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Jacobson JO, Brooks GA. Unspoken Risks of Cancer Care. JCO Oncol Pract 2024; 20:617-620. [PMID: 38382006 DOI: 10.1200/op.23.00795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/03/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Affiliation(s)
- Joseph O Jacobson
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Gabriel A Brooks
- Dartmouth Cancer Center/Dartmouth Hitchcock Medical Center, Lebanon, NH
- Dartmouth Geisel School of Medicine, Hanover, NH
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Scodari BT, Schaefer AP, Kapadia NS, Brooks GA, O'Malley AJ, Moen EL. The Association Between Oncology Outreach and Timely Treatment for Rural Patients with Breast Cancer: A Claims-Based Approach. Ann Surg Oncol 2024:10.1245/s10434-024-15195-y. [PMID: 38538822 DOI: 10.1245/s10434-024-15195-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/05/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Oncology outreach is a common strategy for increasing rural access to cancer care, where traveling oncologists commute across healthcare settings to extend specialized care. Examining the extent to which physician outreach is associated with timely treatment for rural patients is critical for informing outreach strategies. METHODS We identified a 100% fee-for-service sample of incident breast cancer patients from 2015 to 2020 Medicare claims and apportioned them into surgery and adjuvant therapy cohorts based on treatment history. We defined an outreach visit as the provision of care by a traveling oncologist at a clinic outside of their primary hospital service area. We used hierarchical logistic regression to examine the associations between patient receipt of preoperative care at an outreach visit (preoperative outreach) and > 60-day surgical delay, and patient receipt of postoperative care at an outreach visit (postoperative outreach) and > 60-day adjuvant delay. RESULTS We identified 30,337 rural-residing patients who received breast cancer surgery, of whom 4071 (13.4%) experienced surgical delay. Among surgical patients, 14,501 received adjuvant therapy, of whom 2943 (20.3%) experienced adjuvant delay. In adjusted analysis, we found that patient receipt of preoperative outreach was associated with reduced odds of surgical delay (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.61-0.91); however, we found no association between patient receipt of postoperative outreach and adjuvant delay (OR 1.04, 95% CI 0.85-1.25). CONCLUSIONS Our findings indicate that preoperative outreach is protective against surgical delay. The traveling oncologists who enable such outreach may play an integral role in catalyzing the coordination and timeliness of patient-centered care.
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Affiliation(s)
- Bruno T Scodari
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - A James O'Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Erika L Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
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Milligan M, Erfani P, Orav EJ, Schleicher S, Brooks GA, Lam MB. Practice Consolidation Among US Medical Oncologists, 2015-2022. JCO Oncol Pract 2024:OP2300748. [PMID: 38408291 DOI: 10.1200/op.23.00748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/22/2024] [Indexed: 02/28/2024] Open
Abstract
PURPOSE Health care consolidation has significantly affected cancer care delivery, with oncology practices undergoing substantial consolidation over the past two decades. This study investigates practice consolidation trends among medical oncologists (MOs), factors associated with consolidation, and changes in MO geographic distribution. METHODS Medicare data from 2015 to 2022 were used to assess MO practice consolidation in hospital referral regions (HRRs), linked with regional health care market data and physician demographics. The Herfindahl-Hirschman Index (HHI) was used to measure consolidation, and the Gini coefficient was used to measure MO distribution across counties. Multivariable linear regression explored factors associated with MO practice consolidation. RESULTS Between 2015 and 2022, the number of MOs increased by 14.5% (11,727-13,433), whereas the number of MO practices decreased by 18.0% (2,774-2,276). The mean number of MOs per practice increased by 40% (4.26-5.95; P < .001). The percentage of MOs in small practices decreased, whereas larger practices saw an increase. MO consolidation, as indicated by the HHI, increased by 9% (median HHI, 0.3204-0.3480). HRRs with higher baseline hospital consolidation and more hospital beds per capita were more likely to have MO practice consolidation. Despite MO practice consolidation, the county-level distribution of MOs did not change substantially. CONCLUSION On the basis of Federal Trade Commission classifications, MO practices were highly concentrated in 2015 and consolidated even further by 2022. While distribution of MOs at the county level remained stable, further research is needed to assess the effects of rapid consolidation on cancer care cost, quality, and access. These data have important implications for policymakers and payers as they design programs that ensure high-quality, affordable cancer care.
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Affiliation(s)
- Michael Milligan
- Harvard Radiation Oncology Program, Boston, MA
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Parsa Erfani
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | | | | | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
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Scodari BT, Schaefer AP, Kapadia NS, O'Malley AJ, Brooks GA, Tosteson ANA, Onega T, Wang C, Wang F, Moen EL. Characterizing the Traveling Oncology Workforce and Its Influence on Patient Travel Burden: A Claims-Based Approach. JCO Oncol Pract 2024:OP2300690. [PMID: 38386962 DOI: 10.1200/op.23.00690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/30/2023] [Accepted: 01/09/2024] [Indexed: 02/24/2024] Open
Abstract
PURPOSE Oncology outreach is a common strategy for extending cancer care to rural patients. However, a nationwide characterization of the traveling workforce that enables this outreach is lacking, and the extent to which outreach reduces travel burden for rural patients is unknown. METHODS This cross-sectional study analyzed a rural (nonurban) subset of a 100% fee-for-service sample of 355,139 Medicare beneficiaries with incident breast, colorectal, and lung cancers. Surgical, medical, and radiation oncologists were linked to patients using Part B claims, and traveling oncologists were identified by observing hospital service area (HSA) transition patterns. We defined oncology outreach as the provision of cancer care by a traveling oncologist outside of their primary HSA. We used hierarchical gamma regression models to examine the separate associations between patient receipt of oncology outreach and one-way patient travel times to chemotherapy, radiotherapy, and surgery. RESULTS On average, 9,935 of 39,960 oncologists conducted annual outreach, where 57.8% traveled with low frequency (0-1 outreach visits/mo), 21.1% with medium frequency (1-3 outreach visits/mo), and 21.1% with high frequency (>3 outreach visits/mo). Oncologists provided surgery, radiotherapy, and chemotherapy to 51,715, 27,120, and 5,874 rural beneficiaries, respectively, of whom 2.5%, 6.9%, and 3.6% received oncology outreach. Rural patients who received oncology outreach traveled 16% (95% CI, 11 to 21) and 11% (95% CI, 9 to 13) less minutes to chemotherapy and radiotherapy than those who did not receive oncology outreach, corresponding to expected one-way savings of 15.9 (95% CI, 15.5 to 16.4) and 11.9 (95% CI, 11.7 to 12.2) minutes, respectively. CONCLUSION Our study introduces a novel claims-based approach for tracking the nationwide traveling oncology workforce and supports oncology outreach as an effective means for improving rural access to cancer care.
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Affiliation(s)
- Bruno T Scodari
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Andrew P Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - A James O'Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Tracy Onega
- Department of Population Health Sciences and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Changzhen Wang
- Department of Geography and the Environment, The University of Alabama, Tuscaloosa, AL
| | - Fahui Wang
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA
| | - Erika L Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
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5
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Moen EL, Schmidt RO, Onega T, Brooks GA, O’Malley AJ. Association between a network-based physician linchpin score and cancer patient mortality: a SEER-Medicare analysis. J Natl Cancer Inst 2024; 116:230-238. [PMID: 37676831 PMCID: PMC10852616 DOI: 10.1093/jnci/djad180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/20/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Patients with cancer frequently require multidisciplinary teams for optimal cancer outcomes. Network analysis can capture relationships among cancer specialists, and we developed a novel physician linchpin score to characterize "linchpin" physicians whose peers have fewer ties to other physicians of the same oncologic specialty. Our study examined whether being treated by a linchpin physician was associated with worse survival. METHODS In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results-Medicare data for patients diagnosed with stage I to III non-small cell lung cancer or colorectal cancer (CRC) in 2016-2017. We assembled patient-sharing networks and calculated linchpin scores for medical oncologists, radiation oncologists, and surgeons. Physicians were considered linchpins if their linchpin score was within the top 15% for their specialty. We used Cox proportional hazards models to examine associations between being treated by a linchpin physician and survival, with a 2-year follow-up period. RESULTS The study cohort included 10 081 patients with non-small cell lung cancer and 9036 patients with CRC. Patients with lung cancer treated by a linchpin radiation oncologist had a 17% (95% confidence interval = 1.04 to 1.32) greater hazard of mortality, and similar trends were observed for linchpin medical oncologists. Patients with CRC treated by a linchpin surgeon had a 22% (95% confidence interval = 1.03 to 1.43) greater hazard of mortality. CONCLUSIONS In an analysis of Medicare beneficiaries with nonmetastatic lung cancer or CRC, those treated by linchpin physicians often experienced worse survival. Efforts to improve outcomes can use network analysis to identify areas with reduced access to multidisciplinary specialists.
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Affiliation(s)
- Erika L Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Rachel O Schmidt
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Tracy Onega
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
- Department of Population Health Science, University of Utah, Salt Lake City, UT, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - A James O’Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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6
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Chamberlin M, Booth C, Brooks GA, Manirakiza A, Rubagumya F, Vanderpuye V. More Drugs Versus More Data: The Tug of War on Cancer in Low- and Middle-Income Countries. Hematol Oncol Clin North Am 2024; 38:229-238. [PMID: 37516631 DOI: 10.1016/j.hoc.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Although current value frameworks and economic models have allowed us to better quantify the net benefit associated with cancer therapy, holistic cancer care must consider patient time, family and social values, and overall life expectancy. Training programs must include training in health services research, difficult conversations, and shared decision-making strategies that are developed in social and cultural frameworks for their settings.
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Affiliation(s)
- Mary Chamberlin
- Dartmouth Cancer Center, 1 Medical Center Drive, Lebanon, NH 03765, USA
| | | | - Gabriel A Brooks
- Dartmouth Cancer Center, 1 Medical Center Drive, Lebanon, NH 03765, USA
| | | | - Fidel Rubagumya
- Department of Oncology, Rwanda Military Hospital, Kigali, Rwanda
| | - Verna Vanderpuye
- National Center for Radiotherapy, Oncology and Nuclear Medicine, Korlebu Teaching Hospital, PO Box KB 369, Accra.
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Nong MZ, Dove D, Fischer DA, Hourdequin KC, Ripple GH, Amin MA, McGrath EB, Zaki BI, Smith KD, Brooks GA. Surveillance With Serial Imaging and CA 19-9 Tumor Marker Testing After Resection of Pancreatic Cancer: A Single-Center Retrospective Study. Am J Clin Oncol 2024; 47:25-29. [PMID: 37812021 PMCID: PMC10844891 DOI: 10.1097/coc.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES Most patients receiving curative-intent surgery for pancreatic cancer will experience cancer recurrence. However, evidence that postoperative surveillance testing improves survival or quality of life is lacking. We evaluated the use and characteristics of surveillance with serial imaging and CA 19-9 tumor marker testing at an NCI-designated comprehensive cancer center. METHODS We conducted a retrospective cohort study of patients who entered surveillance after curative-intent resection of pancreatic adenocarcinoma. We abstracted information from the electronic medical record about oncology office visits, surveillance testing (cross-sectional imaging and CA 19-9 tumor marker testing), and pancreatic cancer recurrence, with follow-up through 2 years after pancreatectomy. We conducted analyses to describe the use of surveillance testing and to characterize the sensitivity and specificity of CA 19-9 tumor marker testing for the identification of cancer recurrence. RESULTS We identified 90 patients entering surveillance after pancreatectomy. CA 19-9 was the most frequently used surveillance test, followed by CT imaging. Forty-seven patients (52.2%) experienced recurrence within two years of pancreatectomy. Recurrence risk was 58.8% versus 31.8% in patients with elevated versus normal CA 19-9 at diagnosis ( P =0.03). Elevated CA 19-9 at any point during surveillance was significantly associated with 2-year recurrence risk ( P <0.001). Elevated CA 19-9 had a sensitivity of 83% (95% CI 0.72-0.95) and specificity of 87% (0.76-0.98) for identification of recurrence within 2 years of pancreatectomy. CONCLUSIONS CA 19-9 demonstrates clinical validity for identifying recurrence of pancreatic cancer during surveillance. Surveillance approaches with reduced reliance on imaging should be prospectively evaluated.
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Affiliation(s)
| | - Devanshi Dove
- Division of Endocrinology and Metabolism, Department of
Medicine, University of California San Francisco, San Francisco, CA
| | - Dawn A. Fischer
- Department of Surgery, Dartmouth Hitchcock Medical Center,
Lebanon, NH
| | - Kathryn C. Hourdequin
- Dartmouth Cancer Center at Dartmouth Hitchcock Medical
Center, Lebanon, NH
- Geisel School of Medicine, Lebanon, NH
| | - Gregory H. Ripple
- Dartmouth Cancer Center at Dartmouth Hitchcock Medical
Center, Lebanon, NH
- Geisel School of Medicine, Lebanon, NH
| | - Manik A. Amin
- Dartmouth Cancer Center at Dartmouth Hitchcock Medical
Center, Lebanon, NH
- Geisel School of Medicine, Lebanon, NH
| | - Elizabeth B. McGrath
- Dartmouth Cancer Center at Dartmouth Hitchcock Medical
Center, Lebanon, NH
- Geisel School of Medicine, Lebanon, NH
| | - Bassem I. Zaki
- Dartmouth Cancer Center at Dartmouth Hitchcock Medical
Center, Lebanon, NH
- Geisel School of Medicine, Lebanon, NH
| | - Kerrington D. Smith
- Department of Surgery, Dartmouth Hitchcock Medical Center,
Lebanon, NH
- Dartmouth Cancer Center at Dartmouth Hitchcock Medical
Center, Lebanon, NH
- Geisel School of Medicine, Lebanon, NH
| | - Gabriel A. Brooks
- Dartmouth Cancer Center at Dartmouth Hitchcock Medical
Center, Lebanon, NH
- Geisel School of Medicine, Lebanon, NH
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Drummond DK, Kaur-Gill S, Murray GF, Schifferdecker KE, Butcher R, Perry AN, Brooks GA, Kapadia NS, Barnato AE. Problematic Integration: Racial Discordance in End-of-Life Decision Making. Health Commun 2023; 38:2730-2741. [PMID: 35981599 DOI: 10.1080/10410236.2022.2111631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We describe racially discordant oncology encounters involving EOL decision-making. Fifty-eight provider interviews were content analyzed using the tenets of problematic integration theory. We found EOL discussions between non-Black providers and their Black patients were often complex and anxiety-inducing. That anxiety consisted of (1) ontological uncertainty in which providers characterized the nature of Black patients as distrustful, especially in the context of clinical trials; (2) ontological and epistemological uncertainty in which provider intercultural incompetency and perceived lack of patient health literacy were normalized and intertwined with provider assumptions about patients' religion and support systems; (3) epistemological uncertainty as ambivalence in which providers' feelings conflicted when deciding whether to speak with family members they perceived as lacking health literacy; (4) divergence in which the provider advised palliative care while the family desired surgery or cancer-directed medical treatment; and (5) impossibility when an ontological uncertainty stance of Black distrust was seen as natural by providers and therefore impossible to change. Some communication strategies used were indirect stereotyping, negotiating, asking a series of value questions, blame-guilt framing, and avoidance. We concluded that provider perceptions of Black distrust, religion, and social support influenced their ability to communicate effectively with patients.
