Abstract P3-10-03: Socioeconomic disparities in needle biopsy prior to breast cancer surgery across physician referral networks

Introduction

Although needle biopsy (NB) is recommended prior to breast cancer surgery, the use of NB has been shown to vary according to patient socioeconomic status (SES), operating surgeon, and geographic region. We hypothesized that surgeons who work in the same peer referral network (defined by patient sharing) might have similar practice patterns with regard to NB, and that the magnitude of SES disparities might vary across networks. We therefore examined: 1) SES disparities in the receipt of NB, 2) variation in NB across networks, and 3) whether the association between SES and NB varied across networks.

Methods

We used the SEER database and 5% Medicare sample to examine all patients with a new diagnosis of breast cancer from 2004 through 2006. We used Medicare claims to construct peer groups of physicians based on patient-sharing ties. Patients were assigned to peer groups based on the surgeon who performed their definitive surgery. We defined a patient as having low SES if she was in the lowest quintile of area-level income. We used hierarchical generalized linear models (HGLM) to assess the association between low SES and receipt of NB, including random effects for the surgeon, peer group, and Hospital Referral Region (HRR). We then allowed the low SES effect to vary across peer groups in order to determine whether the association between SES and NB varied across groups.

Results

In the full sample of 14,552 patients, 9,498 (65%) received needle biopsy. In bivariable analysis, patients in the lowest income quintile were less likely to receive NB compared to all other patients (59% vs 67%, p<.001). The majority of the variance (59%) in NB use was at the patient level, 22% was at the surgeon level, and 13.7% at the peer group level. The use of NB varied substantially across peer groups, with a median of 69% (interquartile range [51%, 84%]). Even after accounting for physician, peer group, and HRR variation, patients in the lowest stratum of SES were significantly less likely to have received NB compared to all other patient (OR = 0.88; p=.04). Finally, we found that the association between SES and NB varied significantly across referral networks (P<0.05)

Conclusions

Patients with low SES are significantly less likely to receive NB prior to breast cancer surgery, and moreover the magnitude of this SES-related disparity varies significantly according to which referral networks are providing care. Future policies to increase NB rates and standardize care for all breast cancer patients may consider the implications of how care for patients with low SES varies across surgical provider networks.Introduction

Although needle biopsy (NB) is recommended prior to breast cancer surgery, the use of NB has been shown to vary according to patient socioeconomic status (SES), operating surgeon, and geographic region. We hypothesized that surgeons who work in the same peer referral network (defined by patient sharing) might have similar practice patterns with regard to NB, and that the magnitude of SES disparities might vary across networks. We therefore examined: 1) SES disparities in the receipt of NB, 2) variation in NB across networks, and 3) whether the association between SES and NB varied across networks.

Methods

We used the SEER database and 5% Medicare sample to examine all patients with a new diagnosis of breast cancer from 2004 through 2006. We used Medicare claims to construct peer groups of physicians based on patient-sharing ties. Patients were assigned to peer groups based on the surgeon who performed their definitive surgery. We defined a patient as having low SES if she was in the lowest quintile of area-level income. We used hierarchical generalized linear models (HGLM) to assess the association between low SES and receipt of NB, including random effects for the surgeon, peer group, and Hospital Referral Region (HRR). We then allowed the low SES effect to vary across peer groups in order to determine whether the association between SES and NB varied across groups.

Results

In the full sample of 14,552 patients, 9,498 (65%) received needle biopsy. In bivariable analysis, patients in the lowest income quintile were less likely to receive NB compared to all other patients (59% vs 67%, p<.001). The majority of the variance (59%) in NB use was at the patient level, 22% was at the surgeon level, and 13.7% at the peer group level. The use of NB varied substantially across peer groups, with a median of 69% (interquartile range [51%, 84%]). Even after accounting for physician, peer group, and HRR variation, patients in the lowest stratum of SES were significantly less likely to have received NB compared to all other patient (OR = 0.88; p=.04). Finally, we found that the association between SES and NB varied significantly across referral networks (P<0.05)

Conclusions

Patients with low SES are significantly less likely to receive NB prior to breast cancer surgery, and moreover the magnitude of this SES-related disparity varies significantly according to which referral networks are providing care. Future policies to increase NB rates and standardize care for all breast cancer patients may consider the implications of how care for patients with low SES varies across surgical provider networks.

