Oncologist volume and outcomes in older adults diagnosed with diffuse large B cell lymphoma

Provider Specialization in Inflammatory Bowel Diseases: Quality of Care and Outcomes

BACKGROUND & AIMS

Management of inflammatory bowel diseases (IBD) is complex and variation in care has been well-documented. However, the drivers of practice variation remain unexplored. We examined variation based on the treating gastroenterologist's IBD focus (proportion of outpatient visits for IBD).

METHODS

We conducted a retrospective cohort of newly diagnosed patients with IBD using data from Optum's deidentified Clinformatics Data Mart Database (2000-2020). The exposure variable was whether the treating gastroenterologist had an IBD focus (>90th percentile of IBD visits/total outpatient visits). We used adjusted regression models to evaluate associations between provider IBD focus and process measures (use of mesalamine, corticosteroid, biologic, and narcotic medications and endoscopic or radiographic imaging) and clinical outcomes (time to IBD-related hospitalization and bowel resection surgery). We tested for change in treatment patterns over time by including an interaction term for study era (2004-2012 vs 2013-2020).

RESULTS

The study included 772 children treated by 493 providers and 2864 adults treated by 2076 providers. In children, none of the associations between provider focus and process or outcome measures were significant. In adults, care from an IBD-focused provider was associated with more use of biologics, combination therapy, and imaging and endoscopy, and less mesalamine use for Crohn's disease (P < .05 for all comparisons) but not with other process measures. Biologics were prescribed more frequently and narcotics less frequently during the later era (P < .05 for both). Hospitalization and surgery rates were not associated with IBD focus or era.

CONCLUSIONS

IBD care for adults varies by provider specialization. Given the evolving complexity, novel methods may be needed to standardize care.

Real-world treatment patterns, survival, health resource use and costs among Medicare beneficiaries with diffuse large B-cell lymphoma

Aim: To examine real-world treatment patterns, survival, healthcare resource use and costs in elderly Medicare beneficiaries with diffuse large B-cell lymphoma (DLBCL). Methods: 11,880 Medicare patients aged ≥66 years with DLBCL between 1 October 2015 and 31 December 2018 were followed for ≥12 months after initiating front-line treatment. Results: Two-thirds (61.2%) of the patients received standard-of-care R-CHOP as first-line treatment. Hospitalization was common (57%) in the 12-months after initiation of 1L treatment; the mean DLCBL-related total costs were US$84,416 during the same period. Over a median follow-up of 2.1 years, 17.8% received at least 2L treatment. Overall survival was lower among later lines of treatment (median overall survival from initiation of 1L: not reached; 2L: 19.9 months; 3L: 9.8 months; 4L: 5.5 months). Conclusion: A large unmet need exists for more efficacious and well-tolerated therapies for older adults with DLBCL.

Facility Volume as a Prognosticator of Survival in Locally Advanced Papillary Thyroid Cancer

OBJECTIVES

To evaluate the influence of facility case-volume on survival in patients with locally advanced papillary thyroid cancer (PTC), and to identify prognostic case-volume thresholds for facilities managing this patient population.

STUDY DESIGN

Retrospective database study.

METHODS

The 2004-2017 National Cancer Database was queried for patients receiving definitive surgery for locally advanced PTC. Using K-means clustering and multivariable Cox proportional-hazards (CPH) regression, two groups with distinct spectrums of facility case-volumes were generated. Multivariable CPH regression and Kaplan-Meier analysis assessed for the influence of facility case-volume and the prognostic value of its stratification on overall survival (OS).

RESULTS

Of 48,899 patients treated at 1304 facilities, there were 34,312 (70.2%) females and the mean age was 48.0 ± 16.0 years. Increased facility volume was significantly associated with reduced all-cause mortality (HR 0.996; 95% CI, 0.992-0.999; p = 0.008). Five facility clusters were generated, from which two distinct cohorts were identified: low (LVF; <27 cases/year) and high (HVF; ≥27 cases/year) facility case-volume. Patients at HVFs were associated with reduced mortality compared to those at LVFs (HR 0.791; 95% CI, 0.678-0.923, p = 0.003). Kaplan-Meier analysis of propensity score-matched N0 and N1 patients demonstrated higher OS in HVF cohorts (all p < 0.001).

CONCLUSIONS

Facility case-volume was an independent predictor of improved OS in locally advanced PTC, indicating a possible survival benefit at high-volume medical centers. Specifically, independent of a number of sociodemographic and clinical factors, facilities that treated ≥27 cases per year were associated with increased OS. Patients with locally advanced PTC may, therefore, benefit from referrals to higher-volume facilities.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:443-450, 2023.

