Survival in women after diagnosis of lung cancer.
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Female↗
Biomedical subjects
Peter B Bach
Publications and source records attributed to Peter B Bach.
Costs of cancer care: a view from the centers for Medicare and Medicaid services.
Fee-for-service Medicare pays for a very substantial portion of all cancer care delivered in the United States. By virtue of its size and visibility, its payment policies at times also influence those of other health care payers. As a result, Medicare affects both the overall economics and the incentive structures of oncology care. Three aspects of how Medicare finances cancer care are particularly germane to the issue of costs. First, Medicare finances all aspects of cancer care in independent payment units, paying separately for physician services, laboratory tests, procedures, imaging, radiation, drug administration, and drugs. Second, Medicare is currently managing and monitoring a very substantial overhaul in payment for cancer care, which aims to reduce or eliminate incentives that have favored aggressive and costly treatments in clinical situations where alternative therapeutic approaches might have been equivalent or preferable. Third, Medicare is trying to increase the focus on care quality and transparency, as improved efficiency and greater value is needed if costs of care are to be contained. Understanding these three aspects of cancer care financing can help clarify what Medicare is capable of doing to control the rising costs that are occurring in cancer today.
Fee-for-Service Plans↗
Radiation therapy facilities in the United States.
PURPOSE: About half of all cancer patients in the United States receive radiation therapy as a part of their cancer treatment. Little is known, however, about the facilities that currently deliver external beam radiation. Our goal was to construct a comprehensive database of all radiation therapy facilities in the United States that can be used for future health services research in radiation oncology. METHODS AND MATERIALS: From each state's health department we obtained a list of all facilities that have a linear accelerator or provide radiation therapy. We merged these state lists with information from the American Hospital Association (AHA), as well as 2 organizations that audit the accuracy of radiation machines: the Radiologic Physics Center (RPC) and the Radiation Dosimetry Services (RDS). The comprehensive database included all unique facilities listed in 1 or more of the 4 sources. RESULTS: We identified 2,246 radiation therapy facilities operating in the United States as of 2004-2005. Of these, 448 (20%) facilities were identified through state health department records alone and were not listed in any other data source. CONCLUSIONS: Determining the location of the 2,246 radiation facilities in the United States is a first step in providing important information to radiation oncologists and policymakers concerned with access to radiation therapy services, the distribution of health care resources, and the quality of cancer care.
Health Services Accessibility↗
Trends in the use of postoperative radiotherapy for resected non-small-cell lung cancer.
PURPOSE: A 1998 meta-analysis of postoperative radiotherapy (PORT) for non-small-cell lung cancer (NSCLC) found that PORT did not improve outcomes. Yet practice guidelines differ in their recommendations with regard to PORT use. We examine temporal trends in PORT use before and after the 1998 meta-analysis. METHODS AND MATERIALS: Using data from the Surveillance, Epidemiology, and End Results (SEER) Program, we identified 22,953 patients with Stage I, II, or IIIA NSCLC who had resection between 1992 and 2002 in the United States and characterized each patient according to nodal status (N0, N1, or N2 disease). We measured use of PORT by calendar year. We examined the association between clinical and demographic characteristics and receipt of PORT using logistic regression. RESULTS: For N0, N1, and N2 NSCLC, PORT use has declined. The proportion of patients with N0 disease receiving PORT declined from 8% in 1992 to 4% in 2002. For patients with N1 disease, PORT use declined from 51% in 1992 to 19% in 2002; and for patients with N2 disease, PORT use declined from 65% in 1992 to 37% in 2002. CONCLUSION: In the context of uncertainty about what constitutes optimal adjuvant treatment for resected NSCLC, PORT use has substantially declined.
Adult↗
The first months of the prescription-drug benefit--a CMS update.
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Centers for Medicare and Medicaid Services, U.S.↗
Validation of a model of lung cancer risk prediction among smokers.