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Affiliation(s)
| | | | | | - Karen E Schifferdecker
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Center for Program Design & Evaluation, Dartmouth College
| | - Rebecca Butcher
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Center for Program Design & Evaluation, Dartmouth College
| | - Amanda N Perry
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Department of Medicine, Geisel School of Medicine, Dartmouth College
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Department of Medicine, Geisel School of Medicine, Dartmouth College
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College
- Department of Medicine, Geisel School of Medicine, Dartmouth College
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Sha ST, Usadi B, Wang Q, Tomaino M, Brooks GA, Loehrer AP, Wong SL, Tosteson AN, Colla CH, Kapadia NS. The Association of Rural Residence With Surgery and Adjuvant Radiation in Medicare Beneficiaries With Rectal Cancer. Adv Radiat Oncol 2023; 8:101286. [PMID: 38047230 PMCID: PMC10692300 DOI: 10.1016/j.adro.2023.101286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/01/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose Radiation therapy and surgery are fundamental site-directed therapies for nonmetastatic rectal cancer. To understand the relationship between rurality and access to specialized care, we characterized the association of rural patient residence with receipt of surgery and radiation therapy among Medicare beneficiaries with rectal cancer. Methods and Materials We identified fee-for-service Medicare beneficiaries aged 65 years or older diagnosed with nonmetastatic rectal cancer from 2016 to 2018. Beneficiary place of residence was assigned to one of 3 geographic categories (metropolitan, micropolitan, or small town/rural) based on census tract and corresponding rural urban commuting area codes. Multivariable regression models were used to determine associations between levels of rurality and receipt of both radiation and proctectomy within 180 days of diagnosis. In addition, we explored associations between patient rurality and characteristics of surgery and radiation such as minimally invasive surgery (MIS) or intensity modulated radiation therapy (IMRT). Results Among 13,454 Medicare beneficiaries with nonmetastatic rectal cancer, 3926 (29.2%) underwent proctectomy within 180 days of being diagnosed with rectal cancer, and 1792 (13.3%) received both radiation and proctectomy. Small town/rural residence was associated with an increased likelihood of receiving both radiation and proctectomy within 180 days of diagnosis (adjusted subhazard ratio, 1.15; 95% CI, 1.02-1.30). Furthermore, small town/rural radiation patients were significantly less likely to receive IMRT (adjusted odds ratio, 0.62; 95% CI, 0.48-0.80) or MIS (adjusted odds ratio, 0.80; 95% CI, 0.66-0.97) than metropolitan patients. Conclusions Although small town/rural Medicare beneficiaries were overall more likely to receive both radiation and proctectomy for their rectal cancer, they were less likely to receive preoperative IMRT or MIS as part of their treatment regimen. Together, these findings clarify that among Medicare beneficiaries, there appeared to be a similar utilization of radiation resources and time to radiation treatment regardless of rural/urban status.
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Affiliation(s)
- Sybil T. Sha
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Medicine, Section of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Benjamin Usadi
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Qianfei Wang
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Marisa Tomaino
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Gabriel A. Brooks
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Medicine, Section of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
| | - Andrew P. Loehrer
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Sandra L. Wong
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Anna N.A. Tosteson
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
| | - Carrie H. Colla
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Congressional Budget Office, Washington District of Columbia
| | - Nirav S. Kapadia
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Lebanon, New Hampshire
- Department of Medicine, Section of Radiation Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Brooks GA, Tomaino MR, Ramkumar N, Wang Q, Kapadia NS, O’Malley AJ, Wong SL, Loehrer AP, Tosteson ANA. Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival. J Natl Cancer Inst 2023; 115:1171-1178. [PMID: 37233399 PMCID: PMC10560598 DOI: 10.1093/jnci/djad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/07/2023] [Accepted: 05/24/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Pancreatectomy is a necessary component of curative intent therapy for pancreatic cancer, and patients living in nonmetropolitan areas may face barriers to accessing timely surgical care. We evaluated the intersecting associations of rurality, socioeconomic status (SES), and race on treatment and outcomes of Medicare beneficiaries with pancreatic cancer. METHODS We conducted a retrospective cohort study, using fee-for-service Medicare claims of beneficiaries with incident pancreatic cancer (2016-2018). We categorized beneficiary place of residence as metropolitan, micropolitan, or rural. Measures of SES were Medicare-Medicaid dual eligibility and the Area Deprivation Index. Primary study outcomes were receipt of pancreatectomy and 1-year mortality. Exposure-outcome associations were assessed with competing risks and logistic regression. RESULTS We identified 45 915 beneficiaries with pancreatic cancer, including 78.4%, 10.9%, and 10.7% residing in metropolitan, micropolitan, and rural areas, respectively. In analyses adjusted for age, sex, comorbidity, and metastasis, residents of micropolitan and rural areas were less likely to undergo pancreatectomy (adjusted subdistribution hazard ratio = 0.88 for rural, 95% confidence interval [CI] = 0.81 to 0.95) and had higher 1-year mortality (adjusted odds ratio = 1.25 for rural, 95% CI = 1.17 to 1.33) compared with metropolitan residents. Adjustment for measures of SES attenuated the association of nonmetropolitan residence with mortality, and there was no statistically significant association of rurality with pancreatectomy after adjustment. Black beneficiaries had lower likelihood of pancreatectomy than White, non-Hispanic beneficiaries (subdistribution hazard ratio = 0.80, 95% CI = 0.72 to 0.89, adjusted for SES). One-year mortality in metropolitan areas was higher for Black beneficiaries (adjusted odds ratio = 1.15, 95% CI = 1.05 to 1.26). CONCLUSIONS Rurality, socioeconomic deprivation, and race have complex interrelationships and are associated with disparities in pancreatic cancer treatment and outcomes.
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Affiliation(s)
- Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Marisa R Tomaino
- Center for Tobacco Studies, Rutgers University, New Brunswick, NJ, USA
| | | | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - A James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, NH, USA
| | - Sandra L Wong
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Andrew P Loehrer
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Ramkumar N, Wang Q, Brooks GA, Tosteson AN, Wong SL, Loehrer AP. Association of rurality with utilization of palliative care and hospice among Medicare beneficiaries who died from pancreatic cancer: A cohort study. J Rural Health 2023; 39:557-564. [PMID: 36631820 PMCID: PMC10293103 DOI: 10.1111/jrh.12739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pancreatic cancer has a 5-year survival of just 10%. Services such as palliative care and hospice are thus crucial in this population, yet their geographic accessibility and utilization remains unknown. AIM We studied the association between rurality of patient residence and the use of palliative care and hospice. DESIGN, SETTING, AND PARTICIPANTS Cohort study of continuously enrolled fee-for-service Medicare beneficiaries aged ≥65 diagnosed with incident pancreatic cancer between 04/01/2016-08/31/2018 and who died by 12/31/2018. RESULTS In this decedent cohort of 31,460 patients, 77% lived in metropolitan areas, 11% in micropolitan areas, 7% in small towns, and 5% in rural areas. Patient demographics were largely similar across rurality; however, the proportion of White, non-Hispanic patients and social deprivation was highest in rural areas and lowest in metropolitan areas. Overall, 33% of patients used any palliative care and 77% received hospice services. After risk adjustment, there were no statistically significant differences in the use of palliative care for patients residing in metropolitan versus micropolitan, small town, or rural areas. Patients in small town (OR = 0.77, 95% CI: 0.69-0.86) and rural areas (OR = 0.75, 95% CI: 0.66-0.85) had lower adjusted odds of receiving hospice care compared to patients in metropolitan areas. CONCLUSIONS The use of palliative care services captured in Medicare was low, representing either underutilization or failure to accurately measure the extent of services used. While the overall level of hospice enrollment was high, patients in rural communities had relatively lower use of hospice services compared to those in metropolitan areas.
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Affiliation(s)
- Niveditta Ramkumar
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
| | - Qianfei Wang
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
| | - Gabriel A. Brooks
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756
| | - Anna N.A. Tosteson
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
| | - Sandra L. Wong
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon NH 03756
| | - Andrew P. Loehrer
- Geisel School of Medicine at Dartmouth, Hanover, NH 03766
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756
- Dartmouth Cancer Center, Lebanon, NH 03756
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon NH 03756
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12
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Baker SD, Bates SE, Brooks GA, Dahut WL, Diasio RB, El-Deiry WS, Evans WE, Figg WD, Hertz DL, Hicks JK, Kamath S, Kasi PM, Knepper TC, McLeod HL, O'Donnell PH, Relling MV, Rudek MA, Sissung TM, Smith DM, Sparreboom A, Swain SM, Walko CM. DPYD Testing: Time to Put Patient Safety First. J Clin Oncol 2023; 41:2701-2705. [PMID: 36821823 PMCID: PMC10414691 DOI: 10.1200/jco.22.02364] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/02/2022] [Accepted: 01/17/2023] [Indexed: 02/25/2023] Open
Affiliation(s)
- Sharyn D. Baker
- College of Pharmacy, The Ohio State University, Columbus, OH
| | - Susan E. Bates
- Herbert Irving Comprehensive Cancer Center, Columbia University, Irving Medical Center, New York, NY
| | | | | | | | | | | | - William D. Figg
- Clinical Pharmacology Program, National Cancer Institute, Bethesda, MD
| | - Dan L. Hertz
- College of Pharmacy, University of Michigan, Ann Arbor, MI
| | - J. Kevin Hicks
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
| | - Suneel Kamath
- Cleveland Clinic, Lerner College of Medicine, Cleveland, OH
| | | | - Todd C. Knepper
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
| | | | | | | | | | | | - D. Max Smith
- Georgetown Lombardi Comprehensive Cancer Center and MedStar Health, Georgetown University, Washington, DC
| | - Alex Sparreboom
- College of Pharmacy, The Ohio State University, Columbus, OH
| | - Sandra M. Swain
- Georgetown Lombardi Comprehensive Cancer Center and MedStar Health, Georgetown University, Washington, DC
| | - Christine M. Walko
- Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL
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13
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Schifferdecker KE, Butcher RL, Murray GF, Knutzen KE, Kapadia NS, Brooks GA, Wasp GT, Eggly S, Hanson LC, Rocque GB, Perry AN, Barnato AE. Structure and integration of specialty palliative care in three NCI-designated cancer centers: a mixed methods case study. BMC Palliat Care 2023; 22:59. [PMID: 37189073 PMCID: PMC10185464 DOI: 10.1186/s12904-023-01182-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/04/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Early access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration. METHODS Mixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites' palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices. RESULTS Sites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of "favorable" organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care. CONCLUSION Integration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.
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Affiliation(s)
- Karen E Schifferdecker
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Rebecca L Butcher
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Genevra F Murray
- New York University School of Global Public Health, 708 Broadway, New York, NY, 10003, USA
| | - Kristin E Knutzen
- Emory Rollins School of Public Health, 1518 Clitton Rd. NE, Atlanta, GA, 30322, USA
| | - Nirav S Kapadia
- Dartmouth Health Department of Medicine, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Gabriel A Brooks
- Dartmouth Health Department of Medicine, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Garrett T Wasp
- Dartmouth Health Department of Medicine, One Medical Center Drive, Lebanon, NH, 03756, USA
| | - Susan Eggly
- Wayne State University School of Medicine, Karmanos Cancer Institute, Mid-Med Lofts, Suite 3000, 87 E Canfield, Detroit, MI, 48201, USA
| | - Laura C Hanson
- University of North Carolina-Chapel Hill School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Gabrielle B Rocque
- University of Alabama at Birmingham, 500 Second Street South, Birmingham, AL, 35233, USA
| | - Amanda N Perry
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice at Geisel School of Medicine, Dartmouth College, WTRB Level 5, 1 Medical Center Drive, Lebanon, NH, 03756, USA
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14
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Roberts TJ, Kehl KL, Brooks GA, Sholl L, Wright AA, Landrum MB, Keating NL. Practice-Level Variation in Molecular Testing and Use of Targeted Therapy for Patients With Non-Small Cell Lung Cancer and Colorectal Cancer. JAMA Netw Open 2023; 6:e2310809. [PMID: 37115543 PMCID: PMC10148196 DOI: 10.1001/jamanetworkopen.2023.10809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/15/2023] [Indexed: 04/29/2023] Open
Abstract
Importance All patients with newly diagnosed non-small cell lung cancer (NSCLC) and colorectal cancer (CRC) should receive molecular testing to identify those who can benefit from targeted therapies. However, many patients do not receive recommended testing and targeted therapies. Objective To compare rates of molecular testing and targeted therapy use by practice type and across practices. Design, Setting, and Participants This cross-sectional study used 100% Medicare fee-for-service data from 2015 through 2019 to identify beneficiaries with new metastatic NSCLC or CRC diagnoses receiving systemic therapy and to assign patients to oncology practices. Hierarchical linear models were used to characterize variation by practice type and across practices. Data analysis was conducted from June 2019 to October 2022. Exposures Oncology practice providing care. Outcomes Primary outcomes were rates of molecular testing and targeted therapy use for patients with NSCLC and CRC. Secondary outcomes were rates of multigene testing for NSCLC and CRC. Results There were 106 228 Medicare beneficiaries with incident NSCLC (31 521 [29.7%] aged 65-69 years; 50 348 [47.4%] female patients; 2269 [2.1%] Asian, 8282 [7.8%] Black, and 91 215 [85.9%] White patients) and 39 512 beneficiaries with incident CRC (14 045 [35.5%] aged 65-69 years; 17 518 [44.3%] female patients; 896 [2.3%] Asian, 3521 [8.9%] Black, and 32 753 [82.9%] White patients) between 2015 and 2019. Among these beneficiaries, 18 435 (12.9%) were treated at National Cancer Institute (NCI)-designated centers, 8187 (5.6%) were treated at other academic centers, and 94 329 (64.7%) were treated at independent oncology practices. Molecular testing rates increased from 74% to 85% for NSCLC and 45% to 65% for CRC. First-line targeted therapy use decreased from 12% to 8% among patients with NSCLC and was constant at 5% for patients with CRC. For NSCLC, molecular testing rates were similar across practice types while rates of multigene panel use (13.2%) and targeted therapy use (16.6%) were highest at NCI-designated cancer centers. For CRC, molecular testing rates were 3.8 (95% CI: 1.2-6.5), 3.3 (95% CI, 0.4-6.1), and 12.2 (95% CI, 9.1-15.3) percentage points lower at hospital-owned practices, large independent practices, and small independent practices, respectively. Rates of targeted therapy use for CRC were similar across practice types. After adjusting for patient characteristics, there was moderate variation in molecular testing and targeted therapy use across oncology practices. Conclusions and Relevance In this cross-sectional study of Medicare beneficiaries, molecular testing rates for NSCLC and CRC increased in recent years but remained lower than recommended levels. Rates of targeted therapy use decreased for NSCLC and remained stable for CRC. Variation across practices suggests that where a patient was treated may have affected access to recommended testing and efficacious treatments.
