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Freeman HD, Burke LC, Humphrey JG, Wilbers AJ, Vora H, Khorfan R, Solomon NL, Namm JP, Ji L, Lum SS. Fragmentation of care in breast cancer: greater than the sum of its parts. Breast Cancer Res Treat 2024:10.1007/s10549-024-07442-3. [PMID: 39096403 DOI: 10.1007/s10549-024-07442-3] [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: 05/20/2024] [Accepted: 07/19/2024] [Indexed: 08/05/2024]
Abstract
INTRODUCTION Fragmentation of care (FC, the receipt of care at > 1 institution) has been shown to negatively impact cancer outcomes. Given the multimodal nature of breast cancer treatment, we sought to identify factors associated with FC and its effects on survival of breast cancer patients. METHODS A retrospective analysis was performed of surgically treated, stage I-III breast cancer patients in the 2004-2020 National Cancer Database, excluding neoadjuvant therapy recipients. Patients were stratified into two groups: FC or non-FC care. Treatment delay was defined as definitive surgery > 60 days after diagnosis. Multivariable logistic regression was performed to identify factors predictive of FC, and survival was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS Of the 531,644 patients identified, 340,297 (64.0%) received FC. After adjustment, FC (OR 1.27, 95% CI 1.25-1.29) was independently associated with treatment delay. Factors predictive of FC included Hispanic ethnicity (OR 1.04, 95% CI: 1.01-1.07), treatment at comprehensive community cancer programs (OR 1.06, 95% CI: 1.03-1.08) and integrated network cancer programs (OR 1.55, 95% CI: 1.51-1.59), AJCC stage II (OR 1.06, 95% CI 1.05-1.07) and stage III tumors (OR 1.06, 95% CI: 1.02-1.10), and HR + /HER2 + tumors (OR 1.05, 95% CI: 1.02-1.07). Treatment delay was independently associated with increased risk of mortality (HR 1.23, 95% CI 1.20-1.26), whereas FC (HR 0.87, 95% CI 0.86-0.88) showed survival benefit. CONCLUSIONS While treatment delay negatively impacts survival in breast cancer patients, our findings suggest FC could be a marker for multispecialty care that may mitigate some of these effects.
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Affiliation(s)
- Hadley D Freeman
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Linnea C Burke
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Ja'Neil G Humphrey
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Ashley J Wilbers
- Division of Breast Surgery, Department of Surgery, Washington University, St. Louis, MO, USA
| | - Halley Vora
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Rhami Khorfan
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Naveenraj L Solomon
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Jukes P Namm
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Liang Ji
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA
| | - Sharon S Lum
- Division of Surgical Oncology, Department of Surgery, Loma Linda University, Loma Linda, CA, USA.
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Pohl SA, Nelson BA, Patwary TR, Amanuel S, Benz EJ, Lathan CS. Evolution of community outreach and engagement at National Cancer Institute-Designated Cancer Centers, an evolving journey. CA Cancer J Clin 2024; 74:383-396. [PMID: 38703384 DOI: 10.3322/caac.21841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/26/2024] [Accepted: 04/09/2024] [Indexed: 05/06/2024] Open
Abstract
Cancer mortality rates have declined during the last 28 years, but that process is not equitably shared. Disparities in cancer outcomes by race, ethnicity, socioeconomic status, sexual orientation and gender identity, and geographic location persist across the cancer care continuum. Consequently, community outreach and engagement (COE) efforts within National Cancer Institute-Designated Cancer Center (NCI-DCC) catchment areas have intensified during the last 10 years as has the emphasis on COE and catchment areas in NCI's Cancer Center Support Grant applications. This review article attempts to provide a historic perspective of COE within NCI-DCCs. Improving COE has long been an important initiative for the NCI, but it was not until 2012 and 2016 that NCI-DCCs were required to define their catchment areas rigorously and to provide specific descriptions of COE interventions, respectively. NCI-DCCs had previously lacked adequate focus on the inclusion of historically marginalized patients in cancer innovation efforts. Integrating COE efforts throughout the research and operational aspects of the cancer centers, at both the patient and community levels, will expand the footprint of COE efforts within NCI-DCCs. Achieving this change requires sustained commitment by the centers to adjust their activities and improve access and outcomes for historically marginalized communities.
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Affiliation(s)
- Sarah A Pohl
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Barry A Nelson
- Dana-Farber/Harvard Cancer Center Faith Based Cancer Disparities Network, Boston, Massachusetts, USA
| | - Tanjeena R Patwary
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Salina Amanuel
- Columbia University Mailman School of Public Health, New York, New York, USA
| | - Edward J Benz
- Dana-Farber Cancer Center, Dana-Farber/Harvard Cancer Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Lathan
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Brauer DG, Gonen M, Drebin JA, Groeger JS, Jewell EL. Establishing Regionalized Acute Care Across a Health Care System to Decentralize Postoperative Care After Oncologic Surgery. JCO Oncol Pract 2024; 20:666-672. [PMID: 38295332 DOI: 10.1200/op.23.00392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/15/2023] [Accepted: 12/15/2023] [Indexed: 02/02/2024] Open
Abstract
PURPOSE Patients undergoing oncologic surgery at major referral centers frequently experience postdischarge care fragmentation, which has been associated with poor outcomes. This report describes and evaluates the outcomes of an intervention at Memorial Sloan Kettering Cancer Center (MSKCC) to decentralize postdischarge postoperative acute care within our health care system. METHODS In 2018, MSKCC completed the addition of six regional acute care clinics called symptom care clinics (SCCs) to existing regional outpatient clinics. Acute care was previously only available within our system at a single centralized urgent care center (UCC). All patients undergoing surgery in our system between January 1, 2019, and June 30, 2021, were followed for 90 days. The exposure was the site of initial acute care presentation-UCC or SCC-and outcomes included utilization, access, financial toxicity, and mortality. Mortality was adjusted using hierarchical modeling at the level of the region. RESULTS A total of 6,992 postsurgical patients experienced 10,525 acute care visits in our system within 90 days of surgery. Twenty-nine percent of these patients presented to the SCC first. These patients were older but had fewer comorbidities and shorter index length of stay compared with UCC patients. Utilization of SCCs increased substantially while UCC utilization decreased during a period of stable case volume. SCCs were closer to patients' homes, and wait times were shorter. Rates of financial toxicity were similar between groups. Of this high-risk cohort accessing acute care postoperatively, 90-day mortality was similar for UCC and SCC patients (P = .731). CONCLUSION This model of decentralized acute care after oncologic surgery was increasingly used over time with comparable patient safety. Health systems should emphasize patient-centered care by supporting safe strategies for regionalized care even when treatments are delivered at centralized referral centers.
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Affiliation(s)
- David G Brauer
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Mithat Gonen
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey S Groeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Elizabeth L Jewell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Chang S, Liu M, Braun-Inglis C, Holcombe R, Okado I. Cancer care coordination in rural Hawaii: a focus group study. BMC Health Serv Res 2024; 24:518. [PMID: 38658990 PMCID: PMC11043031 DOI: 10.1186/s12913-024-10916-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Rural populations consistently experience a disproportionate burden of cancer, including higher incidence and mortality rates, compared to the urban populations. Factors that are thought to contribute to these disparities include limited or lack of access to care and challenges with care coordination (CC). In Hawaii, many patients residing in rural areas experience unique challenges with CC as they require inter-island travel for their cancer treatment. In this focus group study, we explored the specific challenges and positive experiences that impact the CC in rural Hawaii cancer patients. METHODS We conducted two semi-structured focus group interviews with cancer patients receiving active treatment for any type of cancer (n = 8). The participants were recruited from the rural areas of Hawaii, specifically the Hawaii county and Kauai. Rural was defined using the Rural-Urban Commuting Area Codes (RUCA; rural ≥ 4). The focus group discussions were facilitated using open-ended questions to explore patients' experiences with CC. RESULTS Content analysis revealed that 47% of the discussions were related to CC-related challenges, including access to care (27.3%), insurance (9.1%), inter-island travel (6.1%), and medical literacy (4.5%). Other major themes from the discussions focused on facilitators of CC (30.3%), including the use of electronic patient portal (12.1%), team-based approach (9.1%), family caregiver support (4.5%), and local clinic staff (4.5%). CONCLUSION Our findings indicate that there are notable challenges in rural patients' experiences regarding their cancer care coordination. Specific factors such as the lack of oncologist and oncology services, fragmented system, and the lack of local general medical providers contribute to problems with access to care. However, there are also positive factors found through the help of facilitators of CC, notability the use of electronic patient portal, team-based approach, family caregiver support, and local clinic staff. These findings highlight potential targets of interventions to improve cancer care delivery for rural patients. TRIAL REGISTRATION Not required.
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Affiliation(s)
- Shin Chang
- John A Burns School of Medicine, University of Hawai'i at Mānoa, 651 Ilalo St, 96813, Honolulu, HI, USA
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, 96813, Honolulu, HI, USA
| | - Michelle Liu
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, 96813, Honolulu, HI, USA
| | - Christa Braun-Inglis
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, 96813, Honolulu, HI, USA
| | - Randall Holcombe
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, 96813, Honolulu, HI, USA
- University of Vermont Cancer Center, 149 Beaumont Av. Burlington, 05405, VT, USA
| | - Izumi Okado
- University of Hawai'i Cancer Center, 701 Ilalo St. 6th Floor, 96813, Honolulu, HI, USA.
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Park SS, Verm RA, Abdelsattar ZM, Kramer S, Swanson J, Fernando M, Cohn T, Luchette FA, Baker MS. Fragmented care in localized pancreatic cancer: Is commission on cancer accreditation associated with improved overall survival? Surgery 2024; 175:695-703. [PMID: 37863686 DOI: 10.1016/j.surg.2023.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Prior studies of fragmentation of care in pancreatic cancer have not adjusted for indicators of hospital quality such as Commission on Cancer accreditation. The effect of fragmentation of care has not been well defined. METHODS We queried the National Cancer Database to identify patients undergoing pancreaticoduodenectomy and distal pancreatectomy with perioperative systemic therapy for clinical stages I-III pancreatic cancer between 2006 and 2019. Patients who received systemic therapy at a center different than the center performing surgery were categorized as having fragmentation of care. Patients having fragmentation of care were further categorized on the basis of whether (fragmentation of care Commission on Cancer) or not (fragmentation of care non-Commission on Cancer) systemic therapy was administered at a facility accredited by the Commission on Cancer. RESULTS A total of 11,732 patients met inclusion criteria; 5,668 (48.3%) underwent fragmentation of care, and 3,426 (29.2%) fragmentation of care non-Commission on Cancer. Patients undergoing fragmentation of care non-Commission on Cancer were less likely to receive neoadjuvant systemic therapy than those undergoing fragmentation of care Commission on Cancer or non-fragmented care (27.7% vs 40.1% vs 36.8%, P < .001). On Cox analysis, advanced age, comorbid disease, node-positive disease, and facility type were associated with risk of overall survival. Fragmentation of care was not (adjusted hazard ratio = 0.99, 95% confidence interval [0.94-1.06], P = .8). On Kaplan-Meier analysis, there were no significant differences in 5-year overall survival between treatment cohorts. CONCLUSION In patients undergoing fragmentation of care for localized pancreatic cancer, those treated with systemic therapy in Commission on Cancer accredited facilities are more likely to be given neoadjuvant therapy but demonstrate no significant improvement in survival relative to those undergoing non-fragmented care or those undergoing fragmentation of care but receiving systemic therapy in nonaccredited facilities.
