Creating a National Provider Identifier (NPI) to Unique Physician Identification Number (UPIN) Crosswalk for Medicare Data

Primary care physician continuity, survival, and end-of-life care intensity

OBJECTIVE

To examine the associations of primary care physician (PCP) care continuity with cancer-specific survival and end-of-life care intensity.

DATA SOURCES

Surveillance, epidemiology, and end results linked to Medicare claims data from 2001 to 2015.

STUDY DESIGN

Cox proportional hazards models with mixed effects and hierarchical generalized logistic models were used to examine the associations of PCP care continuity with cancer-specific survival and end-of-life care intensity, respectively. PCP care continuity, defined as having visited the predominant PCP (who saw the patient most frequently before diagnosis) within 6 months of diagnosis.

DATA EXTRACTION METHODS

We identified Medicare patients diagnosed at age 66.5-94 years with stage-III or IV poor-prognosis cancer during 2001-2012 and followed them up until 2015. Patients who died within 6 months after diagnosis were excluded.

PRINCIPAL FINDINGS

Primary study cohort consisted of 85,467 patients (median survival 22 months), 71.7% of whom had PCP care continuity. Patients with PCP care continuity tended to be older, married, nonblack, non-Hispanic, and to have fewer comorbid conditions (p < 0.001 for all). Patients with PCP care continuity had lower cancer-specific mortality (adjusted hazard ratio: 0.93; 95% confidence interval [CI]: 0.91 to 0.95; p = 0.001) than did those without PCP care continuity. Findings of the 2001-2003 cohorts (nearly all of whom died by 2015) show no associations of overall end-of-life care intensity measures with PCP care continuity (adjusted marginal effects: 0.005; 95% CI: -0.016 to 0.026; p = 0.264).

CONCLUSIONS

Among Medicare beneficiaries with advanced poor-prognosis cancer, PCP continuity was associated with modestly improved survival without raising overall aggressive end-of-life care.

A National Study to Compare Effective Management of Constipation in Children Receiving Concurrent Versus Standard Hospice Care

Constipation is a distressing and uncomfortable symptom children experience at end of life. There is a gap in knowledge about how different approaches to hospice care delivery might improve pediatric symptom management of constipation. The purpose of this study was to evaluate the effectiveness of pediatric concurrent hospice versus standard hospice care to manage constipation. Medicaid data (2011-2013) were analyzed. Children who were younger than 21 years enrolled in hospice care and had a hospice enrollment between January 1, 2011, and December 31, 2013, were included. Instrumental variable analysis was used to test the effectiveness of concurrent versus standard hospice care. Among the 18 152 children, approximately 14% of participants were diagnosed or treated for constipation from a nonhospice provider during hospice enrollment. A higher proportion of children received nonhospice care for constipation in concurrent hospice care, compared with standard hospice (19.5% vs 13.2%), although this was not significant (β = .22, P < .05) after adjusting for covariates. The findings demonstrated that concurrent care was no more effective than standard hospice care in managing pediatric constipation. Hospice and nonhospice providers may be doing a sufficient job ordering bowel regimens before constipation becomes a serious problem for children at end of life.

Impact of provider volume on front-line chemotherapy guideline compliance and overall survival in elderly patients with advanced ovarian cancer

PURPOSE

We sought to evaluate whether provider volume or other factors are associated with chemotherapy guideline compliance in elderly patients with epithelial ovarian cancer (EOC).

METHODS

We queried the SEER-Medicare database for patients ≥66 years, diagnosed with FIGO stage II-IV EOC from 2004 to 2013 who underwent surgery and received chemotherapy within 7 months of diagnosis. We compared NCCN guideline compliance (6 cycles of platinum-based doublet) and chemotherapy-related toxicities across provider volume tertiles. Factors associated with guideline compliance and chemotherapy-related toxicities were assessed using logistic regression. Overall survival (OS) was compared across volume tertiles and Cox proportional-hazards model was created to adjust for case-mix.

RESULTS

1924 patients met inclusion criteria. The overall rate of guideline compliance was 70.3% with a significant association between provider volume and compliance (64.5% for low-volume, 72.2% for medium-volume, 71.7% for high-volume, p = .02). In the multivariate model, treatment by low-volume providers and patient age ≥ 80 years were independently associated with worse chemotherapy-guideline compliance. In the survival analysis, there was a significant difference in median OS across provider volume tertiles with median survival of 32.8 months (95%CI 29.6, 36.4) low-volume, 41.9 months (95%CI 37.5, 46.7) medium-volume, 42.1 months (95%CI 38.8, 44.2) high-volume providers, respectively (p < .01). After adjusting for case-mix, low-volume providers were independently associated with higher rates of mortality (aHR 1.25, 95%CI: 1.08, 1.43).

CONCLUSIONS

In a modern cohort of elderly Medicare patients with advanced EOC, we found higher rates of non-compliant care and worse survival associated with treatment by low-volume Medicare providers. Urgent efforts are needed to address this volume-outcomes disparity.

Urban versus Rural Residence and Outcomes in Older Patients with Breast Cancer

BACKGROUND

A total of 20% of the U.S. population resides in rural areas, yet is served by 3% of oncologists, and 7% of nononcology specialists. Access to care issues can be compounded by lower socioeconomic status (SES) in rural areas, yet this issue is unexplored among older patients with breast cancer.

METHODS

Using Surveillance Epidemiology and End Results-Medicare, 109,608 patients diagnosed at ≥65 years with breast cancer between 2000 and 2011 were identified. Residence status was combined with Federal Poverty levels: urban (high, medium, and low poverty) and rural (high, medium, and low poverty). Five-year overall survival (OS) and healthcare utilization [HCU: visits to primary care provider (PCP), oncologist, nononcology specialist, and emergency department (ED)] were examined using urban/low poverty as reference. The residence, HCU, and mortality association was examined using mediation and moderation analyses.

RESULTS

Median age was 76 years; 12.5% were rural, 15.6% high poverty. Five-year OS was 69.8% for rural and 70.9% for urban. Both urban- and rural/high-poverty patients had a 1.2-fold increased mortality hazard. Rural/high-poverty patients had a higher rate of PCP [year 1 (Y1): incidence rate ratio (IRR) = 1.23; year 2 (Y2)-year 5 (Y5): IRR = 1.19] and ED visits (Y1: IRR = 1.82; Y2-Y5: IRR = 1.43), but lower nononcology specialist visit rates (Y1: IRR = 0.74; Y2-Y5: IRR = 0.71). Paucity of nononcology specialist visits mediated 23%-57% of excess mortality risk. The interaction between residence/SES and paucity of nononcology specialist visits accounted for 49%-92% of excess mortality risk experienced by rural/high-poverty patients versus urban/low poverty.

CONCLUSIONS

Urban-rural residence mortality differences among older patients with breast cancer are highly predicated by poverty level.

IMPACT

Rural/high-poverty patients demonstrate less use of nononcology specialists compared with urban/low poverty, with disparities moderated by specialist use.