Association between hospital competition and quality of prostate cancer care.

BACKGROUND: Hospitals account for approximately 6% of United States' gross domestic product. We examined the association between hospital competition and outcomes in elderly with localized prostate cancer (PCa). We also assessed if race moderated this association. METHODS: Retrospective study using Surveillance, Epidemiology, and End Results (SEER) - Medicare database. Cohort included fee-for-service, African American and white men aged ≥ 66, diagnosed with localized PCa between 1998 and 2011 and their claims between 1997 and 2016. We used Hirschman-Herfindahl index (HHI) to measure of hospital competition. Outcomes were emergency room (ER) visits, hospitalizations, Medicare expenditure and mortality assessed in acute survivorship phase (two years post-PCa diagnosis), and long-term mortality. We used Generalized Linear Models for analyzing expenditure, Poisson models for ER visits and hospitalizations, and Cox models for mortality. We used propensity score to minimize bias. RESULTS: Among 253,176 patients, percent change in incident rate of ER visit was 17% higher for one unit increase in HHI (IRR: 1.17, 95% CI: 1.15-1.19). Incident rate of ER was 24% higher for whites and 48% higher for African Americans. For one unit increase in HHI, hazard of short-term all-cause mortality was 7% higher for whites and 11% lower for African Americans. The hazard of long-term all-cause mortality was 10% higher for whites and 13% higher for African Americans. CONCLUSIONS: Lower hospital competition was associated with impaired outcomes of localized PCa care. Magnitude of impairment was higher for African Americans, compared to whites. Future research will explore process through which competition affects outcomes and racial disparity.

Continuity of care in acute survivorship phase, and short and long-term outcomes in prostate cancer patients.

Continuity of care is important for prostate cancer care due to multiple treatment options, and prolonged disease history. We examined the association between continuity of care and outcomes in Medicare beneficiaries with localized prostate cancer, and the moderating effect of race using Surveillance, Epidemiological, and End Results (SEER) - Medicare data between 2000 and 2016. Continuity of care was measured as visits dispersion (continuity of care index or COCI), and density (usual provider care index or UPCI) in acute survivorship phase. Outcomes were emergency room visits, hospitalizations, and cost during acute survivorship phase and mortality (all-cause and prostate cancer-specific) over follow-up phase. Higher continuity of care was associated with improved outcomes, and interaction between race and continuity of care was significant. Continuity of care during acute survivorship phase may lower the racial disparity in prostate cancer care. Future research can analyze the mechanism of the process.

Long-term depression incidence and associated mortality among African American and White prostate cancer survivors.

BACKGROUND: Depression is common after a diagnosis of prostate cancer and may contribute to poor outcomes, particularly among African Americans. The authors assessed the incidence and management of depression and its impact on overall mortality among African American and White veterans with localized prostate cancer. METHODS: The authors used the Veterans Health Administration Corporate Data Warehouse to identify 40,412 African American and non-Hispanic White men diagnosed with localized prostate cancer from 2001 to 2013. Patients were followed through 2019. Multivariable logistic regression was used to measure associations between race and incident depression, which were ascertained from administrative and depression screening data. Cox proportional hazards models were used to measure associations between incident depression and all-cause mortality, with race-by-depression interactions used to assess disparities. RESULTS: Overall, 10,013 veterans (24.5%) were diagnosed with depression after a diagnosis of prostate cancer. Incident depression was associated with higher all-cause mortality (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.23-1.32). African American veterans were more likely than White veterans to be diagnosed with depression (29.3% vs 23.2%; adjusted odds ratio [aOR], 1.15; 95% CI, 1.09-1.21). Among those with depression, African Americans were less likely to be prescribed an antidepressant (30.4% vs 31.7%; aOR, 0.85; 95% CI, 0.77-0.93). The hazard of all-cause mortality associated with depression was greater for African American veterans than White veterans (aHR, 1.32 [95% CI, 1.26-1.38] vs 1.15 [95% CI, 1.07-1.24]; race-by-depression interaction P < .001). CONCLUSIONS: Incident depression is common among prostate cancer survivors and is associated with higher mortality, particularly among African American men. Patient-centered strategies to manage incident depression may be critical to reducing disparities in prostate cancer outcomes.