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Affiliation(s)
- Thomas J. Roberts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Kenneth L. Kehl
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabriel A. Brooks
- Section of Medical Oncology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lynette Sholl
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexi A. Wright
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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15
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Tosteson ANA, Kirkland KB, Holthoff MM, Van Citters AD, Brooks GA, Cullinan AM, Dowling-Schmitt MC, Holmes AB, Meehan KR, Oliver BJ, Wasp GT, Wilson MM, Nelson EC. Harnessing the Collective Expertise of Patients, Care Partners, Clinical Teams, and Researchers Through a Coproduction Learning Health System: A Case Study of the Dartmouth Health Promise Partnership. J Ambul Care Manage 2023; 46:127-138. [PMID: 36820633 PMCID: PMC9976397 DOI: 10.1097/jac.0000000000000460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
The coproduction learning health system (CLHS) model extends the definition of a learning health system to explicitly bring together patients and care partners, health care teams, administrators, and scientists to share the work of optimizing health outcomes, improving care value, and generating new knowledge. The CLHS model highlights a partnership for coproduction that is supported by data that can be used to support individual patient care, quality improvement, and research. We provide a case study that describes the application of this model to transform care within an oncology program at an academic medical center.
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Affiliation(s)
- Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, New Hampshire (Drs Tosteson, Kirkland, Brooks, Oliver, and Nelson and Mss Holthoff and Van Citters); Dartmouth Cancer Center, Geisel School of Medicine and Dartmouth Health, Lebanon, New Hampshire (Drs Tosteson, Brooks, Meehan, and Wasp and Ms Dowling-Schmitt); Division of Palliative Medicine, Department of Medicine, Dartmouth Hitchcock Medical Center & Clinics, Lebanon, New Hampshire (Drs Kirkland, Cullinan, and Wilson); and Office of Care Experience, Value Institute, Dartmouth Health, Lebanon, New Hampshire (Dr Oliver). Ms Holmes is a patient advisors at Dartmouth Hitchcock Medical Center & Clinics, Lebanon, New Hampshire
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Emery LP, Muralikrishnan S, Schrag D, Tosteson AN, Brooks GA. Comparison of Oncologist and Model Estimates of Risk for Hospitalization During Systemic Therapy for Advanced Cancer. JCO Oncol Pract 2023; 19:e336-e344. [PMID: 36475736 PMCID: PMC10022874 DOI: 10.1200/op.22.00422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/07/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE A validated risk model with inputs of pretreatment sodium and albumin can identify patients at risk for hospitalization during cancer treatment. We evaluated how the model compares with risk estimates from treating oncologists. METHODS We evaluated the 30-day risk of hospitalization or death in patients starting palliative-intent systemic therapy for solid tumor malignancy. For each patient, we prospectively recorded categorical estimates of 30-day hospitalization risk (bottom third, middle third, top third) generated by a treating oncologist and by the two-variable model; a third hybrid risk estimate represented a composite of the oncologist and model risk assessments. We analyzed the agreement of oncologist and model-based risk estimates and compared discrimination, sensitivity, and specificity of each risk assessment method. RESULTS We collected oncologist, model, and hybrid estimates of hospitalization risk for 120 patients. The 30-day rate of hospitalization or death was 20%. There was minimal agreement between oncologist and model risk estimates (weighted kappa = 0.27). The c-statistic (a measure of discrimination) was 0.69 (95% CI, 0.57 to 0.81) for the clinician assessment, 0.77 for the model assessment (CI, 0.67 to 0.86; P = .24 compared with the oncologist assessment), and 0.79 for the hybrid assessment (CI, 0.69 to 0.90; P = .007 compared with the oncologist assessment). Sensitivity and specificity of the high-risk categorization did not differ significantly between the oncologist and model assessments; the hybrid assessment was significantly more sensitive (P = .02) and less specific (P = .03) than the oncologist assessment. CONCLUSION A model with inputs of pretreatment sodium and albumin improves oncologists' predictions of hospitalization risk during cancer treatment.
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Affiliation(s)
| | | | - Deb Schrag
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anna N.A. Tosteson
- Dartmouth Cancer Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Gabriel A. Brooks
- Dartmouth Cancer Center, Lebanon, NH
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
- Dartmouth Hitchcock Medical Center, Lebanon, NH
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17
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Yu L, Liu YC, Cornelius SL, Scodari BT, Brooks GA, O'Malley AJ, Onega T, Moen EL. Telehealth Use Following COVID-19 Within Patient-Sharing Physician Networks at a Rural Comprehensive Cancer Center: Cross-sectional Analysis. JMIR Cancer 2023; 9:e42334. [PMID: 36595737 PMCID: PMC9848440 DOI: 10.2196/42334] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In response to the COVID-19 pandemic, cancer centers rapidly adopted telehealth to deliver care remotely. Telehealth will likely remain a model of care for years to come and may not only affect the way oncologists deliver care to their own patients but also the physicians with whom they share patients. OBJECTIVE This study aimed to examine oncologist characteristics associated with telehealth use and compare patient-sharing networks before and after the COVID-19 pandemic in a rural catchment area with a particular focus on the ties between physicians at the comprehensive cancer center and regional facilities. METHODS In this retrospective observational study, we obtained deidentified electronic health record data for individuals diagnosed with breast, colorectal, or lung cancer at Dartmouth Health in New Hampshire from 2018-2020. Hierarchical logistic regression was used to identify physician factors associated with telehealth encounters post COVID-19. Patient-sharing networks for each cancer type before and post COVID-19 were characterized with global network measures. Exponential-family random graph models were performed to estimate homophily terms for the likelihood of ties existing between physicians colocated at the hub comprehensive cancer center. RESULTS Of the 12,559 encounters between patients and oncologists post COVID-19, 1228 (9.8%) were via telehealth. Patient encounters with breast oncologists who practiced at the hub hospital were over twice as likely to occur via telehealth compared to encounters with oncologists who practiced in regional facilities (odds ratio 2.2, 95% CI 1.17-4.15; P=.01). Patient encounters with oncologists who practiced in multiple locations were less likely to occur via telehealth, and this association was statistically significant for lung cancer care (odds ratio 0.26, 95% CI 0.09-0.76; P=.01). We observed an increase in ties between oncologists at the hub hospital and oncologists at regional facilities in the lung cancer network post COVID-19 compared to before COVID-19 (93/318, 29.3%, vs 79/370, 21.6%, respectively), which was also reflected in the lower homophily coefficients post COVID-19 compared to before COVID-19 for physicians being colocated at the hub hospital (estimate: 1.92, 95% CI 1.46-2.51, vs 2.45, 95% CI 1.98-3.02). There were no significant differences observed in breast cancer or colorectal cancer networks. CONCLUSIONS Telehealth use and associated changes to patient-sharing patterns associated with telehealth varied by cancer type, suggesting disparate approaches for integrating telehealth across clinical groups within this health system. The limited changes to the patient-sharing patterns between oncologists at the hub hospital and regional facilities suggest that telehealth was less likely to create new referral patterns between these types of facilities and rather replace care that would otherwise have been delivered in person. However, this study was limited to the 2 years immediately following the initial outbreak of COVID-19, and longer-term follow-up may uncover delayed effects that were not observed in this study period.
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Affiliation(s)
- Liyang Yu
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States
| | - You-Chi Liu
- Quantitative Social Sciences program, Dartmouth College, Hanover, NH, United States
| | - Sarah L Cornelius
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States
| | - Bruno T Scodari
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States
| | - Gabriel A Brooks
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Alistair James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, United States
| | - Tracy Onega
- Department of Population Sciences, University of Utah, Salt Lake City, NH, United States
| | - Erika L Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Lebanon, NH, United States
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, United States
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18
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Moen EL, Brooks GA, O’Malley AJ, Schaefer A, Carlos HA, Onega T. Use of a Novel Network-Based Linchpin Score to Characterize Accessibility to the Oncology Physician Workforce in the United States. JAMA Netw Open 2022; 5:e2245995. [PMID: 36525275 PMCID: PMC9856409 DOI: 10.1001/jamanetworkopen.2022.45995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/17/2022] [Indexed: 12/23/2022] Open
Abstract
Importance Physician headcounts provide useful information about the cancer care delivery workforce; however, efforts to track the oncology workforce would benefit from new measures that capture how essential a physician is for meeting the multidisciplinary cancer care needs of the region. Physicians are considered linchpins when fewer of their peers are connected to other physicians of the same specialty as the focal physician. Because they are locally unique for their specialty, these physicians' networks may be particularly vulnerable to their removal from the network (eg, through relocation or retirement). Objective To examine a novel network-based physician linchpin score within nationwide cancer patient-sharing networks and explore variation in network vulnerability across hospital referral regions (HRRs). Design, Setting, and Participants This cross-sectional study analyzed fee-for-service Medicare claims and included Medicare beneficiaries with an incident diagnosis of breast, colorectal, or lung cancer from 2016 to 2018 and their treating physicians. Data were analyzed from March 2022 to October 2022. Exposures Physician characteristics assessed were specialty, rurality, and Census region. HRR variables assessed include sociodemographic and socioeconomic characteristics and use of cancer services. Main Outcomes and Measures Oncologist linchpin score, which examined the extent to which a physician's peers were connected to other physicians of the same specialty as the focal physician. Network vulnerability, which distinguished HRRs with more linchpin oncologists than expected based on oncologist density. χ2 and Fisher exact tests were used to examine relationships between oncologist characteristics and linchpin score. Spearman rank correlation coefficient (ρ) was used to measure the strength and direction of relationships between HRR network vulnerability, oncologist density, population sociodemographic and socioeconomic characteristics, and cancer service use. Results The study cohort comprised 308 714 patients with breast, colorectal, or lung cancer. The study cohort of 308 714 patients included 161 206 (52.2%) patients with breast cancer, 76 604 (24.8%) patients with colorectal cancer, and 70 904 (23.0%) patients with lung cancer. In our sample, 272 425 patients (88%) were White, and 238 603 patients (77%) lived in metropolitan areas. The cancer patient-sharing network included 7221 medical oncologists and 3573 radiation oncologists. HRRs with more vulnerable networks for medical oncology had a higher percentage of beneficiaries eligible for Medicaid (ρ, 0.19; 95% CI, 0.08 to 0.29). HRRs with more vulnerable networks for radiation oncology had a higher percentage of beneficiaries living in poverty (ρ, 0.17; 95% CI, 0.06 to 0.27), and a higher percentage of beneficiaries eligible for Medicaid (ρ, 0.21; 95% CI, 0.09 to 0.31), and lower rates of cohort patients receiving radiation therapy (ρ, -0.18; 95% CI, -0.28 to -0.06; P = .003). The was no association between network vulnerability for medical oncology and percent of cohort patients receiving chemotherapy (ρ, -0.03; 95% CI, -0.15 to 0.08). Conclusions and Relevance This study found that patient-sharing network vulnerability was associated with poverty and lower rates of radiation therapy. Health policy strategies for addressing network vulnerability may improve access to interdisciplinary care and reduce treatment disparities.
