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ABSTRACT: BACKGROUND:: The use of screening colonoscopy among older persons is controversial due to variability in life expectancy and sex-based differences in colorectal cancer incidence. We assessed the relation between sex, age, and receipt of screening colonoscopy overall and within strata of life expectancy. METHODS:: We used Medicare data to identify beneficiaries during the years 2001 to 2005 who had not undergone a colonoscopy in the prior 3 years. Medicare claims were used to identify screening colonoscopy use; life expectancy was estimated using a life table approach. We used Poisson regression to examine sex and age differences in screening colonoscopy, adjusted for patient demographic characteristics. RESULTS:: Our sample consisted of 161,229 patients (61.9% female; mean age 76.9 y). The screening colonoscopy rates for females and males were 16.9 and 24.4 screening colonoscopies per 1000 person-years, respectively (P<0.001). The screening colonoscopy rate was highest for patients with the longest life expectancy (10 to 15 y: 27.2 screening colonoscopies per 1000 person-years) compared with 3.4 per 1000 person-years in the life expectancy <5-year group. Within specific life expectancy categories, older patients had significantly lower screening rates; in the 10- to 15-year life expectancy category, patients 75 to 79 years old had a lower rate (21.9 screening colonoscopies per 1000 person-years) than patients 68 to 69 years old (34.1 screening colonoscopies per 1000 person-years; P<0.001). CONCLUSIONS:: In a large cohort of Medicare beneficiaries, there was evidence of screening colonoscopy use even among patients with a short life expectancy. After accounting for life expectancy, females and older persons were less likely to undergo screening colonoscopy.
Journal of clinical gastroenterology 04/2013; · 2.21 Impact Factor
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ABSTRACT: Current efforts to improve health care focus on hospital readmission rates as a marker of quality and on the effectiveness of transitions in care during the period after acute care is received. Emergency department (ED) visits are also a marker of hospital-based acute care following discharge but little is known about ED use during this period.
To determine the degree to which ED visits and hospital readmissions contribute to overall use of acute care services within 30 days of discharge from acute care hospitals, to describe the reasons patients return for ED visits, and to describe these patterns among Medicare beneficiaries and those not covered by Medicare insurance.
Prospective study of patients aged 18 years or older (mean age: 53.4 years) who were discharged between July 1, 2008, and September 31, 2009, from acute care hospitals in 3 large, geographically diverse states (California, Florida, and Nebraska) with data recorded in the Healthcare Cost and Utilization Project state inpatient and ED databases.
The 3 primary outcomes during the 30-day period after hospital discharge were ED visits not resulting in admission (treat-and-release encounters), hospital readmissions from any source, and a combined measure of ED visits and hospital readmissions termed hospital-based acute care.
The final cohort included 5,032,254 index hospitalizations among 4,028,555 unique patients. In the 30 days following discharge, 17.9% (95% CI, 17.9%-18.0%) of hospitalizations resulted in at least 1 acute care encounter. Of these 1,233,402 postdischarge acute care encounters, ED visits comprised 39.8% (95% CI, 39.7%-39.9%). For every 1000 discharges, there were 97.5 (95% CI, 97.2-97.8) ED treat-and-release visits and 147.6 (95% CI, 147.3-147.9) hospital readmissions in the 30 days following discharge. The number of ED treat-and-release visits ranged from a low of 22.4 (95% CI, 4.6-65.4) encounters per 1000 discharges for breast malignancy to a high of 282.5 (95% CI, 209.7-372.4) encounters per 1000 discharges for uncomplicated benign prostatic hypertrophy. Among the highest volume discharges, the most common reason patients returned to the ED was always related to their index hospitalization.
After discharge from acute care hospitals in 3 states, ED visits within 30 days were common among adults and accounted for 39.8% of postdischarge hospital-based acute care visits. Improving care transitions should focus not only on decreasing readmissions but also on ED visits.