Citation Format: Killelea BK, Herrin J, Soulos PR, Pollack CE, Forman HP, Yu J, Xu X, Tannenbaum S, Wang S, Gross CP. Socioeconomic disparities in needle biopsy prior to breast cancer surgery across physician referral networks [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-10-03.

Mental health problems as a cause of long-term sick leave in the Norwegian workforce

AIMS

There has been a growing concern about the proportion and socioeconomic consequences of work incapacity due to mental health problems. The aim of the present study was to describe the incidence and duration of different categories of mental health problems with at least two weeks of compensated absence from work in the general working population in Norway.

METHODS

Cases were identified from files of the national medical insurance system, covering 90% of all employees, while census data were used for the denominators. Based on the International Classification of Primary Care, a total of 101,512 individuals with one or more long-term sick leaves (>2 weeks) due to psychological problems were identified in 1997 and 1998.

RESULTS

Employees absent for psychological problems accounted for 16.8% of all incidences and 31.5% of all refunded sick days. The average one-year incidence was 2.47%, and was significantly higher for women (3.53%) than for men (1.66%). The incidence increased with increasing age, and more so for women than for men. The median duration of absence for all claimants was 79 days. Approximately 25% were back to work after one month, 52% after three months, while 8.5% had not returned to work after 12 months and were transferred to other forms of compensation. The length of sick leave varied considerably with diagnostic category, age, and gender.

CONCLUSION

Mental health problems constitute a major health problem in the Norwegian workforce today. There is an urgent need for more knowledge about the effectiveness of interventions.

Utilization of technologies to reduce allogeneic blood transfusion in the United States

Concern over safety of the blood supply has led to the use of technologies to reduce allogeneic blood transfusion. The objective of this research was to determine the utilization of these technologies in the United States. We evaluated the following techniques: preoperative autologous donation (PAD), cell salvage (CS) and acute normovolemic haemodilution (ANH); and the following pharmaceuticals: aprotinin (APR), epsilon-aminocaproic acid (EACA), tranexamic acid (TXA), desmopressin (DDAVP) and recombinant human erythropoietin (EPO). In 1997, we conducted a cross-sectional mail survey of service chiefs at 1000 US hospitals randomly selected and stratified by status as a provider of open-heart surgery, geographical location and hospital bed size. Sixty-nine per cent (690) of hospitals responded to at least one of the four surveys sent to each hospital. Hospitals reported use of techniques more than pharmaceuticals (P < 0.001); PAD (83%, n = 206) and CS (82% n = 420) were used most frequently. Lack of familiarity was the most common reason cited for infrequent use of pharmaceuticals. Organizational characteristics (e.g. provision of open-heart surgery, size, geographical location, teaching status and type of hospital) were differentially associated with technology use. There is greater use of techniques than pharmaceuticals in US hospitals to reduce the need for allogeneic blood in the peri-operative setting. Providing open-heart surgery is strongly associated with the utilization of these technologies.

Continuing education meetings and workshops: effects on professional practice and health care outcomes

BACKGROUND

Educational meetings and printed educational materials are the two most common types of continuing education for health professionals. An important aim of continuing education is to improve professional practice so that patients can receive improved health care.

OBJECTIVES

To assess the effects of educational meetings on professional practice and health care outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE (from 1966), the Research and Development Resource Base in Continuing Medical Education in January 1999 and reference lists of articles.