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Affiliation(s)
- Simon S Park
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Raymond A Verm
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Zaid M Abdelsattar
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL; Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Sarah Kramer
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - James Swanson
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Mitchel Fernando
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Tyler Cohn
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Frederick A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL
| | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Loyola University Chicago Stritch School of Medicine, Maywood, IL; Department of Surgery, Edward Hines Jr Veterans Administration Hospital, Hines, IL; Department of Surgery, Huntsman Cancer Institute, University of Utah Health Salt Lake City, UT.
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Choi DW, Kim S, Kim SJ, Kim DW, Ryu KS, Kim JH, Chang YJ, Han KT. Relationship between patient outcomes and patterns of fragmented cancer care in older adults with gastric cancer: A nationwide cohort study in South Korea. J Geriatr Oncol 2024; 15:101685. [PMID: 38104479 DOI: 10.1016/j.jgo.2023.101685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Fragmented cancer care, defined as receipt of care from multiple hospitals, has been shown to be associated with poor patient outcomes and high expense. However, evidence regarding the effects of hospital choice by patients with cancer on overall survival are lacking. Thus, we investigated the relationship between patterns of fragmented care and five-year mortality in patients with gastric cancer. MATERIALS AND METHODS Using the Korean National Health Insurance senior cohort of adults aged ≥60 years, we identified patients with gastric cancer who underwent gastrectomy during 2007-2014. We examined the distribution of the study population by five-year mortality, and used Kaplan-Meier survival curves/log-rank test and Cox proportional hazard model to compare five-year mortality with fragmented cancer care. RESULTS Among the participants, 19.5% died within five years. There were more deaths among patients who received fragmented care, especially those who transferred to smaller hospitals (46.6%) than to larger ones (40.0%). The likelihood of five-year mortality was higher in patients who received fragmented cancer care upon moving from large to small hospitals than those who did not transfer hospitals (hazard ratio, 1.28; 95% confidence interval, 1.10-1.48, P = .001). Moreover, mortality was higher among patients treated in large hospitals or in the capital area for initial treatment, and this association was greater for patients from rural areas. DISCUSSION Fragmentation of cancer care was associated with reduced survival, and the risk of mortality was higher among patients who moved from large to small hospitals.
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Affiliation(s)
- Dong-Woo Choi
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Seungju Kim
- Department of Nursing, College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Republic of Korea
| | - Dong Wook Kim
- Department of Information and Statistics, RINS, Gyeongsang National University, Jinju, Republic of Korea
| | - Kwang Sun Ryu
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Jae Ho Kim
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Yoon-Jung Chang
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Kyu-Tae Han
- Division of Cancer Control & Policy, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea.
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Verm RA, Baker MM, Cohn T, Park S, Swanson J, Freeman R, Abdelsattar ZM. Fragmented care, Commission on Cancer accreditation, and overall survival in patients receiving surgery and chemotherapy for esophageal cancer. Surgery 2024; 175:618-628. [PMID: 37743107 DOI: 10.1016/j.surg.2023.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/21/2023] [Accepted: 07/08/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Increasing regionalization for esophagectomy for cancer may lead patients to travel for surgery at one institution and receive chemotherapy at another closer to home. We explore the effects on survival for care fragmentation, the Commission on Cancer status of secondary institutions providing chemotherapy, and the type of institution performing surgery. METHODS We queried the National Cancer Database to identify all patients who underwent esophagectomy for esophageal cancer and received perioperative chemotherapy between 2006 and 2019. Patients were divided into single-center care, fragmented-to-Commission on Cancer care, or fragmented-to-non-Commission on Cancer care. We identified associations using multivariable logistic regression, Kaplan-Meier survival analyses, and Cox proportional hazards models. RESULTS A total of 18,502 patients met the criteria for inclusion: 8,290 (44.8%) received single-center care; 3,414 (18.5%) fragmented-to-Commission on Cancer care; and 6,798 (36.4%) fragmented-to-non-Commission on Cancer care. Fragmented care was more likely in White patients (adjusted odds ratio = 1.25; P < .001) and in patients nonadjacent to a metropolitan area (adjusted odds ratio = 1.36; P < .001). Overall survival was equivalent between single-center and fragmented care, but undergoing an esophagectomy at an academic center was associated with improved survival (adjusted hazard ratio = 0.82; P = .016). In patients with an esophagectomy at a nonacademic center, overall survival was best if perioperative chemotherapy was administered at Commission on Cancer-accredited facilities compared with chemotherapy at fragmented-to-non-Commission on Cancer centers (P = .022). CONCLUSION Most of the esophageal cancer care in the US is fragmented at multiple institutions. When care is fragmented, it is most commonly at non-Commission on Cancer centers for perioperative chemotherapy. Overall survival is best when esophagectomy is performed at an academic center, and perioperative therapy is administered at Commission on Cancer-accredited facilities.
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Affiliation(s)
- Raymond A Verm
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL. https://twitter.com/RaymondVerm
| | - Marshall M Baker
- Department of Surgery, Edward Hines VA Medical Center, Hines, IL
| | - Tyler Cohn
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines VA Medical Center, Hines, IL
| | - Simon Park
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - James Swanson
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Richard Freeman
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL
| | - Zaid M Abdelsattar
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL; Department of Surgery, Edward Hines VA Medical Center, Hines, IL.
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Vierra M, Bansal VV, Morgan RB, Witmer HDD, Reddy B, Dhiman A, Godley FA, Ong CT, Belmont E, Polite B, Shergill A, Turaga KK, Eng OS. Fragmentation of Care in Patients with Peritoneal Metastases Undergoing Cytoreductive Surgery. Ann Surg Oncol 2024; 31:645-654. [PMID: 37737968 DOI: 10.1245/s10434-023-14318-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND The delivery of multimodal treatment at a high-volume center is known to optimize the outcomes of gastrointestinal malignancies. However, patients undergoing cytoreductive surgery (CRS) for peritoneal metastases often must 'fragment' their surgical and systemic therapeutic care between different institutions. We hypothesized that this adversely affects outcomes. PATIENTS AND METHODS Adults undergoing CRS for colorectal or appendiceal adenocarcinoma at our institution between 2016 and 2022 were identified retrospectively and grouped by care network: 'coordinated care' patients received exclusively in-network systemic therapy, while 'fragmented care' patients received some systemic therapy from outside-network providers. Factors associated with fragmented care were also ascertained. Overall survival (OS) from CRS and systemic therapy-related serious adverse events (SAEs) were compared across the groups. RESULTS Among 85 (80%) patients, 47 (55%) had colorectal primaries and 51 (60%) received fragmented care. Greater travel distance [OR 1.01 (CI 1.00-1.02), p = 0.02] and educational status [OR 1.04 (CI 1.01-1.07), p = 0.01] were associated with receiving fragmented care. OS was comparable between patients who received fragmented and coordinated care in the colorectal [32.5 months versus 40.8 months, HR 0.95 (CI 0.43-2.10), p = 0.89] and appendiceal [31.0 months versus 27.4 months, HR 1.17 (CI 0.37-3.74), p = 0.55] subgroups. The frequency of SAEs (7.8% versus 17.6%, p = 0.19) was also similar. CONCLUSIONS There were no significant differences in survival or SAEs based on the networks of systemic therapy delivery. This suggests that patients undergoing CRS at a high-volume center may safely receive systemic therapy at outside-network facilities with comparable outcomes.
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Affiliation(s)
- Mason Vierra
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Varun V Bansal
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ryan B Morgan
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Hunter D D Witmer
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Biren Reddy
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Ankit Dhiman
- Department of Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Frederick A Godley
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Cecilia T Ong
- Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Erika Belmont
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Blasé Polite
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Ardaman Shergill
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - Kiran K Turaga
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Oliver S Eng
- Department of Surgery, University of California, Irvine, Orange, CA, USA.
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Han KT, Kim S. The effect of fragmented cancer care and change in nurse staffing grade on cancer patient mortality. Worldviews Evid Based Nurs 2023; 20:610-620. [PMID: 37691136 DOI: 10.1111/wvn.12676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Continuity of patient care ensures timely and appropriate care and is associated with better patient outcomes among cancer patients. However, the impact of nurse staffing grade changes on patient outcomes remains unknown. AIMS This retrospective cohort study aimed to evaluate the effect of fragmented care and changes in nurse staffing grade on the survival of colorectal cancer patients who underwent surgery. METHODS This study included 2228 newly diagnosed colorectal cancer patients. Fragmented care was defined as the receipt of treatment in multiple hospitals and was divided into three categories based on changes in nurse staffing grade. Five-year survival rates were used to evaluate the effect of fragmented care and nurse staffing grade on outcomes of cancer patients. Survival analysis was performed by adjusting for covariates using the Cox proportional hazards model for 5-year mortality. RESULTS Approximately 18.5% of patients died within 5 years; the mortality rate during cancer treatment was higher in patients who received fragmented care, especially in those transferred to hospitals with fewer nurses. Patients who received fragmented care had shorter survival times, and those transferred to hospitals with fewer nurses had higher risks of 5-year mortality (hazard ratio: 1.625; 95% CI: [1.095, 2.412]). Transfers to hospitals with fewer nurses were associated with increased mortality rates in low-income patients, hospitals located in metropolitan and rural areas, and high-severity groups. LINKING EVIDENCE TO ACTION Receipt of fragmented care and change in nurse staffing grade due to patients' transfer to different hospitals were associated with increased mortality rates in cancer patients, thus underlining the importance of ensuring continuity and quality of care. Patients from rural areas, from low-income families, and with high disease severity may have better outcomes if they receive treatment in well-staffed hospitals.
