Linking Medicare, Medicaid, and cancer registry data to study the burden of cancers in West Virginia

Cancer information and population health resource: a resource for catchment area data and cancer outcomes research

BACKGROUND

The University of North Carolina at Chapel Hill Lineberger Comprehensive Cancer Center has developed a novel data resource, the Cancer Information and Population Health Resource (CIPHR), for conducting catchment area evaluation and cancer population health research that links the North Carolina Central Cancer Registry (NCCCR) to medical and pharmacy claims data from Medicare, Medicaid, and private plans operating within North Carolina. This study's aim was to describe the CIPHR data and provide examples of potential cohorts available in those data.

METHODS

We present the underlying populations included in the NCCCR and claims data before linkage and demonstrate estimated sample sizes when these data are linked and commonly used insurance enrollment criteria are applied.

RESULTS

Data for the years 2003-2020 are present in CIPHR and include 947 977 cancer cases from the NCCCR and 21.6 million enrollees in public and private health insurance (cancer and noncancer cases). When limited to first or only cancers (n = 672 377), 86% could be linked to insurance enrollment for at least 1 month during 2003-2020 (n = 582 638), with 62% of individuals linking to enrollment during the month of cancer diagnosis. Among all registry cancer cases, 47% (n = 317 898) had continuous insurance enrollment for at least 12 months before and after cancer diagnosis.

CONCLUSION

CIPHR illustrates the utility of establishing and maintaining a statewide, comprehensive cancer population health database. This resource serves to characterize the cancer center catchment area and aids in tracking cancer outcomes and trends in care delivery as well as identifying disparities that require intervention and policy focus.

Building Data Infrastructure for Disease-Focused Health Economics Research

BACKGROUND

Data infrastructure for cancer research is centered on registries that are often augmented with payer or hospital discharge databases, but these linkages are limited. A recent alternative in some states is to augment registry data with All-Payer Claims Databases (APCDs). These linkages capture patient-centered economic outcomes, including those driven by insurance and influence health equity, and can serve as a prototype for health economics research.

OBJECTIVES

To describe and assess the utility of a linkage between the Colorado APCD and Colorado Central Cancer Registry (CCCR) data for 2012-2017.

RESEARCH DESIGN, PARTICIPANTS, AND MEASURES

This cohort study of 91,883 insured patients evaluated the Colorado APCD-CCCR linkage on its suitability to assess demographics, area-level data, insurance, and out-of-pocket expenses 3 and 6 months after cancer diagnosis.

RESULTS

The linkage had high validity, with over 90% of patients in the CCCR linked to the APCD, but gaps in APCD health plans limited available claims at diagnosis. We highlight the advantages of the CCCR-APCD, such as granular race and ethnicity classification, area-level data, the ability to capture supplemental plans, medical and pharmacy out-of-pocket expenses, and transitions in insurance plans.

CONCLUSIONS

Linked data between registries and APCDs can be a cornerstone of a robust data infrastructure and spur innovations in health economics research on cost, quality, and outcomes. A larger infrastructure could comprise a network of state APCDs that maintain linkages for research and surveillance.

Comparison of primary payer in cancer registry and discharge data

OBJECTIVES

To determine agreement between variables capturing the primary payer at cancer diagnosis across the Pennsylvania Cancer Registry (PCR) and statewide facility discharge records (Pennsylvania Health Care Cost Containment Council [PHC4]) for adults younger than 65 years, and to specifically examine factors associated with misclassification of Medicaid status in the registry given the role of managed care.

STUDY DESIGN

Cross-sectional analysis of the primary cancer cases among adults aged 21 to 64 years in the PCR from 2010 to 2016 linked to the PHC4 facility visit records.

METHODS

We assessed agreement of payer at diagnosis (Medicare, Medicaid, private, other, uninsured, unknown) across data sources, including positive predictive value (PPV) and sensitivity, using the PHC4 records as the gold standard. The probability of misclassifying Medicaid in registry was estimated using multivariate logit models.

RESULTS

Agreement of payers was high for private insurance (PPV, 89.7%; sensitivity, 83.6%), but there was misclassification and/or underreporting of Medicaid in the registry (PPV, 80%; sensitivity, 58%). Among cases with "other" and "unknown" insurance, 73.8% and 62.1%, respectively, had private insurance according to the PHC4 records. Medicaid managed care was associated with a statistically significant increase of 12.6 percentage points (95% CI, 9.4-15.8) in the probability of misclassifying Medicaid enrollment as private insurance in the registry.