SELECTION CRITERIA

Randomised trials or well designed quasi-experimental studies examining the effect of continuing education meetings (including lectures, workshops, and courses) on the clinical practice of health professionals or health care outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied inclusion criteria, assessed the quality of each study, and extracted study data. We attempted to collect missing data from investigators. We conducted both qualitative and quantitative analyses.

MAIN RESULTS

Thirty-two studies were included with a total of 36 comparisons. The studies involved from 13 to 411 health professionals (total N= 2995) and were judged to be of moderate or high quality, although methods were generally poorly reported. There was substantial variation in the complexity of the targeted behaviours, baseline compliance, the characteristics of the interventions and the results. The heterogeneity of the results was best explained by differences in the interventions. For 10 comparisons of interactive workshops, there were moderate or moderately large effects in six (all of which were statistically significant) and small effects in four (one of which was statistically significant). For interventions that combined workshops and didactic presentations, there were moderate or moderately large effects in 12 comparisons (eleven of which were statistically significant) and small effects in seven comparisons (one of which was statistically significant). In seven comparisons of didactic presentations, there were no statistically significant effects, with the exception of one out of four outcome measures in one study.

REVIEWER'S CONCLUSIONS

Interactive workshops can result in moderately large changes in professional practice. Didactic sessions alone are unlikely to change professional practice.

Web-enabled medical databases: a threat to security?

An increasing number of clinical databases are being adapted to allow access through Internet protocols, particularly Hypertext Transfer Protocol (HTTP). The World Wide Web (WWW) provides a user-friendly, standardized, broadly distributed database interface; at the same time, it may also present a threat to the security and confidentiality of patient data. However, there is little empirical evidence concerning such threats. Using publicly available records we estimate the additional risk of security violations due to web-enabling a database. The evidence, though limited, suggests that the additional risk may be small relative to more traditional security threats.

Variations among hospitals in the quality of care for heart failure

CONTEXT

Determining variations in quality of care among hospitals can help direct attention to poorly performing institutions.

PRACTICE PATTERN EXAMINED

The proportion of patients with congestive heart failure meeting various quality criteria in 69 hospitals. HOSPITAL SELECTION: The hospitals were voluntary participants in a quality improvement program in five states (Colorado, Connecticut, Georgia, Oklahoma, and Virginia).

PATIENT SELECTION

All patients with congestive heart failure discharged from the participating hospitals during a 15-month period in 1995 to 1996 (or, for hospitals with more than 50 eligible patients, a random sample of 50 patients). The total sample consisted of 2077 patients.

DATA SOURCE

Documentation in the hospital medical record of left ventricular function, discharge medications, and discharge instructions.

RESULTS

Left ventricular function was determined in 72% of patients (range across hospitals, 18% to 97%). Among patients with left ventricular systolic dysfunction, 79% were prescribed an angiotensin-converting enzyme inhibitor (range, 54% to 94%). Only 23% of the patients prescribed angiotensin-converting enzyme inhibitors received the target dose (range, 0% to 60%). Sixty-four percent of patients were counseled about the importance of a low-sodium diet at discharge (range, 25% to 97%), but only 8% were counseled about daily weight monitoring (range, 0% to 30%).

CONCLUSION

Our results show substantial hospital-to-hospital variation in the quality of care for patients with heart failure.

Household income losses associated with ischaemic heart disease for US employees

OBJECTIVE

To estimate the cost of lost work days due to ischaemic heart disease (IHD), and the cost of this reduced productivity using reduction in household income.

DESIGN AND SETTING

Using 2 years of nationally representative observational data, this study examined the effect on household income of IHD. This effect was estimated after accounting for unemployment, days lost to illness and other effects of illness on the income of workers aged 18 to 64 years.