Patient preference elicitation instrument, OABCare, to facilitate shared decision-making in the care of overactive bladder.

AIMS: To describe the development and feasibility of a preference elicitation instrument, OABCare, using choice-based adaptive conjoint analysis (ACA) among patients with overactive bladder (OAB). METHODS: This was a two-phase study. In Phase 1, an extensive literature review along with patient and provider focus groups yielded the attributes and levels for our OABCare instrument. The hierarchical Bayesian random-effects model generated utilities and mean relative importance scores of treatment attributes. Phase 2 consisted of a cohort study to assess the association between OAB treatment uptake and treatment attributes elicited from OABCare, using generalized linear models. RESULTS: Literature review and provider and patient focus groups in Phase 1 yielded themes related to OAB management that were used to develop 11 attributes for the ACA instrument. For Phase 2 of the study, 108 patients were recruited who completed the OABCare instrument. Results showed that the top five attributes with the highest mean utility values were caregiver burden, impaired bladder function, social interaction constraints, treatment side effects, and use of pads. In addition, impaired bladder function (odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.1, 2.1), disturbed sleep (OR = 1.24, 95% CI = 1.04, 1.47), social interaction constraints (OR = 1.12, 95% CI = 1.05, 1.32), and out-of-pocket costs (OR = 0.79, 95 % CI = 0.61, 0.94) were associated with OAB treatment uptake. CONCLUSIONS: Our ACA-based instrument, OABCare, is a feasible and acceptable tool for assessing preferences in OAB patients. Preference assessment can facilitate shared decision-making and may enhance the quality of OAB care. Future work will evaluate the OABCare instrument in different subgroups based on sociodemographic, clinical, and treatment characteristics, and its integration into clinical care settings.

Association between overactive bladder treatment and falls among older adults.

AIMS: To analyze the risk of falls associated with Overactive bladder (OAB), and the effects of OAB treatment on falls among older adult Medicare fee-for-service enrollees. METHODS: Population based retrospective longitudinal cohort design study using 5% Medicare claims between 2006 and 2010. Patients with a diagnosis of OAB (ICD 9: 596.51); Urinary Incontinence (ICD 9: 788.3); Urinary incontinence, unspecified (ICD 9: 788.30); Urge incontinence (ICD 9: 788.31); Mixed incontinence (male, female) (ICD 9: 788.33); Urinary frequency (ICD 9: 788.41); Nocturia (ICD 9: 788.43); or Urgency of urination (ICD 9: 788.63) were identified and followed retrospectively for 2 years. Falls was the main outcome of the study. Using logistic regressions, we analyzed the association between OAB and falls; and the protective effect of OAB treatment on falls. Propensity score and instrumental variable were used to minimize bias. RESULTS: We identified 33 631 Medicare enrollees (mean age = 77.8 years, sd = 7.6) with OAB. Higher proportion of OAB patients had falls, compared to those without OAB (11% vs 7%, P < 0.001). Diagnosis of OAB was associated with higher odds of falls (OR = 1.59; 95% CI = 1.53, 1.65) compared to those without OAB. Fourteen percent of OAB patients received OAB treatment. Treatment for OAB was associated with lower odds of falls (OR = 0.88; 95% CI = 0.80, 0.98) compared to those OAB patients who were not treated. CONCLUSIONS: Older adults with OAB experience increased risk of falls. Treatment for OAB may reduce this risk. These findings emphasize the need to effectively identify and treat OAB in older adults.

Knowledge and attitude for overactive bladder care among women: development and measurement.