JAMA The Journal of the American Medical Association 01/2013; 309(4):364-71. · 30.03 Impact Factor
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ABSTRACT: BACKGROUND Little is known about the cost to Medicare of breast cancer screening or whether regional-level screening expenditures are associated with cancer stage at diagnosis or treatment costs, particularly because newer breast cancer screening technologies, like digital mammography and computer-aided detection (CAD), have diffused into the care of older women. METHODS Using the linked Surveillance, Epidemiology, and End Results-Medicare database, we identified 137 274 women ages 66 to 100 years who had not had breast cancer and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. For women who developed cancer, we calculated initial treatment cost. We then assessed screening-related cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs. RESULTS In the United States, the annual costs to fee-for-service Medicare for breast cancer screening-related procedures (comprising screening plus workup) and treatment expenditures were $1.08 billion and $1.36 billion, respectively. For women 75 years or older, annual screening-related expenditures exceeded $410 million. Age-standardized screening-related cost per beneficiary varied more than 2-fold across regions (from $42 to $107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost. Women residing in HRRs with high screening costs were more likely to be diagnosed as having early-stage cancer (incidence rate ratio, 1.78 [95% CI, 1.40-2.26]). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs ($151 vs $115; P = .20). CONCLUSIONS The cost to Medicare of breast cancer screening exceeds $1 billion annually in the fee-for-service program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes.
JAMA internal medicine. 01/2013;
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ABSTRACT: Following the acute phase of treatment, national guidelines recommend cancer survivors have routine contact with health care providers and undergo basic ancillary testing while avoiding high-cost imaging (HCI). We conducted this study to determine how frequently breast, prostate, and colorectal cancer survivors received recommended follow-up care and HCI tests during the survivorship period.
Using administrative data from TRICARE beneficiaries, we identified a cohort of patients who were treated for breast, prostate, or colorectal cancer between October 2005 and March 2007. These patients were then followed through September 2010. During the 3 years after initial treatment, we determined how frequently survivors received all minimum recommended survivorship care as defined by national guidelines and underwent HCI tests and if these outcomes varied by geographic region.
Overall, 3148 patients underwent treatment for breast (n = 1630), prostate (n = 1173), or colorectal (n = 345) cancer. Sixty-five percent received all minimum recommended care over 3 years (breast = 74.1%, prostate = 65.3%, colorectal = 25.5%). During the 3-year period, 74.1% of breast cancer survivors received a mammogram each year, whereas 69.1% of colorectal cancer survivors had at least 1 colonoscopy. Sixty-four percent had at least 1 HCI study during the 3-year period (positron emission tomography = 10.9%, computer tomography = 48.8%, magnetic resonance imaging = 36.6%) at a cost of $3.5 million. Substantial state-level variation was noted for both outcomes.
Some cancer survivors do not receive recommended care following initial treatment while frequently undergoing HCI. The existing geographic variation in quality and imaging utilization suggests that improvements to cancer survivorship care are possible.
The Cancer Journal 01/2013; 19(1):1-9. · 3.26 Impact Factor
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ABSTRACT: Neoadjuvant and concurrent androgen deprivation therapy (ncADT) is recommended for men with high-risk prostate cancer, but not low-risk cancer or short life expectancy. It is unclear whether the use of ncADT among older men in the community setting is aligned with the potential for clinical benefit.
We used the Surveillance, Epidemiology, and End Results-Medicare database to assess patterns of ncADT use among men diagnosed with prostate cancer during 2004-2007 who received radiation therapy. Men were stratified according to tumor risk groups and life expectancy. We used logistic regression to identify factors associated with ncADT use within each risk group.
There were 10,686 men in the sample (mean age 74.2 years; 83.4% white). The use of ncADT was 80.7%, 54.1%, and 27.8% in the high-, intermediate-, and low-risk groups, respectively. Men with life expectancy <5 years had higher rates of ncADT use than men with life expectancy ≥10 years in all risk groups. Within each risk group, advancing age was associated with higher likelihood of receiving of ncADT (odds ratio for men aged 80-84 compared to 67-69 = 1.93 (95% CI 1.37-2.70); 1.51 (95% CI 1.22-1.87); and 1.71 (95% CI 1.14-2.57) for high-, intermediate-, and low-risk groups, respectively).
ncADT use is not consistent with guideline recommendations and is more frequent among men who are older, have shorter life expectancy, and are less likely to benefit from therapy.
