[Show abstract][Hide abstract] ABSTRACT: The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures.
To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated.
Retrospective cohort study using the the Surveillance, Epidemiology, and End Results-Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level, <10 ng/mL) or breast cancer (in situ, stage I, or stage II disease), based on Choosing Wisely definitions.
In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa.
We identified 9219 men with prostate cancer and 30 398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12-2.65), 1.19 (0.78-1.81), or 1.76 (1.15-2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile.
At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.
[Show abstract][Hide abstract] ABSTRACT: Background
The surgical robot has been widely adopted in the United States in spite of its high cost and controversy surrounding its benefit. Some have suggested that a “medical arms race” influences technology adoption. We wanted to determine whether a hospital would acquire a surgical robot if its nearest neighboring hospital already owned one.
We identified 554 hospitals performing radical prostatectomy from the Healthcare Cost and Utilization Project Statewide Inpatient Databases for seven states. We used publicly available data from the website of the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale, CA) combined with data collected from the hospitals to ascertain the timing of robot acquisition during year 2001 to 2008. One hundred thirty four hospitals (24%) had acquired a surgical robot by the end of 2008. We geocoded the address of each hospital and determined a hospital's likelihood to acquire a surgical robot based on whether its nearest neighbor owned a surgical robot. We developed a Markov chain method to model the acquisition process spatially and temporally and quantified the “neighborhood effect” on the acquisition of the surgical robot while adjusting simultaneously for known confounders.
After adjusting for hospital teaching status, surgical volume, urban status and number of hospital beds, the Markov chain analysis demonstrated that a hospital whose nearest neighbor had acquired a surgical robot had a higher likelihood itself acquiring a surgical robot (OR=1.71, 95% CI: 1.07–2.72, p=0.02).
There is a significant spatial and temporal association for hospitals acquiring surgical robots during the study period. Hospitals were more likely to acquire a surgical robot during the robot's early adoption phase if their nearest neighbor had already done so.
[Show abstract][Hide abstract] ABSTRACT: To examine public and media response to the United States Preventive Services Task Force's (USPSTF) draft (October 2011) and finalized (May 2012) recommendations against prostate-specific antigen (PSA) testing using Twitter, a popular social network with over 200 million active users.
We used a mixed methods design to analyze posts on Twitter, called "tweets." Using the search term "prostate cancer," we archived tweets in the 24 hour periods following the release of the USPSTF draft and finalized recommendations. We recorded tweet rate per hour and developed a coding system to assess type of user and sentiment expressed in tweets and linked articles.
After the draft and finalized recommendations, 2042 and 5357 tweets focused on the USPSTF report, respectively. Tweet rate nearly doubled within two hours of both announcements. Fewer than 10% of tweets expressed an opinion about screening, and the majority of these were pro-screening during both periods. In contrast, anti-screening articles were tweeted more frequently in both draft and finalized study periods. From the draft to the finalized recommendations, the proportion of anti-screening tweets and anti-screening article links increased (p= 0.03 and p<0.01, respectively).
There was increased Twitter activity surrounding the USPSTF draft and finalized recommendations. The percentage of anti-screening tweets and articles appeared to increase, perhaps due to the interval public comment period. Despite this, most tweets did not express an opinion, suggesting a missed opportunity in this important arena for advocacy.
BJU International 03/2014; 116(1). DOI:10.1111/bju.12748 · 3.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Effective breast cancer management is more complex with diabetes present and may contribute to poor outcomes. Therefore, we conducted two simultaneous systematic reviews to address the association of diabetes with (1) treatment patterns in breast cancer patients and (2) breast cancer recurrence rates or breast cancer-specific and all-cause mortality. We searched major databases for English language peer-reviewed studies through November 2013, which addressed either of the above research questions, following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) method. Analyses compared treatment patterns or health outcomes for breast cancer subjects with and without diabetes. We used STROBE quality criteria and conducted a random-effects meta-analysis of all-cause mortality. The review yielded 11 publications for question 1 and 26 for question 2, with nine overlapping. Treatment studies showed chemotherapy was less likely in patients with diabetes. Of 22 studies, 21 assessing all-cause mortality indicated a statistically significant increased overall mortality for patients with diabetes (hazard ratios: 0.33-5.40), with meta-analysis of eligible studies indicating a 52 % increased risk. Nine studies assessing breast cancer-specific mortality had inconsistent results, with five showing significantly increased risk for diabetes patients. Results were inconsistent for recurrence and metastases. The majority of studies reported detrimental associations between diabetes and optimal treatment or all-cause mortality among women with breast cancer. Divergence in variable and outcomes inclusion and definitions, potential participation bias in individual studies, and differing analytic methods make inferences difficult. This review illuminates the importance of the impact of diabetes on breast cancer patients and explicitly recognizes that co-management of conditions is necessary to prevent excess morbidity and mortality.