BACKGROUND: Overactive bladder (OAB) affects millions of women. It is important to assess knowledge and attitude in affected patients. The study objective was to develop surveys to assess OAB knowledge and OAB related attitude, and its association with OAB treatment status. METHODS: Systematic literature review and qualitative analysis of patient and provider focus groups helped identify OAB knowledge and attitude survey items. We determined psychometric properties of the two surveys in a cross-sectional sample of 104 women, 27% of whom had received OAB treatment. RESULTS: The OAB-knowledge survey consisted of 16 items and 3 condition-related concepts: perception of OAB; cause and information; and signs of OAB. The OAB-attitude survey consisted of 16 items and its concepts were treatment seeking; decision-making and effects. Both surveys demonstrated good construct validity and test-retest reliability ((≥ 0.60). In the cross-sectional validation sample, OAB-knowledge and attitude discriminated between those with different levels of ICIQ-UI scores. We observed some difference in the OAB knowledge, OAB attitude, and severity of symptoms between those treated for OAB vs. treatment naive. CONCLUSIONS: OAB knowledge and attitude surveys provide a novel tool to assess OAB domains in women. Though we did not find statistical significance in OAB knowledge and attitude scores across treatment status, they may be potentially modifiable factors that affect OAB treatment uptake and treatment compliance. Refinement of these surveys in diverse sub-populations is necessary. Our study provides effect sizes for OAB knowledge and attitude. These effect sizes can help development of fully powered trials to study the association between OAB knowledge and attitude, type and length of treatment, treatment compliance, and quality of life, leading to interventions for enhancing OAB care.

Racial and ethnic disparities in substance use disorders and outcomes in elderly prostate cancer patients.

Substance use among cancer patients is an important psychosocial comorbidity. Currently, there is a paucity of information regarding racial disparity in substance use among cancer patients. The objective of this study was to analyze racial and ethnic disparity in prevalence of substance use and its effects on outcomes in Medicare elderly with advanced prostate cancer using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data. We used ICD-9 diagnosis codes to identify substance use disorder. Outcomes were health service use, cost, and mortality. Prevalence of substance use varied among White, African American, and Hispanic patients with advanced-stage prostate cancer. Racial and ethnic disparity existed in the association between substance use and outcomes. A multidisciplinary coordinated care approach is essential to address racial and ethnic disparities in substance use among prostate cancer patients and to achieve optimal clinical management and improved outcomes of care.

Trends in substance use admissions among older adults.

BACKGROUND: Substance abuse is a growing, but mostly silent, epidemic among older adults. We sought to analyze the trends in admissions for substance abuse treatment among older adults (aged 55 and older). METHODS: Treatment Episode Data Set - Admissions (TEDS-A) for period between 2000 and 2012 was used. The trends in admission for primary substances, demographic attributes, characteristics of substance abused and type of admission were analyzed. RESULTS: While total number of substance abuse treatment admissions between 2000 and 2012 changed slightly, proportion attributable to older adults increased from 3.4% to 7.0%. Substantial changes in the demographic, substance use pattern, and treatment characteristics for the older adult admissions were noted. Majority of the admissions were for alcohol as the primary substance. However there was a decreasing trend in this proportion (77% to 64%). The proportion of admissions for following primary substances showed increase: cocaine/crack, marijuana/hashish, heroin, non-prescription methadone, and other opiates and synthetics. Also, admissions for older adults increased between 2000 and 2012 for African Americans (21% to 28%), females (20% to 24%), high school graduates (63% to 75%), homeless (15% to 19%), unemployed (77% to 84%), and those with psychiatric problems (17% to 32%).The proportion of admissions with prior history of substance abuse treatment increased from 39% to 46% and there was an increase in the admissions where more than one problem substance was reported. Ambulatory setting continued to be the most frequent treatment setting, and individual (including self-referral) was the most common referral source. The use of medication assisted therapy remained low over the years (7% - 9%). CONCLUSIONS: The changing demographic and substance use pattern of older adults implies that a wide array of psychological, social, and physiological needs will arise. Integrated, multidisciplinary and tailored policies for prevention and treatment are necessary to address the growing epidemic of substance abuse in older adults.

Concordance Between Clinical Diagnosis and Medicare Claims of Depression Among Older Primary Care Patients.