The centralization of bladder cancer care and its implications for patient travel distance

OBJECTIVES

To evaluate the impact of centralized surgical and nonsurgical care (i.e., radiation and chemotherapy) on travel distances and survival outcomes for patients with advanced bladder cancer. Bladder cancer is a disease with high mortality for which treatment access is paramount and survival is superior in patients receiving surgery at high-volume centers.

METHODS

Using SEER-Medicare, we identified patients 66 years or older diagnosed with bladder cancer between 2004-2013. We categorized patients as treated with either surgical (i.e., radical cystectomy) or nonsurgical (i.e., radiation or chemotherapy) care. We fit a linear probability model to generate the predicted proportion of patients treated at the top quintile of volume over time and assessed travel distance, 1-year all-cause mortality, and 1-year bladder cancer-specific mortality over time.

RESULTS

A total of 6,756 and 10,383 patients underwent surgical and nonsurgical care, respectively. The percentage of patients treated at high-volume centers increased over the study period for both surgical care (53% to 62%) and nonsurgical care (47% to 55%), (both P< 0.001). Median travel distance increased (11.8 to 20.3 miles) for surgical care and (6.5 to 8.3 miles) for nonsurgical care, (both P < 0.001). The 1-year adjusted all-cause mortality and 1-year adjusted bladder-cancer specific mortality decreased significantly for both surgical and nonsurgical care (both P < 0.05).

CONCLUSIONS

Over time, centralization of surgical and nonsurgical care for bladder cancer patients increased, which was associated with increasing patient travel distance and decreased all-cause and bladder-cancer specific mortality.

Benefits of High-Volume Medical Oncology Care for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis

BACKGROUND

Although pancreatic adenocarcinoma (PA) surgery performed by high-volume (HV) providers yields better outcomes, volume-outcome relationships are unknown for medical oncologists. This study examined variation in practice and outcomes in noncurative management of PA based on medical oncology provider volume.

METHODS

This population-based cohort study linked administrative healthcare datasets and included nonresected PA from 2005 through 2016. The volume of PA consultations per medical oncology provider per year was divided into quintiles, with HV providers (≥16 patients/year) constituting the fifth quintile and low-volume (LV) providers the first to fourth quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). The Brown-Forsythe-Levene (BFL) test for equality of variances was performed to assess outcome variability between provider-volume quintiles. Multivariate regression models were used to examine the association between management by HV provider and outcomes.

RESULTS

A total of 7,062 patients with noncurable PA consulted with medical oncology providers. Variability was seen in receipt of chemotherapy and median survival based on provider volume (BFL, P<.001 for both), with superior 1-year OS for HV providers (30.1%; 95% CI, 27.7%-32.4%) compared with LV providers (19.7%; 95% CI, 18.5%-20.6%) (P<.001). After adjustment for age at diagnosis, sex, comorbidity burden, rural residence, income, and diagnosis period, HV provider care was independently associated with higher odds of receiving chemotherapy (odds ratio, 1.19; 95% CI, 1.05-1.34) and with superior OS (hazard ratio, 0.79; 95% CI, 0.74-0.84).

CONCLUSIONS

Significant variation was seen in noncurative management and outcomes of PA based on provider volume, with management by an HV provider being independently associated with superior OS and higher odds of receiving chemotherapy. This information is important to inform disease care pathways and care organization. Cancer care systems could consider increasing the number of HV providers to reduce variation and improve outcomes.

Economic impacts of care by high-volume providers for non-curative esophagogastric cancer: a population-based analysis

BACKGROUND

Esophagogastric cancer (EGC) is one of the deadliest and costliest malignancies to treat. Care by high-volume providers can provide better outcomes for patients with EGC. Cost implications of volume-based cancer care are unclear. We examined the cost-effectiveness of care by high-volume medical oncology providers for non-curative management of EGC.

METHODS

We conducted a population-based cohort study of non-curative EGC over 2005-2017 by linking administrative datasets. High-volume was defined as ≥ 11 patients/provider/year. Healthcare costs ($USD/patient/month-survived) were computed from diagnosis to death or end of follow-up from the perspective of the healthcare system. Multivariable quantile regression examined the association between care by high-volume providers and costs. Sensitivity analyses were conducted by varying costing horizons and high-volume definitions.

RESULTS

Among 7011 non-curative EGC patients, median overall survival was superior with care by high-volume providers with 7.0 (IQR 3.3-13.3) compared to 5.9 (IQR 2.6-12.1) months (p < 0.001) for low-volume providers. Median costs/patient/month-lived were lower for high-volume providers ($5518 vs. $5911; p < 0.001), owing to lower inpatient acute care costs, despite higher medication-associated and radiotherapy costs. Care by high-volume providers was independently associated with a reduction of $599 per patient/month-lived (95% confidence interval - 966 to - 331) compared to low-volume providers. The incremental cost-effectiveness ratio was - 393. Care by high-volume providers remained the dominant strategy when varying the costing horizon and the high-volume definition.