Journal of Geriatric Oncology 01/2013; 4(1):9-18. · 1.00 Impact Factor
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ABSTRACT: Background Proton radiotherapy (PRT) is an emerging treatment for prostate cancer despite limited knowledge of clinical benefit or potential harms compared with other types of radiotherapy. We therefore compared patterns of PRT use, cost, and early toxicity among Medicare beneficiaries with prostate cancer with those of intensity-modulated radiotherapy (IMRT).Methods We performed a retrospective study of all Medicare beneficiaries aged greater than or equal to 66 years who received PRT or IMRT for prostate cancer during 2008 and/or 2009. We used multivariable logistic regression to identify factors associated with receipt of PRT. To assess toxicity, each PRT patient was matched with two IMRT patients with similar clinical and sociodemographic characteristics. The main outcome measures were receipt of PRT or IMRT, Medicare reimbursement for each treatment, and early genitourinary, gastrointestinal, and other toxicity. All statistical tests were two-sided.ResultsWe identified 27,647 men; 553 (2%) received PRT and 27,094 (98%) received IMRT. Patients receiving PRT were younger, healthier, and from more affluent areas than patients receiving IMRT. Median Medicare reimbursement was $32,428 for PRT and $18,575 for IMRT. Although PRT was associated with a statistically significant reduction in genitourinary toxicity at 6 months compared with IMRT (5.9% vs 9.5%; odds ratio [OR] = 0.60, 95% confidence interval [CI] = 0.38 to 0.96, P = .03), at 12 months post-treatment there was no difference in genitourinary toxicity (18.8% vs 17.5%; OR = 1.08, 95% CI = 0.76 to 1.54, P = .66). There was no statistically significant difference in gastrointestinal or other toxicity at 6 months or 12 months post-treatment.Conclusions
Although PRT is substantially more costly than IMRT, there was no difference in toxicity in a comprehensive cohort of Medicare beneficiaries with prostate cancer at 12 months post-treatment.
CancerSpectrum Knowledge Environment 12/2012; · 14.07 Impact Factor
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ABSTRACT: PURPOSE: New radiation therapy modalities have broadened treatment options for older women with breast cancer, but it is unclear how clinical factors, geographic region, and physician preference affect the choice of radiation therapy modality. METHODS AND MATERIALS: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify women diagnosed with stage I-III breast cancer from 1998 to 2007 who underwent breast-conserving surgery. We assessed the temporal trends in, and costs of, the adoption of intensity modulated radiation therapy (IMRT) and brachytherapy. Using hierarchical logistic regression, we evaluated the relationship between the use of these new modalities and patient and regional characteristics. RESULTS: Of 35,060 patients, 69.9% received conventional external beam radiation therapy (EBRT). Although overall radiation therapy use remained constant, the use of IMRT increased from 0.0% to 12.6% from 1998 to 2007, and brachytherapy increased from 0.7% to 9.0%. The statistical variation in brachytherapy use attributable to the radiation oncologist and geographic region was 41.4% and 9.5%, respectively (for IMRT: 23.8% and 22.1%, respectively). Women undergoing treatment at a free-standing radiation facility were significantly more likely to receive IMRT than were women treated at a hospital-based facility (odds ratio for IMRT vs EBRT: 3.89 [95% confidence interval, 2.78-5.45]). No such association was seen for brachytherapy. The median radiation therapy cost per treated patient increased from $5389 in 2001 to $8539 in 2007. CONCLUSIONS: IMRT and brachytherapy use increased substantially from 1998 to 2007; overall, radiation therapy costs increased by more than 50%. Radiation oncologists played an important role in treatment choice for both types of radiation therapy, whereas geographic region played a bigger role in the use of IMRT than brachytherapy.