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Affiliation(s)
- Kyu-Tae Han
- Division of Cancer Control & Policy, National Cancer Control Institute, National Cancer Center, Goyang, South Korea
| | - Seungju Kim
- Department of Health System, College of Nursing, The Catholic University of Korea, Seoul, South Korea
- Research Institute for Hospice/Palliative Care, The Catholic University of Korea, Seoul, South Korea
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10
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Murimwa GZ, Meier J, Nehrubabu M, Zeh HJ, Yopp AC, Polanco PM. Implications of the interaction between travel burden and area deprivation for patients with pancreatic cancer. Am J Surg 2023; 226:515-522. [PMID: 37355377 DOI: 10.1016/j.amjsurg.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Fragmentation of care and distance traveled are classically surrogates for poor access to care, but little is known about how social determinants of health interact with travel burden to affect survival for patients with pancreatic cancer (PC). We sought to characterize the individual and composite impact of these factors. METHODS 20769 patients treated for PC between 2005 and 2019 in the Texas Cancer Registry were included. The Area Deprivation Index and Poverty Index were used to quantify social determinants of health. Survival analyses were performed at 2 years as well as subgroup analysis on patients with the greatest travel burden. RESULTS Improved survival was associated with FC (HR 0.74, CI 0.71-0.77) and distance from an accredited cancer center (Quartile 4 HR 0.90, CI 0.81-1.00). High ADI led to worse outcomes while low ADI led to improved outcomes with increasing travel burden. CONCLUSIONS This data shows a complex relationship between travel burden and survival for patients with pancreatic cancer where stratifying by area deprivation reveals divergent outcomes and the potential to exacerbate disparities.
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Affiliation(s)
- Gilbert Z Murimwa
- Department of Surgery, University of Texas at Southwestern Medical Center, Dallas, TX, United States
| | - Jennie Meier
- Department of Surgery, University of Texas at Southwestern Medical Center, Dallas, TX, United States
| | - Mithin Nehrubabu
- Department of Mathematics, University of Texas at Dallas, Richardson, TX, United States
| | - Herbert J Zeh
- Department of Surgery, University of Texas at Southwestern Medical Center, Dallas, TX, United States
| | - Adam C Yopp
- Department of Surgery, University of Texas at Southwestern Medical Center, Dallas, TX, United States
| | - Patricio M Polanco
- Department of Surgery, University of Texas at Southwestern Medical Center, Dallas, TX, United States.
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11
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Barzi A, Kim AJ, Liang CK, West H, Wong D, Wright C, Nathwani N, Vasko CM, Chung V, Rubinson DA, Sachs T. Pancreatic Adenocarcinoma: Real World Evidence of Care Delivery in AccessHope Data. J Pers Med 2023; 13:1377. [PMID: 37763145 PMCID: PMC10532778 DOI: 10.3390/jpm13091377] [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: 07/15/2023] [Revised: 09/02/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Pancreatic adenocarcinoma is an aggressive disease and the delivery of comprehensive care to individuals with this cancer is critical to achieve appropriate outcomes. The identification of gaps in care delivery facilitates the design of interventions to optimize care delivery and improve outcomes in this population. METHODS AccessHope™ is a growing organization that connects oncology subspecialists with treating providers through contracts with self-insured employers. Data from 94 pancreatic adenocarcinoma cases (August 2019-December 2022) in the AccessHope dataset were used to describe gaps in care delivery. RESULTS In all but 6% of cases, the subspecialist provided guideline-concordant recommendations anticipated to improve outcomes. Gaps in care were more pronounced in patients with non-metastatic pancreatic cancer. There was a significant deficiency in germline testing regardless of the stage, with only 59% of cases having completed testing. Only 20% of cases were receiving palliative care or other allied support services. There was no difference in observed care gaps between patients receiving care in the community setting vs. those receiving care in the academic setting. CONCLUSIONS There are significant gaps in the care delivered to patients with pancreatic adenocarcinoma. A concurrent subspecialist review has the opportunity to identify and address these gaps in a timely manner.
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Affiliation(s)
- Afsaneh Barzi
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA;
| | - Angela J. Kim
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
| | - Crystal K. Liang
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
| | - Howard West
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA;
| | - D. Wong
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA;
| | - Carol Wright
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
| | - Nitya Nathwani
- Department of Hematology and Hematopoietic Stem Cell Transplant, City of Hope, Duarte, CA 91011, USA;
| | - Catherine M. Vasko
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
| | - Vincent Chung
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA 91010, USA;
| | | | - Todd Sachs
- AccessHope, Duarte, CA 91010, USA; (A.J.K.); (C.K.L.); (H.W.); (C.W.); (C.M.V.); (T.S.)
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12
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Komorny KM, Burkett JM, Mensing T, Whaley BA, Robb K, Chen D. Payer site of care mandates with oncology medications: It's time to demand payer accountability on behalf of patients. Am J Health Syst Pharm 2023; 80:939-943. [PMID: 37079923 DOI: 10.1093/ajhp/zxad078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Indexed: 04/22/2023] Open
Affiliation(s)
| | - Jason M Burkett
- Department of Payer Strategies, Moffitt Cancer Center, Tampa, FL, USA
| | - Tracey Mensing
- Department of Patient Care Services and Nursing Support, Moffitt Cancer Center, Tampa, FL, USA
| | - Bridget A Whaley
- Department of Payer Strategies, Moffitt Cancer Center, Tampa, FL, USA
| | - Kyle Robb
- Office of Government Relations, American Society of Health-System Pharmacists, Bethesda, MD, USA
| | - David Chen
- Office of Member Relations, American Society of Health-System Pharmacists, Bethesda, MD, USA
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13
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Han KT, Kim SJ. Is Fragmented Cancer Care Associated With Medical Expenditure? Nationwide Evidence From Patients With Lung Cancer Using National Insurance Claim Data. Int J Public Health 2023; 68:1606000. [PMID: 37485048 PMCID: PMC10356958 DOI: 10.3389/ijph.2023.1606000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/26/2023] [Indexed: 07/25/2023] Open
Abstract
Objectives: We aimed to investigate the association between fragmented cancer care in the early phase after cancer diagnosis and patient outcomes using national insurance claim data. Methods: We identified National Health Insurance beneficiaries diagnosed with lung cancer in South Korea from 2010 to 2014. We included 1,364 lung cancer patients with reduced immortal time bias and heterogeneity. We performed multiple regression analysis using a generalized estimate equation with a gamma distribution for medical expenditures. Results: Among the 1,364 patients with lung cancer, 12.8% had fragmented cancer care. Healthcare costs were higher in fragmented cancer care for both during diagnosis to 365 days and diagnosis to 1,825 days. Linear regression results showed that fragmented cancer care was associated with 1.162 times higher costs during the period from diagnosis to 365 days and 1.163 times the cost for the period from diagnosis to 1,825 days. Conclusion: We found fragmented cancer care is associated with higher medical expenditure. Future health policy should consider the limitation of patients' free will when opting for fragmented cancer care, as there are currently no control mechanisms.
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Affiliation(s)
- Kyu-Tae Han
- Division of Cancer Control and Policy, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan, Republic of Korea
- Center for Healthcare Management Science, Soonchunhyang University, Asan, Republic of Korea
- Department of Software Convergence, Soonchunhyang University, Asan, Republic of Korea
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14
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Riveros C, Chalfant V, Elshafei A, Bandyk M, Balaji KC. Does care fragmentation in patients with bladder cancer lead to worse outcomes? Urol Oncol 2023; 41:147.e7-147.e14. [PMID: 36631369 DOI: 10.1016/j.urolonc.2022.10.028] [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: 01/12/2022] [Revised: 10/18/2022] [Accepted: 10/30/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Care fragmentation may influence oncologic outcomes. The impact of care fragmentation on the outcomes of patients receiving neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) is not well defined. We aimed to compare outcomes between patients who received fragmented care (FC) versus non-fragmented care (NFC). METHODS The National Cancer Database was queried for adult (≥18 years old) patients with cT2-T4aN0M0 urothelial carcinoma of the bladder receiving NAC followed by RC between 2004 and 2017. Patients were dichotomized based on whether they received FC (defined as receiving NAC at a different facility from where RC was performed) or NFC (defined as receiving NAC and RC at a single facility). The main outcome of interest was overall survival (OS). Secondary outcomes included time from diagnosis to treatment (NAC and RC) and perioperative outcomes. Kaplan-Meier survival estimates were calculated after stratifying by type of care received. Multivariable Cox regression analysis was performed to evaluate the association between FC and OS in the context of other clinically relevant covariates. RESULTS A total of 2223 patients were included: 1035 (46.6%) received FC whereas 1188 (53.4%) received NFC. Factors associated with FC included greater travel distance, higher comorbidity burden, and surgical treatment at a high-volume facility. Patients who received FC had a slightly longer median time to RC (160 vs. 154 days, P = 0.001). However, on Kaplan-Meier analysis no differences in median OS were found between the two groups. On multivariable Cox regression analysis, factors associated with worse OS included age, advanced TNM stage, lymphovascular invasion, and positive surgical margins; yet FC was not associated with worse OS (hazard ratio [HR] 1.02; 95% confidence interval [CI] 0.88-1.17). On subgroup analysis, we found that FC received at academic facilities (HR 0.76; 95% CI 0.58-0.99), as well as NFC received at high-volume centers (HR 0.65; 95% CI 0.43-0.98), were associated with a decrease in overall mortality. CONCLUSIONS Fragmented care is not associated with worse survival outcomes in patients with MIBC receiving NAC followed by RC.
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Affiliation(s)
- Carlos Riveros
- Department of Urology, University of Florida, Jacksonville, FL
| | - Victor Chalfant
- Department of Urology, University of Florida, Jacksonville, FL
| | - Ahmed Elshafei
- Department of Urology, University of Florida, Jacksonville, FL
| | - Mark Bandyk
- Department of Urology, University of Florida, Jacksonville, FL
| | - K C Balaji
- Department of Urology, University of Florida, Jacksonville, FL.
