Disease-modifying anti-rheumatic drugs (DMARDs) are recommended for virtually all patients with rheumatoid arthritis (RA). We investigated the use of DMARDs in patients with RA in a nationally representative sample of visits to US physicians in the National Ambulatory Care Medical Survey (NAMCS).
We analyzed NAMCS visit data from 1996 through 2007 if the physician noted a diagnosis of RA. DMARD utilization was based on the medications listed by the physician. We used generalized linear models to examine the adjusted associations between DMARD use and potential predictors.
Among 859 visits with a diagnosis code of RA were identified over the study period, 404 (47%, 95% confidence interval (CI) 44-50%) had an associated DMARD. The percentage of RA visits with DMARDs increased slightly over the twelve years (p = 0.048), with biologic DMARDs increasing to 20% of visits after their introduction (p for trend < 0.001). In fully adjusted models, Black race was associated with a 30% reduction in DMARD prescribing (risk ratio, RR, 0.70, 95% CI 0.48 – 1.00). A visit to a rheumatologist was the strongest correlate of DMARD prescribing (RR 2.33, 95% CI 1.89 – 2.86). Among visits to non-rheumatologists, Blacks were significantly less likely than Whites to receive a DMARD (RR 0.39, 95% CI 0.17-0.92), but not among visits with rheumatologists (RR 0.81, 95% CI 0.52-1.27).
In the NAMCS survey, most visits coded with RA did not have an associated DMARD prescription. Blacks were less likely to receive DMARDs than Whites, particularly when visiting non-rheumatologists.
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.
To compare PCPs and oncologists with regard to their knowledge, attitudes, and practices for follow-up care of breast and colon cancer survivors.
Design and Subjects
Mailed questionnaires were completed by a nationally representative sample of 1,072 PCPs and 1,130 medical oncologists in 2009 (cooperation rate = 65%). Sampling and non-response weights were used to calculate estimates to reflect practicing US PCPs and oncologists.
PCPs and oncologists reported their 1) preferred model for delivering cancer survivors’ care; 2) assessment of PCPs’ ability to perform follow-up care tasks; 3) confidence in their knowledge; and 4) cancer surveillance practices.
Compared with PCPs, oncologists were less likely to believe PCPs had the skills to conduct appropriate testing for breast cancer recurrence (59% vs. 23%, P < 0.001) or to care for late effects of breast cancer (75% vs. 38%, P < 0.001). Only 40% of PCPs were very confident of their own knowledge of testing for recurrence. PCPs were more likely than oncologists to endorse routine use of non-recommended blood and imaging tests for detecting cancer recurrence, with both groups departing substantially from guideline recommendations.
There are significant differences in PCPs’ and oncologists’ knowledge, attitudes, and practices with respect to care of cancer survivors. Improving cancer survivors’ care may require more effective communication between these two groups to increase PCPs’ confidence in their knowledge, and must also address oncologists’ attitudes regarding PCPs’ ability to care for cancer survivors.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1808-4) contains supplementary material, which is available to authorized users.
cancer care; cancer survivorship; physician survey; physician attitudes
Disparities in care have been documented for foreign-born cancer patients in the US. However, limited data are available on lung and colorectal cancer. We assessed whether patient-reported quality and receipt of recommended care differed between US-born and foreign-born cancer patients.
We collected surveys and medical records for a population-based cohort including white, Hispanic, and Asian adults (2,205 US-born and 890 foreign-born) with lung or colorectal cancer diagnosed in California during 2003–2005. We used logistic regression to assess the association of nativity with patient-reported quality of care and receipt of recommended treatments (adjuvant chemotherapy for stage III colon cancer, adjuvant chemotherapy and radiation for stage II/III rectal cancer, and curative surgery for stage I/II non-small cell lung cancer). We also assessed whether language explained any differences in care by nativity.