MAIN OUTCOME MEASURES AND RESULTS

Previous measures of indirect costs of disease have typically not included the loss in productivity due to suboptimal work performance. Among workers in this age group, IHD was associated with a reduction of $US3013 in annual household income; this reduction was independent of occupational class, age, size of household and educational level. Such a reduction may be because of reduced on-the-job performance, employer perception of this, or unrelated lifestyle choices. It represents an estimated $US6.05 billion annual loss in productivity in 1992 dollars (or $US6.45 billion in 1996 dollars).

CONCLUSIONS

Estimates of the indirect costs of chronic disease that do not account fully for the lost income of employees may significantly underestimate the benefits to employers and society of treatment and prevention.

WEB-Enabled Medical Databases: a Threat to Security?

An increasing number of clinical databases are being adapted to allow access through Internet protocols, particularly Hypertext Transfer Protocol (HTTP). The World Wide Web (WWW) provides a user-friendly, standardized, broadly distributed database interface; at the same time, it may also present a threat to the security and confidentiality of patient data. However, there is little empirical evidence concerning such threats. Using publicly available records we estimate the additional risk of security violations due to web-enabling a database. The evidence, though limited, suggests that the additional risk may be small relative to more traditional security threats.

The quality of care for Medicare patients with peptic ulcer disease

OBJECTIVE

The aim of this study was to examine quality of care for hospitalized Medicare beneficiaries with peptic ulcer disease.

METHODS

Collaborating with five Peer Review Organizations, we used 1995 Medicare claim files to select samples of inpatients with a principal diagnosis of peptic ulcer disease. Quality of care indicators developed by content experts included percentages for ulcer patients tested for Helicobacter pylori (H. pylori); biopsied patients who received tissue tests; H. pylori-positive patients who received appropriate therapy; and ulcer patients screened for preadmission nonsteroidal anti-inflammatory drug (NSAID) use and counseled about risks.

RESULTS

Of 2,644 patients eligible for medical record review, 56% were tested for H. pylori, and 73% of those testing positive were treated appropriately; 84% of patients with endoscopic biopsies received a tissue test for H. pylori; 74% of patients were screened for preadmission NSAID use, 24% had documented counseling of NSAID use, and only 2% had documented counseling on the ulcer risk of NSAID use. Statistically significant regional variation occurred in four of six quality indicators. Outpatient records were reviewed for 529 patients to document prior outpatient H. pylori in this population; only 2% (n = 12) were tested for H. pylori in the year before admission.

CONCLUSIONS

Opportunities exist to improve quality of care by testing for and treating H. pylori in hospitalized Medicare beneficiaries with peptic ulcer disease and to improve screening for NSAIDs and counseling on ulcer risks.

Safety of kidney biopsy in pediatric transplantation: a report of the Controlled Clinical Trials in Pediatric Transplantation Trial of Induction Therapy Study Group

BACKGROUND

Historically, young children undergoing renal transplantation have lower allograft survival than adults, and potential causes of this are being addressed by the North American Pediatric Renal Transplant Cooperative Study through the National Institutes of Health-sponsored study Cooperative Clinical Trials in Pediatric Transplantation. Included in this study is evaluation of surveillance renal biopsies (SB) and clinically indicated biopsies (CB). Few data exist in children to identify the risk involved with renal transplant biopsies.

METHODS

Questionnaires were mailed to 21 participating centers asking for descriptions of adverse events associated with kidney biopsies, with choices limited to none, gross hematuria, perinephric hematoma, and other. Further clinical details were obtained from review of medical records of all patients with reported adverse events. Data were collected from 19 centers on 126 patients.

RESULTS

Eighty-six patients had undergone 212 biopsies (75 SB and 137 CB). Nine biopsy-related adverse events were reported (4.2%): three SB (4.0%) and six CB (4.4%). Gross hematuria was reported in six patients (2.8%): two SB (2.7%) and four CB (2.9%). A perinephric hematoma was reported in one patient. Two patients with intraperitoneal kidneys developed significant bleeding after biopsy and required transfusions and surgical exploration. No patient lost kidney function or required nephrectomy after biopsy. No difference was noted in adverse events between SB at day 5 or 12 versus CB.

