Trends in the aggressiveness of cancer care near the end of life.

PURPOSE: To characterize the aggressiveness of end-of-life cancer treatment for older adults on Medicare, and its relationship to the availability of healthcare resources. PATIENTS AND METHODS: We analyzed Medicare claims of 28,777 patients 65 years and older who died within 1 year of a diagnosis of lung, breast, colorectal, or other gastrointestinal cancer between 1993 and 1996 while living in one of 11 US regions monitored by the Surveillance, Epidemiology, and End Results Program. RESULTS: Rates of treatment with chemotherapy increased from 27.9% in 1993 to 29.5% in 1996 (P =.02). Among those who received chemotherapy, 15.7% were still receiving treatment within 2 weeks of death, increasing from 13.8% in 1993 to 18.5% in 1996 (P <.001). From 1993 to 1996, increasing proportions of patients had more than one emergency department visit (7.2% v 9.2%; P <.001), hospitalization (7.8% v 9.1%; P =.008), or were admitted to an intensive care unit (7.1% v 9.4%; P =.009) in the last month of life. Although fewer patients died in acute-care hospitals (32.9% v 29.5%; P <.001) and more used hospice services (28.3% v 38.8%; P <.001), an increasing proportion of patients who received hospice care initiated this service only within the last 3 days of life (14.3% v 17.0%; P =.004). Black patients were more likely than white patients to experience aggressive intervention in nonteaching hospitals but not in teaching hospitals. Greater local availability of hospices was associated with less aggressive treatment near death on multivariate analysis. CONCLUSION: The treatment of cancer patients near death is becoming increasingly aggressive over time.     

Report of the National Heart, Lung, and Blood Institute working group on outcomes research in cardiovascular disease

The National Heart, Lung, and Blood Institute convened a working group on outcomes research in cardiovascular disease (CVD). The working group sought to provide guidance on research priorities in outcomes research related to CVD. For the purposes of this document, "outcomes research" is defined as investigative endeavors that generate knowledge to improve clinical decision making and healthcare delivery to optimize patient outcomes. The working group identified the following priority areas: (1) national surveillance projects for high-prevalence CV conditions; (2) patient-centered care; (3) translation of the best science into clinical practice; and (4) studies that place the cost of interventions in the context of their real-world effectiveness. Within each of these topics, the working group described examples of initiatives that could serve the Institute and the public. In addition, the group identified the following areas that are important to the field: (1) promotion of the use of existing data; (2) facilitation of collaborations with other federal agencies; (3) investigations into the basic science of outcomes research, with an emphasis on methodological advances; (4) strengthening of appropriate study sections with individuals who have expertise in outcomes research; and (5) expansion of opportunities to train new outcomes research investigators. The working group concluded that a dedicated investment in CV outcomes research could directly improve the care delivered in the United States.     

Perceived discrimination and use of preventive health services

BACKGROUND: Little is known about the relation between perceptions of health care discrimination and use of health services. OBJECTIVES: To determine the prevalence of perceived discrimination in health care, its association with use of preventive services, and the contribution of perceived discrimination to disparities in these services by race/ethnicity, gender, and insurance status. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 54,968 respondents to the 2001 California Health Interview Survey. MEASUREMENTS: Subjects were asked about experience with discrimination in receiving health care and use of 6 preventive health services, all within the previous 12 months. METHODS: We used multivariate logistic regression with propensity-score methods to examine the adjusted relationship between perceived discrimination and receipt of preventive care. RESULTS: Discrimination was reported by 4.7% of respondents, and among these respondents the most commonly reported reasons were related to type of insurance (27.6%), race or ethnicity (13.7%), and income (6.7%). In adjusted analyses, persons who reported discrimination were less likely to receive 4 preventive services (cholesterol testing for cardiovascular disease, hemoglobin A1c testing and eye exams for diabetes, and flu shots), but not 2 other services (aspirin for cardiovascular disease, prostate specific antigen testing). Adjusting for perceived discrimination did not significantly change the relative likelihood of receipt of preventive care by race/ethnicity, gender, and insurance status. CONCLUSIONS: Persons who report discrimination may be less likely to receive some preventive health services. However, perceived discrimination is unlikely to account for a large portion of observed disparities in receipt of preventive care.     

Profiling providers on use of adjuvant chemotherapy by combining cancer registry and medical record data

PURPOSE: Treatment information collected by cancer registries can be used to monitor the provision of guideline-recommended chemotherapy to colorectal cancer patients. Incomplete information may bias comparisons of these rates. We developed statistical methods that combine data from a registry and physicians' records to assess hospital quality. DATA: From California Cancer Registry data, we selected all patients (n=12,594) newly diagnosed with stage III colon cancer or stage II or III rectal cancer from 428 hospitals during the years 1994 to 1998. To assess rates and predictors of underreporting of chemotherapy, we surveyed physicians treating 1449 of these patients from 98 hospitals during the years 1996 to 1997. METHODS: Using Bayesian statistical models, we imputed unobserved treatments. We studied the impact of underreporting on provider profiling by comparing rankings, estimates, and credible intervals based only on registry data to those incorporating physician survey data. RESULTS: Analyses that account for incompleteness of reporting yielded wider credible intervals for provider profiles than those that ignored such incompleteness. Among the 109 (25%) hospitals in the highest quartile of chemotherapy rates according to the registry data, 16 were not so classified when incomplete reporting was taken into account. With the more comprehensive model, 12 hospitals could be identified that ranked in the top quartile with probability>0.90. CONCLUSION: Estimates of adjusted hospital chemotherapy rates based solely on cancer registry data overstate the precision of assessments of hospital quality. Using additional information from a physician survey and applying rigorous statistical models, better inferences can be drawn about provider quality.     