International journal of radiation oncology, biology, physics 11/2012; · 4.59 Impact Factor
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ABSTRACT: BACKGROUND:: Among older women with early-stage breast cancer, patients with a short life expectancy (LE) are much less likely to benefit from adjuvant radiation therapy (RT). Little is known about the impact of physicians and regional factors on the use of RT across LE groups. OBJECTIVE:: To determine the relative contribution of patient, physician, and regional factors on the use of RT. DESIGN:: Retrospective cohort. SUBJECTS:: Women aged 67-94 years diagnosed with stage I breast cancer between 1998 and 2007 receiving breast-conserving surgery. MEASURES:: We evaluated patient, physician, and regional factors for their association with RT across strata of LE using a 3-level hierarchical logistic regression model. Risk-standardized treatment rates (RSTRs) for the receipt of radiation were calculated according to primary surgeon and region. RESULTS:: Approximately 43.6% of the 2253 women with a short LE received RT, compared with 90.8% of the 11,027 women with a long LE. Among women with a short LE, the probability of receiving RT varied substantially across primary surgeons; RSTRs ranged from 27.7% to 67.3% (mean, 43.9%). There was less variability across geographic regions; RSTRs ranged from 42.0% to 45.2% (mean, 43.6%). Short LE patients were more likely to receive RT in areas with high radiation oncologist density (odds ratio, 1.59; 95% confidence interval, 1.07-2.36). CONCLUSIONS:: Although there is a wide variation across geographic regions in the use of RT among women with breast cancer and short LE, the regional variation was substantially diminished after accounting for the operating surgeon.
Medical care 11/2012; · 3.24 Impact Factor
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ABSTRACT: OBJECTIVES: The purpose of this study was to estimate heart failure (HF) and cardiomyopathy (CM) rates after adjuvant trastuzumab therapy and chemotherapy in a population of older women with early-stage breast cancer. BACKGROUND: Newer biologic therapies for breast cancer such as trastuzumab have been reported to increase HF and CM in clinical trials, especially in combination with anthracycline chemotherapy. Elderly patients, however, typically have a higher prevalence of cardiovascular risk factors and have been underrepresented in trastuzumab clinical trials. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data from 2000 through 2007, we identified women 67 to 94 years of age with early-stage breast cancer. We calculated 3-year incidence rates of HF or CM for the following mutually exclusive treatment groups: trastuzumab (with or without nonanthracycline chemotherapy), anthracycline plus trastuzumab, anthracycline (without trastuzumab and with or without nonanthracycline chemotherapy), other nonanthracycline chemotherapy, or no adjuvant chemotherapy or trastuzumab therapy. HF or CM events were ascertained from administrative Medicare claims. Poisson regression was used to quantify risk of HF or CM, adjusting for sociodemographic factors, cancer characteristics, and cardiovascular conditions. RESULTS: We identified 45,537 older women (mean age: 76.2 years, standard deviation: 6.2 years) with early-stage breast cancer. Adjusted 3-year HF or CM incidence rates were higher for patients receiving trastuzumab (32.1 per 100 patients) and anthracycline plus trastuzumab (41.9 per 100 patients) compared with no adjuvant therapy (18.1 per 100 patients, p < 0.001). Adding trastuzumab to anthracycline therapy added 12.1, 17.9, and 21.7 HF or CM events per 100 patients over 1, 2, and 3 years of follow-up, respectively. CONCLUSIONS: HF or CM are common complications after trastuzumab therapy for older women, with higher rates than those reported from clinical trials.
Journal of the American College of Cardiology 11/2012; · 14.16 Impact Factor
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ABSTRACT: PURPOSEBrachytherapy has disseminated into clinical practice as an alternative to whole-breast irradiation (WBI) for early-stage breast cancer; however, current national treatment patterns and associated complications remain unknown. PATIENTS AND METHODS
We constructed a national sample of Medicare beneficiaries ages 66 to 94 years who underwent breast-conserving surgery from 2008 to 2009 and were treated with brachytherapy or WBI. We used hospital referral regions (HRRs) to assess national treatment variation and an instrumental variable analysis to compare complication rates between treatment groups, adjusting for patient and clinical characteristics. We compared overall, wound and skin, and deep-tissue and bone complications between brachytherapy and WBI at 1 year of follow-up.ResultsOf 29,648 women in our sample, 4,671 (15.8%) received brachytherapy. The percent of patients receiving brachytherapy varied substantially across HRRs, ranging from 0% to over 70% (interquartile range, 7.5% to 23.3%). Of women treated with brachytherapy, 34.3% had a complication compared with 27.3% of women undergoing WBI (P < .001). After adjusting for patient and clinical characteristics, 35.2% of women treated with brachytherapy (95% CI, 28.6 to 41.9) had a complication compared with 18.4% treated with WBI (95% CI, 15.5 to 21.3; P value for difference, <.001). Brachytherapy was associated with a 16.9% higher rate of wound and skin complications compared with WBI (95% CI, 10.0 to 23.9; P < .001), but there was no difference in deep-tissue and bone complications. CONCLUSION
Brachytherapy is commonly used among Medicare beneficiaries and varies substantially across regions. After 1 year, wound and skin complications were significantly higher among women receiving brachytherapy compared with those receiving WBI.