Overall, 46% of patients reported excellent care, but foreign-born patients were less likely than US-born patients to report excellent quality of care (adjusted odds ratio (AOR)=0.80, 95% confidence interval [CI]=0.65–1.00), a difference partly explained by language of survey, an indicator of English proficiency. Rates of recommended therapies ranged from 64% to 85%; foreign-born patients were less likely to receive chemotherapy and radiation for stage II/III rectal cancer (AOR=0.35, 95% CI=0.12–0.99). Rates of other treatments did not differ significantly by nativity.
Foreign-born cancer patients reported lower quality of care and were less likely to receive some cancer therapies than US-born. Better coordination of care and communication about cancer treatments and expanded use of interpreters may lessen these disparities.
lung cancer; colorectal cancer; recommended care; immigrants; satisfaction; quality; disparities; race/ethnicity; Hispanic; Asian
Lobectomy is considered the standard treatment for early-stage non–small cell lung cancer (NSCLC); however, more limited resections are commonly performed. We examined patient and surgeon factors associated with limited resection and compared postoperative and long-term outcomes between sublobar and lobar resections.
A population- and health system–based sample of patients newly diagnosed with stage I or II NSCLC between 2003 and 2005 in five geographically defined regions, five integrated health-care delivery systems, and 15 Veterans Affairs hospitals was observed for a median of 55 months, through May 31, 2010. Predictors of limited resection and postoperative outcomes were compared using unadjusted and propensity score–weighted analyses. All P values are from two-sided tests.
One hundred fifty-five (23%) patients underwent limited resection and 524 (77%) underwent lobectomy. In adjusted analyses of patient-specific factors, smaller tumor size (P = .004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P = .02), more severe lung disease (P < .001), and a history of stroke (P = .049) were associated with receipt of limited resection. In adjusted analyses of surgeon characteristics, thoracic surgery specialty (P = .02), non–fee-for-service compensation (P = .008), and National Cancer Institute cancer center designation (P = .006) were associated with higher odds of limited resection. Unadjusted 30-day mortality was higher with limited resection than with lobectomy (7.1% vs 1.9%, difference = 5.2%, 95% confidence interval [CI] = 1.5% to 10.8%, P = .003), and the adjusted difference was not statistically significant (6.5% vs 2.9%, difference = 3.6%, 95% CI = −.1% to 9.2%, P = .09). Postoperative complications did not differ by type of surgery (all P > .05). Over the course of the study, a non-statistically significant trend toward improved long-term survival was evident for lobectomy, compared with limited resection, in adjusted analyses (hazard ratio of death = 1.35 for limited resection, 95% CI = 0.99 to 1.84, P = .05).
Evidence is statistically inconclusive but suggestive that lobectomy, compared with limited resection, is associated with increased long-term survival for early-stage lung cancer. Clinical, socioeconomic, and surgeon factors appear to be associated with the choice of surgical resection.
In contrast to a previous study we conducted and other evidence, a recent study found no significant effects of Medicare coverage after age 65 on overall health for previously uninsured adults and significant adverse effects on survival for some of these adults. We discuss explanations for these inconsistent findings, particularly the different ways in which deaths were handled, a key methodological challenge in longitudinal analyses of health. We demonstrate that analytic approaches suitable for examining effects of coverage on health measures may not be suitable for effects on mortality. Thus, estimates may be misleading when these different outcomes are jointly modeled. We also present new survival analyses that suggest Medicare coverage significantly attenuated the rising risk of death for previously uninsured adults.
Medically uninsured; mortality; Medicare; insurance coverage; aging
The association of psychosocial stress with weight gain may have important implications for clinical practice and workplace and public health interventions. To determine whether multiple domains of psychosocial stress were associated with weight gain from 1995 to 2004, the authors analyzed a nationally representative longitudinal cohort of 1,355 men and women in the United States. Change in body mass index was assessed for multiple domains of psychosocial stress related to work, personal relationships, life constraints, and finances, controlling for other factors associated with weight gain. All analyses were stratified by sex and weighted to account for the complex survey design. Among men with high baseline body mass index, weight gain was associated with increasing levels of psychosocial stress related to job-related demands (P < 0.001 for interaction with baseline body mass index), lack of skill discretion (P = 0.014), lack of decision authority (P = 0.026), and difficulty paying bills (P = 0.004). Among women with high baseline body mass index, weight gain was associated with job-related demands (P < 0.001 for interaction with baseline body mass index), perceived constraints in life (P < 0.001), strain in relations with family (P = 0.016), and difficulty paying bills (P = 0.010). Interventions to address psychosocial stress may limit weight gain among overweight and obese men and women.