OBJECTIVE: To identify patient characteristics associated with concordance of Medicare claims with clinically identified depression. METHODS: The authors studied a cohort of 742 older primary care patients linked to Medicare claims data using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive disorder and clinically significant minor depression. RESULTS: Among 474 patients with depression, 198 patients had a Medicare claim for depression (sensitivity: 42%; 95% confidence interval [CI]: 37%-46%). Among 268 patients who did not meet criteria for depression, 235 patients did not have a Medicare claim for depression (specificity: 88%; 95% CI: 83%-91%). After adjustment for demographic and clinical characteristics, non-white participants were nearly twice as likely not to have Medicare claims for depression among patients who met criteria for depression ("false negatives"). Smoking status, depression severity (Hamilton Depression Rating Scale), cardiovascular disease, and more primary care physician office visits were also significantly associated with decreased odds to be false negatives. In contrast, after covariate adjustment, white race and chronic pulmonary disease were associated with increased odds of a Medicare claim for depression among patients who did not meet criteria for depression ("false positives"). Using weights based on the screened sample, the positive predictive value of a Medicare claim for depression was 66% (95% CI [63%, 69%]), whereas the negative predictive value was 77% (95% CI [76%, 78%]). CONCLUSION: Investigators using Medicare data to study depression must recognize that diagnoses of depression from Medicare data may be biased by patient ethnicity and the presence of medical comorbidity.

Substance use disorder and its effects on outcomes in men with advanced-stage prostate cancer.

BACKGROUND: Substance use disorder in patients with cancer has implications for outcomes. The objective of this study was to analyze the effects of the type and timing of substance use on outcomes in elderly Medicare recipients with advanced prostate cancer. METHODS: This was an observational cohort study using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 2000 to 2009. Among men who were diagnosed with advanced prostate cancer between 2001 and 2004, we identified those who had a claim for substance use disorder in the year before cancer diagnosis, 1 year after cancer diagnosis, and an additional 4 years after diagnosis. The outcomes investigated were use of health services, costs, and mortality. RESULTS: The prevalence of substance use disorder was 10.6%. The category drug psychoses and related had greater odds of inpatient hospitalizations (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.9-2.8), outpatient hospital visits (OR, 2.6; 95% CI, 1.9-3.6), and emergency room visits (OR, 1.7; 95% CI, 1.2-2.4). Substance use disorder in the follow-up phase was associated with greater odds of inpatient hospitalizations (OR, 2.0; 95% CI, 1.8-2.2), outpatient hospital visits (OR, 2.0; 95% CI, 1.7-2.4), and emergency room visits (OR, 1.7; 95% CI, 1.5-2.1). Compared with men who did not have substance use disorder, those in the category drug psychoses and related had 70% higher costs, and those who had substance use disorder during the follow-up phase had 60% higher costs. The hazard of all-cause mortality was highest for patients in the drug psychoses and related category (hazard ratio, 1.3; 95% CI, 1.1-1.7) and the substance use disorder in treatment phase category (hazard ratio, 1.5; 95% CI, 1.3-1.7). CONCLUSIONS: The intersection of advanced prostate cancer and substance use disorder may adversely affect outcomes. Incorporating substance use screening and treatments into prostate cancer care guidelines and coordination of care is desirable.

An evidence-based strategy for the conservative management of the male patient with incontinence.

PURPOSE OF REVIEW: Incontinence is not an isolated symptom in men, but rather a component of a multifactorial problem that may include other lower urinary tract symptoms (LUTS). Male urinary incontinence is often seen following prostate surgery and procedures, particularly prostate cancer surgery. Men with enlarged prostates experience overactive bladder symptoms of urgency and frequency. Despite these bothersome lower urinary tract problems in men, conservative treatment remains poorly investigated. This review will provide the current evidence-based strategies for the use of conservative management in men with urinary incontinence and other LUTS. RECENT FINDINGS: Conservative treatment for urinary incontinence is an effective intervention and has been recommended by the evidence-based guidelines as the first-line intervention for LUTS. Despite this prevalence, the only population of men who continue to receive systematic consideration with respect to conservative management are those with postprostatectomy urinary symptoms. Although continence status gradually improves in the ensuing weeks and months, evidence-based research has shown that preoperative and early postoperative pelvic floor muscle training can speed the recovery of continence in the short and long term. Recent research has also shown that behavioral therapy combined with medication can improve the male symptom of nocturia. Lifestyle changes of weight loss in obese men with diabetes and LUTS and dietary modification has also been shown to be effective. SUMMARY: Although sparse, there are data to support conservative interventions as the first-line treatment in men with LUTS. There is a strong recommendation for implementing a pelvic floor muscle training (PFMT) program before and after prostatectomy. Positive lifestyle changes such as weight loss in obese men and dietary modification can lessen urgency, nocturia, and incontinence. Despite this growing evidence on effectiveness, urologists rarely recommend conservative treatment to patients.