Breast Cancer Research and Treatment 01/2014; 143(3). DOI:10.1007/s10549-014-2833-x · 4.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Annual surveillance mammograms in older long-term breast cancer survivors are recommended, but this recommendation is based on little evidence and with no guidelines on when to stop. Surveillance mammograms should decrease breast cancer mortality by detecting second breast cancer events at an earlier stage. We examined the association between surveillance mammography beyond 5 years after diagnosis on breast cancer-specific mortality in a cohort of women aged ≥65 years diagnosed 1990-1994 with early stage breast cancer. Our cohort included women who survived disease free for ≥5 years (N = 1,235) and were followed from year 6 through death, disenrollment, or 15 years after diagnosis. Asymptomatic surveillance mammograms were ascertained through medical record review. We used Cox proportional hazards regression stratified by follow-up year to calculate the association between time-varying surveillance mammography and breast cancer-specific and other-than-breast mortality adjusting for site, stage, primary surgery type, age and time-varying Charlson Comorbidity Index. The majority (85 %) of the 1,235 5-year breast cancer survivors received ≥1 surveillance mammogram in years 5-9 (yearly proportions ranged from 48 to 58 %); 82 % of women received ≥1 surveillance mammogram in years 10-14. A total of 120 women died of breast cancer and 393 women died from other causes (average follow-up 7.3 years). Multivariable models and lasagna plots suggested a modest reduction in breast cancer-specific mortality with surveillance mammogram receipt in the preceding year (IRR 0.82, 95 % CI 0.56-1.19, p = 0.29); the association with other-cause mortality was 0.95 (95 % CI 0.78-1.17, p = 0.64). Among older breast cancer survivors, surveillance mammography may reduce breast cancer-specific mortality even after 5 years of disease-free survival. Continuing surveillance mammography in older breast cancer survivors likely requires physician-patient discussions similar to those recommended for screening, taking into account comorbid conditions and life-expectancy.
Breast Cancer Research and Treatment 10/2013; 142(1). DOI:10.1007/s10549-013-2720-x · 4.20 Impact Factor
[Show abstract][Hide abstract] 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; 173(3):1-7. DOI:10.1001/jamainternmed.2013.1397 · 13.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: Twitter, a microblogging service with over 500 million users, has been used to predict stock market fluctuations, monitor disease spread, and foment political uprising. We used Twitter to understand public sentiment and media coverage of the recent, unfinalized USPSTF recommendations against prostate cancer screening.
Methods: We used a mixed methods design to capture data from postings on Twitter, called tweets. Using the search term prostate cancer, we analyzed 3027 consecutive tweets obtained from an archiving program in the 24 hour period beginning with the first article posted about the USPSTF report. We developed a coding system to assess sentiment expressed in tweets and their associated articles, which demonstrated agreement between two independent reviewers.