body mass index; longitudinal studies; obesity; overweight; stress, psychological; weight gain
To test for discrimination by race/ethnicity arising from clinical uncertainty in treatment for depression, also known as “statistical discrimination.”
We used survey data from 1,321 African-American, Hispanic, and white adults identified with depression in primary care. Surveys were administered every six months for two years in the Quality Improvement for Depression (QID) studies.
To examine whether and how change in depression severity affects change in treatment intensity by race/ethnicity, we used multivariate cross-sectional and change models that difference out unobserved time-invariant patient characteristics potentially correlated with race/ethnicity.
Data Collection/Extraction Methods
Treatment intensity was operationalized as expenditures on drugs, primary care, and specialty services, weighted by national prices from the Medical Expenditure Panel Survey. Patient race/ethnicity was collected at baseline by self-report.
Change in depression severity is less associated with change in treatment intensity in minority patients than in whites, consistent with the hypothesis of statistical discrimination. The differential effect by racial/ethnic group was accounted for by use of mental health specialists.
Enhanced physician–patient communication and use of standardized depression instruments may reduce statistical discrimination arising from clinical uncertainty and be useful in reducing racial/ethnic inequities in depression treatment.
Statistical discrimination; racial/ethnic disparities; depression
Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening rates.
We conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health centers. Participants included 21,860 patients ages 50 to 80 overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal-occult-blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal-occult-blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas.
Screening rates were higher for patients who received mailings compared to those who did not (44.0% vs. 38.1%, p<0.001). The effect increased with age: +3.7% for ages 50-59; +7.3% for ages 60-69; and +10.1% for ages 70-80 (p=0.01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs. 40.2%, p=0.47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs. 52.7%, p=0.07). Detection of adenomas tended to increase with patient mailings (5.7% vs. 5.2%, p=0.10) and physician reminders (6.0% versus 4.9%, p=0.09).
Mailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who more frequently use primary care.
(ClinicalTrials.gov ID number NCT00355004)
Colorectal Cancer Screening; Reminder Systems; Quality Improvement; Randomized Controlled Trial
Recently observed trends toward increasingly aggressive end-of-life care may reflect providers' concerns that hospice may hasten death.
Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified 7879 patients aged 65 years or older who died of advanced non-small–cell lung cancer from 1991 through 1999 after surviving for at least 3 months from their cancer diagnoses. Length of hospice admission post-cancer diagnosis and indicators of aggressive end-of-life care were ascertained based on claims data. We evaluated overall survival and care near death after controlling for baseline characteristics by using propensity score (PS) and instrumental variable analyses (IVA).
Hospice patients were older, more likely to be non-Hispanic white and female, more likely to reside in urban areas with high hospice availability and higher socioeconomic status, more likely to be treated in a teaching hospital, and received less aggressive end-of-life care compared to nonhospice patients. Among hospice patients, those experiencing short-term hospice admissions within 3 days of death were more likely to be male, reside in urban areas, be treated in a teaching hospital, and receive more aggressive end-of-life care. PS analysis found that survival favored hospice patients slightly relative to nonhospice patients by 5.0 percentage points (25.7% versus 20.7%) at 1 year and 1.4 percentage points (6.9% versus 5.5%) at 2 years postdiagnosis (p < 0.001), while there was no significant difference between those with short- and longer duration hospice stays (p = 1.00). IVA confirmed these findings.
Hospice enrollment did not compromise length of survival following advanced lung cancer diagnosis.
To profile hospitals by survival rates of colorectal cancer patients in multiple periods after initial treatment.
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.