Effects of behavioral stress reduction Transcendental Meditation intervention in persons with HIV.

Stress is implicated in the pathogenesis and progression of HIV. The Transcendental Meditation (TM) is a behavioral stress reduction program that incorporates mind-body approach, and has demonstrated effectiveness in improving outcomes via stress reduction. We evaluated the feasibility of implementing TM and its effects on outcomes in persons with HIV. In this community-based single blinded Phase-I, randomized controlled trial, outcomes (psychological and physiological stress, immune activation, generic and HIV-specific health-related quality of life, depression and quality of well-being) were assessed at baseline and at six months, and were compared using parametric and nonparametric tests. Twenty-two persons with HIV were equally randomized to TM intervention or healthy eating (HE) education control group. Retention was 100% in TM group and 91% in HE control group. The TM group exhibited significant improvement in vitality. Significant between group differences were observed for generic and HIV-specific health-related quality of life. Small sample size may possibly limit the ability to observe significant differences in some outcomes. TM stress reduction intervention in community dwelling adults with HIV is viable and can enhance health-related quality of life. Further research with large sample and longer follow-up is needed to validate our results.

Racial Disparity in Outcomes Among Prostate Cancer Patients in the Post-Affordable Care Act Period.

INTRODUCTION: Our objective was to assess whether Medicaid expansion is associated with reduced racial disparity in quality of care measured as 30-day mortality, 90-day mortality, and 30-day readmission in prostate cancer patients receiving surgery. METHODS: We used the National Cancer Database to extract a cohort of African American and White men diagnosed with prostate cancer between 2004 and 2015 and surgically treated. We used 2004-2009 data to observe preexisting racial disparity in outcomes. We used 2010-2015 data to assess racial disparity in outcomes and the interaction of race and Medicaid expansion status. RESULTS: Between 2004 and 2009, 179,762 men met our criteria. In this period, African American patients reported higher hazard of 30- and 90-day mortality and higher odds of 30-day readmission compared to White patients. Between 2010 and 2015, 174,985 men met our criteria. Of these 84% were White and 16% were African American. Main effects models showed that compared to White men, African American men had higher odds of 30-day mortality (OR=1.96, 95% CI = 1.46, 2.67), 90-day mortality (OR=1.40, 95% CI = 1.11, 1.77), and 30-day readmission (OR=1.28, 95% CI = 1.19, 1.38).The interactions between race and Medicaid expansion were not significant (P = .1306, .9499, and .5080, respectively). CONCLUSIONS: Improved access to care via Medicaid expansion may not translate into reduced racial disparity in quality-of-care outcomes in prostate cancer patients treated surgically. System-level factors such as availability of and referrals to care, and complex socioeconomic structure may also play a role in improving quality of care and reducing disparities.

Continuity of care and advanced prostate cancer.

BACKGROUND: Continuity of care is an important element of advanced prostate cancer care due to the availability of multiple treatment options, and associated toxicity. However, the association between continuity of care and outcomes across different racial groups remains unclear. OBJECTIVE: To assess the association of provider continuity of care with outcomes among Medicare fee-for-service beneficiaries with advanced prostate cancer and its variation by race. DESIGN: Retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. SUBJECTS: African American and white Medicare beneficiaries aged 66 or older, and diagnosed with advanced prostate cancer between 2000 and 2011. At least 5 years of follow-up data for the cohort was used. MEASURES: Short-term outcomes were emergency room (ER) visits, hospitalizations, and cost during acute survivorship phase (2-year post-diagnosis), and mortality (all-cause and prostate cancer-specific) during the follow-up period. We calculated continuity of care using Continuity of Care Index (COCI) and Usual Provider Care Index (UPCI), for all visits, oncology visits, and primary care visits in acute survivorship phase. We used Poisson models for ER visits and hospitalizations, and log-link GLM for cost. Cox model and Fine-Gray competing risk models were used for survival analysis, weighted by propensity score. We performed similar analysis for continuity of care in the 2-year period following acute survivorship phase. RESULTS: One unit increase in COCI was associated with reduction in short-term ER visits (incidence rate ratio [IRR] = 0.65, 95% confidence interval [CI] 0.64, 0.67), hospitalizations (IRR = 0.65, 95% CI 0.64, 0.67), and cost (0.64, 95% CI 0.61, 0.66) and lower hazard of long-term mortality. Magnitude of these associations differed between African American and white patients. We observed comparable results for continuity of care in the follow-up period. CONCLUSIONS: Continuity of care was associated with improved outcomes. The benefits of higher continuity of care were greater for African Americans, compared to white patients. Advanced prostate cancer survivorship care must integrate appropriate strategies to promote continuity of care.