The Bach model was developed to predict the absolute 10-year risk of developing lung cancer among smokers by use of participants in the Carotene and Retinol Efficacy Trial of lung cancer prevention. We assessed the validity of the Bach model among 6239 smokers from the placebo arm of the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study. The expected numbers of lung cancer cases and deaths without lung cancer were calculated from the Bach model and compared with the observed numbers of corresponding events over 10 years. We found that the risk model slightly underestimated the observed lung cancer risk (number of lung cancers expected/number observed = 0.89, 95% confidence interval [CI] = 0.80 to 0.99) over 10 years. The competing risk portion of the model substantially underestimated risk of non-lung cancer mortality (number of non-lung cancer deaths expected/number observed = 0.61, 95% CI = 0.57 to 0.64) over 10 years. The age-specific concordance indices for 10-year predictions were 0.77 (95% CI = 0.70 to 0.84), 0.59 (95% CI = 0.53 to 0.65), 0.62 (95% CI = 0.57 to 0.67), and 0.57 (95% CI = 0.49 to 0.67) for the age groups 50-54, 55-59, 60-64, and 65-69 years, respectively. Periodic radiographic screening in the ATBC Study may explain why slightly more cancers were observed than expected from the Bach model.
Age Distribution↗
Prevalence and risk factors for symptomatic thromboembolic events after shoulder arthroplasty.
UNLABELLED: Deep venous thrombosis and pulmonary embolism after shoulder arthroplasty are not well described. We sought to identify the frequency of deep venous thrombosis and pulmonary embolisms in patients after shoulder arthroplasties to compare these rates with the frequency of deep venous thrombosis and pulmonary embolisms among patients who had total hip and total knee arthroplasties, and to identify associated risk factors. The New York State Department of Health Statewide Planning and Research Cooperative System database was used to identify hospital admissions of patients having shoulder, hip, or knee arthroplasties between 1985 and 2003 with or without an associated diagnostic code for deep venous thrombosis or pulmonary embolism. This resulted in a retrospective cohort of 328,301 procedures. The frequency of deep venous thrombosis was 5.0 per 1000 procedures for shoulder arthroplasties compared with 15.7 for hip arthroplasties and 26.9 for knee arthroplasties. The frequency of pulmonary embolisms was 2.3 for shoulder arthroplasties, 4.2 for hip arthroplasties, and 4.4 for knee arthroplasties. Increasing age, trauma, and cancer were risk factors for thromboembolic events after shoulder arthroplasties. Although the absolute rates of thromboembolic complications were less in patients who had shoulder arthroplasties compared with those of patients who had lower extremity procedures, a larger percentage of these complications were pulmonary embolisms. Perioperative antithrombotic prophylaxis may be beneficial to reduce the frequency of deep venous thrombosis and pulmonary embolisms among patients having shoulder arthroplasties, particularly in higher-risk groups. LEVEL OF EVIDENCE: Prognostic study, Level II (retrospective study). See the Guidelines for Authors for a complete description of levels of evidence.
Aged↗
Fragmentation of care for frequently hospitalized urban residents.
BACKGROUND: Fragmentation across sites of care may impede efficient healthcare delivery. OBJECTIVES: The objectives of this study were to evaluate fragmentation of hospital care for chronically ill New York City (NYC) residents and its association with enrollment in the New York State (NYS) Medicaid program. RESEARCH DESIGN: We conducted a cross-sectional study using the NYS Department of Health's Statewide Planning and Research Cooperative System discharge database. We identified 53,031 NYC residents admitted 3 or more times to acute care hospitals between 2000 and 2002 with the same principal diagnosis of a specific chronic illness (diabetes, sickle cell anemia, psychosis, substance abuse, cancer, gastrointestinal disease, chronic obstructive pulmonary disease/asthma, coronary artery disease, or congestive heart failure). We also evaluated a larger cohort of 225,421 patients with >or=3 admissions for a specific chronic illness coded as either the principal or a secondary diagnosis. A generalized logit model was used to examine the relationship between fragmentation and each patient's primary insurance adjusted for diagnosis and demographic characteristics. MEASURES: Fragmentation was characterized as high, moderate, or low based on the number of distinct hospitals a patient visited relative to the patient's total number of hospitalizations over the 3-year interval. RESULTS: Among frequently hospitalized NYC residents with select chronic conditions, 17.1% experienced highly fragmented care. This rate was 9.9% for patients with commercial insurance, 24.4% for those with Medicaid, and 9.7% for those with Medicare. The unadjusted odds ratio describing high fragmentation of Medicaid enrollees compared with commercially insured patients was 3.82 (95% confidence interval [CI], 3.50-4.18) and, although attenuated, remained significant after adjustment for demographic characteristics (odds ratio, 1.33; 95% CI, 1.20-1.47). The strongest predictor of fragmentation was a diagnosis of psychosis (OR, 2.81; 95% CI, 2.43-3.25) or substance abuse (OR, 7.58; 95% CI, 6.55-8.77). CONCLUSIONS: In NYC, Medicaid enrollment is associated with greater fragmentation of hospital care, but this is largely attributable to the preponderance of Medicaid enrollees with diagnoses of psychosis and substance abuse. Strategies to improve the efficiency of healthcare delivery should focus on patients with mental illness who are frequently admitted to general hospitals.