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15
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Logan CD, Feinglass J, Halverson AL, Durst D, Lung K, Kim S, Bharat A, Merkow RP, Bentrem DJ, Odell DD. Rural-Urban Disparities in Receipt of Surgery for Potentially Resectable Non-Small Cell Lung Cancer. J Surg Res 2023; 283:1053-1063. [PMID: 36914996 PMCID: PMC10289009 DOI: 10.1016/j.jss.2022.10.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 08/25/2022] [Accepted: 10/15/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Access to cancer care, especially surgery, is limited in rural areas. However, the specific reasons rural patient populations do not receive surgery for non-small cell lung cancer (NSCLC) is unknown. We investigated geographic disparities in reasons for failure to receive guideline-indicated surgical treatment for patients with potentially resectable NSCLC. METHODS The National Cancer Database was used to identify patients with clinical stage I-IIIA (N0-N1) NSCLC between 2004 and 2018. Patients from rural areas were compared to urban areas, and the reason for nonreceipt of surgery was evaluated. Adjusted odds of (1) primary nonsurgical management, (2) surgery being deemed contraindicated due to risk, (3) surgery being recommended but not performed, and (4) overall failure to receive surgery were determined. RESULTS The study included 324,785 patients with NSCLC with 42,361 (13.0%) from rural areas. Overall, 62.4% of patients from urban areas and 58.8% of patients from rural areas underwent surgery (P < 0.001). Patients from rural areas had increased odds of (1) being recommended primary nonsurgical management (adjusted odds ratio [aOR]: 1.14, 95% confidence interval [CI]: 1.05-1.23), (2) surgery being deemed contraindicated due to risk (aOR: 1.19, 95% CI: 1.07-1.33), (3) surgery being recommended but not performed (aOR: 1.13, 95% CI: 1.01-1.26), and (4) overall failure to receive surgery (aOR: 1.21, 95% CI: 1.13-1.29; all P < 0.001). CONCLUSIONS There are geographic disparities in the management of NSCLC. Rural patient populations are more likely to fail to undergo surgery for potentially resectable disease for every reason examined.
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Affiliation(s)
- Charles D Logan
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611; Canning Thoracic Institute, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - Joe Feinglass
- Department of Medicine, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - Amy L Halverson
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - Dalya Durst
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - Kalvin Lung
- Canning Thoracic Institute, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - Samuel Kim
- Canning Thoracic Institute, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - Ankit Bharat
- Canning Thoracic Institute, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - Ryan P Merkow
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - David J Bentrem
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611
| | - David D Odell
- Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611; Canning Thoracic Institute, Department of Surgery, Northwestern University, Feinberg School of Medicine, 420 East Superior Street, Chicago, Illinois 60611.
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16
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Rhodin KE, Raman V, Jensen CW, Kang L, Nussbaum DP, Tong BC, Blazer DG, D'Amico TA. Multi-institutional Care in Clinical Stage II and III Esophageal Cancer. Ann Thorac Surg 2023; 115:370-377. [PMID: 35872035 PMCID: PMC9851933 DOI: 10.1016/j.athoracsur.2022.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/08/2022] [Accepted: 06/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Management of clinical stage II or III esophageal cancer requires multidisciplinary care. Multi-institutional care has been associated with worse survival in other malignant diseases. This study aimed to determine the impact of multi-institutional care on survival in patients with stage II or III esophageal cancer. METHODS The 2004 to 2016 National Cancer Database was queried for patients with clinical stage II or III esophageal cancer who received neoadjuvant chemotherapy with or without radiation therapy followed by surgical resection. Patients were stratified into 2 groups: multi-institutional or single-institution care. Survival between groups was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. Multivariable logistic regression was performed to identify factors associated with multi-institutional care. RESULTS Overall, 11 399 patients met study criteria: 6569 (57.6%) received multi-institutional care and 4,830 (42.4%) received care at a single institution. In a multivariable analysis, factors associated with multi-institutional care were later year of diagnosis, greater distance from treating facility, residence in an urban or rural setting (vs metro), and residence in states without Medicaid expansion. Care at a single institution was associated with Black race, lack of insurance, and treatment at higher-volume or academic centers. Despite these differences, patients who received multi-institutional care had survival comparable to that in patients who received care at a single institution (HR, 0.97; 95% CI, 0.92-1.03; P = .30). CONCLUSIONS In this National Cancer Database analysis, multi-institutional care was not associated with inferior overall survival. As complex cancer care becomes more regionalized, patients may consider receiving part of their cancer care closer to home, whereas traveling to surgical centers of excellence should be encouraged.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Lillian Kang
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Betty C Tong
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A D'Amico
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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17
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Choi DW, Kim SJ, Kim DJ, Chang YJ, Kim DW, Han KT. Does fragmented cancer care affect survival? Analysis of gastric cancer patients using national insurance claim data. BMC Health Serv Res 2022; 22:1566. [PMID: 36544140 PMCID: PMC9773508 DOI: 10.1186/s12913-022-08988-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND We aimed to investigate the association between fragmented cancer care in the early phase after cancer diagnosis and patient outcomes using national insurance claim data. METHODS From a nationwide sampled cohort database, we identified National Health Insurance beneficiaries diagnosed with gastric cancer (ICD-10: C16) in South Korea during 2005-2013. We analyzed the results of a multiple logistic regression analysis using the generalized estimated equation model to investigate which patient and institution characteristics affected fragmented cancer care during the first year after diagnosis. Then, survival analysis using the Cox proportional hazard model was conducted to investigate the association between fragmented cancer care and five-year mortality. RESULTS Of 2879 gastric cancer patients, 11.9% received fragmented cancer care by changing their most visited medical institution during the first year after diagnosis. We found that patients with fragmented cancer care had a higher risk of five-year mortality (HR: 1.310, 95% CI: 1.023-1.677). This association was evident among patients who only received chemotherapy or radiotherapy (HR: 1.633, 95% CI: 1.005-2.654). CONCLUSIONS Fragmented cancer care was associated with increased risk of five-year mortality. Additionally, changes in the most visited medical institution occurred more frequently in either patients with severe conditions or patients who mainly visited smaller medical institutions. Further study is warranted to confirm these findings and examine a causal relationship between fragmented cancer care and survival.
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Affiliation(s)
- Dong-Woo Choi
- grid.410914.90000 0004 0628 9810Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Gyeonggi-do, Goyang-Si, Republic of Korea
| | - Sun Jung Kim
- grid.412674.20000 0004 1773 6524Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, Asan-Si, Republic of Korea
| | - Dong Jun Kim
- grid.411947.e0000 0004 0470 4224Graduate School of Public Health and Healthcare Management, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon-Jung Chang
- grid.410914.90000 0004 0628 9810Division of Cancer Control and Policy, National Cancer Control Institute, National Cancer Center, Gyeonggi-do, Goyang-Si, Republic of Korea
| | - Dong Wook Kim
- grid.256681.e0000 0001 0661 1492Department of Information and Statistics, RINS, Gyeongsang National University, 501 Jinju-daero, Jinju-si, Gyeongsangnam-do South Korea
| | - Kyu-Tae Han
- grid.410914.90000 0004 0628 9810Division of Cancer Control and Policy, National Cancer Control Institute, National Cancer Center, Gyeonggi-do, Goyang-Si, Republic of Korea
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18
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Fragmentation of Care in Pancreatic Cancer: Effects on Receipt of Care and Survival. J Gastrointest Surg 2022; 26:2522-2533. [PMID: 36221020 DOI: 10.1007/s11605-022-05478-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/24/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The impact of fragmentation of care (FC), i.e., receipt of care at > 1 institution, on treatment of pancreatic cancer is unknown. The purpose of this study was to determine factors associated with FC in curative-intent treatment of pancreatic cancer (PDAC) patients and evaluate how FC affects survival outcomes. METHODS Using the National Cancer Database (NCDB), data on stage I-III PDAC patients diagnosed 2006-2016 were extracted. Multiple logistic regression analyses were performed to identify factors predictive of FC and survival. RESULTS Of the 20,013 patients identified, 24.1% had FC. Factors predictive of FC were stage-III tumors (odds ratio [OR] 1.36; p = 0.014), higher median-income [third quartile (OR 1.38; p = 0.006) and highest-quartile (OR 1.50; p = 0.003)], care at high-volume facility (OR 1.47; p < 0.001), and receipt of multi-modal therapy (OR 1.69; p < 0.001). In contrast, age > 80 years (OR 0.82; p = 0.018), Black (OR 0.85; p = 0.013) or Asian race (OR 0.76; p = 0.033), Charlson comorbidity-index 2 (OR 0.85; p = 0.033), treatment at non-academic facility (OR 0.87; p = 0.041), and non-private insurance were negatively predictive of FC. FC independently predicted decreased 30-day [OR 0.57; p < 0.001] and 90-day mortality [OR 0.61; p < 0.001] and improved overall survival [hazard ratio 0.91; p < 0.001]. DISCUSSION Sociodemographic factors are significantly associated with FC in curative-intent treatment of PDAC patients. FC was found to predict improved 30-day, 90-day, and overall survival outcomes.
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Greenberg JA, Thiesmeyer JW, Egan CE, Lee YJ, Sivarajah M, Zarnegar R, Fahey TJ, Beninato T, Finnerty BM. Care Fragmentation in Patients with Differentiated Thyroid Cancer. World J Surg 2022; 46:3007-3016. [PMID: 36038731 DOI: 10.1007/s00268-022-06712-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Among surgical patients, care fragmentation (CF) is associated with worse outcomes. However, oncologic literature documents an association between high surgical volume and improved outcomes, favoring centralized cancer-surgery centers and thus predisposing to CF in patients with surgically treated tumors. We aimed to identify features associated with CF and ascertain differences in overall survival (OS) among patients with differentiated thyroid cancer (DTC). METHODS The National Cancer Database was queried for DTC patients diagnosed from 2009 to 2017. Patients experienced CF if part of their treatment was performed outside of the reporting facility or an associated office. A multivariable logistic regression analysis identified independent features associated with CF. A Cox multivariable regression analysis assessed the impact of CF on OS. A Kaplan-Meier analysis compared survival differences between patients experiencing CF or unified care (UC). RESULTS A total of 131,620 patients were included. Among them, 70,204 (53.3%) experienced CF and 61,416 (46.7%) experienced UC. Age < 55, residing in high-income areas, and stage 3 and 4 tumors were features independently associated with CF, whereas uninsured patients were less likely to experience CF than the privately insured. The features most strongly associated with CF were treatment at highest thyroid cancer-surgery volume institutions and traveling in the top distance quartile. While patients with CF experienced minor delays in time from diagnosis to surgery, 5-year OS was improved among patients with CF compared to UC for those with Stage 1-3 disease. CONCLUSIONS Among patients with DTC, CF is associated with treatment at a highest thyroid cancer surgery volume facility and improved OS in a setting of minor treatment delays.
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Affiliation(s)
- Jacques A Greenberg
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, F-838, 1300 York Avenue, New York, NY, 10065, USA
| | - Jessica W Thiesmeyer
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, F-838, 1300 York Avenue, New York, NY, 10065, USA
| | - Caitlin E Egan
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, F-838, 1300 York Avenue, New York, NY, 10065, USA
| | - Yeon Joo Lee
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, F-838, 1300 York Avenue, New York, NY, 10065, USA
| | - Maheshwaran Sivarajah
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, F-838, 1300 York Avenue, New York, NY, 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, F-838, 1300 York Avenue, New York, NY, 10065, USA
| | - Thomas J Fahey
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, F-838, 1300 York Avenue, New York, NY, 10065, USA
| | - Toni Beninato
- Department of Surgery, Rutgers-Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, New Brunswick, NJ, 08903, USA
| | - Brendan M Finnerty
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, F-838, 1300 York Avenue, New York, NY, 10065, USA.