Trajectory of Depression among Prostate Cancer Patients: A Secondary Analysis of a Randomized Controlled Trial.

Background: While psychological difficulties, such as depression, among prostate cancer patients are known, their longitudinal burden remains understudied. We assessed the burden of depression across low-, intermediate- and high-risk prostate cancer groups, and the association between regret and long-term depression. Methods: Secondary analysis of data from a multi-centered randomized controlled study among localized prostate cancer patients was carried out. Assessments were performed at baseline, and at 3-, 6-, 12- and 24-month follow-up. Depression was assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. A CES-D score ≥ 16 indicates high depression. Regret was measured using the regret scale of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). The proportion of patients with high depression was compared over time, for each risk category. Logistic regression was used to assess the association between regret, and long-term depression after adjusting for age, race, insurance, smoking status, marital status, income, education, employment, treatment, number of people in the household and study site. Results: The study had 743 localized prostate cancer patients. Median depression scores at 6, 12 and 24 months were significantly larger than the baseline median score, overall and for the three prostate cancer risk groups. The proportion of participants with high depression increased over time for all risk groups. Higher regret at 24-month follow-up was significantly associated with high depression at 24-month follow-up, after adjusting for covariates. Conclusions: A substantial proportion of localized prostate cancer patients continued to experience long-term depression. Patient-centered survivorship care strategies can help reduce depression and regret, and improve outcomes in prostate cancer care.

Validation of Biomechanical Computed Tomography for Fracture Risk Classification in Metastatic Hormone-sensitive Prostate Cancer.

BACKGROUND: Guidelines recommend dual-energy x-ray absorptiometry (DXA) screening to assess fracture risk and benefit from antiresorptive therapy in men with metastatic hormone-sensitive prostate cancer (mHSPC) on androgen deprivation therapy (ADT). However, <30% of eligible patients undergo DXA screening. Biomechanical computed tomography (BCT) is a radiomic technique that measures bone mineral density (BMD) and bone strength from computed tomography (CT) scans. OBJECTIVE: To evaluate the (1) correlations between BCT- and DXA-assessed BMD, and (2) associations between BCT-assessed metrics and subsequent fracture. DESIGN, SETTING, AND PARTICIPANTS: A multicenter retrospective cohort study was conducted among patients with mHSPC between 2013 and 2020 who received CT abdomen/pelvis or positron emission tomography/CT within 48 wk before ADT initiation and during follow-up (48-96 wk after ADT initiation). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used univariate logistic regression to assess the associations between BCT measurements and the primary outcomes of subsequent pathologic and nonpathologic fractures. RESULTS AND LIMITATIONS: Among 91 eligible patients, the median ([interquartile range) age was 67 yr (62-75), 44 (48.4%) were White, and 41 (45.1%) were Black. During the median follow-up of 82 wk, 17 men (18.6%) developed a pathologic and 15 (16.5%) a nonpathologic fracture. BCT- and DXA-assessed femoral-neck BMD T scores were strongly correlated (R2 = 0.93). On baseline CT, lower BCT-assessed BMD (odds ratio [OR] 1.80, 95% confidence interval or CI [1.10, 3.25], p = 0.03) was associated with an increased risk of a pathologic fracture. Lower femoral strength (OR 1.63, 95% CI [0.99, 2.71], p = 0.06) was marginally associated with an increased risk of a pathologic fracture. Neither BMD (OR 1.52, 95% CI [0.95, 2.63], p = 0.11) nor strength (OR 1.14, 95% CI [0.75, 1.80], p = 0.57) was associated with a nonpathologic fracture. BCT identified nine (9.9%) men eligible for antiresorptive therapy, of whom four (44%) were not treated. Limitations include low fracture numbers resulting in lower power to detect fracture associations. CONCLUSIONS: Among men diagnosed with mHSPC, BCT assessments were strongly correlated with DXA, predicted subsequent pathologic fracture, and identified additional men indicated for antiresorptive therapy. PATIENT SUMMARY: We assess whether biomechanical computer tomography (BCT) from routine computer tomography (CT) scans can identify fracture risk among patients recently diagnosed with metastatic prostate cancer. We find that BCT and dual-energy x-ray absorptiometry-derived bone mineral density are strongly correlated and that BCT accurately identifies the risk for future fracture. BCT may enable broader fracture risk assessment and facilitate timely interventions to reduce fracture risk in metastatic prostate cancer patients.