We estimated a single Bayesian hierarchical model to quantify associations of survival to 30 days, 30 days to 1 year, and 1 to 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.
Interperiod correlation coefficients of the random effects are ρ̂12 = 0.62 (95% credible interval 0.27,0.85), ρ̂13 = 0.52 (0.20,0.76) and ρ̂23 = 0.57 (0.19,0.82). The three-period model ranks 5.4% of pairwise comparisons by 30-day survival with at least 95% confidence, versus 3.3% of pairs using a single-period model, and 15%–20% by weighted multiperiod methods.
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.
cancer care; colorectal cancer; provider profiling; quality measurement; Bayesian inference
Although Native Americans experience substantial disparities in health outcomes, little information is available regarding healthcare delivery for this population.
To analyze trends in ambulatory quality of care and physician reports of barriers to quality improvement within the Indian Health Service (IHS).
Longitudinal analysis of clinical performance from 2002 to 2006 within the IHS, and a physician survey in 2007.
Adult patients cared for within the IHS and 740 federally employed physicians within the IHS.
Clinical performance for 12 measures of ambulatory care within the IHS; as well as physician reports of ability to access needed health services and use of quality improvement strategies. We examined the correlation between physician reports of access to mammography and clinical performance of breast cancer screening. A similar correlation was analyzed for diabetic retinopathy screening.
Clinical performance significantly improved for 10 of the 12 measures from 2002 to 2006, including adult immunizations, cholesterol testing, and measures of blood pressure and cholesterol control for diabetes and cardiovascular disease. Breast cancer screening rates decreased (44% to 40%, p = 0.002), while screening rates for diabetic retinopathy remained constant (51%). Fewer than half of responding primary care physicians reported adequate access to high-quality specialists (29%), non-emergency hospital admission (37%), high-quality imaging services (32%), and high-quality outpatient mental health services (16%). Breast cancer screening rates were higher at sites with higher rates of physicians reporting routine access to mammography compared to sites with lower rates of physicians reporting such access (46% vs. 35%, ρ = 0.27, p = 0.04). Most physicians reported using patient registries and decision support tools to improve patient care.
Quality of care has improved within the IHS for many services, however performance in specific areas may be limited by access to essential resources.
Indian health service; Native American; American Indian; racial disparities; quality of care; quality improvement
Colorectal cancer is a leading cause of cancer mortality, yet effective screening tests are often underused. Electronic patient messages and personalized risk assessments delivered via an electronic personal health record could increase screening rates.
We conducted a randomized, controlled trial in 14 ambulatory health centers involving 1,103 patients ages 50 to 75 with an active electronic personal health record who were overdue for colorectal cancer screening. Patients were randomly assigned to receive a single electronic message highlighting overdue screening status with a link to a web-based tool to assess their personal risk of colorectal cancer. The outcomes included colorectal cancer screening rates at 1 and 4 months.
Screening rates were higher at 1 month for patients who received electronic messages compared to those who did not (8.3% vs. 0.2%, p<0.001), but this difference was no longer significant at 4 months (15.8% versus 13.1%, p=0.18). Among 552 patients randomized to receive the intervention, 296 (54%) viewed the message, and 47 (9%) used the web-based risk assessment tool. Among 296 intervention patients who viewed the electronic message, risk tool users were more likely than non-users to request screening examinations (17% versus 4%, p=0.04) and to be screened (30% versus 15%, p=0.06). One-fifth (19%) of patients utilizing the risk assessment tool were estimated to have above-average risk for colorectal cancer.
Electronic messages to patients produce an initial increase in colorectal cancer screening rates, but this effect is not sustained over time.
Colorectal cancer screening; reminder systems; quality improvement; randomized controlled trial; electronic health record; personal health record
Health care organizations often measure processes of care using only administrative data. We assessed whether measuring processes of diabetes care using administrative data without medical record data is likely to underdetect compliance with accepted standards for certain groups of patients.
Data Sources/Study Setting
Assessment of quality indicators during 1998 using administrative and medical records data for a cohort of 1,335 diabetic patients enrolled in three Minnesota health plans.