CONCLUSION

Evaluation of transplanted kidney tissue may provide important information for the care of the transplantation patient. This analysis suggests that transplanted kidney biopsies can be performed with minimal risks in pediatric patients.

Mycophenolate mofetil in pediatric renal transplantation

The use of mycophenolate mofetil (MMF) in adult renal transplantation has been associated with significantly decreased incidence of acute rejection. However, limited data are available for children after renal transplantation. A total of 67 patients undergoing renal transplantation at the University of Alabama at Birmingham, AL, USA and Children's Hospital of Boston, MA, USA were enrolled into the Cooperative Clinical Trials in Pediatric Transplantation randomized controlled trial of induction with OKT3 vs. i.v. cyclosporin A (CsA) at the time of transplantation. The first 31 patients entered were begun on azathioprine (AZA), 2 mg/kg on the first post-operative day. The subsequent 36 patients were begun on MMF, 1000 mg/m2/d. Other maintenance immunosuppression included oral CsA and Prednisone. Biopsy confirmation was obtained for all suspected rejection episodes. Glomerular filtration rate (GFR) was calculated using the Schwartz formula. Data were analyzed using Kaplan Meier survival curves and compared using log-rank tests. At the time of analysis, 52 patients (mean age 10.1 +/- 5 yr) had completed at least 12 months and 15 others had completed at least 6 months of follow-up post-transplantation. Of these, there were 39 male/28 female; 48 white/15 black/4 other; 49 living donor/18 cadaver donor. There were no significant differences in the incidence of rejection episodes, number of rejection episodes, the GFR at 6 and 12 months, allograft, or patient survival between patients receiving MMF vs. AZA. We could demonstrate no significant differences in these outcomes based on sex, race or induction therapy, leading to the conclusion that pediatric patients treated under a consistent protocol in two institutions have no improvement in short-term allograft outcome with the addition of MMF therapy.

Early onset of nephrotic syndrome after treatment with D-penicillamine in a patient with Wilson's disease

Wilson's disease responds to a variety of treatments including D-penicillamine and trientene. Nephrotic syndrome is a late complication of D-penicillamine treatment. We report a pediatric patient with Wilson's disease who developed nephrotic syndrome 2 wk after beginning D-penicillamine. His nephrosis resolved and his disease is quiescent with trientene treatment.

Meta analysis of the relationship between tuberous sclerosis complex and renal cell carcinoma

The association of angiomyolipoma with tuberous sclerosis complex (TSC) patients is well recognised. Some literature has suggested that patients with TSC are at increased risk of renal neoplasm, particularly since angiomyolipomas can be locally invasive and demonstrate tumor like neovascularity on angiography. In an attempt to place in context one case of metastatic renal cell carcinoma in a patient with TSC a meta analysis of the literature was performed. One pediatric patient with TSC and metastatic renal cell carcinoma was evaluated. Reviews and case reports of TSC and renal cell carcinoma and related imaging findings were identified by searching the MEDLINE database, the 'bibliography of reviews' in Index Medicus, personal files and the reference lists from all identified reviews. Individual cases suitable for review in the available literature from 1922 through 1993 comprised the data base. The data base was analysed with the method of proportions and unpaired two-tailed Student's t-test for different populations. A cumulative summary of the literature amassed 107 additional cases from 62 reports over 71 years. Our case is the 17th case, to our knowledge, of renal cell carcinoma in TSC. Analysis of the distribution of characteristics and incidence of; renal cysts, renal cell carcinoma, and lymph node involvement demonstrate no increased risk of renal cell carcinoma in patients with TSC (P = NS). Though anecdotal evidence has suggested a relationship between TSC and renal cell carcinoma, meta analysis of cases of coincident TSC renal complex, cystic changes, angiomyolipoma and renal cell carcinoma implies an identical, though small, risk of malignancy in TSC patients as compared with the normal population.

