Medicaid recipients 40% increased (HR = 1.40; 95%CI,1.35-1.44) compared to privately insured patients. Examining both payer mix and insurance, only individual insurance retained a significant impact on mortality. CONCLUSIONS Individual insurance may be a more important predictor of survival than site-of-care and hospital payer mix for women with cervical cancer. There is substantial variation in outcomes within hospitals based on individual insurance, regardless of hospital payer mix.
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Affiliation(s)
- Caroline Cherston
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Katherine Yoh
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Yongmei Huang
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Alexander Melamed
- Columbia University, College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - Charlotte R Gamble
- Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | | | - Yeran Li
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Dawn L Hershman
- Columbia University, College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA
| | - Jason D Wright
- Columbia University, College of Physicians and Surgeons, New York, NY, USA; Herbert Irving Comprehensive Cancer Center, USA; New York Presbyterian Hospital, USA.
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Insurance-Mediated Disparities in Gynecologic Oncology Care. Obstet Gynecol 2022; 139:305-312. [PMID: 34991133 PMCID: PMC8759538 DOI: 10.1097/aog.0000000000004643] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
Abstract
Insurance coverage has lagged behind improvements in gynecologic cancer care, with one third of women never seeing a gynecologic oncologist and half experiencing financial toxicity during cancer treatment. With 102,000 new cases of gynecologic cancer, 30,000 associated deaths annually, and increasing rates of endometrial cancer, gynecologic cancer is a growing problem. Although gynecologic cancer care has advanced significantly in the past decade owing to new therapeutics and specialized training in radical surgery, even insured women face major barriers to accessing and affording quality gynecologic cancer care. This commentary reviews current literature on insurance-mediated disparities in gynecologic cancer and provides education to clinicians on barriers to care. One third of women with a gynecologic cancer never see a gynecologic oncologist. Up to 40% of Medicare Advantage plans lack an in-network gynecologic oncologist, and 33% of private insurance plans do not include an in-network National Cancer Institute-accredited cancer center, limiting access to surgical advances and clinical trials. Women with Medicaid insurance and gynecologic cancer are 25% less likely to receive guideline-concordant care. Among insured women, 50% experience financial toxicity during gynecologic cancer treatment, and costs may be even higher for certain Medicare enrollees. Addressing these insurance-mediated disparities will be important to help our patients fully benefit from the scientific advances in our field and thrive after a gynecologic cancer diagnosis.
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Ko EM, Bekelman JE, Hicks-Courant K, Brensinger CM, Kanter GP. Association of gynecologic oncology versus medical oncology specialty with survival, utilization, and spending for treatment of gynecologic cancers. Gynecol Oncol 2021; 164:295-303. [PMID: 34949437 DOI: 10.1016/j.ygyno.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND We examined the association of gynecologic oncology (GYO) versus medical oncology (MEDONC) based care with survival, health care utilization and spending outcomes in women undergoing chemotherapy for advanced gynecologic cancers. METHODS Women with newly diagnosed stage III-IV uterine, ovarian, and cervical cancers from 2000 to 2015 were identified in SEER-Medicare. We assessed the association of provider specialty with overall survival, emergency department utilization, admissions, and spending. Outcomes were assessed using unadjusted and Inverse Treatment Probability Weighted propensity-score applied, multi-variable cox modeling, Poisson regression, and generalized models of log-transformed data. RESULTS We identified 7930 gynecologic cancer patients (4360 ovarian, 2934 uterine, 643 cervix). 37% were treated by GYO and 63% by MEDONC. For ovarian patients, GYO care was associated with improved OS (median OS 3.3 v. 2.9 years; HR 0.85, 95%CI 0.80, 0.91, p < .0001) and similar mean spending per month ($4015 v. $4316, mean ratio 0.97 (95% CI 0.93, 1.02), p = .19), compared to MEDONC in adjusted analyses. For uterine patients, GYO care was associated with similar OS, but decreased spending ($3573 v. $4081, mean ratio 0.87 (95% CI.81, 0.93), p < .0001), and decreased ED utilization (RR 0.76, 95% CI 0.69, 0.85, p < .0001). For cervical patients, GYO care was associated with similar OS, and similar spending. Admissions were more likely in ovarian (RR 1.23, 95%CI 1.11, 1.37, p = .0001) and cervical patients (RR 1.26, 95% CI 1.05, 1.51, p = .015) treated by GYO, in adjusted analyses. CONCLUSIONS GYO based care was associated with improved OS and equal spending for patients with advanced stage ovarian cancer. Uterine and cervix patients had similar OS, and less or equal spending respectively, when treated by GYO compared to MEDONC.