Adolescent↗
A prescription for a modern Medicare program.
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Centers for Medicare and Medicaid Services, U.S.↗
Using practice guidelines to assess cancer care quality.
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Data Collection↗
Delivery of preventive services to older adults by primary care physicians.
CONTEXT: Rates of preventive services remain below national goals. OBJECTIVE: To identify characteristics of physicians and their practices that are associated with the quality of preventive care their patients receive. DESIGN: Cross-sectional analysis of data on US physician respondents to the 2000-2001 Community Tracking Study Physician Survey linked to claims data on Medicare beneficiaries they treated in 2001. Physician variables included training and qualifications and sex. Practice setting variables included practice type, size, sources of revenue, and access to information technology. Analyses were adjusted for patient demographics and comorbidity, as well as community characteristics. SETTING AND PARTICIPANTS: Primary care delivered by 3660 physicians providing usual care to 24 581 Medicare beneficiaries aged 65 years and older. MAIN OUTCOME MEASURES: Proportion of eligible beneficiaries receiving each of 6 preventive services: diabetic monitoring with hemoglobin A(1c) measurement or eye examinations, screening for colon or breast cancer, and vaccination for influenza or pneumococcus in 2001. RESULTS: Overall, the proportion of beneficiaries receiving services was below national goals. Physician and, more consistently, practice-level characteristics were both associated with differences in the delivery of services. The strongest associations were with practice type and the percentage of practice revenue derived from Medicaid. For instance, beneficiaries receiving usual care in practices with less than 6% of revenue from Medicaid were more likely than those with more than 15% of revenue derived from Medicaid to receive diabetic eye examinations (48.9% vs 43%; P = .02), hemoglobin A1c monitoring (61.2% vs 48.4%; P<.001), mammograms (52.1% vs 38.9%; P<.001), colon cancer screening (10.0% vs 8.5%; P = .60), and influenza (50.2% vs 39.2%; P<.001) and pneumococcal (8.2% vs 6.4%; P<.001) vaccinations. Other variables associated with delivery of preventive services after adjustment for patient and geographic factors included obtaining usual health care from a physician who worked in group practices of 3 or more, who was a graduate of a US or Canadian medical school, or who reported availability of information technology to generate preventive care reminders or access treatment guidelines. CONCLUSIONS: Delivery of routine preventive services is suboptimal for Medicare beneficiaries. However, patients treated within particular practice settings and by particular subgroups of physicians are at particular risk of low-quality care. Profiling these practices may help develop tailored interventions that can be directed to sites where the opportunities for quality improvement are greatest.
Aged↗
Cystectomy for muscle-invasive bladder cancer: patterns and outcomes of care in the Medicare population.