CONCLUSION

Care by high-volume providers for non-curative EGC is associated with superior survival and lower healthcare costs, indicating a dominant strategy that may provide an opportunity to improve cost-effectiveness of care delivery.

Variation in receipt of therapy and survival with provider volume for medical oncology in non-curative esophago-gastric cancer: a population-based analysis

BACKGROUND

While surgical care by high-volume providers for esophago-gastric cancer (EGC) yields better outcomes, volume-outcome relationships are unknown for systemic therapy. We examined receipt of therapy and outcomes in the non-curative management of EGC based on medical oncology provider volume.

METHODS

We conducted a population based retrospective cohort study of non-curative EGC over 2005-2017 by linking administrative healthcare datasets. The volume of new EGC consultations per medical oncology provider per year was calculated and divided into quintiles. High-volume (HV) medical oncologists were defined as the 4-5th quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). Multivariate logistic and Cox-proportional hazards regressions examined the association between management by HV medical oncologist, receipt of systemic therapy, and OS.

RESULTS

7011 EGC patients with non-curative management consulted with medical oncology. 1-year OS was superior for HV medical oncologists (> 11 patients/year), with 28.4% (95% CI 26.7-30.2%) compared to 25.1% (95% CI 23.8-26.3%) for low volume (p < 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV medical oncologist was independently associated with higher odds of receiving chemotherapy (OR 1.13, 95% CI 1.01-1.26), and independently associated with superior OS (HR 0.89, 95% CI 0.84-0.93).

CONCLUSIONS

Medical oncology provider volume was associated with variation in non-curative management and outcomes of EGC. Care by an HV medical oncologist was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case mix. This information is important to inform disease care pathways and care organization; an increase in the number of HV medical oncologists may reduce variation and improve outcomes.

Underutilization of guideline-recommended supportive care among older adults with multiple myeloma in the United States

BACKGROUND

With improving survival for patients with multiple myeloma (MM), supportive care that is focused on optimizing quality of life and minimizing treatment-related toxicities is increasingly important. The extent to which patients with MM are receiving recommended supportive care is unknown.

METHODS

This study used the Surveillance, Epidemiology, and End Results-Medicare database to identify older adults (age ≥66 years) diagnosed with MM in 2008-2013 who had received active treatment and survived 1 year or longer after their diagnosis. Outcomes of interest included guideline-recommended supportive care, which was defined as 1) bone-modifying drugs (BMDs) within the 12 months after the diagnosis, 2) influenza vaccination in the first season after the diagnosis, and 3) concomitant use of prophylactic antivirals with proteasome inhibitors. Multivariable logistic regression models were used to evaluate associations between patient/facility-level characteristics and supportive care use.

RESULTS

Among 1996 patients receiving MM-directed therapy, 64%, 52%, and 49% received BMDs, an influenza vaccination, and antiviral prophylaxis, respectively. Non-Hispanic black patients (odds ratio [OR] vs white patients, 0.63; 95% confidence interval [CI], 0.46-0.88) and patients with baseline renal impairment (OR, 0.43; 95% CI, 0.34-0.54) had lower odds of BMDs. Non-Hispanic blacks (OR, 0.52; 95% CI, 0.37-0.73) and those with dual Medicaid enrollment (OR, 0.76; 95% CI, 0.58-0.99) had lower odds of influenza vaccination. Treatment in a community-based setting was associated with reduced odds of antiviral prophylaxis (OR, 0.58; 95% CI, 0.46-0.72).

CONCLUSIONS

Substantial underutilization of guideline-recommended supportive care was observed among older adults with MM in the United States, and this was associated with both patient and facility characteristics. Targeted interventions are needed to improve supportive care for patients with MM.

Prognostic Case Volume Thresholds in Patients With Head and Neck Squamous Cell Carcinoma

IMPORTANCE

Though described as an important prognostic indicator, facility case volume thresholds for patients with head and neck squamous cell carcinoma (HNSCC) have not been previously developed to date.

OBJECTIVE

To identify prognostic case volume thresholds of facilities that manage HNSCC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of 351 052 HNSCC cases reported from January 1, 2004, through December 31, 2014, by Commission of Cancer-accredited cancer centers from the US National Cancer Database. Data were analyzed from August 1, 2018, to April 5, 2019.

EXPOSURES

Treatment of HNSCC at facilities with varying case volumes.