Profiling hospitals by survival of patients with colorectal cancer

Objective. To profile hospitals by survival rates of colorectal cancer patients in multiple periods after initial treatment. Data Sources. California Cancer Registry data from 50,544 patients receiving primary surgery with curative intent for stage I–III colorectal cancer in 1994–1998, supplemented with hospital discharge abstracts. Study Design. We estimated a single Bayesian hierarchical model to quantify associations of survival to 30 days, 30 days to 1 year, and 1–5 years by hospital, adjusted for patient age, sex, race, stage, tumor site, and comorbidities. We compared two profiling methods for 30‐day survival and four longer‐term profiling methods by the fractions of hospitals with demonstrably superior survival profiles and of hospital pairs whose relative standings could be established confidently. Principal Findings. Interperiod correlation coefficients of the random effects are (95 percent credible interval 0.27, 0.85), (0.20, 0.76), and (0.19, 0.82). The three‐period model ranks 5.4 percent of pairwise comparisons by 30‐day survival with at least 95 percent confidence, versus 3.3 percent of pairs using a single‐period model, and 15–20 percent by weighted multiperiod methods. Conclusions. The quality of care for colorectal cancer provided by a hospital system is somewhat consistent across the immediate postoperative and long‐term follow‐up periods. Combining mortality profiles across longer periods may improve the statistical reliability of outcome comparisons.     

Longitudinal Trends in Enrollees’ Employment and Student Status after Medicaid Expansion

Medicaid “community engagement” requirement (work, school, job training, job searching, or volunteering) waivers have received CMS approval in nine states, but there are little data on current trends in Medicaid enrollees’ engagement in these activities. Our objective was to assess longitudinal changes in enrollees’ employment and student status after implementation of Michigan’s Medicaid expansion, which expanded coverage in 2014 and now covers ~664,000 individuals. We conducted a longitudinal telephone survey in English, Spanish, and Arabic with a cohort of Medicaid expansion enrollees at 3 time points in 2016 (N = 4090, RR = 53.7%), 2017 (N = 3104; RR = 83.4%), and 2018 (N = 2608, RR = 89.4%). Survey items measured employment status and student status; demographic characteristics were obtained from Michigan Medicaid program files. We used mixed models with year as a fixed effect to assess changes in the proportion of enrollees who were employed or students, incorporating weights adjusting for sample design and nonresponse. Enrollees aged 19-64, with incomes up to 133% of the federal poverty level (FPL). Most respondents had incomes under 100% FPL (61.7% with 0-35% FPL, 22.9% with 36-99% FPL, and 15.4% with 100-133% FPL), 89.3% had at least a high school diploma/equivalent, and respondents ranged in age (39.6%, age 19-34; 34.5%, age 35-50; and 25.9%, age 51-64). From 2016 to 2018, the proportion of enrollees who were employed or students increased from 54.5% to 61.4% (P < .001). Increases were observed in subgroups with lower baseline rates of employment or student status, including those with a chronic condition (47.8% to 53.8%, P < .001) and those with a mental health or substance use disorder (48.5% to 56.0% P < .001). Employed enrollees worked 34.7 mean hours per week on all paid jobs in 2018. Among enrollees who were in school, 57.7% were full-time and 42.3% were part-time students. Enrollees who were not employed or students in 2018 (38.6%) reported being unable to work (47.3%), out of work (40.4%), or retired (12.3%). Among enrollees who reported being unable to work, primary reasons included poor health/disability (91.4%) and caregiving responsibilities (7.1%). Among all enrollees who were not employed in 2018, 36.8% were searching for a job and 9.1% had completed or were enrolled in job training. From 2016 to 2018, employment or student status increased among Michigan Medicaid expansion enrollees, including among subgroups with comorbidities. This occurred prior to implementation of the state’s planned community engagement requirement in January 2020. Federal courts are currently weighing whether community engagement requirements will promote the Medicaid program’s goals of improved coverage and health, as well as associated improvements in employment and related activities. Three of the approved state waivers have been set aside by the courts and two have been delayed or suspended, while nine additional states have pending waivers seeking approval for similar requirements. Our findings suggest that Medicaid expansion itself was associated with the desired outcome of employment and related activities. The value of Medicaid community engagement requirements should be considered along with the additional administrative burden on individuals and states. The University of Michigan Institute for Healthcare Policy and Innovation (IHPI) is conducting the evaluation required by the Centers for Medicare and Medicaid Services (CMS) of the Healthy Michigan Plan (HMP) under contract with MDHHS. Data collected for this paper were funded by MDHHS and CMS for the purposes of the evaluation but do not represent the official views of either agency.     

Differences Between Primary Care Physicians’ and Oncologists’ Knowledge,Attitudes and Practices Regarding the Care of Cancer Survivors

Background  

The growing number of cancer survivors combined with a looming shortage of oncology specialists will require greater coordination of post-treatment care responsibilities between oncologists and primary care physicians (PCPs). However, data are limited regarding these physicians’ views of cancer survivors’ care.