An observational study of the prevalence and incidence of comorbid conditions in older women with breast cancer.

BACKGROUND: Longitudinal analyses of comorbid conditions in women with breast cancer are few. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we included 51,950 women aged≥66 years with in situ and stage I to IV breast cancer diagnosed in 1998-2002. We identified the prevalence and incidence of 34 comorbid conditions in these women, as well as in a matched cohort without cancer whose rates were standardized to the age and race/ethnicity distribution of the cancer patients. We also estimated rates of office encounters and diagnostic or testing procedures during the 12 months before diagnosis. RESULTS: The prevalence of most conditions at diagnosis was comparable among breast cancer and noncancer patients. New conditions after diagnosis were more common in breast cancer patients, and the incidence rates increased with higher stage at diagnosis. Before diagnosis, women presenting with stage IV disease had 41% [95% confidence interval (CI) 38% to 43%] fewer physician encounters and 34% (95% CI 24% to 31%) fewer unique diagnostic tests than women diagnosed with carcinoma in situ. CONCLUSIONS: Many comorbid conditions are identified as a consequence of the breast cancer diagnosis. There appears to be an important contribution from a lack of interaction with the health care system before diagnosis.

Health care utilization and mortality among elderly patients with myelodysplastic syndromes.

BACKGROUND: Mortality in patients with myelodysplastic syndromes (MDS) is high, and patients are likely to require hospitalizations, emergency department (ED) visits, and transfusions. The relationships between these events and the MDS complications of anemia, neutropenia, and thrombocytopenia are not well understood. PATIENTS AND METHODS: A total of 1864 patients registered in the United States' Surveillance Epidemiology and End Results (SEER) program and aged ≥ 66 years old when diagnosed with MDS in 2001 or 2002 were included. Medicare claims were used to identify MDS complications and utilization (hospitalizations, ED visits, and transfusions) until death or the end of 2005. Mortality was based on SEER data. Kaplan-Meier incidence rates were estimated and multivariable Cox models were used to study the association between complications and outcomes. RESULTS: The 3-year incidence of anemia, neutropenia, and thrombocytopenia was 81%, 25%, and 41%, and the incidence of hospitalization, ED visit, and transfusion was 62%, 42%, and 45%, respectively. Median survival time was 22 months. Cytopenia complications were significantly associated with each of these outcomes. CONCLUSIONS: All types of cytopenia are common among patients with MDS and are risk factors for high rates of health care utilization and mortality. Management of the complications of MDS may improve patient outcomes.

Catheter use is high even among hemodialysis patients with a fistula or graft.

At any given time, approximately 27% of patients in the United States (US) receive hemodialysis through a permanent catheter. However, this cross-sectional estimate may significantly underestimate the lifetime exposure of patients to hemodialysis catheters, and hence, to the excess risk of the adverse clinical events associated with catheter use. To further clarify catheter use in hemodialysis patients, we identified a cohort of fistula and graft patients in the US Renal Data System using Current Procedural Terminology (CPT) codes. Patients were included if their first hemodialysis was between 1 January 1996 and 31 December 2001, and Medicare was their primary payer. We identified permanent catheter insertions in these patients using CPT codes starting 6 months before their first hemodialysis session (or fistula or graft placement, if earlier), and ending 40 months afterward. Most patients (82%) were >65 years old, 57% were male, and 72% were white. The overall rate of permanent catheter insertions was 44 per 100 patient years, with 57% of patients having at least one catheter insertion. The percent of patients receiving a catheter was similar before (30%) and after (27%) the first fistula or graft placement. Cross-sectional analysis may significantly underestimate the lifetime risk of exposure to hemodialysis catheters. Because catheter use is common even in fistula and graft patients, measures used to prevent adverse events associated with catheter use are important in all patients regardless of current access type.

Evaluation of common problems in primary care: effects of physician, practice, and financial characteristics.

OBJECTIVES: To identify the resource use and costs associated with the diagnosis of common problems in primary care practice and to investigate the influence of physician characteristics, practice organization, and financial incentives on physician behavior. STUDY DESIGN: Cross-sectional survey. PATIENTS AND METHODS: A national sample of 1721 primary care physicians from 53 managed care organizations were surveyed about their use of diagnostic laboratory, imaging, and invasive procedures; ambulatory visits; empiric drug therapies; and specialty consultations for a hypothetical middle-aged female patient presenting with 1 of 6 common clinical problems: depression, fatigue, impaired memory, anxiety, low back pain, or high cholesterol. Information regarding the physician's arrangement with managed care organizations was also collected. Cost estimates were made from Maryland Medicare Fee Schedule and Red Book data. RESULTS: Total costs (mean +/- standard deviation) were estimated for management of depression ($520 +/- $235), fatigue ($389 +/- $201), impaired memory ($569 +/- $243), high cholesterol ($367 +/- $191), low back pain ($726 +/- $369), and anxiety ($438 +/- $207). Younger physicians (less than 50 years old) generated higher costs in the treatment of depression but used fewer resources in the evaluation of high cholesterol. Physicians paid by salary had significantly lower costs compared with physicians in fee-for-service arrangements for depression and high cholesterol (P < .05). Physicians in multispecialty groups were more likely to have lower costs for depression and low back pain in multivariate analyses. More stringent financial incentives such as capitation, withholds, and bonuses were not associated with lower costs. CONCLUSIONS: Multispecialty group practice and compensation by salary consistently predict lower costs for evaluation of common problems in primary care practice. Financial incentives such as capitation, withholds, and bonuses were not associated with an effect on costs of diagnostic evaluation.