OBJECTIVES: To describe the population-based patterns of care among patients with muscle-invasive bladder cancer. METHODS: A retrospective cohort study using the Surveillance, Epidemiology and End Results (SEER)-Medicare database identified 4664 patients aged 65 years or older with muscle-invasive bladder cancer diagnosed between 1991 and 1999. The use of particular treatment modalities was evaluated according to the clinical and demographic characteristics available in the SEER-Medicare database. RESULTS: Considerable variation was found in the treatments delivered to the cohort members. Overall, 39% had undergone cystectomy; 30% of Stage II, 57% of Stage III, and 38% of Stage IV patients underwent this operation within 6 months of diagnosis. The frequency of resection declined with age, such that 55% of patients aged 65 to 69 years and 27% of those aged 80 to 84 years underwent cystectomy. For 36% of Stage II, 18% of Stage III, and 27% of Stage IV patients, no evidence was found of surgery, chemotherapy, or radiotherapy within 6 months of diagnosis. Other management strategies included chemotherapy alone (14% Stage II, 6% Stage III, and 12% Stage IV), radiotherapy alone (11% for each stage), or combined modality chemoradiotherapy (10% Stage II, 8% Stage III, and 12% Stage IV). Multivariate analyses suggested that cystectomy conferred a survival advantage. CONCLUSIONS: A marked heterogeneity exists in the strategies used to treat muscle-invasive bladder cancer. The extent to which this variation can be attributed to the lack of informative clinical trials, the presence of comorbid illness, patient or physician preferences, or access to care warrants further evaluation.
Aged↗
The association between hospital volume and total shoulder arthroplasty outcomes.
The purpose of this study was to evaluate the relationship between increasing hospital volume and the following outcomes for total shoulder arthroplasties done in the state of New York: length of stay, hospital costs, readmission within 60 days, revision surgery within 24 months, and death within 60 days. The Statewide Planning and Research Cooperative System (SPARCS) database from the New York State Department of Health, a census of all hospital discharges in the state, was used to evaluate the relationship between hospital volume and outcomes for total shoulder arthroplasties for 1996 to 1999. One thousand three hundred seven total shoulder arthroplasties were done in New York from 1996 to 1999. Nearly (1/2) were done at the five highest-volume hospitals. Middle-volume hospitals has the least lengths of stay and hospital costs. Independent of age and comorbidities, patients at hospitals with greater volumes of total shoulder arthroplasties were at reduced risk of patients being readmitted within 60 days. No other outcomes were significantly associated with hospital volume. The finding that greater hospital volume decreases risk of readmission may have important public health implications, but additional research is needed before implementing policy changes.
Age Distribution↗
Racial disparities and site of care.
Numerous studies have demonstrated that minority patients receive poorer quality health care than non-minorities. The mechanisms underlying this problem have not been identified, but the pervasiveness and consistency of racial and ethnic differences in healthcare quality have led most investigators to identify at most one or two overarching causes. To some, the consistency of these findings supports a hypothesis that physicians are at the heart of the problem. It is posited that due to sub-conscious biases, more overt prejudice, or cultural insensitivity, physicians do not treat minority patients as well as they treat non-minority patients. This hypothesis has received a great deal of attention, both in reviews from the Institute of Medicine and position statements from the American Medical Association and National Medical Association. In this paper, I review several studies that have focused on an alternative potential mechanism of racial and ethnic disparities in health care, which is based more on inequities in the structure of the healthcare system, rather than inequities in the treatment patterns of individual physicians. Determining the relative contribution of each of these mechanisms to racial and ethnic disparities in health care should be a priority.
Black or African American↗
Resurrecting treatment histories of dead patients: a study design that should be laid to rest.
In this article we address whether studies of care rendered to patients prior to their death ("studies of decedents") produce an accurate portrait of care provided to patients who are dying. Studies of decedents typically analyze the care provided to patients over a defined interval antecedent to death. Studies of dying patients analyze care provided to patients subsequent to the time that their terminal status is perceived. We address whether 2 fundamental differences between studies of decedents and studies of the dying--the ways that subjects are identified and the time periods that are examined--lead to differences in interpretation of study results. Using examples from population-based cohorts of individuals with cancer, we show that both the differences in subject selection and time period introduce very substantial biases into studies of decedents. We conclude that studying care received prior to death can lead to invalid conclusions about the quality or type of care provided to dying patients.
Bias↗
Clinical prediction rule for atrial fibrillation after coronary artery bypass grafting.