Journal of Clinical Oncology 10/2012; · 18.37 Impact Factor
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Archives of internal medicine 09/2012; · 11.46 Impact Factor
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ABSTRACT: BACKGROUND: Compared to the open approach, randomized trials have shown that laparoscopic colectomy is associated with a shorter hospitalization without increases in morbidity or mortality rates. With broader adoption of laparoscopic colectomy for cancer in the USA, it is unclear if laparoscopic colectomy continues to be associated with shorter hospitalization and comparable morbidity. PURPOSE: The purpose of this study is to determine if hospitals where a greater proportion of colon resections for cancer are approached laparoscopically (laparoscopy rate) achieve improved short-term outcomes compared to hospitals with lower laparoscopy rates. METHODS: From the 2008-2009 Nationwide Inpatient Sample, we identified hospitals where ≤12 colon resections for cancer were reported with ≥1 approached laparoscopically. We assessed the correlation between a hospital's laparoscopy rate and risk-standardized outcomes (intra- and postoperative morbidity, in-hospital mortality rates, and average length of stay). RESULTS: Overall, 6,806 colon resections were performed at 276 hospitals. Variation was noted in hospital laparoscopy rates (median = 52.0 %, range = 3.8-100 %) and risk-standardized intra- (2.7 %, 1.8-8.6 %) and postoperative morbidity (27.8 %, 16.4-53.4 %), in-hospital mortality (0.7 %, 0.3-42.0 %), and average length of stay (7.0 days, 4.9-10.3 days). While no association was noted with in-hospital mortality, higher laparoscopy rates were correlated with lower postoperative morbidity [correlation coefficient (r) = -0.12, p = 0.04) and shorter hospital stays (r = -0.23, p < 0.001), but higher intraoperative morbidity (r = 0.19, p < 0.001) rates. This was not observed among hospitals with high procedure volumes. CONCLUSIONS: Higher laparoscopy rates were associated with only slightly lower postoperative morbidity rates and modestly shorter hospitalizations.
Journal of Gastrointestinal Surgery 09/2012; · 2.83 Impact Factor
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ABSTRACT: ABSTRACT BACKGROUND: Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as video assisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare beneficiaries with stage I NSCLC is unknown. METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment. RESULTS: There were 13,458 patients in our sample (mean age 75.7). The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% (p<0.001), although the proportion of surgery patients undergoing VATS increased from 11.3% to 32.0%. Similarly, while the use of new radiation modalities increased from nil to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgery compared to no treatment (OR 0.12 (95% CI 0.09-0.16)) and more likely to receive radiation compared to surgery (OR 13.61 (95% CI 9.75-19.0)). CONCLUSION: From 1998-2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less invasive forms of surgery and radiation.1Department of Internal Medicine, Section of Pulmonary and Critical Care Medicine, michael.vest@yale.edu, lynn.tanoue@yale.edu, gaetane.michaud@yale.edu2Department of Internal Medicine, Section of Cardiology, Yale, jeph.herrin@yale.edu3Health Research and Educational Trust, Chicago IL, jeph.herrin@yale.edu4Department of Internal Medicine, Section of General Internal Medicine, pamela.soulos@yale.edu, cary.gross@yale.edu5Yale Cancer Outcomes, Public Policy, and Effectiveness Resear1ch (COPPER) Center, roy.decker@yale.edu, anthony.kim@yale.edu, jeph.herrin@yale.edu, pamela.soulos@yale.edu, cary.gross@yale.edu6Department of Radiation Oncology, roy.decker@yale.edu7Department of Surgery, Section of Thoracic Surgery, frank.detterbeck@yale.edu, anthony.kim@yale.edu8Department of Internal Medicine, Section of Medical Oncology, and the Yale Comprehensive Cancer Center. daniel.morgensztern@yale.eduAddress correspondence and requests for reprints to: Cary Gross, MD, Yale University School of Medicine, 333 Cedar Street P.O. Box 208093, New Haven, CT 06520-8057, E-mail: cary.gross@yale.eduFunding: This was supported by a grant from the National Cancer Institute (5R01CA149045).
