Inadequate access to surgeons: reason for disparate cancer care?
ABSTRACT To compare the likelihood of seeing a surgeon between elderly dually eligible non-small-cell lung cancer (NSCLC) and colon cancer patients and their Medicare counterparts. Surgery rates between dually eligible and Medicare patients who were evaluated by a surgeon were also assessed.
We used statewide Medicaid and Medicare data merged with the Michigan Tumor Registry to extract a sample of patients with a first primary NSCLC (n = 1100) or colon cancer (n = 2086). The study period was from January 1, 1997 to December 31, 2000. We assessed the likelihood of a surgical evaluation using logistic models that included patient characteristics, tumor stage, and census tracts. Among patients evaluated by a surgeon, we used logistic regression to predict if a resection was performed.
Dually eligible patients were nearly half as likely to be evaluated by a surgeon as Medicare patients (odds ratio [OR] = 0.49; 95% confidence interval = 0.32, 0.77 and odds ratio = 0.59; 95% confidence interval = 0.41, 0.86 for NSCLC and colon cancer patients, respectively). Among patients who were evaluated by a surgeon, the likelihood of resection was not statistically significantly different between dually eligible and Medicare patients.
This study suggests that dually eligible patients, in spite of having Medicaid insurance, are less likely to be evaluated by a surgeon relative to their Medicare counterparts. Policies and interventions aimed toward increasing access to specialists and complete diagnostic work-ups (eg, colonoscopy, bronchoscopy) are needed.
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ABSTRACT: Implementation lessons •It is hypothesized that this delivery model can decrease wait times for diagnosis and treatment of cancer, increase awareness and knowledge of cancer prevention and treatment, and foster trust with providers and patients from vulnerable communities.•Involving oncologists in clinical diagnosis at community health centers can link specialty care more closely to vulnerable communities.•Funding for this type of clinical innovation is currently limited to institutional and philanthropic sources. A shift in the academic and public sector funding paradigms may be required to enable implementation on a broader level.Healthcare. 12/2013; 1(s 3–4):123–129.
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ABSTRACT: The rare earth zirconates have attracted interest for thermal barrier coatings (TBCs) because they have very low intrinsic thermal conductivities, are stable above 1200 °C and are more resistant to sintering than yttria-stabilized zirconia (YSZ). Samarium zirconate (SZO) has the lowest thermal conductivity of the rare earth zirconates and its pyrochore structure is stable to 2200 °C but little is known about its response to thermal cycling. Here, columnar morphology SZO coatings have been deposited on bond coated superalloy substrates using a directed vapor deposition method that facilitated the incorporation of pore volume fractions of 25 to 45%. The as-deposited coatings had a fluorite structure which transformed to the pyrochlore phase upon thermal cycling between 100 and 1100 °C. This cycling eventually led to delamination of the coatings, with failure occurring at the interface between the TGO and a “mixed zone” that formed between the thermally grown alumina oxide (TGO) and the SZO. While the delamination lifetime increased with coating porosity (reduction in coating modulus), it was significantly less than that of similar YSZ coatings applied to the same substrates. The reduced life resulted from a reaction between the rare earth zirconate and the alumina-rich bond coat TGO, leading to the formation of a mixed zone consisting of SZO and SmAlO3. Thermal strain energy calculations show that the delamination driving force increases with TGO and mixed layer thicknesses and with coating modulus. The placement of a 10 μm thick YSZ layer between the TGO and SZO layers eliminated the mixed zone and restored the thermal cyclic life to that of YSZ structures.Research highlights► The Sm2Zr2O7 coatings transformed from fluorite to pyrochlore upon thermal cycling. ► The coating delamination occurred at the alumina-TGO/mixed zone interface. ► A chemical reaction between SZO and alumina led to the formation of SmAlO3. ► A YSZ layer between TGO and SZO retarded the migration of samaria to the TGO. ► It inhibited the chemical reaction and increased the lifetime of bi-layer coatings.Surface and Coatings Technology 04/2011; 205(19):4355-4365. · 2.20 Impact Factor
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ABSTRACT: PURPOSEPrior studies report that half of patients with lung cancer do not receive guideline-concordant care. With data from a national Veterans Health Administration (VHA) study on quality of care, we sought to determine what proportion of patients refused or had a contraindication to recommended lung cancer therapy. PATIENTS AND METHODS Through medical record abstraction, we evaluated adherence to six quality indicators addressing lung cancer-directed therapy for patients diagnosed within the VHA during 2007 and calculated the proportion of patients receiving, refusing, or having contraindications to recommended treatment.ResultsMean age of the predominantly male population was 67.7 years (standard deviation, 9.4 years), and 15% were black. Adherence to quality indicators ranged from 81% for adjuvant chemotherapy to 98% for curative resection; however, many patients met quality indicator criteria without actually receiving recommended therapy by having a refusal (0% to 14%) or contraindication (1% to 30%) documented. Less than 1% of patients refused palliative chemotherapy. Black patients were more likely to refuse or bear a contraindication to surgery even when controlling for comorbidity; race was not associated with refusals or contraindications to other treatments. CONCLUSION Refusals and contraindications are common and may account for previously demonstrated low rates of recommended lung cancer therapy performance at the VHA. Racial disparities in treatment may be explained, in part, by such factors. These results sound a cautionary note for quality measurement that depends on data that do not reflect patient preference or contraindications in conditions where such considerations are important.Journal of Clinical Oncology 06/2013; · 17.88 Impact Factor