Cross-sectional retrospective study assessing hemoglobin A1c testing, LDL cholesterol testing, and retinopathy screening from the two data sources. Analyses examined whether patient or clinic characteristics were associated with underdetection of quality indicators when administrative data were not supplemented with medical record data.
Data Collection/Extraction Methods
The health plans provided administrative data, and trained abstractors collected medical records data.
Quality indicators that would be identified if administrative data were supplemented with medical records data are often not identified using administrative data alone. In adjusted analyses, older patients were more likely to have hemoglobin A1c testing underdetected in administrative data (compared to patients <45 years, OR 2.95, 95 percent CI 1.09 to 7.96 for patients 65 to 74 years, and OR 4.20, 95 percent CI 1.81 to 9.77 for patients 75 years and older). Black patients were more likely than white patients to have retinopathy screening underdetected using administrative data (2.57, 95 percent CI 1.16 to 5.70). Patients in different health plans also differed in the likelihood of having quality indicators underdetected.
Diabetes quality indicators may be underdetected more frequently for elderly and black patients and the physicians, clinics, and plans who care for such patients when quality measurement is based on administrative data alone. This suggests that providers who care for such patients may be disproportionately affected by public release of such data or by its use in determining the magnitude of financial incentives.
Quality measurement; quality indicators; diabetes care
This study assessed the relationship between area-level poverty and stage of breast cancer at diagnosis among low-income women when screening mammography was available at no cost.
The authors identified women diagnosed with breast cancer, 1999-2005, through the Massachusetts Cancer Registry, and compared the odds of advanced stage disease for women with low-incomes (n = 546) for whom screening mammography and diagnostic services were available at no cost through the Massachusetts Breast and Cervical Cancer Early Detection Program (MBCCEDP), relative to a non-participating comparison group (n = 1,287) residing in the same neighborhoods with similar distribution of age, race, and ethnicity as MBCCEDP participants. Among MBCCEDP participants, we estimated the odds of advanced stage disease by mammography use.
Although screening mammography was available at no cost, only 36% of program participants diagnosed with breast cancer used screening mammography. Stage of breast cancer at diagnosis was not associated with area-level poverty among MBCCEDP participants. For the comparison group, advanced stage disease was more likely for residents in high-poverty areas, relative to low-poverty areas (49% vs. 37%, p < 0.01). The adjusted odds of advanced stage disease at diagnosis was greater for women age 41-49 years, compared to 50-64 years (p=0.01).
Programs that ensure breast cancer screening and diagnostic services are available at no cost to low-income women can mitigate the adverse effect of area-level poverty on stage of breast cancer. However, such programs require effective strategies to encourage use of screening mammography to promote diagnosis at an earlier stage.
Healthcare Disparities; Socioeconomic Factors; Health Policy; Early Detection of Cancer; Breast Cancer
Programs to promote colorectal cancer screening are common, yet information regarding the cost effectiveness of such efforts is limited.
To assess the cost effectiveness of patient mailings to increase rates of colorectal cancer screening.
Incremental cost-effectiveness analysis of a randomized, controlled trial. The intervention involved 21,860 patients aged 50 to 80 years across 11 health centers overdue for colorectal cancer screening. Patients were randomized to receive a mailing that included a tailored letter, educational brochure, and fecal-occult-blood test kit at baseline and 6 months follow up.
We calculated the incremental cost-effectiveness of these mailings to promote colorectal cancer screening via fecal-occult-blood testing, flexible sigmoidoscopy, or colonoscopy using internal cost estimates of labor and supplies.
Colorectal cancer screening rates were higher for patients in the intervention compared to control patients (44% versus 38%, p<0.001). The total cost of the intervention was approximately $5.48 per patient, resulting in a cost-effectiveness ratio of $94 per additional patient screened. This estimate ranged from $69 to $156, based on assumptions of the cost of the intervention components, magnitude of intervention effect, age range and size of the targeted patient population.
