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Hari A, Chang J, Villanueva C, Ziogas A, Vieira V, Bristow RE. Short-term survival analysis of a risk-adjusted model for ovarian cancer care. Gynecol Oncol 2024; 184:123-131. [PMID: 38309029 DOI: 10.1016/j.ygyno.2024.01.005] [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: 06/29/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To quantify the impact on short-term ovarian cancer survival associated with treatment at high-performing hospitals using the observed-to-expected ratio (O/E) for adherence to ovarian cancer treatment guidelines as a risk-adjusted measure of hospital quality care. METHODS This was a retrospective population-based study of stage I-IV invasive epithelial ovarian cancer reported to California Cancer Registry 1996-2017. A fit logistic regression model, risk-adjusted for patient and disease characteristics, was used to calculate O/E for each hospital stratified by hospital annual case volume. Cox proportional hazards model was used for survival analyses at 3, 6, 12, 24 months and stratified according to sociodemographic characteristics. RESULTS The study population included 35,725 subjects treated at 443 hospitals: Low-O/E - 26.4% of cases; Intermediate-O/E - 55.5% of cases; and High-O/E - 18.1% of cases. Overall median survival by hospital category was: High-O/E = 72.5 months (95% CI = 68.6-78.6 months), Intermediate-O/E = 68.6 months (95% CI = 65.9-71.6 months), Low-O/E = 47.0 months (95% CI = 44.2-49.2 months). Initial treatment at a High-O/E hospital (HR = 1.00) was a statistically significant and independent predictor of improved short-term survival compared to Low-O/E hospitals at 3 months (HR = 1.46, 95% CI = 1.29-1.65), 6 months (HR = 1.35, 95% CI = 1.22-1.50), 12 months (HR = 1.27, 95% CI = 1.17-1.38), and 24 months (HR = 1.19, 95% CI = 1.11-1.27). Significant and independent associations between improved sort-term survival and High/O/E care were observed for Whites, Hispanics, Asian/Pacific Islanders (A/PI), across SES strata, and among all payer categories. CONCLUSION Ovarian cancer care at a High-O/E hospital is an independent predictor of improved outcome and the survival advantage is disproportionately weighted toward the short-term time horizon following diagnosis.
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Affiliation(s)
- Anjali Hari
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, Orange, CA, USA; Chao Family Comprehensive Cancer Center, Orange, CA, USA.
| | - Jenny Chang
- Department of Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Carolina Villanueva
- Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, CA, USA
| | - Argyrios Ziogas
- Department of Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA
| | - Veronica Vieira
- Chao Family Comprehensive Cancer Center, Orange, CA, USA; Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, CA, USA
| | - Robert E Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine School of Medicine, Orange, CA, USA; Chao Family Comprehensive Cancer Center, Orange, CA, USA
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Kumar P, Del Rosario M, Chang J, Ziogas A, Jafari MD, Bristow RE, Tanjasiri SP, Zell JA. Population-Based Analysis of National Comprehensive Cancer Network (NCCN) Guideline Adherence for Patients with Anal Squamous Cell Carcinoma in California. Cancers (Basel) 2023; 15:cancers15051465. [PMID: 36900256 PMCID: PMC10000877 DOI: 10.3390/cancers15051465] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/02/2023] Open
Abstract
PURPOSE We analyzed adherence to the National Comprehensive Cancer Network treatment guidelines for anal squamous cell carcinoma in California and the associated impacts on survival. METHODS This was a retrospective study of patients in the California Cancer Registry aged 18 to 79 years with recent diagnoses of anal squamous cell carcinoma. Predefined criteria were used to determine adherence. Adjusted odds ratios and 95% confidence intervals were estimated for those receiving adherent care. Disease-specific survival (DSS) and overall survival (OS) were examined with a Cox proportional hazards model. RESULTS 4740 patients were analyzed. Female sex was positively associated with adherent care. Medicaid status and low socioeconomic status were negatively associated with adherent care. Non-adherent care was associated with worse OS (Adjusted HR 1.87, 95% CI = 1.66, 2.12, p < 0.0001). DSS was worse in patients receiving non-adherent care (Adjusted HR 1.96, 95% CI = 1.56, 2.46, p < 0.0001). Female sex was associated with improved DSS and OS. Black race, Medicare/Medicaid, and low socioeconomic status were associated with worse OS. CONCLUSIONS Male patients, those with Medicaid insurance, or those with low socioeconomic status are less likely to receive adherent care. Adherent care was associated with improved DSS and OS in anal carcinoma patients.