The burden of depression in prostate cancer.

OBJECTIVE: We sought to analyze the prevalence and incremental burden of depression among elderly with prostate cancer. METHODS: We adopted a retrospective cohort design using the Surveillance, Epidemiology and End Results-Medicare linked database between 1995 and 2003. Patients with prostate cancer diagnosed between 1995 and 1998 were identified and followed retrospectively for 1 year pre-diagnosis and up to 8 years post diagnosis. In this cohort of patients with prostate cancer, depression during treatment phase (1 year after diagnosis of prostate cancer) or in the follow-up phase was identified using the International Classification of Diseases-Ninth Revision depression-related codes. Poisson, general linear (log-link) and Cox regression models were used to determine the association between depression status during treatment and follow-up phases and outcomes-health resource utilization, cost and mortality. RESULTS: Of the 50,147 patients newly diagnosed with prostate cancer, 4285 (8.54%) had a diagnosis of depression. A diagnosis of depression during treatment phase was associated with higher odds of emergency room visits (odds ratio (OR) = 4.45, 95% CI = 4.13, 4.80), hospitalizations (OR = 3.22, CI = 3.08, 3.37), outpatient visits (OR = 1.71, CI = 1.67, 1.75) and excess risk of death over the course of the follow-up interval (hazard ratio = 2.82, CI = 2.60, 3.06). Health care costs associated with depression remained elevated compared with costs for men without depression, over the course of the follow-up. CONCLUSIONS: Depression during the treatment phase was associated with significant health resource utilization, costs and mortality among men with prostate cancer. These findings emphasize the need to effectively identify and treat depression in the setting of prostate cancer.

Photodynamic therapy for stage I and II non-small cell lung cancer: A SEER-Medicare analysis 2000-2016.

ABSTRACT: We analyzed mortality (all-cause and lung cancer-specific) and time to follow-up treatment in stage I and II non-small cell lung cancer (NSCLC) patients treated with photodynamic therapy (PDT) compared with ablation therapy and radiation therapy.From Surveillance, Epidemiology, and End Results-Medicare linked data, patients diagnosed with stage I and II NSCLC between 2000 and 2015 were identified. Outcomes were mortality (overall and lung cancer-specific) and time to follow-up treatment. We analyzed mortality using Cox proportional hazard models. We used generalized linear model to assess time to follow-up treatment (PDT and ablation groups). Models were adjusted for inverse probability weighted propensity score.Of 495,441 NSCLC patients, 56 with stage I and II disease received PDT (mono or multi-modal), 477 received ablation (mono or multi-modal), and 14,178 received radiation therapy alone. None from PDT group had metastatic disease (M0) and 70% had no nodal involvement (N0). Compared with radiation therapy alone, PDT therapy was associated with lower hazard of overall (hazard ratio = 0.56, 95% CI = 0.39-0.80), and lung cancer-specific mortality (hazard ratio = 0.64, 95% CI = 0.43-0.97). Unadjusted mean time to follow-up treatment was 70days (standard deviation = 146) for PDT group and 67 days (standard deviation = 174) for ablation group. Compared with ablation, PDT was associated with an average increase of 125days to follow-up treatment (P = .11).Among stage I and II NSCLC patients, PDT was associated with improved survival, compared with radiation alone; and longer time to follow-up treatment compared with ablation. Currently, PDT is offered in various combinations with surgery and radiation. Larger studies can investigate the efficacy and effectiveness of these combinations.