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Affiliation(s)
- Erika L. Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Gabriel A. Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andrew Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Heather A. Carlos
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tracy Onega
- Huntsman Cancer Institute, University of Utah, Salt Lake City
- Department of Population Health Science, University of Utah, Salt Lake City
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Brooks GA, Clark L. The gamblers of the future? Migration from loot boxes to gambling in a longitudinal study of young adults. Computers in Human Behavior 2022. [DOI: 10.1016/j.chb.2022.107605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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20
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Buteau MAC, Brooks GA. Risk Stratification for Patients With Cancer and Febrile Neutropenia: Art or Science? JCO Oncol Pract 2022; 18:828-829. [PMID: 36256913 DOI: 10.1200/op.22.00644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Gabriel A Brooks
- Dartmouth Hitchcock Medical Center, Lebanon, NH.,Dartmouth Cancer Center, Lebanon, NH
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21
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Brooks GA, Tapp S, Daly AT, Busam JA, Tosteson ANA. Cost-effectiveness of DPYD Genotyping Prior to Fluoropyrimidine-based Adjuvant Chemotherapy for Colon Cancer. Clin Colorectal Cancer 2022; 21:e189-e195. [PMID: 35668003 PMCID: PMC10496767 DOI: 10.1016/j.clcc.2022.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Adjuvant fluoropyrimidine-based chemotherapy substantially reduces recurrence and mortality after resection of stage 3 colon cancer. While standard doses of 5-fluorouracil and capecitabine are safe for most patients, the risk of severe toxicity is increased for the approximately 6% of patients with dihydropyimidine dehydrogenase (DPD) deficiency caused by pathogenic DPYD gene variants. Pre-treatment screening for pathogenic DPYD gene variants reduces severe toxicity but has not been widely adopted in the United States. METHODS We conducted a cost-effectiveness analysis of DPYD genotyping prior to fluoropyrimidine-based adjuvant chemotherapy for stage 3 colon cancer, covering the c.1129-5923C>G (HapB3), c.1679T>G (*13), c.1905+1G>A (*2A), and c.2846A>T gene variants. We used a Markov model with a 5-year horizon, taking a United States healthcare perspective. Simulated patients with pathogenic DPYD gene variants received reduced-dose fluoropyrimidine chemotherapy. The primary outcome was the incremental cost-effectiveness ratio (ICER) for DPYD genotyping. RESULTS Compared with no screening for DPD deficiency, DPYD genotyping increased per-patient costs by $78 and improved survival by 0.0038 quality-adjusted life years (QALYs), leading to an ICER of $20,506/QALY. In 1-way sensitivity analyses, The ICER exceeded $50,000 per QALY when the cost of the DPYD genotyping assay was greater than $286. In probabilistic sensitivity analysis using a willingness-to-pay threshold of $50,000/QALY DPYD genotyping was preferred to no screening in 96.2% of iterations. CONCLUSION Among patients receiving adjuvant chemotherapy for stage 3 colon cancer, screening for DPD deficiency with DPYD genotyping is a cost-effective strategy for preventing infrequent but severe and sometimes fatal toxicities of fluoropyrimidine chemotherapy.
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Affiliation(s)
- Gabriel A Brooks
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH.
| | - Stephanie Tapp
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Allan T Daly
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | | | - Anna N A Tosteson
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
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22
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Zipkin RJ, Schaefer A, Wang C, Loehrer AP, Kapadia NS, Brooks GA, Onega T, Wang F, O'Malley AJ, Moen EL. Rural-Urban Differences in Breast Cancer Surgical Delays in Medicare Beneficiaries. Ann Surg Oncol 2022; 29:5759-5769. [PMID: 35608799 PMCID: PMC9128633 DOI: 10.1245/s10434-022-11834-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/15/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Delays between breast cancer diagnosis and surgery are associated with worsened survival. Delays are more common in urban-residing patients, although factors specific to surgical delays among rural and urban patients are not well understood. METHODS We used a 100% sample of fee-for-service Medicare claims during 2007-2014 to identify 238,491 women diagnosed with early-stage breast cancer undergoing initial surgery and assessed whether they experienced biopsy-to-surgery intervals > 90 days. We employed multilevel regression to identify associations between delays and patient, regional, and surgeon characteristics, both in combined analyses and stratified by rurality of patient residence. RESULTS Delays were more prevalent among urban patients (2.5%) than rural patients (1.9%). Rural patients with medium- or high-volume surgeons had lower odds of delay than patients with low-volume surgeons (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.58-0.88; OR = 0.74, 95% CI = 0.61-0.90). Rural patients whose surgeon operated at ≥ 3 hospitals were more likely to experience delays (OR = 1.29, 95% CI = 1.01-1.64, Ref: 1 hospital). Patient driving times ≥ 1 h were associated with delays among urban patients only. Age, black race, Hispanic ethnicity, multimorbidity, and academic/specialty hospital status were associated with delays. CONCLUSIONS Sociodemographic, geographic, surgeon, and facility factors have distinct associations with > 90-day delays to initial breast cancer surgery. Interventions to improve timeliness of breast cancer surgery may have disparate impacts on vulnerable populations by rural-urban status.
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Affiliation(s)
- Ronnie J Zipkin
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Andrew Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Changzhen Wang
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA, USA
| | - Andrew P Loehrer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Department of Surgery, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Tracy Onega
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
- Department of Population Sciences, University of Utah, Salt Lake City, UT, USA
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Fahui Wang
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA, USA
| | - Alistair J O'Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Erika L Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
- Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
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23
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Ramkumar N, Colla CH, Wang Q, O’Malley AJ, Wong SL, Brooks GA. Association of Rurality, Race and Ethnicity, and Socioeconomic Status With the Surgical Management of Colon Cancer and Postoperative Outcomes Among Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2229247. [PMID: 36040737 PMCID: PMC9428741 DOI: 10.1001/jamanetworkopen.2022.29247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/09/2022] [Indexed: 01/13/2023] Open
Abstract
Importance Rural patients with colon cancer experience worse outcomes than urban patients, but the extent to which disparities are explained by social determinants is not known. Objectives To evaluate the association of rurality with surgical treatment and outcomes of colon cancer and to investigate the intersection of rurality with race and ethnicity and socioeconomic status. Design, Settings, and Participants This cohort study included fee-for-service Medicare beneficiaries 65 years or older diagnosed with incident, nonmetastatic colon cancer between April 1, 2016, and September 30, 2018, with follow-up until December 31, 2018. Data were analyzed from August 3, 2020, to April 30, 2021. Exposures Rurality of patient's residence, categorized as metropolitan, micropolitan, or small town or rural, using Rural-Urban Commuting Area codes. Main Outcomes and Measures Receipt of surgery, emergent surgery, or minimally invasive surgery (MIS); 90-day surgical complications; and 90-day mortality. Results Among 57 710 Medicare beneficiaries with incident, nonmetastatic colon cancer, 46.6% were men, 53.4% were women, and the mean (SD) age was 76.6 (7.2) years. In terms of race and ethnicity, 3.7% were Hispanic, 6.4% were non-Hispanic Black (hereinafter Black), 86.1% were non-Hispanic White (hereinafter White), and 3.8% were American Indian or Alaska Native, Asian or Pacific Islander, or unknown race or ethnicity. Patients residing in nonmetropolitan areas were more likely to undergo surgical resection than those residing in metropolitan areas (69.2% vs 63.9%; P < .001). Black race was independently associated with lower hazard of surgical resection (hazard ratio, 0.92 [95% CI, 0.88-0.95]). Race and ethnicity and measures of socioeconomic status did not modify the association of rurality with surgery. Beneficiaries from small town and rural areas had higher odds of undergoing emergent surgery (adjusted odds ratio [OR], 1.32 [95% CI, 1.20-1.44]) but lower odds of undergoing MIS (adjusted OR, 0.75 [95% CI, 0.70-0.80]), with similar findings for patients residing in micropolitan areas. Members of racial and ethnic minority groups who resided in small town and rural settings experienced higher odds of postoperative surgical complications (P = .001 for interaction) and mortality (P = .001 for interaction). Notably, White patients who resided in small town and rural areas experienced lower odds of postoperative mortality than their White metropolitan counterparts (adjusted OR, 0.81 [95% CI, 0.71-0.92]), but Black patients who resided in small town and rural areas had significantly higher odds of postoperative mortality (adjusted OR, 1.86 [95% CI, 1.16-2.97]) than their Black metropolitan counterparts. Conclusions and Relevance These findings suggest that Medicare beneficiaries from small town and rural areas were more likely to undergo surgery for nonmetastatic colon cancer than metropolitan beneficiaries but also more likely to undergo emergent surgery and less likely to have MIS. The experiences of rural patients varied by race; rurality was associated with higher postoperative mortality for Black patients but not for other racial and ethnic groups.
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Affiliation(s)
- Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Congressional Budget Office, Washington, DC
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Biomedical Data Sciences, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Sandra L. Wong
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Congressional Budget Office, Washington, DC
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Gabriel A. Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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Sidloski B, Brooks GA, Zhang K, Clark L. Exploring the association between loot boxes and problem gambling: Are video gamers referring to loot boxes when they complete gambling screening tools? Addict Behav 2022; 131:107318. [PMID: 35381433 DOI: 10.1016/j.addbeh.2022.107318] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/18/2022] [Accepted: 03/28/2022] [Indexed: 11/01/2022]
Abstract
Concerns regarding the similarities between video game 'loot boxes' and gambling have been supported by correlations in survey studies between loot box engagement and problem gambling scores. It is generally noted that this correlation could reflect loot box users migrating to conventional gambling, and/or people with gambling problems being attracted to loot boxes when they play video games. We describe a third possibility, that when gamers complete problem gambling screens they may be referring to harms incurred from their loot box use. Using three secondary datasets from cross-sectional online surveys, we explore this account in two ways. First, in participants who do not endorse any participation in conventional forms of gambling, we compare rates of positive (i.e. non-zero) scores on the Problem Gambling Severity Index (PGSI) in participants with and without loot box use. Second, noting that some PGSI items have less relevance to loot box use versus gambling, we compare endorsement rates of individual PGSI items, in gamers versus gamblers, and loot box users vs non-loot box users (focusing on item 3 "going back another day to win back the money you lost"). In analysis 1, positive PGSI scorers among non-gamblers were significantly elevated in loot box users vs non-loot box users, although absolute numbers were low overall. In analysis 2, there were no reliable differences (gamers vs gamblers, loot box users vs non-loot box users) in PGSI item 3 endorsement rates. We conclude that these results provide partial support for this third option, and highlight a need for future studies to consider this possibility more directly.
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25
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Bergquist S, Brooks GA, Landrum MB, Keating NL, Rose S. Uncertainty in lung cancer stage for survival estimation via set-valued classification. Stat Med 2022; 41:3772-3788. [PMID: 35675972 PMCID: PMC9540678 DOI: 10.1002/sim.9448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 02/16/2022] [Accepted: 05/13/2022] [Indexed: 11/22/2022]
Abstract
The difficulty in identifying cancer stage in health care claims data has limited oncology quality of care and health outcomes research. We fit prediction algorithms for classifying lung cancer stage into three classes (stages I/II, stage III, and stage IV) using claims data, and then demonstrate a method for incorporating the classification uncertainty in survival estimation. Leveraging set‐valued classification and split conformal inference, we show how a fixed algorithm developed in one cohort of data may be deployed in another, while rigorously accounting for uncertainty from the initial classification step. We demonstrate this process using SEER cancer registry data linked with Medicare claims data.
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Affiliation(s)
- Savannah Bergquist
- Haas School of Business, University of California, Berkeley, Berkeley, California, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Sherri Rose
- Department of Health Policy and Center for Health Policy, Stanford University, Stanford, California, USA
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Kakani P, Beaulieu N, Brooks GA, Gray SW, Wright AA, Chernew M, Cutler DM, Landrum MB, Keating NL. The impact of physician-hospital integration on spending and quality of oncology care. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1584 Background: There has been increasing hospital and health system ownership of physician practices in recent years, particularly in oncology. However, relatively little is known about how this impacts care delivery for patients with cancer, who use many hospital-based services that may be impacted by integration. We evaluated the impact of physician-hospital integration in oncology on spending and quality of care for Medicare beneficiaries with cancer. Methods: We used Medicare Fee-for-Service claims from 2005-2019 linked with a unique Health System and Provider Database, developed by National Bureau of Economic Research and Harvard University researchers, to track practice ownership relationships over time. We used a stacked event study to assess outcomes for patients three years before and after oncologists move from independent practices to hospital- or system- owned practices. We compared outcomes to a control group with oncologists who shifted from independent to hospital- or system-owned practices in later years. We focused on two cohorts of patients. The first cohort included cancer patients with presumed incident or recurrent cancer based on ≥2 visits to an oncologist and no visit in the past year. For these patients, we evaluated the impact of physician-hospital integration on the likelihood of receiving chemotherapy following the visit. The second cohort included 6-month episodes for patients receiving chemotherapy. For these patients we evaluated the impact of physician-hospital integration on spending, utilization, and quality. Quality measures included receipt of timely chemotherapy (within 60 days) following surgery, inpatient readmissions, non-use of tamoxifen + strong CYPD26 inhibitors, and end-of-life intensity of care measures. Results: There was no change in the likelihood of receiving chemotherapy with an initial oncology consultation following an oncologist’s transition to hospital-based employment. Total spending during six-month chemotherapy episodes increased by $1391 (95%CI: $465, $2316). The primary contributors to this growth were increases in spending on inpatient care, chemotherapy administration, and office visits. Spending growth, where observed, was driven primarily by higher Medicare prices for care in hospital outpatient settings. We found no positive impact of physician-hospital integration on timeliness of chemotherapy initiation, readmissions, concurrent use of tamoxifen+strong CYPD26 inhibitors, or intensity of end-of-life care. Conclusions: Physician-hospital integration resulted in higher prices and thus higher spending, but had limited impact on utilization and no detectable impacts on measures of quality. These results suggest that claims of quality improvements and concerns regarding overuse associated with physician-hospital integration may be overstated. Our results also support continued movement towards site-neutral payments.