MAIN OUTCOMES AND MEASURES

Using all-cause mortality outcomes among adult patients with HNSCC, 10 groups with increasing facility case volume were created and thresholds were identified where group survival differed compared with each of the 2 preceding groups (univariate log-rank analysis). Groups were collapsed at these thresholds and the prognostic value was confirmed using multivariable Cox regression. Prognostic meaning of these thresholds was assessed in subgroups by category (localized [I/II] and advanced [III/IV]), without metastasis (M0), with metastasis (M1), and anatomic subsites (nonoropharyngeal HNSCC and oropharyngeal HNSCC with known human papillomavirus status).

RESULTS

Of 250 229 eligible patients treated at 1229 facilities in the United States, there were 185 316 (74.1%) men and 64 913 (25.9%) women and the mean (SD) age was 62.8 (12.1) years. Three case volume thresholds were identified (low: ≤54 cases per year; moderate: >54 to ≤165 cases per year; and high: >165 cases per year). Compared with the moderate-volume group, multivariate analysis found that treatment at low-volume facilities (LVFs) was associated with a higher risk of mortality (hazard ratio [HR], 1.09; 99% CI, 1.07-1.11), whereas treatment at high-volume facilities (HVFs) was associated with a lower risk of mortality (HR, 0.92; 99% CI, 0.89-0.94). Subgroup analysis with Bonferroni correction revealed that only the moderate- vs low- threshold had meaningful differences in outcomes in localized stage (I/II) cancers, (LVFs vs moderate-volume facilities [MVFs]: HR, 1.09 [99% CI, 1.05-1.13]; HVF vs MVF: HR, 0.95 [99% CI, 0.90-1.00]), whereas both thresholds were meaningful in advanced stage (III/IV) cancers (LVF vs MVF: HR, 1.09 [99% CI, 1.06-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.88-0.94]). Survival differed by prognostic thresholds for both M0 (LVF vs MVF: HR, 1.09 [99% CI, 1.07-1.12]; HVF vs MVF: HR, 0.91 [99% CI, 0.89-0.94]) and nonoropharyngeal HNSCC (LVF vs MVF: HR, 1.10 [99% CI, 1.07-1.13]; HVF vs MVF: HR, 0.93 [99% CI, 0.90-0.97]) site cases, but not for M1 (LVF vs MVF: HR, 1.00 [99% CI, 0.92-1.09]; HVF vs MVF: HR, 0.94 [99% CI, 0.83-1.07]) or oropharyngeal HNSCC cases (when controlling for human papillomavirus status) (LVF vs MVF: HR, 1.10 [99% CI, 0.99-1.23]; HVF vs MVF: HR, 1.07 [99% CI, 0.94-1.22]).

CONCLUSIONS AND RELEVANCE

Higher volume facility threshold results appear to be associated with increases in survival rates for patients treated for HNSCC at MVFs or HVFs compared with LVFs, which suggests that these thresholds may be used as quality markers.

Association Between Ownership of Imaging Equipment and Appropriateness of Staging Positron-Emission Tomography in Non-Hodgkin Lymphoma

Physician ownership of imaging equipment has been shown to be associated with greater use of low-value imaging. However, it is unclear whether ownership also influences utilization of appropriate imaging. We conducted a cohort study of older adults diagnosed with three non-Hodgkin lymphomas with distinct guideline recommendations concerning the use of positron emission tomography (PET) during staging (recommended, not recommended, or equivocal). We found patients who were treated by oncologists with PET ownership were more likely to receive a staging PET regardless of lymphoma subtype. However, the difference in utilization by ownership status was smallest (6%, 95% confidence interval = 2% to 11%, P = .01) in the setting of diffuse large B cell lymphoma, where consensus guidelines recommend routine use of PET. Overall, removing financial incentives related to imaging self-referral may reduce utilization during cancer care, with the potential for greatest impact on imaging of equivocal or low clinical utility.

Rural and urban patients with diffuse large B-cell and follicular lymphoma experience reduced overall survival: a National Cancer DataBase study

We examined 83,108 patients with diffuse large B-cell lymphoma (DLBCL) and 43,393 patients with follicular lymphoma (FL) to investigate disparities related to geographic population density, stratified as rural, urban, or metropolitan. We found that urban and rural patients less commonly had private insurance and high socioeconomic status. Urban and rural DLBCL patients were more likely to receive treatment within 14 days of diagnosis (OR 0.93, 95% confidence interval [CI] 0.89-0.98; and OR 0.81, 95% CI 0.72-0.91) while urban FL patients were more likely to have treatment >14 days after diagnosis (OR 1.08, 95% CI 1.01-1.16). Multivariable analyses demonstrated that rural and urban patients had worse overall survival with DLBCL (hazard ratio [HR] 1.09; 95% CI 1-1.19 and HR 1.08; 95% CI 1.04-1.11) and FL (HR 1.11; 95% CI 1.04-1.18 and HR 1.2; 95% CI 1.02-1.41), respectively, suggesting needs for focused study and interventions for these populations.