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Trivedi PS, Guerra B, Kumar V, Akinwande G, West D, Abi-Jaoudeh N, Salazar G, Rochon P. Healthcare Disparities in Interventional Radiology. J Vasc Interv Radiol 2022; 33:1459-1467.e1. [PMID: 36058539 DOI: 10.1016/j.jvir.2022.08.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/08/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022] Open
Abstract
Racial, ethnic, and sex-based healthcare disparities have been documented for the past several decades. Nonetheless, disparities remain firmly entrenched in our care delivery systems, with multiple contributing factors, including patient interactions with care providers, systemic barriers to access, and socioeconomic determinants of health. Interventional radiology is also subject to these drivers of health inequity. In this review, documented disparities for the most common conditions being addressed by interventional radiologists are summarized; their magnitude is quantified where relevant, and underlying drivers are identified. Specific examples are provided to illustrate how medical, cultural, and socioeconomic factors interact to produce unequal outcomes. By outlining known disparities and common contributors, this review aims to motivate future efforts to mitigate them.
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Affiliation(s)
- Premal S Trivedi
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Bernardo Guerra
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Vishal Kumar
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Goke Akinwande
- Midwest Institute for Non-Surgical Therapy, St. Louis, Missouri
| | - Derek West
- Department of Radiology, Emory School of Medicine, Atlanta, Georgia
| | - Nadine Abi-Jaoudeh
- Department of Radiology, University of California Irvine, Irvine, California
| | - Gloria Salazar
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina
| | - Paul Rochon
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Powell BL, Jones A, Clancy T, Fairweather M, Wang J, Molina G. Association of Liver Resection and Visiting More Than One Commission on Cancer Hospital for CRLM. J Surg Res 2022; 279:247-255. [DOI: 10.1016/j.jss.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/17/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022]
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Crispo A, Rivieccio G, Cataldo L, Coluccia S, Luongo A, Coppola E, Grimaldi M, Montagnese C, Nocerino F, Celentano E, Saviano R, Bastone A, Baglio G, De Angelis C, Ciardiello F, Avallone A, Cassata A, Costanzo R, Morabito A, Maione P, Gridelli C, Cigolari S, Borrelli A, De Placido S, Schiavone F, Bianchi AAM, Pignata S, Aquino A, Bonito C, Buonerba C, Caccavallo F, Carlomagno C, Cavaliere M, Centonze S, Damiano S, De Divitiis C, De Nardo R, Del Deo Vito A, D'Errico D, Esposito G, Esposito L, Famiglietti V, Formisano L, Formisano L, Franzese E, Gaeta V, Gragnano E, Grimaldi R, Iovane G, Lauria R, Migliore G, Mirto M, Napoletano A, Napoli D, Vitale P, Pepe S, Rambaldo MP, Renato M, Rescigno M, Rossi E, Santabarbara G, Stanzione C. New approach to implement cancer patient care: The valutazione percorso rete oncologica campana (ValPeROC)‐experience from an Italian oncology network. Eur J Cancer Care (Engl) 2022; 31:e13736. [PMID: 37039607 DOI: 10.1111/ecc.13736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 09/12/2022] [Accepted: 09/27/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The primary goal of the Campania Oncology Network (ROC) was to reduce cancer delay and care fragmentation through the establishment of cancer-specific multidisciplinary oncologic groups (GOMs) and diagnostic and therapeutic assistance paths (PDTAs). METHODS Five cancer centres of the ROC, with their own cancer specific GOM, were selected. In our analysis, we have focused on four neoplasms: lung, colon, ovarian and prostate cancers. The median time for pre-GOM and GOM Times was calculated for each tumour site. Univariate and multivariate logistic regressions were performed to individuate risk factors for pre-GOM and GOM Time. RESULTS Significant differences were observed for prostate cancer compared to other patients either for pre-GOM or GOM Times. Significant risks were found for ovarian and prostate cancers in pre-GOM time and for prostate cancer in GOM-Time. CONCLUSIONS This experience will produce knowledge and data to guide decision-making and to manage more effectively the challenges of fighting cancer in Campania region. The Valutazione Percorso Rete Oncologica Campana (ValPeROC) study evaluates, for the first time, the ROC activity, through the analysis of key performance indices. Pre-GOM and GOM Time represent the quality of the entire regional health system and are useful to define models, which can evaluate the performance of the ROC over time.
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Affiliation(s)
- Anna Crispo
- Epidemiology and Biostatistics Unit Istituto Nazionale Tumori IRCCS 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Giorgia Rivieccio
- Department of Managerial Studies and Quantitative Methods University of Naples Parthenope Faculty of Economics Naples Italy
| | - Luca Cataldo
- Department of Managerial Studies and Quantitative Methods University of Naples Parthenope Faculty of Economics Naples Italy
| | - Sergio Coluccia
- Epidemiology and Biostatistics Unit Istituto Nazionale Tumori IRCCS 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Assunta Luongo
- Epidemiology and Biostatistics Unit Istituto Nazionale Tumori IRCCS 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Elisabetta Coppola
- Department of Urology and Gynecology Istituto Nazionale Tumori IRCCS ‘Fondazione G. Pascale’ Naples Italy
| | - Maria Grimaldi
- Epidemiology and Biostatistics Unit Istituto Nazionale Tumori IRCCS 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Concetta Montagnese
- Epidemiology and Biostatistics Unit Istituto Nazionale Tumori IRCCS 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Flavia Nocerino
- Epidemiology and Biostatistics Unit Istituto Nazionale Tumori IRCCS 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Egidio Celentano
- Epidemiology and Biostatistics Unit Istituto Nazionale Tumori IRCCS 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Rocco Saviano
- National Cancer Institute IRCCS Pascale Foundation Naples Italy
| | - Anna Bastone
- Department of Managerial Studies and Quantitative Methods University of Naples Parthenope Faculty of Economics Naples Italy
| | - Giovanni Baglio
- AGENAS ‐ Italian National Agency for Regional Healthcare Services Rome Italy
| | - Carmine De Angelis
- Department of Clinical Medicine and Surgery University of Naples Federico II Naples Italy
| | - Fortunato Ciardiello
- Oncologia Medica, Dipartimento di Medicina di Precisione Università degli Studi della Campania ‘L. Vanvitelli’ Naples Italy
| | - Antonio Avallone
- Experimental Clinical Abdominal Oncology Unit Istituto Nazionale Tumori 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Antonino Cassata
- Medical Oncology Unit Istituto Nazionale Tumori 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Raffaele Costanzo
- Thoracic Department Istituto Nazionale Tumori 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Alessandro Morabito
- Thoracic Department Istituto Nazionale Tumori 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Paolo Maione
- Division of Medical Oncology S.G. Moscati Hospital Avellino Italy
| | - Cesare Gridelli
- Division of Medical Oncology S.G. Moscati Hospital Avellino Italy
| | - Silvio Cigolari
- Hospital Health Direction Azienda Ospedaliera Universitaria ‘San Giovanni di Dio e Ruggi d'Aragona’ Salerno Italy
| | - Anna Borrelli
- Hospital Health Direction Azienda Ospedaliera Universitaria ‘San Giovanni di Dio e Ruggi d'Aragona’ Salerno Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery University of Naples Federico II Naples Italy
| | - Francesco Schiavone
- Department of Managerial Studies and Quantitative Methods University of Naples Parthenope Faculty of Economics Naples Italy
| | - Attilio A. M. Bianchi
- Directorate‐General for Management Istituto Nazionale Tumori 'Fondazione G. Pascale', Naples, Italy Naples Italy
| | - Sandro Pignata
- Department of Urology and Gynecology Istituto Nazionale Tumori IRCCS ‘Fondazione G. Pascale’ Naples Italy
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Rhodin KE, Raman V, Eckhoff A, Liu A, Creasy J, Nussbaum DP, Blazer DG. Patterns and Impact of Fragmented Care in Stage II and III Gastric Cancer. Ann Surg Oncol 2022; 29:5422-5431. [PMID: 35723791 PMCID: PMC9378672 DOI: 10.1245/s10434-022-12031-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal management of stage II/III gastric cancer requires multidisciplinary care, often necessitating treatment at more than one facility. We aimed to determine patterns of "fragmented" care and its impact on outcomes, including concordance with National Comprehensive Cancer Network (NCCN) guidelines and overall survival. METHODS The 2006-2016 National Cancer Database was queried for patients with clinical stage II/III gastric adenocarcinoma who received preoperative therapy in addition to surgery. Patients were stratified based on whether surgery and chemotherapy/chemoradiation were performed at one versus multiple facilities (termed "coordinated" and "fragmented" care, respectively). Multivariable logistic regression was performed to identify factors associated with fragmented care. Survival was compared using Kaplan-Meier and Cox proportional hazards methods. RESULTS Overall, 2033 patients met study criteria: 1043 (51.3%) received coordinated care and 990 (48.7%) fragmented care. There was no significant difference in time to surgery or pathologic upstaging by care structure. On adjusted analysis, factors associated with receipt of fragmented care included increasing age and distance traveled to the treating facility. Factors associated with coordinated care included metropolitan residence and treatment at academic and high-volume centers. Fragmented care was associated with a reduction in guideline-preferred perioperative chemotherapy (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.63-0.97, p = 0.02) and increased mortality (HR 1.16, 95% CI 1.00-1.34, p = 0.05). CONCLUSIONS For patients with stage II/III gastric cancer, fragmented care is associated with inferior outcomes, including a reduction in preferred perioperative treatment and survival. Further work is needed to ensure equitable outcomes among patients as complex cancer care becomes more regionalized.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Austin Eckhoff
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Annie Liu
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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24
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Rhodin KE, Nussbaum DP, Blazer DG. ASO Author Reflections: Care Fragmentation in an Era of Centralization. Ann Surg Oncol 2022; 29:5432-5433. [PMID: 35764834 DOI: 10.1245/s10434-022-12071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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25
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Choi DW, Kim S, Kim DW, Han KT. Fragmentation of care and colorectal cancer survival in South Korea: comparisons according to treatment at multiple hospitals. J Cancer Res Clin Oncol 2022; 148:2323-2333. [PMID: 35522291 DOI: 10.1007/s00432-022-04035-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Fragmented cancer care (FC) means that patients visit multiple providers for treatment, which is common in cancer care. While FC is associated with poor health outcomes in patients with colorectal cancer (CRC) worldwide, there is still a lack of evidence in South Korea. We investigated the association between FC and 5-year morality in patients with CRC using population-based claims data. METHODS The study population was followed up from 2002 to 2015. Data were collected from Korea National Health Insurance claims. Participants comprised patients with CRC diagnosed with International Classification of Diseases (ICD)-10 (C18.x-C20.x) and a special claim code for cancer (V193). Data were analyzed using the Kaplan-Meier curve with a log-rank test and Cox proportional hazard model. The effect of FC on patients' 5-year survival was examined. RESULTS Of 3467 patients with CRC, 20.0% had experienced FC. FC was significantly associated with an increased risk of 5-year mortality (hazard ratio 1.516, 95% confidence interval 1.274-1.804). FC was prevalent in those who had a low income level, underwent chemotherapy, did not undergo radiation therapy, and did not visit a tertiary hospital for their first treatment. CONCLUSION Efforts to decrease FC and integrate complex cancer care within appropriate healthcare delivery systems may improve survivorship among patients with CRC.