Effect of panel composition on physician ratings of appropriateness of abdominal aortic aneurysm surgery: elucidating differences between multispecialty panel results and specialty society recommendations

OBJECTIVE

To investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies.

DATA SOURCES/STUDY SETTING

We examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery.

STUDY DESIGN

The panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels' rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery.

PRINCIPAL FINDINGS

Of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons' rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties.

CONCLUSIONS

statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies.

The severe perinatal form of autosomal recessive polycystic kidney disease maps to chromosome 6p21.1-p12: implications for genetic counseling

Autosomal recessive polycystic kidney disease (ARPKD) is a one of the most common hereditary renal cystic diseases in children. Its clinical spectrum is widely variable with most cases presenting in infancy. Most affected neonates die within the first few hours of life. At present, prenatal diagnosis relies on fetal sonography, which is often imprecise in detecting even the severe form of the disease. Recently, in a cohort of families with mostly milder ARPKD phenotypes, an ARPKD locus was mapped to a 13-cM region of chromosome 6p21-cen. To determine whether severe perinatal ARPKD also maps to chromosome 6p, we have analyzed the segregation of seven microsatellite markers from the ARPKD interval in 22 families with the severe phenotype. In the majority of the affected infants, ARPKD was documented by histopathology. Our data confirm linkage and refine the ARPKD region to a 3.8-cM interval, delimited by the markers D6S465/D6S427/D6S436/D6S272 and D6S466. Taken together, these results suggest that, despite the wide variability in clinical phenotypes, there is a single ARPKD gene. These linkage data and the absence of genetic heterogeneity in all families tested to date have important implications for DNA-based prenatal diagnoses as well as for the isolation of the ARPKD gene.

Non-nephrotic children with membranoproliferative glomerulonephritis: are steroids indicated?

Alternate-day steroids are currently recommended to treat children with membranoproliferative glomerulonephritis (MPGN). This recommendation is based largely on uncontrolled studies demonstrating improved renal survival with steroid therapy. We reviewed the outcome of 39 children who presented with MPGN between 1968 and 1990; 27 children were treated with steroids and 12 children received no drug therapy. Life-table analysis comparing renal survival of treated versus untreated children demonstrated no difference by log rank analysis. Treated and untreated groups were compared on the basis of nine features at presentation: age, sex, type of MPGN, presence and type of hematuria, hypocomplementemia renal insufficiency, hypertension, and nephrosis. Treated children were likely to be female (P < 0.01) and nephrotic (P < 0.02). Actuarial survival analyses were performed comparing the nine features with renal survival through 10 years of follow-up. Normotensive (P < 0.025) and non-nephrotic (P < 0.05) children had improved renal survival. The 11 non-nephrotic children demonstrated 100% long-term renal survival, including 7 who received no steroid therapy. At last follow-up, all non-nephrotic children had normal renal function, serum albumin levels > 3 g/dl, and were normotensive. These data suggest that non-nephrotic children with MPGN may forego steroid treatment without compromising long-term renal function. The current common practice of treating all children with MPGN with steroids should be re-examined.

Prednisone dose limitation of growth hormone treatment of steroid-induced growth failure

Seven children with prednisone-induced growth failure were treated with recombinant growth hormone to improve linear growth. Six of seven patients had an increase in linear growth during therapy with recombinant growth hormone. The response to recombinant growth hormone was found to be related to the prednisone dose. When the prednisone dose was greater than 0.35 mg/kg per day, recombinant growth hormone did not increase the linear growth rate. At lower doses the response was inversely related to the amount of prednisone taken.

Slippage of the distal tibial epiphysis

Three cases of valgus slippage of the distal tibial and fibular epiphysis that masqueraded as severe idiopathic flatfoot are described. These occurred in patients with renal osteodystrophy and were treated by osteotomies of the reverse dome type without internal fixation. All the osteotomies healed well.