Chest 09/2012; · 5.25 Impact Factor
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ABSTRACT: During 2004-2006, two hypomethylating agents (HMAs) were approved for the treatment of myelodysplastic syndromes (MDS) in the United States. We assessed the impact of HMAs on the cost of care and survival of MDS patients, by constructing a cohort of patients who were diagnosed during 2001-2007 (n=6556, age ≥66.5 years) and comparable non-cancer controls. We assessed MDS patients' and controls' Medicare expenditures to derive MDS-related cost. We evaluated the two-year survival of patients as a group and by major subtypes. Taking into account the survival probabilities of MDS, the expected MDS-related 5-year cost was $63,223 (95% confidence interval: $59,868-66,432 in 2009 dollars), higher than the reported comparable cost for any of the 18 most prevalent cancers in the United States. Compared with MDS patients diagnosed in the earlier period (January 2001-June 2004) who received no HMAs, patients diagnosed later (July 2004-December 2007) who received HMAs had a significantly higher 24-month cost ($97,977 vs. $42,628 in 2009 dollars) and an improved 24-month survival (especially among patients with refractory anemia or refractory anemia with excess blasts). The magnitude of the cost of care underscores a need for comparative cost-effectiveness studies to reduce the clinical and economic burden of MDS.
Leukemia research 08/2012; 36(11):1370-5. · 2.36 Impact Factor
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ABSTRACT: Racial disparities in access to surgical resection for treatment of early-stage non-small-cell lung cancer (NSCLC) are well documented. However it is unclear how race, clinical, and hospital characteristics affect the surgical approach among patients undergoing resection.
Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)/Medicare linked database, we identified patients 67 years of age or older diagnosed with stage I NSCLC who underwent surgical resection from 2000 to 2007. Surgical approach was categorized as lobectomy or segmentectomy (anatomic) versus wedge resection (nonanatomic). We used logistic regression to identify the association between demographic, clinical, and hospital factors and the use of nonanatomic resections.
There were 8,986 patients in the sample (mean age, 75 years; 53% women); 12.8% underwent nonanatomic resection. The use of nonanatomic resection increased significantly, from 11.0% in 2000 to 15.9% in 2007 (p=0.008). In multivariable analysis, race was not associated with the receipt of nonanatomic resection. Factors associated with the use of nonanatomic resections included age greater than 80 years (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.15-1.98), T1a primary tumor status, chronic obstructive pulmonary disease (COPD) (OR, 1.81; 95% CI, 1.55-2.12), and volume of hospital lung resections performed (highest versus lowest hospital volume, OR, 1.58; 95% CI, 1.23-2.04). More nonanatomic resections were performed in 2007 than in 2000 (OR, 1.73; 95% CI, 1.27-2.37). After stratifying by tumor size, the temporal trend in the use of nonanatomic resection remained significant only among patients with tumors greater than 3 cm.
Since 2000, the use of nonanatomic resections in stage I NSCLC has increased, most significantly among patients with larger tumors. After adjusting for clinical factors, there was no relation between race and type of surgical resection.
The Annals of thoracic surgery 07/2012; 94(3):895-901. · 3.74 Impact Factor
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ABSTRACT: To determine empirically the diseases contributing most commonly and strongly to death in older adults, accounting for coexisting diseases.
Longitudinal.
United States.
Twenty-two thousand eight hundred ninety Medicare Current Beneficiary Survey participants, a national representative sample of Medicare beneficiaries, enrolled during 2002 to 2006.
Information on chronic and acute diseases was ascertained from Medicare claims data. Diseases contributing to death during follow-up were identified empirically using regression models for all diseases with a frequency of 1% or greater and hazard ratio for death of greater than 1. The additive contributions of these diseases, adjusting for coexisting diseases, were calculated using a longitudinal extension of average attributable fraction; 95% confidence intervals were estimated from bootstrapping.
Fifteen diseases and acute events contributed significantly to death, together accounting for nearly 70% of death. Heart failure (20.0%), dementia (13.6%), chronic lower respiratory disease (12.4%), and pneumonia (5.3%) made the largest contributions to death. Cancer, including lung, colorectal, lymphoma, and head and neck, together contributed to 5.6% of death. Other diseases and events included acute kidney injury, stroke, septicemia, liver disease, myocardial infarction, and unintentional injuries.