Results: In the hour of the first article tweeted about the report, there was a 47% rise in tweets about prostate cancer and an additional 19% increase the next hour, before returning to baseline overnight and sharply increasing (85%) again the following morning. Of all coded tweets, 2042 (67%) were about the panel's report. Users tweeting about the report had a median 4811 tweets and 481 followers. No opinions were expressed in 1840 (91%) of these tweets: 1626 simply tweeted articles, 113 indicated controversy or initiated discussion, 40 used humor, 39 indicated shock or confusion, and 32 drew special attention to the report. Of the 192 (9%) that expressed an opinion, 22% were against screening and 78% were for screening. Functional links were present in 1754 tweets, from which we identified 90 unique articles about the report: 56 neutral, 17 against screening, and 17 in favor of screening. Some of these articles were posted more frequently than others: 999 (57%) total articles were neutral, 643 (37%) were against screening, and 112 (6.4%) were in favor of screening. Tweets and articles against screening reached a total of 63,379 and 2,931,791 followers, respectively, while those in favor of screening reached 193,913 and 207,814 followers, respectively.
Conclusions: Analysis of Twitter feeds posted shortly after the USPSTF's announcement demonstrated an outpouring of user sentiment in favor of prostate cancer screening, despite the fact that most posted articles were against screening. Policy makers who rely on public opinion may look increasingly to social media to gauge public sentiment, influence public attitudes and, ultimately, change policy.
The 34th Annual Meeting of the Society for Medical Decision Making; 10/2012
[Show abstract][Hide abstract] ABSTRACT: Purpose: The United States Preventive Services Task Force (USPSTF) makes recommendations for 60 distinct clinical services, but clinicians rarely have time to fully implement the recommendations. A systematic approach to prioritizing and personalizing guidelines for individual patients may improve outcomes.
Methods: We created a state transition Markov model for each of the 25 USPSTF Grade A and B guidelines for non-pregnant adults. For each guideline, we included factors to personalize the expected benefits and risks at the patient level, based on individual patient characteristics (e.g., smoking status, hypertension, and obesity), medical history, and family history. We personalized national life expectancy curves for a patient’s age, race, and gender, to estimate how much longer an individual would be expected to live from following each preventive care recommendation. We rank-ordered recommendations based on expected number of life-years gained, to help identify the preventive care guidelines with the greatest benefit for each patient.
Results: For a 62 year-old obese (height=68 inches, weight=200 lbs., BMI=30.4) male smoker with high cholesterol (TC=300, LDL=250), hypertension (BP=150/90) and family history of colorectal cancer (≥2 family members), the model's rank order of recommendations would be to quit smoking (3.1 life-years gained), lose weight (16 lbs., +1.6 life-years), lower blood pressure (to 120/80, +0.8 life years), eat a healthier diet (+0.3 life-years), lower cholesterol (to TC=199, LDL=108, +0.3 life-years), use aspirin daily (+0.1 life-years), and undergo colonoscopy (every 10 years, +0.1 life-years). Therefore, quitting smoking would confer about 1.9x the life expectancy gain as losing weight and 3.7x the life expectancy gain as lowering blood pressure. Expected gains from colonoscopy and use of aspirin would be similar, about 0.1x the life expectancy gain as losing weight. For the same individual who also had uncontrolled type II diabetes (HbA1c=8), the model’s top recommendation would be to get diabetes under control (to HbA1c≤7, +1.7 life-years). Quitting smoking would still confer about 1.9x the life expectancy gain as losing weight (+1.6 vs. +0.8 life-years), but now only 1.2x the life expectancy gain as lowering blood pressure (+1.6 vs. +1.3 life-years).
Conclusion: Quantitative models could help generate rank order recommendations of personalized preventive care. Future studies should consider patient adherence to recommendations and determine whether personalized preventive care would improve patient outcomes and save time for providers.