Tailored patient mailings are a cost-effective approach to improve rates of colorectal cancer screening.
Colorectal cancer screening; cost effectiveness; quality improvement; patient mailings
Overuse of anti-cancer therapy is an important quality-of-care issue. An aggressive approach to treatment can have negative effects on quality of life and cost, but its effect on survival is not well-defined.
Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified 7,879 Medicare-enrolled patients aged 65 or older who died after having survived at least 3 months after diagnosis of advanced non-small cell lung cancer (NSCLC) between 1991 and 1999. We used Cox proportional hazards regression analysis, propensity scores, and instrumental variable analysis (IVA) to compare survival among patients who never received chemotherapy (n = 4,345), those who received standard chemotherapy but not within two weeks prior to death (n = 3,235), and those who were still receiving chemotherapy within 14 days of death (n = 299). Geographic variation in the application of chemotherapy was used as the instrument for IVA.
Receipt of chemotherapy was associated with a 2-month improvement in overall survival. However, based on three different statistical approaches, no additional survival benefit was evident from continuing chemotherapy within 14 days of death. Moreover, patients receiving chemotherapy near the end of life were much less likely to enter hospice (81% versus 51% with no chemotherapy and 52% with standard chemotherapy, P < 0.001), or were more likely to be admitted within only 3 days of death.
Continuing chemotherapy for advanced NSCLC until very near death is associated with a decreased likelihood of receiving hospice care but not prolonged survival. Oncologists should strive to discontinue chemotherapy as death approaches and encourage patients to enroll in hospice for better end-of-life palliative care.
To assess patients' experiences with cancer care, ratings of their quality of care, and correlates of these assessments.
Patients and Methods
For 4,093 patients with lung cancer and 3,685 patients with colorectal cancer in multiple US regions and health care delivery systems, we conducted telephone surveys of patients or their surrogates in English, Spanish, or Chinese at 4 to 7 months after diagnosis. The surveys assessed ratings of the overall quality of cancer care and experiences with three domains of interpersonal care (physician communication, nursing care, and coordination and responsiveness of care).
English-speaking Asian/Pacific Islander patients and Chinese-speaking patients and those in worse health reported significantly worse adjusted experiences with all three domains of interpersonal care, whereas white, black, and Hispanic patients reported generally similar experiences with interpersonal care. The overall quality of cancer care was rated as excellent by 44.4% of patients with lung cancer and 53.0% of patients with colorectal cancer, and these ratings were most strongly correlated with positive experiences with coordination and responsiveness of care (Spearman rank coefficients of 0.49 and 0.42 for lung and colorectal cancer, respectively). After multivariate adjustment, excellent ratings were less common for each cancer among black patients, English-speaking Asian/Pacific Islander patients, Chinese-speaking patients, and patients reporting worse health status (all P ≤ .05).
Patients' reports and ratings of care differed significantly by race, language, and health status. Efforts to improve patients' experiences with cancer care should focus on problems affecting Asian and Pacific Islander patients and those in worse health.
Heterogeneous results for research investigating health-related quality of life (HRQL) in patients undergoing sphincter-ablating procedures for rectal cancer are likely due to single institution experiences and measurement of HRQL. To address this heterogeneity, we evaluated HRQL in patients with rectal cancer by type of surgery, location of tumor and receipt of adjuvant therapy using an HRQL instrument that has not been used to address rectal cancer patients in a population-based sample over time.
The Functional Assessment of Cancer Therapy-Colorectal instrument (FACT-C) instrument was administered at 9 and 19 months after diagnosis to a consecutive sample of 160 patients in Northern California identified by the California Cancer Registry. A broad multidimensional interpretation of HRQL was used to examine the impact of tumor location and treatment status, stage of disease, age and gender.
In general, men had lower social well-being scores and younger patients had lower physical and emotional well-being scores and colorectal concerns scores. We found no differences in HRQL by either tumor location or type of surgery, at either 9 or 19 months after diagnosis. Lower physical well-being and greater adverse colorectal concerns were reported at 9 months among patients who received adjuvant therapy; however, only adverse colorectal concerns persisted over time.