CONCLUSIONS

Findings suggest caution in conducting and interpreting research using insurance variables in cancer registries.

Using LexisNexis to Improve Social Security Number Information in the New York State Cancer Registry

Background

Social Security numbers (SSNs) collected by cancer surveillance registries in the United States are used for patient matching, deduplication, follow-up, and linkage studies. However, due to various reasons, a small proportion of patient records have missing or inaccurate SSNs. Recently, New York State Cancer Registry (NYSCR) data have been linked to LexisNexis data to obtain patient demographic information, including SSNs. The current study evaluated the feasibility of using LexisNexis to improve SSN information in the NYSCR.

Materials and Methods

Patients diagnosed during the years 2005-2016, aged 21 or older, in the NYSCR were linked to LexisNexis data. For the matched patients, LexisNexis returned demographic information, including SSNs as available. Percentages of patients without LexisNexis matches or without LexisNexis SSNs were examined by demographic characteristics. We used multivariate logistic regression analyses to further evaluate how patient demographic characteristics affected the likelihood of no LexisNexis matches or of no SSNs returned. For patients with SSNs returned, LexisNexis SSNs were compared with registry SSNs. If patients had prior missing registry SSNs or if LexisNexis SSNs were inconsistent with registry SSNs, we used Match*Pro to review and verify match status. Registry SSNs were updated for those confirmed to be true matches. Improvement of SSNs was assessed based on percentage reduction of missingness.

Results

Of 1,396,078 patient records submitted for LexisNexis linkage, 1.6% were not matched. Among those matched, 1.5% did not have SSNs returned. Multivariate logistic regression analyses indicated that patients who were female, Black, Asian Pacific Islander (API), Hispanic, born outside the United States, deceased, or living in poorer census tracts were more likely to not have LexisNexis matches, or to not have SSNs returned. Among 47,271 patients with missing registry SSNs (3.4%), 26,895 had SSNs returned from LexisNexis, and 24,919 were confirmed to be true matches. After registry SSNs updates, the percentage of SSN missingness was reduced to 1.7%, with a larger absolute reduction observed among those who were younger than 60 years, API, or alive. For 33,057 patients with inconsistent SSNs, 11,474 were due to incorrect consolidations of SSNs in the registry, and those SSNs were subsequently fixed.

Conclusions

LexisNexis is a valuable resource for improving the quality of SSN information in registries. Our results showed that the overall percentage of patients with missing SSNs was reduced from 3.4% to 1.7% after LexisNexis link-age, and SSNs that were initially incorrectly consolidated for some patients were also identified and subsequently fixed. However, the magnitude of SSN improvement varied by patient demographic characteristics. Data quality improvements often require resources, and this evaluation can assist registries with decisions related to similar efforts.

Development and Evaluation of a Process to Link Cancer Patients in the SEER Registries to National Medicaid Enrollment Data

Cancer patients receiving Medicaid have worse prognosis. Patients in 14 Surveillance, Epidemiology, and End Results (SEER) cancer registries were linked to national Medicaid enrollment files, 2006-2013, to determine enrollment status during the year before and after diagnosis. A deterministic algorithm based on Social Security number, Medicare Health Insurance Claim number, sex, and date of birth was utilized. Results were compared with an independent linkage of Kentucky-based SEER and Medicaid data. A total 559 484 cancer cases were linked to national Medicaid enrollment files, representing 15-17% of persons with cancer yearly. About 60% of these cases were a complete match on all variables. There was 99% agreement on enrollment status compared with the Kentucky linked data. SEER data were successfully linked to national Medicaid enrollment data. NCI will make the linked data available to researchers, allowing for more detailed assessments of the impact Medicaid enrollment has on cancer diagnosis and outcomes.

Unlocking the potential of population-based cancer registries

Population-based cancer registries have improved dramatically over the last 2 decades. These central cancer registries provide a critical framework that can elevate the science of cancer research. There have also been important technical and scientific advances that help to unlock the potential of population-based cancer registries. These advances include improvements in probabilistic record linkage, refinements in natural language processing, the ability to perform genomic sequencing on formalin-fixed, paraffin-embedded (FFPE) tissue, and improvements in the ability to identify activity levels of many different signaling molecules in FFPE tissue. This article describes how central cancer registries can provide a population-based sample frame that will lead to studies with strong external validity, how central cancer registries can link with public and private health insurance claims to obtain complete treatment information, how central cancer registries can use informatics techniques to provide population-based rapid case ascertainment, how central cancer registries can serve as a population-based virtual tissue repository, and how population-based cancer registries are essential for guiding the implementation of evidence-based interventions and measuring changes in the cancer burden after the implementation of these interventions.