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Affiliation(s)
- Dong-Woo Choi
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Gyeonggi-do, 10408, Republic of Korea
| | - Seungju Kim
- Department of Nursing, College of Nursing, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Dong Wook Kim
- Department of Information and Statistics. RINS, Gyeongsang National University, 501, Jinju-daero, Jinju, Gyeongsangnam-do, 52828, Republic of Korea
| | - Kyu-Tae Han
- Division of Cancer Control & Policy, National Cancer Control Institute, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, Gyeonggi-do, 10408, Republic of Korea.
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Han KT, Chang J, Choi DW, Kim S, Kim DJ, Chang YJ, Kim SJ. Association of institutional transition of cancer care with mortality in elderly patients with lung cancer: a retrospective cohort study using national claim data. BMC Cancer 2022; 22:452. [PMID: 35468762 PMCID: PMC9040246 DOI: 10.1186/s12885-022-09590-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although survival based outcomes of lung cancer patients have been well developed, institutional transition of cancer care, that is, when patients transfer from primary visiting hospitals to other hospitals, and mortality have not yet been explored using a large-scale representative population-based sample. Methods Data from the Korean National Elderly Sampled Cohort survey were used to identify patients with lung cancer who were diagnosed during 2005–2013 and followed up with for at least 1 year after diagnosis (3738 patients with lung cancer aged over 60 years). First, the authors examined the distribution of the study population by mortality, and Kaplan-Meier survival curves/log-rank test were used to compare mortality based on institutional transition of cancer care. Survival analysis using the Cox proportional hazard model was conducted after controlling for all other variables. Results Results showed that 1-year mortality was higher in patients who underwent institutional transition of cancer care during 30 days after diagnosis (44.2% vs. 39.7%, p = .027); however, this was not associated with 5-year mortality. The Cox proportional hazard model showed that patients who underwent institutional transition of cancer care during 30 days after diagnosis exhibited statistically significant associations with high mortality for 1 year and 5 years (1-year mortality, Hazard ratio [HR]: 1.279, p = .001; 5-year mortality, HR: 1.158, p = .002). Conclusion This study found that institutional transition of cancer care was associated with higher mortality among elderly patients with lung cancer. Future consideration should also be given to the limitation of patients’ choice when opting for institutional transition of care since there are currently no control mechanisms in this regard. Results of this study merit health policymakers’ attention.
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Affiliation(s)
- Kyu-Tae Han
- Division of Cancer Control & Policy, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Jongwha Chang
- Department of Healthcare Administration, College of Business, Texas Woman's University, Denton, TX, USA
| | - Dong-Woo Choi
- Cancer Big Data Center, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Seungju Kim
- Department of Nursing, College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Jun Kim
- Division of Cancer Control & Policy, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Yoon-Jung Chang
- Division of Cancer Control & Policy, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration and Management, College of Medical Science, Soonchunhyang University, 22 Soonchunhyang-ro, Asan, 31538, Republic of Korea. .,Center for Healthcare Management Science, Soonchunhyang University, Asan, Republic of Korea. .,Department of Software Convergence, Soonchunhyang University, Asan, Republic of Korea.
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Cardio-Oncology Care Delivered in the Non-academic Environment. Curr Treat Options Oncol 2022; 23:762-773. [DOI: 10.1007/s11864-022-00978-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
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28
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Brown ZJ, Labiner HE, Shen C, Ejaz A, Pawlik TM, Cloyd JM. Impact of care fragmentation on the outcomes of patients receiving neoadjuvant and adjuvant therapy for pancreatic adenocarcinoma. J Surg Oncol 2022; 125:185-193. [PMID: 34599756 PMCID: PMC9113396 DOI: 10.1002/jso.26706] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/25/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Neoadjuvant therapy (NT) is increasingly used for localized pancreatic ductal adenocarcinoma (PDAC). The impact of care fragmentation during NT on the outcomes of patients with PDAC is unknown. METHODS Adult patients with Stage I-III PDAC who received NT and patients who underwent surgery first followed by adjuvant therapy (AT) between 2004 and 2016 were queried from the National Cancer Database. Short- and long-term outcomes were compared between patients who received fragmented care (FC; care provided at >1 hospital) versus integrated care (IC; care at a single institution). RESULTS Among 6522 patients who underwent NT before pancreatectomy, 3755 (57.6%) received FC and 2767 (42.4%) received IC. While patients who received FC had a longer time to initiation of treatment (33.2 vs. 29.7 days, p < 0.001), there was no difference in median overall survival (OS) (26.7 vs. 26.5 months, p = 0.6). Among patients who underwent upfront surgery followed by AT (n = 15 291), patients who received FC had a longer time from diagnosis to undergoing surgery but less time from surgery to AT and no difference in OS (24.0 vs. 24.0 months, p = 0.910). CONCLUSION Although care fragmentation was associated with slightly longer times to initiate and complete treatment among patients with localized PDAC, long-term survival outcomes were similar.
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Affiliation(s)
- Zachary J. Brown
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Hanna E. Labiner
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Chengli Shen
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Jordan M. Cloyd
- Division of Surgical Oncology, Department of Surgery The Ohio State University Wexner Medical Center Columbus Ohio USA
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Bouchard-Fortier G, Gien LT, Sutradhar R, Chan WC, Krzyzanowska MK, Liu S(L, Ferguson SE. Impact of care by gynecologic oncologists on primary ovarian cancer survival: A population-based study. Gynecol Oncol 2022; 164:522-528. [DOI: 10.1016/j.ygyno.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/16/2021] [Accepted: 01/03/2022] [Indexed: 11/04/2022]
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30
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Ohta R, Ueno A, Sano C. Changes in the Comprehensiveness of Rural Medical Care for Older Japanese Patients during the COVID-19 Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182010772. [PMID: 34682516 PMCID: PMC8535374 DOI: 10.3390/ijerph182010772] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 12/11/2022]
Abstract
Help-seeking behaviors (HSBs) refer to how people use lay and medical care to address their symptoms and diseases. The COVID-19 pandemic may have changed older, rural patients’ preferences and experiences regarding HSBs, thereby, affecting the comprehensiveness of medical support for communities. This study identified changes in the comprehensiveness of medical care for older, rural patients, who are often dependent on others for accessing medical services. This observational study was performed with patients who lived in Unnan City. Patients’ dependency and changes in comprehensiveness of medical services were assessed and calculated. The total usage of medical care decreased from 2018 to 2020 at all medical care levels. The proportion of patients who received comprehensive care was higher in 2020 than in 2018, at all care levels. At care dependent levels 3 to 5, the differences in the proportions were statistically significant. This study illustrates an association between the COVID-19 pandemic and the proportion of comprehensiveness of medical care among older rural patients with a decrease in medical care usage. Moreover, an improved proportion of comprehensiveness of medical care leads to appropriate HSBs. Going forward, HSBs and patient-centered care should be promoted by policy makers.
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Affiliation(s)
- Ryuichi Ohta
- Community Care, Unnan City Hospital, Daito-cho Iida, Unnan 699-1221, Japan
- Correspondence: ; Tel.: +81-9050605330
| | - Akinori Ueno
- Unnan Public Health Center, Unnan 699-1311, Japan;
| | - Chiaki Sano
- Department of Community Medicine Management, Faculty of Medicine, Shimane University, Enya-cho, Izumo 693-8501, Japan;
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31
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Doose M, Sanchez JI, Cantor JC, Plascak JJ, Steinberg MB, Hong CC, Demissie K, Bandera EV, Tsui J. Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems. JCO Oncol Pract 2021; 17:e637-e644. [PMID: 33974834 DOI: 10.1200/op.20.01089] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation. MATERIALS AND METHODS We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation. RESULTS Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer-accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation (P > .05). CONCLUSION The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.
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Affiliation(s)
- Michelle Doose
- Helthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD.,Rutgers School of Public Health, Piscataway, NJ.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Janeth I Sanchez
- Helthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Joel C Cantor
- Rutgers Center for State Health Policy, New Brunswick, NJ.,Rutgers Edward J. Bloustein School of Planning and Public Policy, New Brunswick, NJ
| | | | | | - Chi-Chen Hong
- University at Buffalo, Buffalo, NY.,Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Elisa V Bandera
- Rutgers School of Public Health, Piscataway, NJ.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Jennifer Tsui
- Rutgers Center for State Health Policy, New Brunswick, NJ.,Keck School of Medicine, University of Southern California, Los Angeles, CA
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Yan J, Hester CA, Zhu H, Yan J, Augustine MM, Porembka MR, Wang SC, Mansour JC, Iii HJZ, Yopp AC, Polanco PM. Treatment and Survival Disparities of Colon Cancer in the Texas-Mexico Border Population: Cancer Disparities in Border Population. J Surg Res 2021; 267:432-442. [PMID: 34237628 DOI: 10.1016/j.jss.2021.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/12/2021] [Accepted: 05/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Previous studies have reported healthcare disparities in the Texas-Mexico border population. Our aim was to evaluate treatment utilization and oncologic outcomes of colon cancer patients in this vulnerable population. METHODS Patients with localized and regional colon cancer (CC) were identified in the Texas Cancer Registry (1995-2016). Clinicopathological data, hospital factors, receipt of optimal treatment, and overall survival (OS) were compared between Texas-Mexico Border (TMB) and the Non-Texas-Mexico Border (NTMB) cohorts. Multivariable analysis was performed to identify risk factors associated with decreased survival. RESULTS We identified 43,557 patients with localized/regional CC (9% TMB and 91% NTMB). TMB patients were more likely to be Hispanic (73% versus 13%), less likely to have private insurance (13% versus 21%), were more often treated at safety net hospitals (82% versus 22%) and less likely at ACS-CoC accredited hospitals (32% versus 57%). TMB patients were more likely to receive suboptimal treatment (21% versus 16%) and had a lower median OS for localized (8.58 versus 9.58 y) and regional colon cancer (5.75 versus 6.18 y, all P < 0.001). In multivariable analysis, TMB status was not associated with worse OS. Factors associated with worse survival included receipt of suboptimal treatment, Medicare/insured status, and treatment in safety net and non-accredited ACS-CoC hospitals (all P < 0.001) CONCLUSIONS: While TMB CC patients had worse OS, TMB status itself was not found to be a risk factor for decreased survival. This survival disparity is likely associated with higher rate of suboptimal treatment, Medicare/Uninsured status, and decreased access to ACS-CoC accredited hospitals.