This study provides additional evidence that sphincter-ablating procedures do not necessarily reduce quality of life in patients with rectal cancer. Distinctive features of this study include a broad multidimensional interpretation of HRQL, the 19 months of longitudinal follow-up, and a prospective population-based study design.
rectal cancer oncology quality-of-life
Few studies have assessed associations of surgeons’ practice volume with processes of care that lead to better outcomes.
We surveyed surgeons treating colorectal cancer to determine whether high-volume surgeons were more likely to collaborate with other physicians in decisions about adjuvant therapies.
Subjects and methods
Surgeons caring for patients with colorectal cancer in multiple regions and health-care organizations were surveyed to assess their volume of colorectal cancer resections and participation in decisions about adjuvant chemotherapy and radiation therapy. We used logistic regression to assess physician and practice characteristics associated with surgical volume and the relation of surgical volume and these other characteristics to collaborative decision-making regarding adjuvant therapies.
Of 635 responding surgeons, those who identified themselves as surgical oncologists or colorectal surgeons were more likely than others to report high volume of colorectal cancer resections (p<.001), as were those who practiced at a comprehensive cancer center (P=.06) and attended tumor board meetings weekly (vs. quarterly or less, P=.09). Most surgeons reported a collaborative role in decisions about chemotherapy and radiation therapy. However, in adjusted analyses, higher-volume surgeons more often reported a collaborative role with other physicians in decisions about chemotherapy (P<0.001) and radiation therapy (P<0.001).
Higher-volume surgeons are more likely to report collaborating with other physicians in decisions about adjuvant therapies for patients following colorectal cancer surgery. This collaborative decision-making of higher-volume surgeons may contribute to outcome differences by surgeon volume.
colorectal neoplasms; surgery; chemotherapy; radiation therapy; physicians’ practice patterns; physician survey; consultation
Racial/ethnic disparities exist in the prevalence and outcomes of diabetes and hypertension in the U.S. A better understanding of the health beliefs and experiences of non-Hispanic Blacks and Latinos with these diseases could help to improve their care outcomes.
We conducted eight focus groups stratified by participants’ race/ethnicity, with 34 non-Hispanic Blacks and Latinos receiving care for diabetes and/or hypertension in one of 7 community health centers in Boston. Focus groups were designed to determine participants’ levels of understanding about their chronic illness, assess their barriers to the management of their illness, and inquire about interventions they considered may help achieve better health outcomes.
Among both groups of participants, nutrition (traditional diets), genetics and environmental stress (e.g. neighborhood crime and poor conditions) were described as primary contributors to diabetes and hypertension. Unhealthy diets were reported as being a major barrier to disease management. Participants also believed that they would benefit from attending groups on management and education for their conditions that include creative ways to adopt healthy foods that complement their ethnic diets, exercise opportunities, and advice on how to prevent disease manifestation among family members.
Interactive discussion groups focused on lifestyle modification and disease management should be created for patients to learn more about their diseases. Future research evaluating the effectiveness of interactive diabetes and hypertension groups that apply patient racial/ethnic traditions should be considered.
diabetes; hypertension; Blacks ; Latinos; racial disparities
Because Pacific Islanders and Asian Americans have often been aggregated in federal health surveys, we assessed whether they differ substantially in important health measures.
Retrospective analyses of the 2005–2007 Behavioral Risk Factor Surveillance System (BRFSS) surveys.
A total of 2,609 Pacific Islanders, 17,892 Asians, and 894,289 whites over age 18.
We compared self-reported health risk factors (smoking, BMI ≥25 kg/m2, alcohol intake, physical activity, fruit/vegetable intake), chronic diseases (diabetes, hypertension, coronary heart disease, asthma, hypercholesterolemia, arthritis, fair or poor health status), and access to care (insurance status, cost barriers, and regular physician) for Pacific Islanders relative to Asian Americans and whites. Logistic regression was used to adjust for sociodemographic factors.