OBJECTIVES: This study was designed to devise and validate a practical prediction rule for atrial fibrillation/atrial flutter (AF) after coronary artery bypass grafting (CABG) using easily available clinical and standard electrocardiographic (ECG) criteria. BACKGROUND: Reported prediction rules for postoperative AF have suffered from inconsistent results and controversy surrounding the added predictive value of a prolonged P-wave duration. METHODS: In 1,851 consecutive patients undergoing CABG with cardiopulmonary bypass, preoperative clinical characteristics and standard 12-lead ECG data were examined. Patients were continuously monitored for the occurrence of sustained postoperative AF while hospitalized. Multiple logistic regression was used to determine significant predictors of AF and to develop a prediction rule that was evaluated through jackknifing. RESULTS: Atrial fibrillation occurred in 508 of 1,553 patients (33%). Multivariate analysis showed that greater age (odds ratio [OR] 1.1 per year [95% confidence intervals (CI) 1.0 to 1.1], p < 0.0001), prior history of AF (OR 3.7 [95% CI 2.3 to 6.0], p < 0.0001), P-wave duration >110 ms (OR 1.3 [95% CI 1.1 to 1.7], p = 0.02), and postoperative low cardiac output (OR 3.0 [95% CI 1.7 to 5.2], p = 0.0001) were independently associated with AF risk. Using the prediction rule we defined three risk categories for AF: <60 points, 61 of 446 (14%); 60 to 79 points, 330 of 908 (36%); and >or=80 points, 117 of 199 (59%). The area under the receiver-operator characteristic curve for the model was 0.69. CONCLUSIONS: These data show that post-CABG AF can be predicted with moderate accuracy using easily available patient characteristics and may prove useful in prognostic and risk stratification of patients after CABG. The presence of intraatrial conduction delay on ECG contributed least to the prediction model.
Adrenergic beta-Antagonists↗
Primary care physicians who treat blacks and whites.
BACKGROUND: In the United States, black patients generally receive lower-quality health care than white patients. Black patients may receive their care from a subgroup of physicians whose qualifications or resources are inferior to those of the physicians who treat white patients. METHODS: We performed a cross-sectional analysis of 150,391 visits by black Medicare beneficiaries and white Medicare beneficiaries 65 years of age or older for medical "evaluation and management" who were seen by 4355 primary care physicians who participated in a biannual telephone survey, the 2000-2001 Community Tracking Study Physician Survey. RESULTS: Most visits by black patients were with a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent, P=0.02) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs. 19.3 percent, P=0.005). The physicians treating black patients also reported facing greater difficulties in obtaining access for their patients to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to the hospital. CONCLUSIONS: Black patients and white patients are to a large extent treated by different physicians. The physicians treating black patients may be less well trained clinically and may have less access to important clinical resources than physicians treating white patients. Further research should be conducted to address the extent to which these differences may be responsible for disparities in health care.
Aged↗
Lung cancer in US women: a contemporary epidemic.
Lung cancer is the leading cause of cancer death in US women and is responsible for as many deaths as breast cancer and all gynecological cancers combined. Most lung cancer is caused by cigarette smoke. Despite all that is known about the devastating effects of cigarettes, one quarter of women in the United States continue to smoke. Women are targeted in tobacco advertising, and teenage girls are often drawn to cigarette smoking under a variety of social pressures. Following the increase in smoking, the death rate from lung cancer in US women rose 600% from 1930 to 1997. Women may be more susceptible than men to the carcinogenic properties of cigarette smoke. In addition, differences in the biology of lung cancer exist between the 2 sexes with higher levels of DNA adduct formation, increased CYP1A1 expression, decreased DNA repair capacity, and increased incidence of K-ras gene mutations in women. The novel estrogen receptor beta has also been detected in lung tumors and suggests that estrogen signaling may have a biological role in tumorigenesis. Given these differences and given the enormous toll this disease has on US women, undertaking sex-specific research in lung cancer is crucial. Finally, disseminating information about this epidemic may prevent a similar epidemic in other parts of the world where women are just now becoming addicted to tobacco.
Disease Susceptibility↗