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Affiliation(s)
- Priyanka Kumar
- Department of Internal Medicine, University of California, Irvine, CA 92868-3201, USA
- Correspondence: ; Tel.: +1-714-456-5691; Fax: +1-714-456-8874
| | | | - Jenny Chang
- Department of Internal Medicine, University of California, Irvine, CA 92868-3201, USA
| | - Argyrios Ziogas
- Department of Internal Medicine, University of California, Irvine, CA 92868-3201, USA
| | - Mehraneh D. Jafari
- Department of Surgery, Section of Colon and Rectal Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | - Robert E. Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, CA 92868-3201, USA
| | - Sora Park Tanjasiri
- Department of Epidemiology & Biostatistics, University of California, Irvine, CA 92868-3201, USA
- Division of Hematology-Oncology, Department of Medicine, University of California, Irvine, CA 92868-3201, USA
| | - Jason A. Zell
- Division of Hematology-Oncology, Department of Medicine, University of California, Irvine, CA 92868-3201, USA
- Chao Family Comprehensive Cancer Center, University of California, Irvine, CA 92868-3201, USA
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Weeks K, West M, Lynch C, Hunter L, Keenan C, Borman S, McDonald M, Charlton M. Patient and Provider Perspectives on Barriers to Accessing Gynecologic Oncologists for Ovarian Cancer Surgical Care. WOMEN'S HEALTH REPORTS 2020; 1:574-583. [PMID: 35982990 PMCID: PMC9380881 DOI: 10.1089/whr.2020.0090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
Objective: National Comprehensive Cancer Network (NCCN) guidelines recommend that patients with ovarian cancer receive surgical care from a gynecologic oncologist. However, 15%–30% of patients with ovarian cancer do not receive surgical care from this specialist. The reasons for this remain unknown. We aim at assessing the barriers and attitudes perceived by patients with ovarian cancer who did not receive their primary surgery from a gynecologic oncologist and by diagnosing providers in an exploratory qualitative study. Materials and Methods: Patients and providers were sampled through the Iowa Cancer Registry. Participants were interviewed by telephone about barriers that patients face receiving surgical care from a specialist. Interviews were transcribed verbatim, and thematic analysis was completed by two team members. Findings: Providers (n = 10, 13% participation rate) identified many system-level barriers, including poor provider-to-provider communication, long time-to-surgery wait times, and a limited number of gynecologic oncologists working in their referral range. Patients (n = 16, 38% participation rate) denied system-level barriers; however, no patients reported receiving a referral to a gynecologic oncologist. This, in and of itself, constitutes a system-level barrier. Providers identified many barriers that their patients face, whereas patients failed to identify these barriers and denied facing them. Patients described the shock that they experienced after diagnosis and its limitations on their decision-making process. Both providers and patients agreed that the providers were influential in determining care decisions. Discussion: There is a divergence in the perceptions of barriers to care between providers and patients. Open discussions are needed about options and clinical guidelines for surgical ovarian cancer care. Further research is needed to develop and evaluate mechanisms to improve provider-to-patient discussions about surgical recommendations.