Unlocking the potential of population-based cancer registries

Population-based cancer registries have improved dramatically over the last 2 decades. These central cancer registries provide a critical framework that can elevate the science of cancer research. There have also been important technical and scientific advances that help to unlock the potential of population-based cancer registries. These advances include improvements in probabilistic record linkage, refinements in natural language processing, the ability to perform genomic sequencing on formalin-fixed, paraffin-embedded (FFPE) tissue, and improvements in the ability to identify activity levels of many different signaling molecules in FFPE tissue. This article describes how central cancer registries can provide a population-based sample frame that will lead to studies with strong external validity, how central cancer registries can link with public and private health insurance claims to obtain complete treatment information, how central cancer registries can use informatics techniques to provide population-based rapid case ascertainment, how central cancer registries can serve as a population-based virtual tissue repository, and how population-based cancer registries are essential for guiding the implementation of evidence-based interventions and measuring changes in the cancer burden after the implementation of these interventions.

Differences in Medicare Expenditures Between Appalachian and Nationally Representative Cohorts of Elderly Women With Breast Cancer: An Application of Decomposition Technique

Background: Differences in Medicare expenditures during the initial phase of cancer care among rural and medically underserved elderly women with breast cancer (BC) and those from a nationally representative cohort have not been reported. The objective of this study was to determine Medicare expenditures during the initial phase of care among women in West Virginia (WV) who were Medicare beneficiaries with BC and compare them with national estimates. The magnitude of differences in these expenditures was also determined by using a linear decomposition technique. Methods: A retrospective observational study was conducted using the WV Cancer Registry-Medicare database and the SEER-Medicare database. Our study cohorts consisted of elderly women aged ≥66 years diagnosed with incident BC in 2003 to 2006. Medicare expenditures during the initial year after BC diagnosis were derived from all of the Medicare files. Generalized linear regressions were performed to model expenditures, after controlling for predisposing factors, enabling resources, need, healthcare use, and external healthcare environmental factors. Blinder-Oaxaca decomposition was conducted to examine the proportion of the differences in the average expenditures explained by independent variables included in the model. Results: Average Medicare expenditures for the WV Medicare cohort during the initial phase of BC care were $25,626 compared with $29,502 for the SEER-Medicare cohort; a difference of $3,876. In the multivariate regression, this difference decreased to $708 and remained significant. Only 16% of the differences in the average expenditures between the cohorts were explained by the independent variables included in the model. Enabling resources (6.86%), healthcare use (7.55%), and external healthcare environmental factors (3.33%) constituted most of the explained portion of the differences in the average expenditures. Conclusions: The difference in average Medicare expenditures between the elderly beneficiaries with BC from a rural state (WV) and their national counterparts narrowed but remained significantly lower after multivariate adjustment. The explained portion of this difference was mainly driven by enabling and healthcare use factors, whereas 84% of this difference remained unexplained.

A pilot study for long-term outcome assessment after aortic aneurysm repair using Vascular Quality Initiative data matched to Medicare claims

OBJECTIVE

Accurate and complete long-term postoperative outcome data are critical to improving value in health care delivery. The Society for Vascular Surgery Vascular Quality Initiative (VQI) is an important tool to achieve this goal in vascular surgery. To improve on the capture of long-term outcomes after vascular surgery procedures for patients in the VQI, we sought to match VQI data to Medicare claims for comprehensive capture of major clinical outcomes in the first several years after vascular procedures.

METHODS

Patient and procedure characteristics for abdominal aortic aneurysm procedures captured in the Society for Vascular Surgery VQI between January 1, 2002, and December 31, 2013, were matched to Medicare claims data using an indirect identifier methodology. Late outcomes captured in the VQI and in Medicare claims were compared.

RESULTS

Matching procedures yielded 9895 endovascular aneurysm repair (EVAR) patients (82.4% of eligible VQI patients) and 3405 open aneurysm repair (OAR) patients (74.4% of eligible). Comparison of patients who did and did not match to a Medicare claim demonstrated similar patient and procedure characteristics. Evaluation of late outcomes revealed good patient-level agreement on mortality for both EVAR (κ, 0.64) and OAR (κ, 0.82). Postoperative reintervention rates demonstrated lower agreement for both EVAR (κ, 0.26) and OAR (κ, 0.16).