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Affiliation(s)
| | | | | | | | | | | | - David M Cutler
- Harvard Faculty of Arts and Sciences Department of Economics, Cambridge, MA
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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Roberts T, Kehl KL, Brooks GA, Sholl LM, Wright AA, Bai B, Landrum MB, Keating NL. Variation of use of targeted therapies and molecular diagnostic testing by practice type for non-small cell lung cancer and colorectal cancer. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.6551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6551 Background: Targeted therapies are important first-line treatments for many patients with non-small cell lung cancer (NSCLC) and colorectal cancer (CRC). All patients with newly-diagnosed metastatic NSCLC and CRC should undergo molecular diagnostic testing to guide treatment selection. Methods: We used 100% Medicare fee-for-service data from 2015 through 2019 to identify beneficiaries with incident metastatic NSCLC or CRC receiving systemic therapy and to assign beneficiaries to oncology practices. We then assessed for use of molecular diagnostic testing and targeted therapies in these cohorts. We used linear mixed effects models to assess patient and practice characteristics associated with molecular diagnostic testing and targeted therapy use. Results: Rates of molecular diagnostic testing increased between 2015 and 2019 for NSCLC and CRC. In 2019, rates of molecular diagnostic testing were 85% and 65% for NSCLC and CRC, respectively. Rates of targeted therapy use did not increase over time for NSCLC or CRC, and were 8% and 5%, respectively, in 2019. Compared to National Cancer Institute (NCI)-designated cancer centers, rates of molecular diagnostic testing for CRC were 3.7 percentage points lower at practices associated with non-academic hospitals and 10.6 percentage points lower at small independent practices. Rates of targeted therapy use for NSCLC were 4.8, 5.9 and 5.5 percentage points lower at academic medical centers, large independent practices and small independent practices, respectively, compared to NCI centers. Conclusions: Rates of molecular diagnostic testing for NSCLC and CRC increased in recent years, but testing rates remain below recommended levels, and targeted therapy use remains low. Substantial variation in testing and targeted therapy use by practice type suggest that the practice where a patient is treated may impact access to recommended testing and efficacious treatments. [Table: see text]
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Affiliation(s)
| | | | | | - Lynette M. Sholl
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | | | | | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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Milligan M, Erfani P, Orav EJ, Brooks GA, Lam M. Practice consolidation among U.S. medical oncologists over time. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e13627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e13627 Background: Physician practices across the U.S. are increasingly merging with hospitals and other practices. The extent of such “practice consolidation” varies by specialty and across geography but has not been well characterized within medical oncology. Methods: Utilizing Medicare data, we identified all medical oncologists (MO) who billed for Medicare services each year between 2015 and January 2022. We associated each physician to one or more unique practices via organizational Taxpayer Identification Numbers (TIN), and classified practices by the number of medical oncologists—including solo (1 MO), small (2-10 MOs), medium (11-24 MOs), and large (25+ MOs) practices. We defined the extent of regional healthcare markets according to Hospital Referral Regions (HRRs), and calculated levels of practice consolidation using the Herfindahl-Hirschman Index (HHI). The HHI is a commonly used measure of consolidation, calculated by summing the square of each practice’s market share. HHI values range from 0 to 1 with higher numbers indicating greater consolidation and less competition among practices. Finally, we generated a multivariable linear regression model to determine which regional market factors were associated with changes in levels of medical oncology practice consolidation over time. Results: Between 2015 and 2022, the number of practices with MOs in the U.S. declined 18.0% from 2,774 to 2,276, while the number of practicing MOs increased 14.5% from 11,727 to 13,433. The median medical oncology practice HHI increased from 0.3204 to 0.3480. Over time the proportion of solo practices fell (48.4% in 2015, 43.9% in 2022) while the proportion of medium and large practices increased (medium: 5.7% to 8.4%; large: 2.7% to 4.5%). By 2022, large practices had grown to employ a significantly larger proportion of all medical oncologists (33.6% to 43.7%, p < 0.001). Between 2015 and 2022, the proportion of practices solely comprised of MOs (as opposed to multispecialty practices) decreased from 40.0% to 28.2%. On multivariable analysis, HRRs with higher levels of hospital consolidation (p < 0.001), greater numbers of hospital beds per 1,000 persons (p = 0.02), and a lesser degree of baseline medical oncology practice consolidation in 2015 (p < 0.001) experienced more consolidation during the study period. Conclusions: Medical oncologists across the U.S. are increasingly working in larger practices. By 2022, more than 40% of all practicing MOs were employed at the largest 5% of practices. Consolidation of medical oncology practices occurred more readily in regions with higher levels of hospital consolidation and a greater supply of hospital beds, suggesting that integration into hospital systems may be a leading source of consolidation. Further study is required to determine the impact of practice consolidation on the cost, quality, and accessibility of cancer care.
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Affiliation(s)
| | | | | | | | - Miranda Lam
- Brigham and Women's Hospital/Dana Farber Cancer Institute, Boston, MA
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Khayal IS, Brooks GA, Barnato AE. Development of dynamic health care delivery heatmaps for end-of-life cancer care: a cohort study. BMJ Open 2022; 12:e056328. [PMID: 35589364 PMCID: PMC9121487 DOI: 10.1136/bmjopen-2021-056328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 05/05/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Measures of variation in end-of-life (EOL) care intensity across hospitals are typically summarised using unidimensional measures. These measures do not capture the full dimensionality of complex clinical care trajectories over time that are needed to inform quality improvement efforts. The objective is to develop a novel visual map of EOL care trajectories that illustrates multidimensional utilisation over time. SETTING United States' National Cancer Institute or National Comprehensive Cancer Network (NCI/NCCN)-designated hospitals. PARTICIPANTS We identified Medicare claims for fee-for-service beneficiaries with poor prognosis cancers who died between April and December 2016 and received the preponderance of treatment in the last 6 months of life at an NCI/NCCN-designated hospital. DESIGN For each beneficiary, we transformed each Medicare claim into two elements to generate a two-dimensional individual-level heatmap. On the y-axis, each claim was classified into a categorical description of the service delivered by a healthcare resource. On the x-axis, the date for each claim was converted into the day number prior to death it occurred on. We then summed up individual-level heatmaps of patients attributed to each hospital to generate two-dimensional hospital-level heatmaps. We used four case studies to illustrate the feasibility of interpreting these heatmaps and to shed light on how they might be used to guide value-based, quality improvement initiatives. RESULTS We identified nine distinct EOL care delivery patterns from hospital-level heatmaps based on signal intensity and patterns for inpatient, outpatient and home-based hospice services. We illustrate that in most cases, heatmaps illustrating patterns of multidimensional healthcare utilisation over time provide more information about care trajectories and highlight more heterogeneity than current unidimensional measures. CONCLUSIONS This study illustrates the feasibility of representing multidimensional EOL utilisation over time as a heatmap. These heatmaps may provide potentially actionable insights into hospital-level care delivery patterns, and the approach may generalise to other serious illness populations.
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Affiliation(s)
- Inas S Khayal
- The Dartmouth Institute for Health Policy & Clinical Practice and Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Department of Computer Science, Dartmouth College, Hanover, New Hampshire, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Section of Medical Oncology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Section of Palliative Care, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Brooks GA, Clark L. Gambling along the schizotypal spectrum: The associations between schizotypal personality, gambling-related cognitions, luck, and problem gambling. J Behav Addict 2022; 11. [PMID: 35594166 PMCID: PMC9295216 DOI: 10.1556/2006.2022.00021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Schizotypal personality (schizotypy) is a cluster of traits in the general population, including alterations in belief formation that may underpin delusional thinking. The psychological processes described by schizotypy could also fuel cognitive distortions in the context of gambling. This study sought to characterize the relationships between schizotypy, gambling-related cognitive distortions, and levels of problem gambling. Methods Analyses were conducted on three groups, a student sample (n = 104) with minimal self-reported gambling involvement, a crowdsourced sample of regular gamblers (via MTurk; n = 277), and an additional crowdsourced sample with a range of gambling involvement (via MTurk; n = 144). Primary measures included the Schizotypal Personality Questionnaire - Brief (SPQ-B), the Peters et al. Delusions Inventory (PDI-21), the Gambling Related Cognitions Scale (GRCS), and the Problem Gambling Severity Index (PGSI). Luck was measured with either the Belief in Good Luck Scale (BIGLS) or the Beliefs Around Luck Scale (BALS). Results Small-to-moderate associations were detected between the components of schizotypy, including delusion proneness, and the gambling-related variables. Schizotypy was associated with the general belief in luck and bad luck, but not beliefs in good luck. A series of partial correlations demonstrated that when the GRCS was controlled for, the relationship between schizotypy and problem gambling was attenuated. Conclusions This study demonstrates that schizotypy is a small-to-moderate correlate of erroneous gambling beliefs and PG. These data help characterize clinical comorbidities between the schizotypal spectrum and problem gambling, and point to shared biases relating to belief formation and decision-making under chance.
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Affiliation(s)
- Gabriel A. Brooks
- Centre for Gambling Research, Department of Psychology, University of British Columbia, Vancouver, Canada
| | - Luke Clark
- Centre for Gambling Research, Department of Psychology, University of British Columbia, Vancouver, Canada
- Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada
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Zipkin RJ, Schaefer A, Wang C, Loehrer AP, Kapadia NS, Brooks GA, Onega T, Wang F, O'Malley AJ, Moen EL. ASO Visual Abstract: Rural-Urban Differences in Breast Cancer Surgical Delays in Medicare Beneficiaries. Ann Surg Oncol 2022. [PMID: 35552923 DOI: 10.1245/s10434-022-11877-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Ronnie J Zipkin
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Andrew Schaefer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Changzhen Wang
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA, USA
| | - Andrew P Loehrer
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Department of Surgery, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Tracy Onega
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.,Department of Population Sciences, University of Utah, Salt Lake City, UT, USA.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Fahui Wang
- Department of Geography and Anthropology, Louisiana State University, Baton Rouge, LA, USA
| | - Alistair J O'Malley
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.,Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Erika L Moen
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA. .,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA. .,Dartmouth Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
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Keating NL, Landrum MB, Samuel-Ryals C, Sinaiko AD, Wright A, Brooks GA, Bai B, Zaslavsky AM. Measuring Racial Inequities In The Quality Of Care Across Oncology Practices In The US. Health Aff (Millwood) 2022; 41:598-606. [PMID: 35377762 DOI: 10.1377/hlthaff.2021.01594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Racial inequities in clinical performance diminish overall health care system performance; however, quality assessments have rarely incorporated reliable measures of racial inequities. We studied care for more than one million Medicare fee-for-service beneficiaries with cancer to assess the feasibility of calculating reliable practice-level measures of racial inequities in chemotherapy-associated emergency department (ED) visits and hospitalizations. Specifically, we used hierarchical models to estimate adjusted practice-level Black-White differences in these events and described differences across practices. We calculated reliable inequity measures for 426 and 322 practices, depending on the measure. These practices reflected fewer than 10 percent of practices treating Medicare beneficiaries with chemotherapy, but they treated approximately half of all White and Black Medicare beneficiaries receiving chemotherapy and two-thirds of Black Medicare beneficiaries receiving chemotherapy. Black patients experienced chemotherapy-associated ED visits and hospitalizations at higher rates (54.2 percent and 35.8 percent, respectively) than White patients (45.7 percent and 31.9 percent, respectively). The median within-practice Black-White difference was 8.1 percentage points for chemotherapy-associated ED visits and 2.7 percentage points for chemotherapy-associated hospitalizations. Additional research is needed to identify other reliable measures of racial inequities in health care quality, measure care inequities in smaller practices, and assess whether providing practice-level feedback could improve equity.
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Affiliation(s)
- Nancy L Keating
- Nancy L. Keating , Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Cleo Samuel-Ryals
- Cleo Samuel-Ryals, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Alexi Wright
- Alexi Wright, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabriel A Brooks
- Gabriel A. Brooks, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Emery LP, Brooks GA. Revisiting UGT1A1 Pharmacogenetic Testing Before Irinotecan-Why Not? JCO Oncol Pract 2022; 18:281-282. [PMID: 35108028 PMCID: PMC9014453 DOI: 10.1200/op.21.00840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/12/2021] [Indexed: 01/07/2023] Open
Affiliation(s)
- Lukas P. Emery
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Gabriel A. Brooks
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Geisel School of Medicine, Lebanon, NH
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Brooks GA, Landrum MB, Kapadia NS, Liu PH, Wolf R, Riedel LE, Hsu VD, Jhatakia Parekh S, Simon C, Hassol A, Keating NL. Impact of the Oncology Care Model on Use of Supportive Care Medications During Cancer Treatment. J Clin Oncol 2022; 40:1763-1771. [PMID: 35213212 DOI: 10.1200/jco.21.02342] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The Oncology Care Model (OCM) is an episode-based alternative payment model for cancer care that seeks to reduce Medicare spending while maintaining care quality. We evaluated the impact of OCM on appropriate use of supportive care medications during cancer treatment. METHODS We evaluated chemotherapy episodes assigned to OCM (n = 201) and comparison practices (n = 534) using Medicare claims (2013-2019). We assessed denosumab use for beneficiaries with bone metastases from breast, lung, or prostate cancer; prophylactic WBC growth factor use for beneficiaries receiving chemotherapy for breast, lung, or colorectal cancer; and prophylactic use of neurokinin-1 (NK1) antagonists and long-acting serotonin antagonists for beneficiaries receiving chemotherapy for any cancer type. Analyses used a difference-in-difference approach. RESULTS After its launch in 2016, OCM led to a relative reduction in the use of denosumab for beneficiaries with bone metastases receiving bone-modifying medications (eg, 5.0 percentage point relative reduction in breast cancer episodes [90% CI, -7.1 to -2.8]). There was no OCM impact on use of prophylactic WBC growth factors during chemotherapy with high or low risk for febrile neutropenia. Among beneficiaries receiving chemotherapy with intermediate febrile neutropenia risk, OCM led to a 7.6 percentage point reduction in the use of prophylactic WBC growth factors during breast cancer episodes (90% CI, -12.6 to -2.7); there was no OCM impact in lung or colorectal cancer episodes. Among beneficiaries receiving chemotherapy with high or moderate emetic risk, OCM led to reductions in the prophylactic use of NK1 antagonists and long-acting serotonin antagonists (eg, 6.0 percentage point reduction in the use of NK1 antagonists during high emetic risk chemotherapy [90% CI, -9.0 to -3.1]). CONCLUSION OCM led to the reduced use of some high-cost supportive care medications, suggesting more value-conscious care.