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Affiliation(s)
- Justin Yan
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Caitlin A Hester
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Hong Zhu
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jingsheng Yan
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew M Augustine
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sam C Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John C Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Herbert J Zeh Iii
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
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33
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Cham S, Huang Y, Melamed A, Worley MJ, Hou JY, Tergas AI, Khoury-Collado F, Gockley A, Clair CMST, Hershman DL, Wright JD. Fragmentation of surgery and chemotherapy in the initial phase of ovarian cancer care and its association with overall survival. Gynecol Oncol 2021; 162:56-64. [PMID: 33965245 DOI: 10.1016/j.ygyno.2021.04.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Fragmentation occurs when a patient receives care at more than one hospital, and the long-term effects in ovarian cancer are unknown. We examined the association between fragmentation of primary debulking surgery (PDS) and adjuvant chemotherapy (AC) and overall survival (OS). METHODS The National Cancer Database was used to identify women with stage II-IV epithelial ovarian cancer between 2004 and 2016 who underwent PDS followed by AC. Fragmentation was defined as receipt of AC at a different institution than where PDS was performed. After propensity score weighting, proportional hazard models were developed to estimate the association between fragmented care and OS. RESULTS Of the 36,300 patients identified, 13,347 (36.8%) had fragmented care. Patient factors associated with fragmentation included older age, higher income, and longer travel distance for PDS; hospital factors included PDS performed at a community center or a facility with lower annual surgical volume (P < 0.05, all). Fragmentation was associated with a 15% risk of 30-day delay to AC (aRR 1.15, 95% CI 1.09-1.22). In a propensity scoring weighted analysis, mortality was reduced when AC was fragmented (HR 0.95, 95% CI 0.92-0.97). Sensitivity analyses indicated fragmentation was associated with improved survival in metropolitan residents. Stratified analyses indicated patients who traveled 50 miles or more with PDS and AC at the same institution had the worst OS. CONCLUSION Fragmentation of PDS and AC has no adverse effects on long-term survival. Survival outcomes were worst for those who received care at the same institution 50 miles or more away.
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Affiliation(s)
- Stephanie Cham
- Division of Gynecologic Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, United States of America
| | - Yongmei Huang
- Columbia University Vagelos College of Physicians and Surgeons, United States of America
| | - Alexander Melamed
- Columbia University Vagelos College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Michael J Worley
- Division of Gynecologic Oncology, Brigham and Women's Hospital/Dana Farber Cancer Institute, United States of America
| | - June Y Hou
- Columbia University Vagelos College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Ana I Tergas
- Columbia University Vagelos College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Fady Khoury-Collado
- Columbia University Vagelos College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Allison Gockley
- Columbia University Vagelos College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Caryn M S T Clair
- Columbia University Vagelos College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America
| | - Dawn L Hershman
- Columbia University Vagelos College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; Joseph L. Mailman School of Public Health, United States of America
| | - Jason D Wright
- Columbia University Vagelos College of Physicians and Surgeons, United States of America; New York Presbyterian Hospital, United States of America; Herbert Irving Comprehensive Cancer Center, United States of America; Joseph L. Mailman School of Public Health, United States of America.
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Brauer DG, Wu N, Keller MR, Humble SA, Fields RC, Hammill CW, Hawkins WG, Colditz GA, Sanford DE. Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database. J Am Coll Surg 2021; 232:921-932.e12. [PMID: 33865977 DOI: 10.1016/j.jamcollsurg.2021.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/19/2021] [Accepted: 03/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatopancreatobiliary (HPB) and gastric oncologic operations are frequently performed at referral centers. Postoperatively, many patients experience care fragmentation, including readmission to "outside hospitals" (OSH), which is associated with increased mortality. Little is known about patient-level and hospital-level variables associated with this mortality difference. STUDY DESIGN Patients undergoing HPB or gastric oncologic surgery were identified from select states within the Healthcare Cost and Utilization Project database (2006-2014). Follow-up was 90 days after discharge. Analyses used Kruskal-Wallis test, Youden index, and multilevel modeling at the hospital level. RESULTS There were 7,536 patients readmitted within 90 days of HPB or gastric oncologic surgery to 636 hospitals; 28% of readmissions (n = 2,123) were to an OSH, where 90-day readmission mortality was significantly higher: 8.0% vs 5.4% (p < 0.01). Patients readmitted to an OSH lived farther from the index surgical hospital (median 24 miles vs 10 miles; p < 0.01) and were readmitted later (median 25 days after discharge vs 12; p < 0.01). These variables were not associated with readmission mortality. Surgical complications managed at an OSH were associated with greater readmission mortality: 8.4% vs 5.7% (p < 0.01). Hospitals with <100 annual HPB and gastric operations for benign or malignant indications had higher readmission mortality (6.4% vs 4.7%, p = 0.01), although this was not significant after risk-adjustment (p = 0.226). CONCLUSIONS For readmissions after HPB and gastric oncologic surgery, travel distance and timing are major determinants of care fragmentation. However, these variables are not associated with mortality, nor is annual hospital surgical volume after risk-adjustment. This information could be used to determine safe sites of care for readmissions after HPB and gastric surgery. Further analysis is needed to explore the relationship between complications, the site of care, and readmission mortality.
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Affiliation(s)
- David G Brauer
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO.
| | - Ningying Wu
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew R Keller
- Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Sarah A Humble
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Chet W Hammill
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - William G Hawkins
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Graham A Colditz
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Dominic E Sanford
- Department of Surgery, Washington University School of Medicine, Saint Louis, MO
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Yang DX, Khera R, Miccio JA, Jairam V, Chang E, Yu JB, Park HS, Krumholz HM, Aneja S. Prevalence of Missing Data in the National Cancer Database and Association With Overall Survival. JAMA Netw Open 2021; 4:e211793. [PMID: 33755165 PMCID: PMC7988369 DOI: 10.1001/jamanetworkopen.2021.1793] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Cancer registries are important real-world data sources consisting of data abstraction from the medical record; however, patients with unknown or missing data are underrepresented in studies that use such data sources. OBJECTIVE To assess the prevalence of missing data and its association with overall survival among patients with cancer. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, all variables within the National Cancer Database were reviewed for missing or unknown values for patients with the 3 most common cancers in the US who received diagnoses from January 1, 2006, to December 31, 2015. The prevalence of patient records with missing data and the association with overall survival were assessed. Data analysis was performed from February to August 2020. EXPOSURES Any missing data field within a patient record among 63 variables of interest from more than 130 total variables in the National Cancer Database. MAIN OUTCOMES AND MEASURES Prevalence of missing data in the medical records of patients with cancer and associated 2-year overall survival. RESULTS A total of 1 198 749 patients with non-small cell lung cancer (mean [SD] age, 68.5 [10.9] years; 628 811 men [52.5%]), 2 120 775 patients with breast cancer (mean [SD] age, 61.0 [13.3] years; 2 101 758 women [99.1%]), and 1 158 635 patients with prostate cancer (mean [SD] age, 65.2 [9.0] years; 100% men) were included in the analysis. Among those with non-small cell lung cancer, 851 295 patients (71.0%) were missing data for variables of interest; 2-year overall survival was 33.2% for patients with missing data and 51.6% for patients with complete data (P < .001). Among those with breast cancer, 1 161 096 patients (54.7%) were missing data for variables of interest; 2-year overall survival was 93.2% for patients with missing data and 93.9% for patients with complete data (P < .001). Among those with prostate cancer, 460 167 patients (39.7%) were missing data for variables of interest; 2-year overall survival was 91.0% for patients with missing data and 95.6% for patients with complete data (P < .001). CONCLUSIONS AND RELEVANCE This study found that within a large cancer registry-based real-world data source, there was a high prevalence of missing data that were unable to be ascertained from the medical record. The prevalence of missing data among patients with cancer was associated with heterogeneous differences in overall survival. Improvements in documentation and data quality are necessary to make optimal use of real-world data for clinical advancements.
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Affiliation(s)
- Daniel X. Yang
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Rohan Khera
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Joseph A. Miccio
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Vikram Jairam
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Enoch Chang
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - James B. Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Henry S. Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M. Krumholz
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Sanjay Aneja
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
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Ajayi F, Jan J, Singal AG, Rich NE. Racial and Sex Disparities in Hepatocellular Carcinoma in the USA. CURRENT HEPATOLOGY REPORTS 2020; 19:462-469. [PMID: 33828937 PMCID: PMC8020839 DOI: 10.1007/s11901-020-00554-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In this review, we aim to provide a summary of the current literature on race and gender disparities in hepatocellular carcinoma (HCC) incidence, stage at diagnosis, treatment and prognosis in the United States. RECENT FINDINGS HCC incidence rates are rising in the U.S. in all racial/ethnic groups except for Asian/Pacific Islanders, with disproportionate rises and the highest rates among Hispanics compared to Blacks and non-Hispanic whites. There are striking sex disparities in HCC incidence and mortality; however, with the shifting epidemiology of HCC risk factors in the U.S, there is recent evidence that HCC is trending towards less male predominance, particularly among younger birth cohorts. Despite significant advances in HCC treatment over the past decade, disparities in HCC surveillance and treatment receipt persist among racial and ethnic minorities and the socioeconomically disadvantaged. Black patients continue to experience worse survival outcomes than non-Black patients with HCC. SUMMARY There are significant racial and gender disparities in HCC incidence, treatment, and mortality in the U.S. Though these disparities are well-documented, data are still limited on the specific determinants driving disparities in HCC. To achieve health equity for all patients with HCC, we must advance beyond simply reporting on disparities and begin implementing targeted interventions to eliminate disparities.