Variation in quality of care among older men with localized prostate cancer.

BACKGROUND: The objective of this study was to assess the racial and ethnic disparities in outcomes and their association with process-of-care measures for elderly Medicare recipients with localized prostate cancer. METHODS: The Surveillance, Epidemiology, and End Results-Medicare databases for the period from 1995 to 2003 were used to identify African-American men, non-Hispanic white men, and Hispanic men with localized prostate cancer, and data were obtained for the 1-year period before the diagnosis of prostate cancer and up to 8 years postdiagnosis. The short-term outcomes of interest were complications, emergency room visits, readmissions, and mortality; the long-term outcomes of interest were prostate cancer-specific mortality and all-cause mortality; and process-of-care measures of interest were treatment and time to treatment. Cox proportional hazards regression, logistic regression, and Poisson regression were used to study the racial and ethnic disparities in outcomes and their association with process-of-care measures. RESULTS: Compared with non-Hispanic white patients, African-American patients (Hazard ration [HR], 1.43; 95% confidence interval [CE], 1.19-1.86) and Hispanic patients (HR=1.39; 95% CI, 1.03-1.84) had greater hazard of long term prostate specific mortality. African-American patients also had greater odds of emergency room visits (odds ratio, 1.4; 95% CI, 1.2-1.7) and greater all-cause mortality (HR, 1.39; 95% CI, 1.3-1.5) compared with white patients. The time to treatment was longer for African-American patients and was indicative of a greater hazard of all-cause, long-term mortality. Hispanic patients who underwent surgery or received radiation had a greater hazard of long-term prostate-specific mortality compared with white patients who received hormone therapy. CONCLUSIONS: Racial and ethnic disparities in outcomes were associated with process-of-care measures (the type and time to treatment). The current results indicated that there is an opportunity to reduce these disparities by addressing these process-of-care measures.

Burden of Chronic Conditions Among Persons with HIV/AIDS and Psychiatric Comorbidity.

BACKGROUND: Improved survivorship among persons living with HIV translates into a higher risk of medical comorbidities. OBJECTIVES: We assessed the association between the intersection of physical (HIV) and mental health (psychiatric) conditions and intermediate outcomes. METHODS: This was a cross-sectional study of the Medical Expenditure Panel Survey (MEPS)- Household Component between 1996 and 2016. We created four groups for persons aged ≥18: (1) HIV + psychiatric comorbidity, (2) HIV, (3) psychiatric comorbidity, and (4) no-HIV/no-psychiatric comorbidity. We compared the burden of medical comorbidities (metabolic disorders, cardiovascular disease, cancers, infectious diseases, pain, and substance use) among groups using chisquare tests. We used logistic regression to determine the association between group status and medical comorbidity. RESULTS: Of 218,133,630 (weighted) persons aged ≥18, 0.18% were HIV-positive. Forty-three percent of the HIV group and 19% of the no-HIV group had psychiatric comorbidities. Half of the HIV+ psychiatric disorder group had at least one medical comorbidity. Compared to the no- HIV/no-psychiatric comorbidity group, the HIV + psychiatric comorbidity group had the highest odds of medical comorbidity (OR= 3.69, 95% CI = 2.99, 4.52). CONCLUSION: Persons presenting with HIV + psychiatric comorbidity had higher odds of medical comorbidities of pain, cancer, cardiovascular disease, substance use, metabolic disorders and infectious diseases, beyond that experienced by persons with HIV infection or psychiatric disorders, independently. Future research will focus on the mediating effects of social determinants and biological factors on outcomes such as the quality of life, cost and mortality. This will facilitate a shift away from the single-disease framework and compress morbidity of the aging cohort of HIV-infected persons.