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Affiliation(s)
- Gabriel A Brooks
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Nirav S Kapadia
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH
| | - Pang-Hsiang Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Robert Wolf
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Lauren E Riedel
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Van Doren Hsu
- General Dynamics Information Technology, Falls Church, VA
| | | | | | | | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
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35
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Keating NL, Brooks GA, Landrum MB, Liu PH, Wolf R, Riedel LE, Kapadia NS, Jhatakia S, Tripp A, Simon C, Hsu VD, Kummet CM, Hassol A. The Oncology Care Model and Adherence to Oral Cancer Drugs: A Difference-in-Differences Analysis. J Natl Cancer Inst 2022; 114:871-877. [PMID: 35134972 PMCID: PMC9194623 DOI: 10.1093/jnci/djac026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/06/2021] [Accepted: 01/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adherence to oral cancer drugs is suboptimal. The Oncology Care Model (OCM) offers oncology practices financial incentives to improve the value of cancer care. We assessed the impact of OCM on adherence to oral cancer therapy for chronic myelogenous leukemia (CML), prostate cancer, and breast cancer. METHODS Using 2014-2019 Medicare data, we studied chemotherapy episodes for Medicare fee-for-service beneficiaries prescribed tyrosine kinase inhibitors (TKIs) for CML, antiandrogens (ie, enzalutamide, abiraterone) for prostate cancer, or hormonal therapies for breast cancer in OCM-participating and propensity-matched comparison practices. We measured adherence as the proportion of days covered and used difference-in-difference (DID) models to detect changes in adherence over time, adjusting for patient, practice, and market-level characteristics. RESULTS There was no overall impact of OCM on improved adherence to TKIs for CML (DID = -0.3%, 90% confidence interval [CI] = -1.2% to 0.6%), antiandrogens for prostate cancer (DID = 0.4%, 90% CI = -0.3% to 1.2%), or hormonal therapy for breast cancer (DID = 0.0%, 90% CI = -0.2% to 0.2%). Among episodes for Black beneficiaries in OCM practices, for whom adherence was lower than for White beneficiaries at baseline, we observed small improvements in adherence to high cost TKIs (DID = 3.0%, 90% CI = 0.2% to 5.8%) and antiandrogens (DID = 2.2%, 90% CI = 0.2% to 4.3%). CONCLUSIONS OCM did not impact adherence to oral cancer therapies for Medicare beneficiaries with CML, prostate cancer, or breast cancer overall but modestly improved adherence to high-cost TKIs and antiandrogens for Black beneficiaries, who had somewhat lower adherence than White beneficiaries at baseline. Patient navigation and financial counseling are potential mechanisms for improvement among Black beneficiaries.
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Affiliation(s)
- Nancy L Keating
- Correspondence to: Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115, USA (e-mail: )
| | - Gabriel A Brooks
- Section of Medical Oncology, Department of Medicine, Geisel School of Medicine, Lebanon, NH, USA
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Pang-Hsiang Liu
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Robert Wolf
- Department of Health Care Policy , Harvard Medical School, Boston, MA, USA
| | - Lauren E Riedel
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Nirav S Kapadia
- Section of Medical Oncology, Department of Medicine, Geisel School of Medicine, Lebanon, NH, USA
| | | | | | | | - Van Doren Hsu
- General Dynamics Information Technology, Falls Church, VA, USA
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36
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Keating NL, Jhatakia S, Brooks GA, Tripp AS, Cintina I, Landrum MB, Zheng Q, Christian TJ, Glass R, Hsu VD, Kummet CM, Woodman S, Simon C, Hassol A. Association of Participation in the Oncology Care Model With Medicare Payments, Utilization, Care Delivery, and Quality Outcomes. JAMA 2021; 326:1829-1839. [PMID: 34751709 PMCID: PMC8579232 DOI: 10.1001/jama.2021.17642] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE In 2016, the US Centers for Medicare & Medicaid Services initiated the Oncology Care Model (OCM), an alternative payment model designed to improve the value of care delivered to Medicare beneficiaries with cancer. OBJECTIVE To assess the association of the OCM with changes in Medicare spending, utilization, quality, and patient experience during the OCM's first 3 years. DESIGN, SETTING, AND PARTICIPANTS Exploratory difference-in-differences study comparing care during 6-month chemotherapy episodes in OCM participating practices and propensity-matched comparison practices initiated before (January 2014 through June 2015) and after (July 2016 through December 2018) the start of the OCM. Participants included Medicare fee-for-service beneficiaries with cancer treated at these practices through June 2019. EXPOSURES OCM participation. MAIN OUTCOMES AND MEASURES Total episode payments (Medicare spending for Parts A, B, and D, not including monthly payments for enhanced oncology services); utilization and payments for hospitalizations, emergency department (ED) visits, office visits, chemotherapy, supportive care, and imaging; quality (chemotherapy-associated hospitalizations and ED visits, timely chemotherapy, end-of-life care, and survival); and patient experiences. RESULTS Among Medicare fee-for-service beneficiaries with cancer undergoing chemotherapy, 483 319 beneficiaries (mean age, 73.0 [SD, 8.7] years; 60.1% women; 987 332 episodes) were treated at 201 OCM participating practices, and 557 354 beneficiaries (mean age, 72.9 [SD, 9.0] years; 57.4% women; 1 122 597 episodes) were treated at 534 comparison practices. From the baseline period, total episode payments increased from $28 681 for OCM episodes and $28 421 for comparison episodes to $33 211 for OCM episodes and $33 249 for comparison episodes during the intervention period (difference in differences, -$297; 90% CI, -$504 to -$91), less than the mean $704 Monthly Enhanced Oncology Services payments. Relative decreases in total episode payments were primarily for Part B nonchemotherapy drug payments (difference in differences, -$145; 90% CI, -$218 to -$72), especially supportive care drugs (difference in differences, -$150; 90% CI, -$216 to -$84). The OCM was associated with statistically significant relative reductions in total episode payments among higher-risk episodes (difference in differences, -$503; 90% CI, -$802 to -$204) and statistically significant relative increases in total episode payments among lower-risk episodes (difference in differences, $151; 90% CI, $39-$264). The OCM was not significantly associated with differences in hospitalizations, ED visits, or survival. Of 22 measures of utilization, 10 measures of quality, and 7 measures of care experiences, only 5 were significantly different. CONCLUSIONS AND RELEVANCE In this exploratory analysis, the OCM was significantly associated with modest payment reductions during 6-month episodes for Medicare beneficiaries receiving chemotherapy for cancer in the first 3 years of the OCM that did not offset the monthly payments for enhanced oncology services. There were no statistically significant differences for most utilization, quality, and patient experience outcomes.
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Affiliation(s)
- Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | | | | | | | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Qing Zheng
- Abt Associates, Cambridge, Massachusetts
| | | | | | - Van Doren Hsu
- General Dynamics Information Technology, Falls Church, Virginia
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Brooks GA, Waleed M, McGrath EB, Beloin K, Walsh SK, Benoit PR, Khan WA, Tsongalis GJ, Amin MA, Faris JE, Ripple GH, Hourdequin KC. Sustainability and clinical outcomes of routine screening for pathogenic DPYD gene variants prior to fluoropyrimidine (FP) chemotherapy for gastrointestinal (GI) cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
216 Background: Dihyropyrimidine dehydrogenase (DPD) deficiency is present in 3-5% of patients, and is associated with substantially increased risk of severe and/or fatal toxicity during standard-dose FP chemotherapy. Genotyping of pathogenic DPYD variants is a readily available screening test for DPD deficiency, and prospective studies show that dose-reduced FP chemotherapy can be used safely in heterozygous DPYD variant carriers. Methods: Following a sentinel toxicity event the GI medical oncology group at the Norris Cotton Cancer Center adopted a shared practice of routine screening for pathogenic DPYD gene variants prior to FP chemotherapy (5-FU or capecitabine). Screening procedures involved physicians, NP/PAs, nurses, pharmacists, and schedulers. Testing was completed at a send-out lab until late 2020, when an in-house test became available. The current test panel evaluates for 3 gene variants: c.1905+1G > A (*2A), c.1679T > G (*13), and c.2846A > T. We report on the sustainability and clinical outcomes of DPYD gene variant screening. We identified all patients starting new FP-containing intravenous chemotherapy regimens (e.g., FOLFOX, CAPOX) for treatment of GI cancer at two sites (LEB & STJ) between Jan. 2019 and May 2021. We used electronic medical records to evaluate for completion of DPYD genotyping, and we describe the prevalence and management of DPYD gene variant carriers. Results: We identified 333 patients starting FP-containing chemotherapy regimens during the study period, including 287 patients without prior history of FP chemotherapy. Screening with DPYD genotyping was completed in 228 of 287 eligible patients (79%). Screening rates increased from 34% in Q1 of 2019 to 90% in Jan-May 2021. Five GI oncology sub-specialists accounted for 89% of screen-eligible patients and 96% of completed tests, but 10 unique physicians ordered ≥1 test. Of 228 screened patients, six (2.6%) were heterozygous carriers of pathogenic DPYD gene variants (*2A [2 patients], *13 [1], and c.2846A > T [3]). Variant carriers started FP chemotherapy with a 33-50% reduction. Two of six patients required further dose reduction due to FP-related toxicity (grade 4 neutropenia, grade 3 diarrhea). All evaluable variant carriers completed planned initial treatment. Implementation challenges included variable insurance coverage of DPYD genotyping, site-specific test ordering and reporting processes, and inconsistent turn-around time for send-out testing (resolved with on-site testing). Conclusions: Routine screening for pathogenic DPYD gene variants prior to FP chemotherapy is feasible and sustainable in the U.S. DPYD genotyping coupled with chemotherapy dose reductions for DPYD variant carriers facilitates safe and timely completion of planned chemotherapy treatments.
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Affiliation(s)
| | | | | | - Kara Beloin
- Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | | | - Gregory J. Tsongalis
- The Geisel School of Medicine at Dartmouth and Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Ramkumar N, Colla C, Wang Q, O'Malley J, Wong SL, Brooks GA. Association of rurality and race with surgical treatment and outcomes for nonmetastatic colon cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2020.39.28_suppl.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
78 Background: Rural cancer patients face limited access to care due to greater travel distance and lack of specialty cancer care. Little is known about the intersection of rurality with well-documented racial disparities in colon cancer treatment and outcomes. Methods: We used fee-for-service Medicare claims to study patients age 65+ diagnosed with incident colon cancer without evidence of metastases who underwent cancer-directed surgery between 04/01/2016 and 09/30/2018. The primary exposure wasrurality of patient’s residence categorized as metropolitan (metro), micropolitan, and small town/rural. Outcomes were non-elective surgery (emergency department visit or transfer within 2 days prior to surgery), receipt of minimally invasive surgery (laparoscopic or robotic), 90-day surgical complications, and 90-day mortality. Logistic regression adjusted for patient demographics, cancer side (right vs left), comorbidities, and Area Deprivation Index. We assessed effect modification by race/ethnicity. Results: Of 57,710 patients with incident non-metastatic colon cancer, 37,691 (65%) underwent surgery. In this surgical cohort, small town/rural and micropolitan residents were more likely to be older, white, and Medicare-Medicaid dual-eligible than metro residents. After risk adjustment, patients in small town/rural areas had higher odds of non-elective surgery (OR =1.24, 95% CI:1.13-1.36) and lower odds of minimally invasive surgery (OR = 0.75, 95% CI:0.71-0.80) than patients living in metro areas. Similar results were seen for micropolitan areas. White rural patients had lower mortality than white urban patients, whereas black rural patients had higher mortality than black metro patients (see Table). Increasing area deprivation was associated with higher odds of non-elective surgery, surgical complications and mortality, and lower odds of minimally invasive surgery, even after adjusting for race and rurality. Conclusions: Small town/rural-residing Medicare beneficiaries undergoing surgery for non-metastatic colon cancer were less likely to receive optimal surgical management and had worse outcomes, especially among non-white patients. The compounded effect of rurality, race/ethnicity, and social deprivation should be incorporated in developing policies and interventions to improve care for rural cancer patients.[Table: see text]
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Affiliation(s)
- Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Carrie Colla
- Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - James O'Malley
- Dartmouth College Geisel School of Medicine, Lebanon, NH
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Nekhlyudov L, Campbell GB, Schmitz KH, Brooks GA, Kumar AJ, Ganz PA, Von Ah D. Cancer-related impairments and functional limitations among long-term cancer survivors: Gaps and opportunities for clinical practice. Cancer 2021; 128:222-229. [PMID: 34529268 PMCID: PMC9292035 DOI: 10.1002/cncr.33913] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/27/2021] [Accepted: 08/27/2021] [Indexed: 12/20/2022]
Abstract
This commentary provides a concise overview of the epidemiology of cancer survivorship and work, common functional limitations experienced by cancer survivors, and evidence‐based recommendations for interventions available to improve function. It also describes the US Social Security Administration's disability claims process, its eligibility requirements, and barriers for long‐term survivors in securing approval for disability claims, and offers insights for practicing clinicians in holistically addressing functional limitations in practice.
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Affiliation(s)
- Larissa Nekhlyudov
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Grace B Campbell
- Duquesne University School of Nursing, Pittsburgh, Pennsylvania.,Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kathryn H Schmitz
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Gabriel A Brooks
- Norris Cotton Cancer Center, Geisel School of Medicine, Lebanon, New Hampshire
| | - Anita J Kumar
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Patricia A Ganz
- School of Medicine, University of California Los Angeles, Los Angeles, California.,Department of Health Policy and Management, School of Public Health, University of California Los Angeles, Los Angeles, California.,Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, California
| | - Diane Von Ah
- College of Nursing, Ohio State University, Columbus, Ohio
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Sharma BB, Rai K, Blunt H, Zhao W, Tosteson TD, Brooks GA. Pathogenic DPYD Variants and Treatment-Related Mortality in Patients Receiving Fluoropyrimidine Chemotherapy: A Systematic Review and Meta-Analysis. Oncologist 2021; 26:1008-1016. [PMID: 34506675 DOI: 10.1002/onco.13967] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/06/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pathogenic variants of the DPYD gene are strongly associated with grade ≥3 toxicity during fluoropyrimidine chemotherapy. We conducted a systematic review and meta-analysis to estimate the risk of treatment-related death associated with DPYD gene variants. MATERIALS AND METHODS We searched for reports published prior to September 17, 2020, that described patients receiving standard-dose fluoropyrimidine chemotherapy (5-fluorouracil or capecitabine) who had baseline testing for at least one of four pathogenic DPYD variants (c.1129-5923C>G [HapB3], c.1679T>G [*13], c.1905+1G>A [*2A], and c.2846A>T) and were assessed for toxicity. Two reviewers assessed studies for inclusion and extracted study-level data. The primary outcome was the relative risk of treatment-related mortality for DPYD variant carriers versus noncarriers; we performed data synthesis using a Mantel-Haenszel fixed effects model. RESULTS Of the 2,923 references screened, 35 studies involving 13,929 patients were included. DPYD variants (heterozygous or homozygous) were identified in 566 patients (4.1%). There were 14 treatment-related deaths in 13,363 patients without identified DPYD variants (treatment-related mortality, 0.1%; 95% confidence interval [CI], 0.1-0.2) and 13 treatment-related deaths in 566 patients with any of the four DPYD variants (treatment-related mortality, 2.3%; 95% CI, 1.3%-3.9%). Carriers of pathogenic DPYD gene variants had a 25.6 times increased risk of treatment-related death (95% CI, 12.1-53.9; p < .001). After excluding carriers of the more common but less deleterious c.1129-5923C>G variant, carriers of c.1679T>G, c.1905+1G>A, and/or c.2846A>T had treatment-related mortality of 3.7%. CONCLUSION Patients with pathogenic DPYD gene variants who receive standard-dose fluoropyrimidine chemotherapy have greatly increased risk for treatment-related death. IMPLICATIONS FOR PRACTICE The syndrome of dihydropyrimidine dehydrogenase (DPD) deficiency is an uncommon but well-described cause of severe toxicity related to fluoropyrimidine chemotherapy agents (5-fluorouracil and capecitabine). Patients with latent DPD deficiency can be identified preemptively with genotyping of the DPYD gene, or with measurement of the plasma uracil concentration. In this systematic review and meta-analysis, the authors study the rare outcome of treatment-related death after fluoropyrimidine chemotherapy. DPYD gene variants associated with DPD deficiency were linked to a 25.6 times increased risk of fluoropyrimidine-related mortality. These findings support the clinical utility of DPYD genotyping as a screening test for DPD deficiency.