Pacific Islanders were more likely than Asian Americans to report an elevated body-mass index (adjusted odds ratio 2.26; 95% confidence interval 1.80, 2.84), current smoking (2.15; 1.57, 2.93), and high alcohol intake (3.14; 1.60, 6.18), but also more likely to report adequate physical activity (1.62; 1.23, 2.14). Pacific Islanders reported higher adjusted rates of hypertension (1.50; 1.06, 2.13), diabetes (1.82; 1.25, 2.63), asthma (2.32; 1.65, 3.25), and arthritis (1.68; 1.20, 2.35). Pacific Islanders also more frequently reported having fair or poor health (1.46; 1.05, 2.04). Most differences in self-reported health status and chronic disease outcomes were mediated by higher rates of overweight and obesity, but not higher rates of smoking, among Pacific Islanders. Differences in smoking, hypertension, and diabetes were more pronounced among Pacific Islander women than men. Relative to whites, Pacific Islanders were more likely to report a diagnosis of diabetes (1.56; 1.13, 2.14) and less likely to report arthritis (0.61; 0.46, 0.82). All other outcomes measures were statistically similar for whites and Pacific Islanders.
Health surveys and policies should distinguish between Pacific Islanders and Asian Americans given the significantly higher rates of health risks and chronic diseases among Pacific Islanders.
Pacific Islander Americans; Asian Americans; health care disparities; chronic disease
To identify the frequency of and factors associated with changes in employment among cancer survivors.
This prospective cohort study took place in the context of the population-based Cancer Care Outcomes Research and Surveillance Consortium. Patients with nonmetastatic lung or colorectal cancer who survived approximately 15 months after diagnosis without cancer recurrence provided their self-reported employment status, employment experiences, and changes in insurance coverage at 4 and 15 months after diagnosis. Multiple logistic regression was used to relate sociodemographic and disease factors to the probability of labor force departure.
Among 2,422 eligible patients, employment declined from 3% to 31% over the 15 months after cancer was diagnosed. Labor force departures attributable to cancer occurred in 17% of those employed at baseline. Factors associated with significantly higher rates of labor force departure were lung versus colon cancer, stage III versus I or II disease, lower educational and income levels, and, among colorectal patients, older age. Married women were significantly more likely than unmarried women to leave the workforce. Only 2% of patients lacked health insurance during the study period.
Most employed patients with nonmetastatic lung or colorectal cancer return to work, but approximately one sixth of patients leave the workforce, particularly those with worse prognoses or lower socioeconomic status. Potential economic effects must be considered in management decisions about cancer.
Since 1990, the National Breast and Cervical Cancer Early Detection Program (BCCEDP) has funded breast cancer screening and diagnostic services for low income, underinsured women. Case management was implemented in 2001 to address barriers to follow-up after an abnormal mammogram, and free treatment was introduced in 2004. However, the effect of these policies on timeliness of care has not been empirically evaluated.
Among 2,252 BCCEDP participants in Massachusetts during 1998 through 2007, we conducted a time-to-event analysis with pre-post comparisons to examine associations of case management and free treatment with diagnostic and treatment delays (>60 days and >90 days, respectively) following an abnormal mammogram.
The proportion of women experiencing a diagnostic delay decreased from 33% to 23% after the introduction of case management (p<0.001), with a significant reduction in the adjusted risk of diagnostic delay (RR 0.65; 95% CI 0.53, 0.79) that did not differ by race/ethnicity. However, case management was not associated with changes in treatment delay (RR 0.93; 95% CI 0.80, 1.10). Free treatment was not associated with changes in the adjusted risk of diagnostic delay (RR 0.61; 95% CI 0.33, 1.14) or treatment delay (RR 0.77; 95% CI 0.43, 1.38), beyond improvements associated with case management.
Case management to assist women overcome logistical and psychosocial barriers to care may improve time to diagnosis among low-income women who receive free breast cancer screening and diagnostic services. Programs that provide services to coordinate care, in addition to free screening and diagnostic tests, may improve population health.