CONCLUSIONS

This work demonstrates the feasibility of an algorithm using indirect identifiers to match VQI patients and procedures to Medicare claims data. The refinement of this strategy will focus on establishing and improving algorithms related to identifying and categorizing late events after EVAR and may serve as a mechanism to ensure that the best quality follow-up information is achieved within the VQI.

Tobacco-use Cessation Counseling Service Usage

Objectives

Tobacco-use is common among elderly lung cancer patients and continued tobacco-use can impact prognosis. This study evaluates patterns of receipt of Tobacco-use Cessation Counseling (TCC) services among these patients.

Methods

Using West Virginia Cancer Registry-Medicare linked database (2004-2007), we identified elderly patients with lung cancer (n = 922) and categorized them by receipt of TCC services. Hierarchical generalized logistic model was constructed and survival outcomes were analyzed by Kaplan-Meier analysis, Log-Rank test, and Cox proportional hazards modeling.

Results

Majority of patients (76.7%) received TCC services. Unadjusted analysis showed favorable survival outcomes in patients who received TCC services. However, adjusted lung cancer mortality risk was no different between the groups (HR (95% CI) = 1.78 (0.87-3.64)).

Conclusion

This study highlights the critical need to address disparities in receipt of TCC services among elderly. Although lung cancer preventive services are covered under the Medicare program, underutilization of these services is a concern.

Comparison of the Initial Loco-Regional Treatment Received for Early-Stage Breast Cancer between Elderly Women in Appalachia and a United States - Based Population: Good and Bad News

BACKGROUND

Breast conserving surgery (BCS) followed by radiation therapy (RT) (BCS+RT) is as effective for long-term survival of invasive early-stage breast cancer (ESBC) as mastectomy, and is the local treatment option selected by the majority of women with ESBC. Women of older age and vulnerable socio-demographic characteristics are at greater risk for receiving substandard (BCS only) and non-preferred treatments (mastectomy), such as populations of women from the Appalachian region of United States.

METHODS

Using a retrospective cohort study design, we identified 26,106 patients from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset and 811 patients from the West Virginia Cancer Registry (WVCR)-Medicare dataset age ≥ 66 diagnosed from 2003 to 2006 with stage I-II breast cancer. Multivariable logistic regression models estimated type of initial treatment received between WVCR-Medicare and SEER-Medicare patients, and the association with type of treatment.

RESULTS

Overall, women in WV were 0.82 (95% CI 0.68-0.99) and 0.70 (95% CI 0.58-0.84) times less likely to have mastectomy or BCS only vs. BCS+RT, than those in SEER regions. Women in WV of increasing age, greater comorbidity, stage II disease, and non-white race were more likely to have mastectomy or BCS only vs. BCS+RT, whereas, those residing in areas of higher income, higher education, and metro status were less likely, than similarly characterized women from SEER regions.

CONCLUSIONS

Findings from this study suggest that the magnitude of disparities in breast cancer treatment between groups of women with more and less resources are even greater in the Appalachian region, than they are among US populations. Improving access to oncology treatment services, as well as, the implementation of patient navigation programs are needed to improve patterns of initial treatment for ESBC among at-risk populations.

Treatment and Survival of Medicare Beneficiaries with Colorectal Cancer: A Comparative Analysis Between a Rural State Cancer Registry and National Data

The aim was to examine and compare with "national" estimates, receipt of colorectal cancer (CRC) treatment in the initial phase of care and survival following a CRC diagnosis in rural Medicare beneficiaries. A retrospective study was conducted on fee-for-service Medicare beneficiaries diagnosed with CRC in 2003-2006, identified from West Virginia Cancer Registry (WVCR)-Medicare linked database (N = 2119). A comparative cohort was identified from Surveillance, Epidemiology, and End Results (SEER)-Medicare (N = 38,168). CRC treatment received was ascertained from beneficiaries' Medicare claims in the 12 months post CRC diagnosis or until death, whichever happened first. Receipt of minimally appropriate CRC treatment (MACT) was defined using recommended CRC treatment guidelines. All-cause and CRC-specific mortality in the 36-month period post CRC diagnosis were examined. Differences in usage of CRC surgery, chemotherapy, and radiation were observed between the 2 populations, with those from WVCR-Medicare being less likely to receive any type of CRC surgery (adjusted odds ratio [AOR] = 0.82; 95% confidence interval [CI] = [0.73-0.93]). Overall, those from WVCR-Medicare had a lower likelihood of receiving MACT, (AOR = 0.85; 95% CI = [0.76-0.96]) compared to their national counterparts. Higher hazard of CRC mortality was observed in the WVCR-Medicare cohort (adjusted hazard ratio = 1.26; 95% CI = [1.20-1.32]) compared to the SEER-Medicare cohort. Although more beneficiaries from WVCR-Medicare were diagnosed in early-stage CRC compared to their SEER-Medicare counterparts, they had a lower likelihood of receiving MACT and a higher hazard of CRC mortality. This study highlights the need for an increased focus on improving access to care at every phase of the CRC care continuum, especially for those from rural settings.