The use of methods that focus on determining a single underlying cause may lead to underestimation of the extent of the contribution of some diseases such as dementia and respiratory disease to death in older adults and overestimation of the contribution of other diseases. Current conceptualization of a single underlying cause may not account adequately for the contribution to death of coexisting diseases that older adults experience.
Journal of the American Geriatrics Society 06/2012; 60(8):1448-56. · 3.74 Impact Factor
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ABSTRACT: Objectives. We decomposed the total effect of coexisting diseases on a timed occurrence of an adverse outcome into additive effects from individual diseases. Methods. In a cohort of older adults enrolled in the Precipitating Events Project in New Haven County, Connecticut, we assessed a longitudinal extension of the average attributable fraction method (LE-AAF) to estimate the additive and order-free contributions of multiple diseases to the timed occurrence of a health outcome, with right censoring, which may be useful when relationships among diseases are complex. We partitioned the contribution to death into additive LE-AAFs for multiple diseases. Results. The onset of heart failure and acute episodes of pneumonia during follow-up contributed the most to death, with the overall LE-AAFs equal to 13.0% and 12.1%, respectively. The contribution of preexisting diseases decreased over the years, with a trend of increasing contribution from new onset of diseases. Conclusions. LE-AAF can be useful for determining the additive and order-free contribution of individual time-varying diseases to a time-to-event outcome. (Am J Public Health. Published online ahead of print April 19, 2012: e1-e6. doi:10.2105/AJPH.2011.300458).
American Journal of Public Health 04/2012; · 3.93 Impact Factor
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ABSTRACT: Policy makers interested in containing health care costs are targeting regional variation in utilization, including the use of advanced imaging. However, bluntly decreasing utilization among the highest-utilization regions may have negative consequences. In a cross-sectional study of prostate cancer patients from 2004 to 2005, we found that regions with lower rates of inappropriate imaging also had lower rates of appropriate imaging. Similarly, regions with higher overall imaging rates tended to have not only higher rates of inappropriate imaging, but also higher rates of appropriate imaging. In fact, men with high-risk prostate cancer were more likely to receive appropriate imaging if they resided in areas with higher rates of inappropriate imaging. This "thermostat model" of regional health care utilization suggests that poorly designed policies aimed at reducing inappropriate imaging could limit access to appropriate imaging for high-risk patients. Health care organizations need clearly defined quality metrics and supportive systems to encourage appropriate treatment for patients and to ensure that cost containment does not occur at the expense of quality.
Health Affairs 04/2012; 31(4):730-40. · 4.31 Impact Factor
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ABSTRACT: The Cancer and Leukemia Group B (CALGB) C9343 trial found that adjuvant radiation therapy (RT) provided minimal benefits for older women with breast cancer. Although treatment guidelines were changed to indicate that some women could forego RT, the impact of the C9343 results on clinical practice is unclear.
We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare data set to assess the use of adjuvant RT in a sample of women ≥ 70 years old diagnosed with stage I breast cancer from 2001 to 2007 who fulfilled the C9343 inclusion criteria. We used log-binomial regression to estimate the relation between publication of C9343 and use of RT in the full sample and across strata of patient and health system characteristics.
Of the 12,925 Medicare beneficiaries in our sample (mean age, 77.7 years), 76.5% received RT. Approximately 79% of women received RT before study publication compared with 75% after (adjusted relative risk of receiving RT postpublication v prepublication: 0.97; 95% CI, 0.95 to 0.98). Although use of RT was lower after the trial within all strata of age and life expectancy, the magnitude of this decrease did not differ significantly by strata. For instance, among patients with life expectancy less than 5 years, RT use decreased by 3.7%, from 44.4% prepublication to 40.7% postpublication. Among patients with life expectancy ≥ 10 years, RT use decreased by 3.0%, from 92.0% to 89.0%.
The C9343 trial had minimal impact on the use of RT among older women in the Medicare population, even among the oldest women and those with shorter life expectancies.
Journal of Clinical Oncology 03/2012; 30(14):1601-7. · 18.37 Impact Factor
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Circulation Cardiovascular Quality and Outcomes 03/2012; 5(2):238-40. · 4.91 Impact Factor