The 34th Annual Meeting of the Society for Medical Decision Making; 10/2012
[Show abstract][Hide abstract] ABSTRACT: Accelerated partial breast radiotherapy (RT) strategies (3-D conformal external-beam RT (3-D CRT) and brachytherapy with balloon catheter) reduce time and transportation burdens of whole breast RT for breast cancer. Long-term clinical trial evidence is unavailable for accelerated modalities, but uncertainty might be acceptable for patients likely to receive suboptimal whole breast RT. The objective of this study is to assess the cost effectiveness of accelerated partial breast RT compared to on-time and delayed whole breast RT. The design used in this study is decision analytic Markov model. The data sources are published literature; and national/federal sources. The target population of this study is a hypothetical cohort of 60 years old women previously treated with breast-conserving surgery for node-negative, estrogen receptor-positive breast cancer with tumors <1 cm. The time horizon is 15 years, and the perspective is societal. The interventions are whole breast RT, 3-D CRT, and brachytherapy breast irradiation. The outcome measures are costs (2008 US$), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. The base-case results were: 3-D CRT was the preferred strategy, costing on average $10,800 and yielding 11.21 QALYs. On-time whole breast RT costs $368,000/QALY compared to 3-D CRT, above the $100,000/QALY WTP threshold. 3-D CRT was also preferred over delayed whole breast RT. Brachytherapy was never preferred. Sensitivity analysis indicated that the results were sensitive to the rate of recurrence outside the initial tumor quadrant ("elsewhere failure") in one-way analysis. Probabilistic sensitivity analysis indicated that results were sensitive to parameter uncertainty, and that the elsewhere-failure rate and treatment preferences may drive results. The limitation of this study is that efficacy estimates are derived from studies that may not fully represent the population modeled. As a conclusion, 3-D CRT was preferred to whole breast RT and for women likely to delay RT, indicating that 3-D CRT could be targeted more efficiently before randomized trial evidence.
Breast Cancer Research and Treatment 09/2012; 136(1):221-9. DOI:10.1007/s10549-012-2242-y · 4.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/Aims Cervical cancer screening is performed to detect pre-cancerous cervical intraepithelial neoplasia or invasive cancerous cervical lesions prior to the onset of symptoms so they can be removed before the cancer has developed or spread. With the addition of high-risk human papillomavirus (HPV) testing to the long-established Papanicolaou (Pap) smear, national and health plan screening guidelines have been regularly updated in recent years. Guidelines on screening frequency and follow-up protocols have also changed over time and will likely continue to do so as HPV vaccination becomes more widespread. Here we describe patterns and results of cervical cancer testing and follow-up over a 10-year period within four geographically-dispersed U.S. managed care organizations. Methods Using data collected by the SEARCH: Screening Effectiveness And Research in Community-Based Healthcare project, we analyzed electronic medical record data on all women aged 20-65 during the period 1998-2007 across four HMORN sites. We created standardized files for Pap smear dates and results; cervical histology dates, types, and results; and HPV test dates and results. We also collected Virtual Data Warehouse data on HPV vaccinations, and selected diagnosis and procedure codes. We calculated rates of Pap testing, HPV testing, colposcopy, and cervical histology (biopsy and treatment). We also calculated rates for Pap testing we classified as "screening." Among women who had Pap tests in 2002 and 2007 and no abnormal test directly preceding the index test, we examined patterns of screening frequency. We also examined frequencies and trends in the results of "screening" Pap testing and cervical histology. Results Overall, annual Pap testing rates decreased and HPV testing rates dramatically increased over the 10 years, while rates of colposcopy, cervical histology, and cervical treatment did not display obvious patterns. Trends varied by age group and health plan. Pap screening frequency differed by health plan; overall, in 2007 a higher proportion of subjects had longer screening intervals (2 years or greater) than in 2002. Information on patterns of Pap and histology results will be presented. Discussion Evaluating trends in cervical cancer testing and follow-up may highlight opportunities to optimize cervical cancer screening delivery in community-based settings.
Clinical Medicine & Research 08/2012; 10(3):150-1. DOI:10.3121/cmr.2012.1100.ps1-25
[Show abstract][Hide abstract] ABSTRACT: The definitive local therapy options for early-stage breast cancer are mastectomy and breast-conserving surgery followed by radiation therapy. Older women and those with comorbidities frequently receive breast-conserving surgery alone. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of definitive therapy have not been well-studied.
In a cohort of 1,837 women aged 65 years and older receiving treatment for early-stage breast cancer in 6 integrated health care delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving nondefinitive local therapy and assessed the impact on breast cancer recurrence within levels of severity, defined as level of risk for recurrence.