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Affiliation(s)
| | - Karan Rai
- Geisel School of Medicine at Dartmouth, Lebanon, New Hamphsire, USA
| | - Heather Blunt
- Biomedical Libraries, Dartmouth College, Hanover, New Hampshire, USA
| | - Wenyan Zhao
- Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Tor D Tosteson
- Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, New Hampshire, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Gabriel A Brooks
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire, USA
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Keating NL, Landrum MB, Zaslavsky A, Samuel CA, Sinaiko A, Brooks GA, Wright AA, Bai B. Measuring disparities in quality of oncology care across oncology practices. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.6533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6533 Background: Equity is now recognized as an essential aspect of health care quality. Racial inequities in clinical performance diminish overall system performance. We assessed the feasibility and reliability of practice-level measures of racial disparities in chemotherapy-associated emergency department (ED) visits and hospitalizations. Methods: Using fee-for-service Medicare data, we identified 1,196,970 Black or White fee-for-service Medicare beneficiaries with cancer receiving chemotherapy in 2016-2019, who were attributed to 5511 oncology practices that treated at least 1 Black and 1 White beneficiary (96.4% of all beneficiaries). We studied two CMS quality measures: chemotherapy associated ED visits and chemotherapy associated hospitalizations. For each outcome, we estimated multi-level models with separate practice-level random intercepts for Black and White patients to quantify practice-level Black-White disparities in adjusted rates of these measures and assess the associations of these rates with the proportion of Black patients in the practice. Results: Overall, 108,177 Black and 966,381 White beneficiaries with cancer were treated at 1321 practices with reliable estimates (reliability ≥70%) of Black-White differences in rates of chemotherapy-associated ED visits; 101,411 Black and 915,895 White beneficiaries were treated at 1,012 practices with reliable estimates of chemotherapy-associated hospitalizations. These practices treated 80% or more of all Black and White beneficiaries; 10% of these practices treated 75% of Black beneficiaries. The median adjusted Black-White rate difference across practices was +8.9% [interquartile interval (IQI) +5.0%, +12.8%; 5th, 95th percentile -1.8 to +19.2%] for chemotherapy associated ED visits and +4.4% [IQI +1.3%, +7.7%; 5th, 95th percentile -3.5% to +13.5%] for chemotherapy associated hospitalizations. Chemotherapy-associated ED visit rates were 3.2 percentage points higher for Black vs White patients (P <.001) at the practice with the mean % of Black patients, but the difference was smaller in practices with more Black patients (0.4 percentage points less for each 10% increase in Black share, P <.001). Chemotherapy-associated hospitalization rates were 0.6 percentage points lower for Black vs White patients (P =.01) but did not vary by practice racial composition. Conclusions: Using data from more than 1000 practices over 4 years, we calculated reliable estimates of practice-level racial disparities in chemotherapy-associated ED visits and hospitalizations. Practice-level performance for these quality measures was generally lower for Black versus White beneficiaries. Measuring and providing feedback on practice-level Black-White disparities in oncology performance measures may be one effective tool for advancing racial equity in care quality for cancer patients receiving chemotherapy.
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Affiliation(s)
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | | | - Cleo A. Samuel
- UNC Gillings School of Global Public Health, Chapel Hill, NC
| | - Anna Sinaiko
- Harvard T.H. Chan School of Public Health, Boston, MA
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Emery LP, Muralikrishnan S, Tosteson A, Schrag D, Brooks GA. Comparison of clinician and model estimates of risk for hospitalization during systemic therapy for advanced cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.1530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1530 Background: Patients receiving treatment for advanced cancer are at substantial risk for unplanned hospitalization. A validated two-variable risk model can identify patients at increased risk for hospitalization. However, little is known about how model-based estimates of hospitalization risk compare with assessments of treating clinicians. Methods: We identified patients initiating a new line of systemic therapy for advanced non-hematologic cancer. For each patient, we assigned three categorical estimates of 30-day hospitalization risk. The first risk estimate was generated by a validated two-variable risk prediction model with inputs of pretreatment plasma sodium and albumin (PMID: 30995122); continuous risk scores were converted to risk tertiles. We solicited a second risk estimate by real-time survey of a treating oncology clinician; clinicians were instructed to estimate hospitalization risk as low, intermediate, or high, as compared with other patients. A third hybrid risk estimate retained the highest risk category from either the clinician or model risk assessment. We describe the agreement of clinician and model-based estimates of 30-day hospitalization risk, and we compare the sensitivity and specificity of clinician, model, and hybrid high-risk assessments, using McNemar’s test. We compared discrimination of the three risk estimates via the area under the ROC curve (AUC). Results: We identified 104 patients with valid clinician and model hospitalization risk estimates and complete 30-day follow-up. The most common cancer type was lung cancer (27%), the median age was 68 years, and 62% of patients were male. 30-day hospitalization occurred in 21 patients (20.2%). There was moderate to poor agreement between clinician and model categorical estimates of hospitalization risk (weighted kappa = 0.245). The proportion of patients identified as high-risk by the clinician, model, and hybrid assessments was 15.4%, 26.0%, and 33.7%. Sensitivity and specificity of the high-risk categorization for 30-day hospitalization were 38% and 90% for the clinician assessment, 57% and 82% for the model assessment (NSS for comparison with clinician assessment), and 76% and 77% for the hybrid assessment (greater sensitivity [p = 0.008] and lesser specificity [p = 0.001] than clinician assessment). The AUC values for the clinician, model, and hybrid assessments were 0.674, 0.757, and 0.764, respectively. Conclusions: Compared with the estimate of a treating clinician, a two-variable risk model exhibited similar sensitivity and specificity for 30-day hospitalization risk. A hybrid risk assessment incorporating information from the risk model significantly improved on the sensitivity of the clinician risk assessment. Future research should test strategies to prevent hospitalizations by targeting interventions to high-risk patients.
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Ramkumar N, Colla C, Wong SL, Wang Q, Brooks GA. Association of rurality and race with surgical treatment and outcomes for nonmetastatic colon cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18536 Background: Rural cancer patients face limited access to care due to greater travel distance and lack of specialty cancer care. Little is known about the intersection of rurality with well-documented racial disparities in colon cancer treatment and outcomes. Methods: We used fee-for-service Medicare claims to study patients age 65+ diagnosed with incident colon cancer without evidence of metastases who underwent cancer-directed surgery between 04/01/2016 and 09/30/2018. The primary exposure was rurality of patient’s residence categorized as metropolitan (metro), micropolitan, and small town/rural. Outcomes were non-elective surgery (emergency department visit or transfer within 2 days of surgery), receipt of minimally invasive surgery (laparoscopic or robotic), 90-day surgical complications, and 90-day mortality. Logistic regression adjusted for patient demographics, cancer side (right vs left), comorbidities, and Area Deprivation Index. We assessed effect modification by race/ethnicity. Results: Of 57,710 patients with incident non-metastatic colon cancer, 37,691 (65%) underwent surgery. In this surgical cohort, small town/rural and micropolitan residents were more likely to be older, white, and Medicare-Medicaid dual-eligible than metro residents. After risk adjustment, patients in small town/rural areas had higher odds of non-elective surgery (OR=1.24, 95% CI:1.13-1.36) and lower odds of minimally invasive surgery (OR=0.75, 95% CI:0.71-0.80) than patients living in metro areas. Similar results were seen for micropolitan areas. The association between rurality and 90-day outcomes differed by race/ethnicity (p-interaction=0.001 for surgical complications and mortality, see Table). Hispanics and other races had higher odds of 90-day surgical complications in non-metro versus metro areas but there was no notable difference for white patients. Likewise, compared to metro areas, racial/ethnic minorities had higher odds of 90-day mortality in small town/rural areas but white patients had lower odds. Conclusions: Small town/rural-residing Medicare beneficiaries undergoing surgery for non-metastatic colon cancer were less likely to receive optimal surgical management and worse outcomes, especially among non-white patients. The compounded effect of sociodemographic factors should be further studied to develop targeted policies and improve care for rural cancer patients.[Table: see text]
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Affiliation(s)
- Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Carrie Colla
- Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
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Brooks GA, Landrum MB, Kapadia NS, Liu PH, Wolf RR, Riedel LE, Hsu VD, Jhatakia S, Simon C, Hassol A, Keating NL. Impact of the Oncology Care Model on use of bone supportive medications, antiemetics, and growth factors. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.1517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1517 Background: The Oncology Care Model (OCM) is a voluntary, episode-based alternative payment model for cancer care launched by the Centers for Medicare & Medicaid Services in July 2016. OCM incentivizes participating practices to reduce spending during chemotherapy treatment while maintaining quality of care. We evaluated the impact of OCM on the use of costly supportive care medications. Methods: Using 100% Medicare claims (2013-2019), we evaluated use of outpatient supportive care medications during chemotherapy episodes assigned to OCM practices (n = 186) or propensity-matched comparison practices (n = 534). For bone supportive medications, we evaluated use of bisphosphonates and/or denosumab in beneficiaries with bone metastases from breast, lung, or prostate cancer. For anti-emetic drugs, we evaluated prophylactic use of neurokinin-1 (NK1) antagonists and long-acting (LA) serotonin antagonists. For white blood cell growth factors (GCSFs), we evaluated prophylactic use in beneficiaries starting chemotherapy for breast, lung, or colorectal cancer; we separately evaluated use of biosimilar (vs originator) filgrastim. Analyses employed the difference-in-differences (DID) approach, excepting the filgrastim biosimilar analysis where we assessed the adoption trend. Results: There was no OCM impact on receipt of any bone supportive medication (denosumab or bisphosphonate) among beneficiaries with bone metastases; however, OCM led to a relative decrease in use of denosumab for breast cancer (DID = -5.0 percentage points [90% CI -7.1, -2.8]), prostate cancer (-4.0 percentage points [90% CI -5.9, -2.2]), and lung cancer (-4.1 percentage points [90% CI -7.4, -0.9]). In beneficiaries starting chemotherapy regimens with high or moderate emetic risk, OCM led to reductions in prophylactic use of NK1 antagonists and LA serotonin antagonists (e.g. 6.0 percentage point reduction in use of NK1 antagonists during high emetic risk chemotherapy [90% CI -9.0, -3.1]); there was no impact on antiemetic use during low emetic risk chemotherapy. There was no OCM impact on use of prophylactic WBC growth factors among beneficiaries receiving chemotherapy with high risk for febrile neutropenia (FN). Among beneficiaries receiving chemotherapy with intermediate risk for FN, OCM led to a 7.6 percentage point reduction in prophylactic GCSF use for patients with breast cancer (90% CI -12.6, -2.7); however, there was no OCM impact on prophylactic GCSF use in patients with lung or colorectal cancer. Among beneficiaries receiving filgrastim, OCM led to faster adoption of biosimilar vs. originator filgrastim (differential trend estimate 2.6%, 90% CI 1.0, 4.4). Conclusions: OCM led to reduced use of some high cost supportive care medications, with patterns suggesting more value-conscious care. Alternative payment models have potential to drive value-based changes in medication use during cancer care.
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Affiliation(s)
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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Keating NL, Cleveland JLF, Wright AA, Brooks GA, Meneades L, Riedel L, Zubizarreta JR, Landrum MB. Evaluation of Reliability and Correlations of Quality Measures in Cancer Care. JAMA Netw Open 2021; 4:e212474. [PMID: 33749769 PMCID: PMC7985722 DOI: 10.1001/jamanetworkopen.2021.2474] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Measurement of the quality of care is important for alternative payment models in oncology, yet the ability to distinguish high-quality from low-quality care across oncology practices remains uncertain. OBJECTIVE To assess the reliability of cancer care quality measures across oncology practices using registry and claims-based measures of process, utilization, end-of-life (EOL) care, and survival, and to assess the correlations of practice-level performance across measure and cancer types. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used the Surveillance, Epidemiology, and End Results (SEER) Program registry linked to Medicare administrative data to identify individuals with lung cancer, breast cancer, or colorectal cancer (CRC) that was newly diagnosed between January 1, 2011, and December 31, 2015, and who were treated in oncology practices with 20 or more patients. Data were analyzed from January 2018 to December 2020. MAIN OUTCOMES AND MEASURES Receipt of guideline-recommended treatment and surveillance, hospitalizations or emergency department visits during 6-month chemotherapy episodes, care intensity in the last month of life, and 12-month survival were measured. Summary measures for each domain in each cohort were calculated. Practice-level rates for each measure were estimated from hierarchical linear models with practice-level random effects; practice-level reliability (reproducibility) for each measure based on the between-measure variance, within-measure variance, and distribution of patients treated in each practice; and correlations of measures across measure and cancer types. RESULTS In this study of SEER registry data linked to Medicare administrative data from 49 715 patients with lung cancer treated in 502 oncology practices, 21 692 with CRC treated in 347 practices, and 52 901 with breast cancer treated in 492 practices, few practices had 20 or more patients who were eligible for most process measures during the 5-year study period. Patients were 65 years or older; approximately 50% of the patients with lung cancer and CRC and all of the patients with breast cancer were women. Most measures had limited variability across practices. Among process measures, 0 of 6 for lung cancer, 0 of 6 for CRC, and 3 of 11 for breast cancer had a practice-level reliability of 0.75 or higher for the median-sized practice. No utilization, EOL care, or survival measure had reliability across practices of 0.75 or higher. Correlations across measure types were low (r ≤ 0.20 for all) except for a correlation between the CRC process and 1-year survival summary measures (r = 0.35; P < .001). Summary process measures had limited or no correlation across lung cancer, breast cancer, and CRC (r ≤ 0.16 for all). CONCLUSIONS AND RELEVANCE This study found that quality measures were limited by the small numbers of Medicare patients with newly diagnosed cancer treated in oncology practices, even after pooling 5 years of data. Measures had low reliability and had limited to no correlation across measure and cancer types, suggesting the need for research to identify reliable quality measures for practice-level quality assessments.