Racial differences in receipt of adjuvant hormonal therapy among Medicaid enrollees in South Carolina diagnosed with breast cancer

Several factors contribute to the pervasive Black-White disparity in breast cancer mortality in the U.S., such as tumor biology, access to care, and treatments received including adjuvant hormonal therapy (AHT), which significantly improves survival for hormone receptor-positive breast cancers (HR+). We analyzed South Carolina Central Cancer Registry-Medicaid linked data to determine if, in an equal access health care system, racial differences in the receipt of AHT exist. We evaluated 494 study-eligible, Black (n = 255) and White women (n = 269) who were under 65 years old and diagnosed with stages I-III, HR+ breast cancers between 2004 and 2007. Bivariate and multivariate analyses were conducted to assess receipt of ≥1 AHT prescriptions at any point in time following (ever-use) or within 12 months of (early-use) breast cancer diagnosis. Seventy-two percent of the participants were ever-users (70 % Black, 74 % White) and 68 % were early-users (65 % Black, 71 % White) of AHT. Neither ever-use (adjusted OR (AOR) = 0.75, 95 % CI 0.48-1.17) nor early-use (AOR = 0.70, 95 % CI 0.46-1.06) of AHT differed by race. However, receipt of other breast cancer-specific treatments was independently associated with ever-use and early-use of AHT [ever-use: receipt of surgery (AOR = 2.15, 95 % CI 1.35-3.44); chemotherapy (AOR = 1.97, 95 % CI 1.22-3.20); radiation (AOR = 2.33, 95 % CI 1.50-3.63); early-use: receipt of surgery (AOR = 2.03, 95 % CI 1.30-3.17); chemotherapy (AOR = 1.90, 95 % CI 1.20-3.03); radiation (AOR = 1.73, 95 % CI 1.14-2.63)]. No racial variations in use of AHT among women with HR+ breast cancers insured by Medicaid in South Carolina were identified, but overall rates of AHT use by these women is low. Strategies to improve overall use of AHT should include targeting breast cancer patients who do not receive adjuvant chemotherapy and/or radiation.

Disparities in Lung Cancer Care and Outcomes among Elderly in a Medically Underserved State Population-A Cancer Registry-Linked Database Study

Despite availability of guidelines for lung cancer care, variations in lung cancer care among the elderly exist across the nation and are a cause for concern in rural and medically underserved areas. Therefore, the purpose of this study was to evaluate the patterns of lung cancer care and associated health outcomes among elderly residing in a rural and medically underserved area. The authors identified 1924 elderly lung cancer patients from the West Virginia Cancer Registry-Medicare linked database (2002-2007) and categorized them by receipt of guideline-concordant (appropriate and timely) care using guidelines from the American College of Chest Physicians, British Thoracic Society, and the RAND Corporation. Hierarchical generalized logistic models were constructed to identify variables associated with receipt of guideline-concordant care. Kaplan-Meier analysis and log-rank test were used to compare 3-year survival outcomes. Multivariate Cox proportional hazards models were constructed to estimate lung cancer mortality risk associated with nonreceipt of guideline-concordant care. Although guideline-concordant appropriate care was received by fewer than half of all patients (46.5%), of those receiving care, 78.7% received it in a timely manner. Delays in diagnosis and treatment varied significantly. Survival outcomes significantly improved with appropriate care (799 vs. 366 days; P≤0.05), but did not improve with timely care. This study highlights the critical need to address disparities in receipt of guideline-concordant lung cancer care among the elderly residing in rural and medically underserved areas. Although lung cancer diagnostic and management services are covered under the Medicare program, underutilization of these services is a concern. (Population Health Management 2016;19:109-119).