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Affiliation(s)
- Kristin Weeks
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Michele West
- Iowa Cancer Registry, University of Iowa, Iowa City, Iowa, USA
| | - Charles Lynch
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Iowa Cancer Registry, University of Iowa, Iowa City, Iowa, USA
| | - Lisa Hunter
- Iowa Cancer Registry, University of Iowa, Iowa City, Iowa, USA
| | - Chelsea Keenan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Savannah Borman
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Megan McDonald
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Iowa Cancer Registry, University of Iowa, Iowa City, Iowa, USA
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Bristow RE, Chang J, Villanueva C, Ziogas A, Vieira VM. A Risk-Adjusted Model for Ovarian Cancer Care and Disparities in Access to High-Performing Hospitals. Obstet Gynecol 2020; 135:328-339. [PMID: 31923082 PMCID: PMC7012338 DOI: 10.1097/aog.0000000000003665] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/28/2019] [Accepted: 09/05/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To validate the observed/expected ratio for adherence to ovarian cancer treatment guidelines as a risk-adjusted measure of hospital quality care, and to identify patient characteristics associated with disparities in access to high-performing hospitals. METHODS This was a retrospective population-based study of stage I-IV invasive epithelial ovarian cancer reported to the California Cancer Registry between 1996 and 2014. A fit logistic regression model, which was risk-adjusted for patient and disease characteristics, was used to calculate the observed/expected ratio for each hospital, stratified by hospital annual case volume. A Cox proportional hazards model was used for survival analyses, and a multivariable logistic regression model was used to identify independent predictors of access to high-performing hospitals. RESULTS The study population included 30,051 patients who were treated at 426 hospitals: low observed/expected ratio (n=304) 23.5% of cases; intermediate observed/expected ratio (n=92) 57.8% of cases; and high observed/expected ratio (n=30) 18.7% of cases. Hospitals with high observed/expected ratios were significantly more likely to deliver guideline-adherent care (53.3%), compared with hospitals with intermediate (37.8%) and low (27.5%) observed/expected ratios (P<.001). Median disease-specific survival time ranged from 73.0 months for hospitals with high observed/expected ratios to 48.1 months for hospitals with low observed/expected ratios (P<.001). Treatment at a hospital with a high observed/expected ratio was an independent predictor of superior survival compared with hospitals with intermediate (hazard ratio [HR] 1.06, 95% CI 1.01-1.11, P<.05) and low (HR 1.10, 95% CI 1.04-1.16, P<.001) observed/expected ratios. Being of Hispanic ethnicity (odds ratio [OR] 0.85, 95% CI 0.78-0.93, P<.001, compared with white), having Medicare insurance (OR 0.74, 95% CI 0.68-0.81 P<.001, compared with managed care), having a Charlson Comorbidity Index score of 2 or greater (OR 0.91, 95% CI 0.83-0.99, P<.05), and being of lower socioeconomic status (lowest quintile OR 0.41, 95% CI 0.36-0.46, P<.001, compared with highest quintile) were independent negative predictors of access to a hospital with a high observed/expected ratio. CONCLUSION Ovarian cancer care at a hospital with a high observed/expected ratio is an independent predictor of improved survival. Barriers to high-performing hospitals disproportionately affect patients according to sociodemographic characteristics. Triage of patients with suspected ovarian cancer according to a performance-based observed/expected ratio hospital classification is a potential mechanism for expanded access to expert care.
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Affiliation(s)
- Robert E Bristow
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, School of Medicine, and the Chao Family Comprehensive Cancer Center, Orange, and the Department of Medicine, University of California, Irvine, School of Medicine, and the Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, Irvine, California
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McGuire KP. Commentary on "Population-Based Analysis of Patient Age and Other Disparities in the Treatment of Ovarian Cancer in Central Appalachia and Kentucky". South Med J 2018; 111:342-343. [PMID: 29863221 DOI: 10.14423/smj.0000000000000822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Kandace P McGuire
- From the Department of Surgery, Massey Cancer Center, Virginia Commonwealth University, Richmond
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