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Affiliation(s)
- Faith Ajayi
- Division of Digestive and Liver Diseases, Department of Internal Medicine
| | - Jenny Jan
- Division of Digestive and Liver Diseases, Department of Internal Medicine
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine
- Harold C. Simmons Comprehensive Cancer Center
- Department of Population and Data Sciences, UT Southwestern Medical Center
| | - Nicole E. Rich
- Division of Digestive and Liver Diseases, Department of Internal Medicine
- Harold C. Simmons Comprehensive Cancer Center
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Understanding Gaps in the Hepatocellular Carcinoma Cascade of Care: Opportunities to Improve Hepatocellular Carcinoma Outcomes. J Clin Gastroenterol 2020; 54:850-856. [PMID: 33030855 DOI: 10.1097/mcg.0000000000001422] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality. Existing studies have highlighted significant disparities in HCC outcomes, particularly among vulnerable populations, including ethnic minorities, safety-net populations, underinsured patients, and those with low socioeconomic status and high risk behaviors. The majority of these studies have focused on HCC surveillance. Although HCC surveillance is one of the most important first steps in HCC monitoring and management, it is only one step in the complex HCC cascade of care that evolves from surveillance to diagnosis and tumor staging that leads to access to HCC therapies. In this current review, we explore the disparities that exist along this complex HCC cascade of care and further highlight potential interventions that have been implemented to improve HCC outcomes. These interventions focus on patient, provider, and system level factors and provide a potential framework for health systems to implement quality improvement initiatives to improve HCC monitoring and management.
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Abelson JS, Bauer PS, Barron J, Bommireddy A, Chapman WC, Schad C, Ohman K, Hunt S, Mutch M, Silviera M. Fragmented Care in the Treatment of Rectal Cancer and Time to Definitive Therapy. J Am Coll Surg 2020; 232:27-33. [PMID: 33190785 DOI: 10.1016/j.jamcollsurg.2020.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/15/2020] [Accepted: 10/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The National Accreditation Program for Rectal Cancer (NAPRC) emphasizes a multidisciplinary approach for treating rectal cancer and has developed performance measures to ensure that patients receive standardized care. We hypothesized that rectal cancer patients receiving care at multiple centers would be less likely to receive timely and appropriate care. STUDY DESIGN A single institution retrospective review of a prospectively maintained database was performed. All patients undergoing proctectomy and ≤1 other treatment modality (eg radiation and/or chemotherapy) for Stage II/III rectal adenocarcinoma were included. Unified care was defined as receiving all modalities of care at our institution, and fragmented care was defined as having at least 1 treatment modality at another institution. RESULTS From 2009 to 2019, 415 patients met inclusion criteria, with 197 (47.5%) receiving fragmented care and 218 (52.5%) receiving unified care. The unified cohort patients were more likely to see a colorectal surgeon before starting treatment (89.0% vs 78.7%, p < 0.01) and start definitive treatment within 60 days of diagnosis (89.0% vs 79.7%, p = 0.01). On adjusted analysis, unified care patients were 2.78 times more likely to see a surgeon before starting treatment (95% CI 1.47-5.24) and 2.63 times more likely to start treatment within 60 days (95% CI 1.35-5.13). There was no difference in 90-day mortality or 5-year disease-free survival. CONCLUSIONS This retrospective cohort study suggests patients with rectal cancer receiving fragmented care are at an increased risk of delays in care without any impact on disease-free survival. These findings need to be considered within the context of ongoing regionalization of rectal cancer care to ensure all patients receive optimal care, irrespective of whether care is delivered across multiple institutions.
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Affiliation(s)
- Jonathan S Abelson
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO.
| | - Philip S Bauer
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - John Barron
- Saint Louis University School of Medicine, Saint Louis, MO
| | - Ani Bommireddy
- Saint Louis University School of Medicine, Saint Louis, MO
| | - William C Chapman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Christine Schad
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Kerri Ohman
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Steven Hunt
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Matthew Silviera
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, MO
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Cohen-Mekelburg S, Waljee AK, Kenney BC, Tapper EB. Coordination of Care Is Associated With Survival and Health Care Utilization in a Population-Based Study of Patients With Cirrhosis. Clin Gastroenterol Hepatol 2020; 18:2340-2348.e3. [PMID: 31927111 PMCID: PMC7875119 DOI: 10.1016/j.cgh.2019.12.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Improving care coordination for patients with high-intensity specialty care needs, such as cirrhosis, can increase quality of healthcare and reduce utilization. We examined the relationship between care concentration and risk of hospitalization for patients with cirrhosis. METHODS We performed a retrospective cohort study of 26,006 Medicare enrollees with cirrhosis with more than 4 outpatient visits over 180 days. We collected data on 2 validated measures of care concentration: the usual provider of care (UPC) index, a measure of the proportion of a patient's total visits that is with their most regularly seen provider, and the continuity of care (COC) index, a measure of care density and dispersion. Both use a scale of 0 to 1. Time to death or liver transplantation was evaluated using a multivariable Cox proportional hazards model. Hospital days and 30-day readmissions per person-year were evaluated in negative binomial models. RESULTS The median COC score was 0.40 (interquartile range, 0.26-0.60) and the median UPC was 0.60 (interquartile range, 0.50-0.80). Increasing care concentration (based on COC and UPC index scores) were associated with increased mortality and hospitalization. The highest 25th percentile of COC and UPC scores were associated with adjusted hazard ratios for mortality of 1.20 (95% CI, 1.10-1.31) and 1.14 (95% CI, 1.06-1.24), adjusted incidence rate ratios for hospital days of 1.12 (95% CI, 1.02-1.23) and 1.10 (95% CI, 1.01-1.20), and adjusted incidence rate ratios for readmissions of 1.19 (95% CI, 1.06-1.34) and 1.12 (95% CI, 1.00-1.25), respectively. CONCLUSIONS Based on a study of Medicare enrollees, care concentration is low among patients with cirrhosis. However, increased concentration is associated with increased mortality and increased healthcare utilization. These data indicate that, to optimize outcomes for persons with cirrhosis, team-based care might be necessary.
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Affiliation(s)
- Shirley Cohen-Mekelburg
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan; Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Akbar K. Waljee
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan;,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan;,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan;,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan;,Michigan Integrated Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor, Michigan
| | - Brooke C. Kenney
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Elliot B. Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan;,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan;,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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40
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Shannon AB, Mo J, Song Y, Paulson EC, Roses RE, Fraker DL, Kelz RR, Miura JT, Karakousis GC. Does multicenter care impact the outcomes of surgical patients with gastrointestinal malignancies requiring complex multimodality therapy? J Surg Oncol 2020; 122:729-738. [PMID: 32563196 DOI: 10.1002/jso.26075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/10/2020] [Indexed: 12/01/2023]
Abstract
BACKGROUND Regionalization of oncologic care has increased, but less is known whether patient outcomes are influenced by receipt of multimodality care through multicenter care (MCC) or single-center care (SCC). METHODS Patients from 2004 to 2015 National Cancer Data Base diagnosed with stage II-III esophageal (EA), stage II-III pancreatic (PA), and stage II-IV rectal (RA) adenocarcinoma who underwent resection at a high volume center (HVC) and required radiation and/or chemotherapy were included. MCC (care at 2+ facilities) and SCC patients were propensity-score matched 1:2 and Cox proportional hazards regression used to analyze survival. RESULTS On multivariable regression analysis, MCC in RA patients (N = 325/2097, 15.5%) was more associated with residing ≥40 miles from the HVC (odds ratio [OR] = 2.37; P = .044) and receipt of neoadjuvant chemotherapy (1.42, P = .040). In PA patients (N = 75/380, 19.7%), residing ≥40 miles from the HVC (OR = 3.22; P = .001), and in EA patients (N = 88/534, 16.5%), younger patients (<50 years: OR = 2.96; P = .011) were associated with MCC. Following propensity score matching, EA (N = 147), PA (N = 133), and RA (N = 661) patients had no difference in 1-year and 3-year overall survival when comparing MCC to SCC. CONCLUSIONS The use of MCC appears safe without a difference in survival and may offer significant advantages in convenience to patients as they undergo their complex oncologic care.
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Affiliation(s)
- Adrienne B Shannon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Mo
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yun Song
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily C Paulson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Miura
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Molina G, Clancy TE, Tsai TC, Lam M, Wang J. Racial Disparity in Pancreatoduodenectomy for Borderline Resectable Pancreatic Adenocarcinoma. Ann Surg Oncol 2020; 28:1088-1096. [PMID: 32651695 DOI: 10.1245/s10434-020-08717-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Previous studies have found racial disparity in pancreatectomies for resectable pancreatic adenocarcinoma. The aim of this study was to investigate if racial disparities were worse in the performance of pancreaticoduodenectomy for borderline resectable pancreatic adenocarcinoma. METHODS This study used the National Cancer Database (2004-2016) and included patients with non-metastatic and head of the pancreas borderline resectable pancreatic adenocarcinoma. Multivariable, Poisson regression models with robust standard errors evaluated the relative risk (RR) of undergoing a pancreaticoduodenectomy among non-White patients (Black, Asian, and non-White Hispanic) compared with White patients. A Poisson regression model with hospital fixed effects was performed to evaluate if findings were due to within-hospital or between-hospital variation. Interaction between race and neoadjuvant therapy was also evaluated. RESULTS There were 15,482 patients (median age 68 years, interquartile range 60-76 years; 48.6% male) with borderline resectable pancreatic adenocarcinoma who were predominantly White (84.3%, n = 13,058; non-White, 15.7%, n = 2424). Overall, 18.4% (n = 2853) had a pancreatic resection. Non-White patients had a significantly lower likelihood of undergoing a pancreatic resection for borderline resectable pancreatic adenocarcinoma when compared with White patients (RR 0.75, 95% confidence interval 0.68-0.83; p < 0.001). These findings persisted in the hospital fixed-effects model. In the interaction analysis, there were no significant differences in the likelihood of pancreatic resection if patients received neoadjuvant therapy. CONCLUSIONS Non-White patients were 25% less likely to undergo a pancreatic resection for borderline resectable pancreatic adenocarcinoma compared with White patients. This racial disparity was due to variation in care within-hospitals and disappeared if non-White patients were treated with neoadjuvant therapy.
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Affiliation(s)
- George Molina
- Division of Surgical Oncology, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Thomas E Clancy
- Division of Surgical Oncology, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Thomas C Tsai
- Division of General and Gastrointestinal Surgery, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Miranda Lam
- Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jiping Wang
- Division of Surgical Oncology, Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA. .,Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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Molina G, Qadan M. Addressing fragmentation of care requires strengthening of health systems and cross-institutional collaboration. Cancer 2019; 125:3296-3298. [PMID: 31299086 DOI: 10.1002/cncr.32337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 12/24/2022]
Affiliation(s)
- George Molina
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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