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Affiliation(s)
- Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jessica L. F. Cleveland
- Department of Informatics and Analytics, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alexi A. Wright
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gabriel A. Brooks
- Section of Medical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Laurie Meneades
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Lauren Riedel
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jose R. Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Statistics, Harvard Faculty of Arts and Sciences, Cambridge, Massachusetts
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Brooks GA, Tapp S, Daly AT, Busam J, Tosteson AN. Cost effectiveness of DPYD genotyping to screen for dihydropyrimidine dehydrogenase (DPD) deficiency prior to adjuvant chemotherapy for colon cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
55 Background: Fluoropyrimidine chemotherapy agents, including 5-fluorouracil and capecitabine, are the backbone of adjuvant treatment for colon cancer, and adjuvant chemotherapy substantially reduces recurrence and mortality after surgical resection of stage 3 colon cancer. While fluoropyrimidine chemotherapy is generally safe, the risk of severe, potentially fatal chemotherapy toxicity is substantially increased for the 2-3% of U.S. patients with DPD deficiency caused by pathogenic variants in the DPYD gene. DPYD genotype testing is readily available in the U.S. but has not been widely adopted. We evaluated the cost effectiveness of DPYD genotyping prior to adjuvant chemotherapy for colon cancer in the U.S. Methods: We constructed a Markov model to simulate screening for DPD deficiency with DPYD genotyping (versus no screening) among patients receiving fluoropyrimidine-based adjuvant chemotherapy for stage 3 colon cancer. Screen-positive patients were modeled to receive dose-reduced fluoropyrimidine chemotherapy. Model transition probabilities for treatment-related toxicities were derived from published clinical trial data with annotation of DPYD genotype and chemotherapy dosing strategy. Our analysis is from the healthcare perspective, with a time horizon of five years and an annual discount rate of 3% for future costs and benefits. Direct healthcare costs and health utilities were estimated from published sources and converted to 2020 US dollars, and post-treatment survival was modeled from SEER data. The primary outcome was the incremental cost-effectiveness ratio (ICER), defined as dollars per quality-adjusted life year (QALY). We used a value of $100,000/QALY as the cost-effectiveness threshold. One-way sensitivity analyses were used to examine model uncertainty. Results: Compared with no screening, screening for DPD deficiency with DPYD genotyping increased per-patient costs by $106 and improved quality-adjusted survival by 0.0028 QALYs, leading to an ICER of $37,300/QALY. In one-way sensitivity analyses, the ICER exceeded $100,000/QALY when the carrier frequency of pathogenic DPYD gene variants was less than 1.17%, and when the specificity of DPYD genotyping was less than 98.9%. Cost-effectiveness estimates were not sensitive to the cost of DPYD genotyping, the cost of toxicity-related hospitalizations, or the health utility associated with grade 3-4 toxicity. Conclusions: Among patients receiving adjuvant chemotherapy for stage 3 colon cancer, screening for DPD deficiency with DPYD genotyping is a cost-effective strategy for preventing infrequent but severe, sometimes fatal toxicities of fluoropyrimidine chemotherapy.
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Christian TJ, Hassol A, Brooks GA, Gu Q, Kim S, Landrum MB, Keating NL. How Do Claims-Based Measures of End-of-Life Care Compare to Family Ratings of Care Quality? J Am Geriatr Soc 2020; 69:900-907. [PMID: 33165965 DOI: 10.1111/jgs.16905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Assess whether frequently-used claims-based end-of-life (EOL) measures are associated with higher ratings of care quality. DESIGN Retrospective cohort study. SETTING/PARTICIPANTS Deceased fee-for-service Medicare beneficiaries with cancer who underwent chemotherapy during July 2016 to January 2017 and died within 12 months and their caregiver respondents to an after-death survey (n = 2,559). MEASUREMENTS We examined claims-based measures of EOL care: chemotherapy 14 days or more before death; inpatient admissions, intensive care unit (ICU) use, and emergency department (ED) visits 30 days or more before death; hospice election and the timing of election before death. Primary outcomes are family ratings of "excellent" care in the last month of life and reports that hospice care began "at the right time." Associations were assessed with logistic regression, adjusted by patient characteristics. RESULTS Family rated EOL care as excellent less often, if within 30 days before death the cancer patient had inpatient admissions (1 hospitalization = 41.5% vs 51.5% none, adjusted difference -10.1 percentage points), ICU use (38.6% for any ICU use vs 47.4% none; adjusted difference -8.8 percentage points), ED visits (41.0% 1 visit vs 51.6% no visits; adjusted difference -10.6 percentage points), or elected hospice within 7 days before death. Among hospice enrollees, family more often reported that hospice began at the right time if it started at least 7 days before death (hospice 1-2 days before death 60.2% vs hospice 7-13 days 74.9%; adjusted difference +14.7 percentage points). CONCLUSIONS Claims-based measures of EOL care for cancer patients that reflect avoidance of hospital-based care and earlier hospice enrollment are associated with higher ratings of care quality by bereaved family members.
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Affiliation(s)
- Thomas J Christian
- Division of Health & Environment, Abt Associates, Inc., Cambridge, Massachusetts, USA
| | - Andrea Hassol
- Division of Health & Environment, Abt Associates, Inc., Cambridge, Massachusetts, USA
| | - Gabriel A Brooks
- Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Qian Gu
- Division of Health & Environment, Abt Associates, Inc., Cambridge, Massachusetts, USA.,KPMG US, Bethesda, Maryland, USA
| | - Seyoun Kim
- Division of Health & Environment, Abt Associates, Inc., Cambridge, Massachusetts, USA.,Department of Health Care Management and Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
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Hassett MJ, Hazard H, Osarogiagbon RU, Wong SL, Bian JJ, Dizon DS, Wedge J, Basch EM, Mallow J, McCleary NJ, Dougherty DW, Remick SC, Brooks GA, Mecchella J, Solberg P, Tasker L, Faris N, Pacheco A, Cronin C, Schrag D. Design of eSyM: An ePRO-based symptom management tool fully integrated in the electronic health record (Epic) to foster patient/clinician engagement, sustainability, and clinical impact. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
164 Background: Chemotherapy and surgery can cause distressing symptoms, which can be a burden for health systems to address. Programs that directly engage patients, including electronic tracking of patient-reported outcomes (ePROs), can improve symptom control and decrease the need for acute care. Previous ePRO programs have relied on third party vendors with limited EHR integration, constraining their clinical utility and scalability. An integrated solution could offer distinct advantages. Methods: As part of NCI’s Moonshot-funded IMPACT consortium, 6 health systems and Epic built an electronic symptom management program (eSyM) based on the PRO-CTCAE questionnaire that is fully integrated into the EHR. The agile, user-centered design process engaged patients, clinicians, and institutions. The core functional components include: 1) symptom surveys in the postoperative period or between chemotherapy visits, 2) self-management tip sheets, 3) clinician alerts, and 4) dashboards for population management. Critical points of integration with supporting EHR functions and workflow impacts were identified; and major challenges of integration and implementation were described. Results: eSyM, which was implemented at two health systems (Baptist Memorial in Tennessee and Mississippi and West Virginia University Health) in the fall of 2019, required multiple supporting EHR functions: 1) access a secure, HIPPA-compliant patient portal/messaging system (MyChart); 2) record diagnosis, procedure and chemotherapy treatment plan data; 3) identify target populations and track metrics/events; 4) define and execute autonomous logic-based workflow rules; 5) generate reports for clinicians/patients; and 6) documentation. Major challenges included: 1) working within pre-existing EHR system standards and capabilities, which limited the ability to customize interfaces and workflows specifically for the eSyM use case; and 2) adapting to different EHR configurations and polices across multiple health systems. Conclusions: The eSyM build leveraged many existing EHR capabilities and overcame regulatory hurdles; but it required design and workflow compromise. Integration of ePRO-based symptom management programs into the EHR could help overcome barriers, consolidate clinical workflows, and foster scalability/sustainability. Ongoing efforts include launching eSyM at four more sites and evaluating its adoption, usability, and impact on clinical outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | - Ethan M. Basch
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Knutzen KE, Schifferdecker KE, Murray GF, Alam SS, Brooks GA, Kapadia NS, Butcher R, Barnato AE. Role of norms in variation in cancer centers' end-of-life quality: qualitative case study protocol. BMC Palliat Care 2020; 19:136. [PMID: 32854691 PMCID: PMC7453548 DOI: 10.1186/s12904-020-00641-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background A critical barrier to improving the quality of end-of-life (EOL) cancer care is our lack of understanding of the mechanisms underlying variation in EOL treatment intensity. This study aims to fill this gap by identifying 1) organizational and provider practice norms at major US cancer centers, and 2) how these norms influence provider decision making heuristics and patient expectations for EOL care, particularly for minority patients with advanced cancer. Methods This is a multi-center, qualitative case study at six National Comprehensive Cancer Network (NCCN) and National Cancer Institute (NCI) Comprehensive Cancer Centers. We will theoretically sample centers based upon National Quality Forum (NQF) endorsed EOL quality metrics and demographics to ensure heterogeneity in EOL intensity and region. A multidisciplinary team of clinician and non-clinician researchers will conduct direct observations, semi-structured interviews, and artifact collection. Participants will include: 1) cancer center and clinical service line administrators; 2) providers from medical, surgical, and radiation oncology; palliative or supportive care; intensive care; hospital medicine; and emergency medicine who see patients with cancer and have high clinical practice volume or high local influence (provider interviews and observations); and 3) adult patients with metastatic solid tumors and whom the provider would not be surprised if they died in the next 12 months and their caregivers (patient and caregiver interviews). Leadership interviews will probe about EOL institutional norms and organization. We will observe inpatient and outpatient care for two weeks. Provider interviews will use vignettes to probe explicit and implicit motivations for treatment choices. Semi-structured interviews with patients near EOL, or their family members and caregivers will explore past, current, and future decisions related to their cancer care. We will import transcribed field notes and interviews into Dedoose software for qualitative data management and analysis, and we will develop and apply a deductive and inductive codebook to the data. Discussion This study aims to improve our understanding of organizational and provider practice norms pertinent to EOL care in U.S. cancer centers. This research will ultimately be used to inform a provider-oriented intervention to improve EOL care for racial and ethnic minority patients with advanced cancer. Trial registration Clinicaltrials.gov; NCT03780816; December 19, 2018.
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Affiliation(s)
- Kristin E Knutzen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Karen E Schifferdecker
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Genevra F Murray
- Department of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Shama S Alam
- Evidera, Pharmaceutical Product Development, Bethesda, MD, USA
| | - Gabriel A Brooks
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine, Hanover, NH, USA.,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Nirav S Kapadia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA.,Department of Medicine, Geisel School of Medicine, Hanover, NH, USA.,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Rebecca Butcher
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA
| | - Amber E Barnato
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH, USA. .,Department of Medicine, Geisel School of Medicine, Hanover, NH, USA. .,Norris Cotton Cancer Center at Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
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Pawloski PA, Brooks GA, Nielsen ME, Olson-Bullis BA. A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice. J Natl Compr Canc Netw 2020; 17:331-338. [PMID: 30959468 DOI: 10.6004/jnccn.2018.7104] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 11/05/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Electronic health records are central to cancer care delivery. Electronic clinical decision support (CDS) systems can potentially improve cancer care quality and safety. However, little is known regarding the use of CDS systems in clinical oncology and their impact on patient outcomes. METHODS A systematic review of peer-reviewed studies was performed to evaluate clinically relevant outcomes related to the use of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. Peer-reviewed studies published from 1995 through 2016 were included if they assessed clinical outcomes, patient-reported outcomes (PROs), costs, or care delivery process measures. RESULTS Electronic database searches yielded 2,439 potentially eligible papers, with 24 studies included after final review. Most studies used an uncontrolled, pre-post intervention design. A total of 23 studies reported improvement in key study outcomes with use of oncology CDS systems, and 12 studies assessing the systems for computerized chemotherapy order entry demonstrated reductions in prescribing error rates, medication-related safety events, and workflow interruptions. The remaining studies examined oncology clinical pathways, guideline adherence, systems for collection and communication of PROs, and prescriber alerts. CONCLUSIONS There is a paucity of data evaluating clinically relevant outcomes of CDS system implementation in oncology care. Currently available data suggest that these systems can have a positive impact on the quality of cancer care delivery. However, there is a critical need to rigorously evaluate CDS systems in oncology to better understand how they can be implemented to improve patient outcomes.
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Affiliation(s)
- Pamala A Pawloski
- aHealthPartners Institute, Minneapolis, Minnesota.,bThe Health Care Systems Research Network (HCSRN) Cancer Research Network (CRN)
| | - Gabriel A Brooks
- cDartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and
| | - Matthew E Nielsen
- dUniversity of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
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