Age and comorbidity were associated with receipt of nondefinitive therapy. Compared with those at low risk, women at the highest risk were less likely to receive nondefinitive therapy (odds ratio = 0.32; 95% CI, 0.22-0.47), and women at moderate risk were about half as likely (odds ratio = 0.54; 95% CI, 0.35-0.84). Nondefinitive local therapy was associated with higher rates of recurrence among women at moderate (hazard ratio = 5.1; 95% CI, 1.9-13.5) and low risk (hazard ratio = 3.2; 95% CI, 1.1-8.9). The association among women at high risk was weak (hazard ratio = 1.3; 95% CI, 0.75-2.1).
Among these older women with early-stage breast cancer, decisions about therapy partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk, omitting definitive local therapy was associated with increased recurrence.
Journal of the American College of Surgeons 12/2011; 213(6):757-65. DOI:10.1016/j.jamcollsurg.2011.09.010 · 4.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Employment status is related to treatment recovery and quality of life in breast cancer survivors, yet little is known about return to work in immigrant and minority survivors. We conducted an exploratory qualitative study using ethnically cohesive focus groups of urban breast cancer survivors who were African-American, African-Caribbean, Chinese, Filipina, Latina, or non-Latina white. We audio- and video-recorded, transcribed, and thematically coded the focus group discussions and we analyzed the coded transcripts within and across ethnic groups. Seven major themes emerged related to the participants' work experiences after diagnosis: normalcy, acceptance, identity, appearance, privacy, lack of flexibility at work, and employer support. Maintaining a sense of normalcy was cited as a benefit of working by survivors in each group. Acceptance of the cancer diagnosis was most common in the Chinese group and in participants who had a family history of breast cancer; those who described this attitude were likely to continue working throughout the treatment period. Appearance was important among all but the Chinese group and was related to privacy, which many thought was necessary to derive the benefit of normalcy at work. Employer support included schedule flexibility, medical confidentiality, and help maintaining a normal work environment, which was particularly important to our study sample. Overall, we found few differences between the different ethnic groups in our study. These results have important implications for the provision of support services to and clinical management of employed women with breast cancer, as well as for further large-scale research in disparities and employment outcomes.
Journal of Community Health 11/2011; 37(4):763-72. DOI:10.1007/s10900-011-9509-9 · 1.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background/Aims Mastectomy and breast conserving surgery followed by radiotherapy are considered initial guideline therapies for early stage breast cancer with randomized trials demonstrating reduced risk of recurrence. However, older women and those with comorbidities frequently receive only breast conserving surgery. The interaction of age and comorbidity with breast cancer severity and their impact on receipt of guideline therapy have not been well studied. Methods In the population-based BOW cohort of 1837 women age=65 years receiving initial treatment for early stage breast cancer in 6 integrated healthcare delivery systems in 1990-1994 and followed for 10 years, we examined predictors of receiving less than guideline therapy. We also assessed the impact of less than guideline therapy on breast cancer recurrence stratified by breast cancer severity (low, moderate, or high risk for recurrence using the 1992 St Gallen criteria). Results Age and comorbidity were independently associated with receipt of less than guideline therapy after controlling for breast cancer severity and race. However, compared to those at lowest risk for recurrence, women at the highest risk were unlikely to receive less than guideline therapy (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.21, 0.46) while women at moderate risk were about half as likely (OR 0.55, CI 0.36, 0.85). During follow-up, 295 women had a breast cancer recurrence. Using Cox regression modeling stratified by the 3 levels of risk for recurrence, non-receipt of guideline therapy was associated with recurrence among women at moderate (HR 5.10, CI 1.93, 13.49) and even low risk (HR 3.24, CI 1.15, 9.12). The elevated hazard rate ratio was not observed for the high risk level group (HR 1.29, CI 0.78, 2.15). Age and comorbidity were not associated with recurrence in any of the analyses. Conclusions Among these older women with early stage breast cancer, decisions about guideline therapy appear to have partially balanced breast cancer severity against age and comorbidity. However, even among women at low risk of recurrence, omitting guideline therapy placed them at elevated risk of recurrence.
Clinical Medicine & Research 11/2011; 9(3-4):144. DOI:10.3121/cmr.2011.1020.ps2-12