Clinical review 115: effect of thyroxine therapy on serum lipoproteins in patients with mild thyroid failure: a quantitative review of the literature.

The objective of our study was to estimate the expected change in serum lipoprotein concentrations after treatment with T4 in patients with mild thyroid failure (i.e. subclinical hypothyroidism). Our data sources included MEDLINE, between January 1966 and May 1999, and review of references from relevant articles. There were 1,786 published studies identified, 461 abstracts reviewed, 74 articles retrieved, 24 articles evaluated against predetermined entry criteria, and 13 studies systematically reviewed and abstracted. All studies reported serum total cholesterol concentration changes during T4 treatment, 12 reported triglyceride changes, 10 reported high-density lipoprotein (HDL) cholesterol changes, and 9 reported low-density lipoprotein (LDL) cholesterol changes. There were 247 patients in 13 studies. The mean decrease in the serum total cholesterol concentration was -0.20 mmol/L (-7.9 mg/ dL), with a 95% confidence interval of -0.09 to -0.34. The decline in serum total cholesterol was directly proportional to its baseline concentration. Studies enrolling hypothyroid participants receiving suboptimal T4 doses reported significantly larger decreases in serum total cholesterol after thyroid-stimulating hormone normalization than studies enrolling previously untreated individuals with mild thyroid failure [-0.44 mmol/L (-17 mg/dL) vs. -0.14 mmol/L (-5.6 mg/dL), P = 0.05]. The change in serum LDL cholesterol concentration was -0.26 mmol/L (-10 mg/dL), with a 95% confidence interval of -0.12 to -0.41. Serum HDL and triglyceride concentrations showed no change. These results, although based on fewer than 250 patients, suggest that T4 therapy in individuals with mild thyroid failure lowers mean serum total and LDL cholesterol concentrations. The reduction in serum total cholesterol may be larger in individuals with higher pretreatment cholesterol levels and in hypothyroid individuals taking suboptimal T4 doses. There do not seem to be significant effects of T4 on serum HDL or triglyceride concentrations.

When to treat mild hypothyroidism.

The availability and wide acceptance of TSH assays for primary assessment of thyroid function has led to the recognition that mild thyroid hormone deficiency is characterized by elevation of the serum TSH concentration despite a normal free thyroxine level. Other conditions can also cause isolated serum TSH elevation, and these conditions can be distinguished from mild thyroid failure usually based-on clinical and circumstantial observations alone. Thyroxine treatment of patients with mild hypothyroidism has been shown in most, but not all, clinical trials to lower atherogenic lipid levels and relieve certain somatic and neuropsychiatric symptoms. Such treatment also prevents the progression to overt hypothyroidism, which is particularly likely in patients who are older, who have circulating thyroid autoantibodies, or who have a serum TSH greater than 10 mU/L. After the optimal thyroxine dose has been defined, long-term monitoring of patients with an annual clinical evaluation and serum TSH measurement is appropriate. The high prevalence of mild hypothyroidism, particularly in older women, and its subtle clinical presentation have led some authorities to recommend a low threshold for case-finding or routine population screening for the disorder.

Decision analysis in endocrinology and metabolism.

Decision analysis is a powerful tool for synthesizing and analyzing clinical decisions in the practice of endocrinology and metabolism. The technique involves defining strategies for comparison, choosing a time horizon, constructing a decision tree and model, selecting outcomes and assigning probabilities, taking into account the value of time, calculating the net clinical and cost outcomes, and performing sensitivity analysis. This technique and its utility for different populations and changing health care settings are illustrated for the decision of screening for mild thyroid failure with a thyroid-stimulating hormone assay at the periodic health examination. The strengths and limitations of decision analysis and future applications in endocrinology and metabolism are explored.

Screening for mild thyroid failure at the periodic health examination: a decision and cost-effectiveness analysis.

OBJECTIVE: To estimate the cost-effectiveness of periodic screening for mild thyroid failure by measurement of serum thyroid stimulating hormone (TSH) concentration. DESIGN: Cost-utility analysis using a state-transition computer decision model that accounted for case finding, medical consequences of mild thyroid failure, and costs of care during 40 years of simulated follow-up. SETTING: Periodic health examinations in offices of primary care physicians. PATIENTS: Hypothetical cohorts of women and men screened every 5 years during the recommended periodic examination, beginning at age 35 years. INTERVENTIONS: Adding the serum TSH assay to total serum cholesterol screening was compared to cholesterol screening alone. MAIN OUTCOME MEASURES: Discounted quality-adjusted life years (QALYs) and direct medical costs from a societal perspective. RESULTS: The cost-effectiveness of screening 35-year-old patients with a serum TSH assay every 5 years was $9223 per QALY for women and $22595 per QALY for men. The cost-effectiveness became more favorable when age at first screening was increased for both sexes and was always more favorable for women than men. Reduced progression to overt hypothyroidism and relief of symptoms increased QALYs, but did not substantially reduce direct medical costs. Finding hypercholesterolemia induced by mild thyroid failure reduced direct medical costs, but did not substantially increase QALYs. The cost of a TSH assay and the importance to patients of symptoms associated with thyroid failure were the most influential factors in sensitivity analyses. CONCLUSIONS: The cost-effectiveness of screening for mild thyroid failure compares favorably with other generally accepted preventive medical practices. Physicians should consider measuring serum TSH concentration in patients aged 35 years and older undergoing routine periodic health examinations. The cost-effectiveness of screening is most favorable in elderly women.