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Affiliation(s)
- Emily M Ko
- Department of Obstetrics and Gynecology: Division of Gynecologic Oncology, Perelman School of Medicine, University of Pennsylvania, USA; Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, USA.
| | - Justin E Bekelman
- Department of Obstetrics and Gynecology: Division of Gynecologic Oncology, Perelman School of Medicine, University of Pennsylvania, USA; Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, USA.
| | - Katherine Hicks-Courant
- Department of Obstetrics and Gynecology: Division of Gynecologic Oncology, Perelman School of Medicine, University of Pennsylvania, USA; Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, USA.
| | - Colleen M Brensinger
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, USA.
| | - Genevieve P Kanter
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, USA; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, USA; General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, USA.
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An increase in multi-site practices: The shifting paradigm for gynecologic cancer care delivery. Gynecol Oncol 2020; 160:3-9. [PMID: 33243442 DOI: 10.1016/j.ygyno.2020.10.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess whether the number of practice sites per gynecologic oncologist (GO) and geographic access to GOs has changed over time. METHODS This is a retrospective repeated cross-sectional study using the 2015-2019 Physician Compare National File. All GOs in the 50 United States and Washington, DC, who had completed at least one year of practice were included in the study. All practice sites with complete addresses were included. Linear regression analyses estimated trends in GOs' number of practice sites and geographic dispersion of practice sites. Secondary analyses assessed temporal trends in the number of geographic areas served by at least one GO. RESULTS Although there was no significant change in the number of GOs from 2015 to 2019 (n = 1328), there was a significant increase in the number of practice sites (881 to 1416, p = 0.03), zip codes (642 to 984, p = 0.03), HSAs (404 to 536, p = 0.04), and HRRs (218 to 230, p = 0.03) containing a GO practice. The mean number of practice sites (1.64 versus 2.13, p < 0.001) and dispersion of practice sites (0.03 versus 0.43 miles, p = 0.049) per GO increased significantly. CONCLUSIONS Between 2015 and 2019, an increasing number of GOs have multi-site practices, and more geographic regions contain a GO practice. Improvements in geographic access to GOs may represent improved access to care for many women in the US, but its effect on patients, physicians, and geographic disparities is unknown.
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Abstract
Patients with gynecologic cancers experience better outcomes when treated by specialists and institutions with experience in their diseases. Unfortunately, high-volume centers tend to be located in densely populated regions, leaving many women with geographic barriers to care. Remote management through telemedicine offers the possibility of decreasing these disparities by extending the reach of specialty expertise and minimizing travel burdens. Telemedicine can assist in diagnosis, treatment planning, preoperative and postoperative follow-up, administration of chemotherapy, provision of palliative care, and surveillance. Telemedical infrastructure requires careful consideration of the needs of relevant stakeholders including patients, caregivers, referring clinicians, specialists, and health system administrators.
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Shalowitz DI, Goodwin A, Schoenbachler N. Does surgical treatment of atypical endometrial hyperplasia require referral to a gynecologic oncologist? Am J Obstet Gynecol 2019; 220:460-464. [PMID: 30527944 DOI: 10.1016/j.ajog.2018.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/01/2018] [Accepted: 12/03/2018] [Indexed: 01/17/2023]
Abstract
Patients with atypical endometrial hyperplasia in the United States are commonly referred to a gynecologic oncologist, given a moderate risk of concurrent carcinoma. However, selective referral of patients to nononcologic gynecologic surgeons for surgical treatment of atypical endometrial hyperplasia may offer increased access to care without compromising clinical outcomes. Nononcologic surgeons who consider providing surgical treatment for atypical endometrial hyperplasia must be able to offer minimally invasive surgery when appropriate and have sufficient surgical volume to deliver optimal clinical outcomes. Patients considering referral to a nononcologic surgeon must be thoroughly counseled regarding the risk of occult malignancy, the possibility of a second surgery for lymph node evaluation and/or oophorectomy, and the risk of morbidity that may accompany a second surgery. Available data suggest that approximately 2-6% of patients will have postoperative risk factors meriting consideration of a second surgery. Patients who are high-risk surgical candidates or who may desire nonsurgical or fertility-sparing treatment should universally be referred for consultation with a gynecologic oncologist.
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Duska LR. Access to quality gynecologic oncology care: A work in progress. Cancer 2018; 124:2680-2683. [DOI: 10.1002/cncr.31391] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Linda R. Duska
- Division of Gynecologic Oncology; University of Virginia School of Medicine; Charlottesville Virginia
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