Geographic and facility variation in inpatient stroke rehabilitation: multilevel analysis of functional status.

OBJECTIVE: To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke. DESIGN: Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions. SETTING: Inpatient rehabilitation units and facilities. PARTICIPANTS: Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility-Patient Assessment Instrument. RESULTS: Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level. CONCLUSIONS: Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.

Trends in otitis media-related health care use in the United States, 2001-2011.

IMPORTANCE: Otitis media (OM) is a leading cause of pediatric health care visits and the most frequent reason children consume antibiotics or undergo surgery. During recent years, several interventions have been introduced aiming to decrease OM burden. OBJECTIVE: To study the trend in OM-related health care use in the United States during the pneumococcal conjugate vaccine (PCV) era (2001-2011). DESIGN, SETTING, AND PARTICIPANTS: An analysis of an insurance claims database of a large, nationwide managed health care plan was conducted. Enrolled children aged 6 years or younger with OM visits were identified. MAIN OUTCOMES AND MEASURES: Annual OM visit rates, OM-related complications, and surgical interventions were analyzed. RESULTS: Overall, 7.82 million unique children (5.51 million child-years) contributed 6.21 million primary OM visits; 52% were boys and 48% were younger than 2 years. There was a downward trend in OM visit rates from 2004 to 2011, with a significant drop that coincided with the advent of the 13-valent vaccine (PCV-13) in 2010. The observed OM visit rates in 2010 (1.00/child-year) and 2011 (0.81/child-year) were lower than the projected rates based on the 2005-2009 trend had there been no intervention (P < .001). Recurrent OM (≥3 OM visits within 6-month look-back) rates decreased at 0.003/child-year (95% CI, 0.002-0.004/child-year) in 2001-2009 and at 0.018/child-year (95% CI, 0.008-0.028/child-year) in 2010-2011. In the PCV-13 premarket years, there was a stable rate ratio (RR) between OM visit rates in children younger than 2 years and in those aged 2 to 6 years (RR, 1.38; 95% CI, 1.38-1.39); the RR decreased significantly (P < .001) during the transition year 2010 (RR 1.32; 95% CI, 1.31-1.33) and the postmarket year 2011 (RR 1.01; 95% CI, 1.00-1.02). Tympanic membrane perforation/otorrhea rates gradually increased (from 3721 per 100,000 OM child-years in 2001 to 4542 per 100,000 OM child-years in 2011; P < .001); the increase was significant only in the older children group. Mastoiditis rates substantially decreased (from 61 per 100,000 child-years in 2008 to 37 per 100,000 child-years in 2011; P < .001). Ventilating tube insertion rate decreased by 19% from 2010 to 2011 (P = .03). CONCLUSIONS AND RELEVANCE: There was an overall downward trend in OM-related health care use from 2001 to 2011. The significant reduction in OM visit rates in 2010-2011 in children younger than 2 years coincided with the advent of PCV-13. Although tympanic membrane perforation/otorrhea rates steadily increased during that period, mastoiditis and ventilating tube insertion rates decreased in the last years of the study.

The effect of postoperative beam, implant, and combination radiation therapy on GI and bladder toxicities in female Medicare beneficiaries with stage I uterine cancer.

OBJECTIVE: Determine the risk of late gastrointestinal (GI) and bladder toxicities in women treated for Stage I uterine cancer with postoperative beam, implant, or combination radiation. METHODS: The Surveillance, Epidemiology, and End Results (SEER) tumor registry and Medicare claims were used to estimate the risk of developing late GI and bladder toxicities by type of radiation received. Bladder and GI diagnoses were identified 6-60 months after cancer diagnosis. Cox-proportional hazard models were used to estimate risk of any late GI or bladder toxicity due to type of radiation received. RESULTS: A total of 3,024 women with uterine cancer diagnosed from 1992-2005 were identified for analysis with a mean age of 73.9 (Standard Deviation (SD) ± 6.5). Bladder and GI toxicities occurred most frequently in the combination group, and least in the implant group. After controlling for demographic characteristics, tumor grade, diagnosis year, SEER region, comorbidities, prior GI and bladder diagnosis, and chemotherapy, women receiving implant radiation had a 21% absolute decrease in GI toxicities compared to women receiving combination radiation (Hazard Ratio (HR) 0.79, 95% confidence interval (CI) 0.68-0.92). No differences were observed between those receiving beam and combination in GI (HR 1.01 (0.89-1.14)) and bladder (HR 0.95 (0.80-1.11)) toxicities. CONCLUSIONS: Older women receiving combined radiation had the highest rates of GI and bladder toxicities, while women receiving implant radiation alone had the lowest rates. When selecting type of radiation for a patient, these toxicities should be considered. Counseling older women surviving cancer on late toxicities due to radiation must be a priority for physicians caring for them.

Socioeconomic status and chemotherapy use for melanoma in older people.

The study objective was to examine the association, among older persons with cutaneous melanoma, between areal socioeconomic status (SES) and receiving chemotherapy. SEER-Medicare-linked database (1,239 white men and women aged ≥ 66, with invasive melanoma [regional and distant stages]; 1991-1999) was used. SES was measured by census tract poverty level (average of 1990 and 2000 Census data). Covariates were sociodemographics, tumor characteristics, and comorbidity index. Residing in poorer SES areas was associated with a lower likelihood for receiving chemotherapy among patients in the overall sample (adjusted odds ratios = OR 0.97, 95% confidence interval = CI 0.95-0.99), and those with regional stage at diagnosis (OR 0.97, 95% CI 0.94-0.98). These findings reflect socioeconomic disparities in chemotherapy use for melanoma among older white patients in the United States.

Atrial fibrillation and stroke associated with intravenous bisphosphonate therapy in older patients with cancer.

PURPOSE: Recent studies have linked the use of intravenous and orally administered bisphosphonates with subsequent development of atrial fibrillation. Patients with cancer who receive intravenous bisphosphonate therapy may be at particular risk for this adverse event because they receive higher doses of these drugs than do patients treated for other indications. We examined the association of intravenous bisphosphonates with atrial fibrillation, all classifications of supraventricular tachycardia (SVT), and stroke among older patients with cancer. PATIENTS AND METHODS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data, we identified older (≥ age 65 years) patients with cancer who were treated with intravenous infusions of bisphosphonates between January 1, 1995 and December 31, 2003. We then matched 13,714 bisphosphonate nonusers to 6,857 bisphosphonate users, at a 2:1 ratio, on cancer type, age, sex, presence of bone metastases, and SEER geographic region. Patients were observed until December 31, 2003 or until they lost coverage from Medicare Parts A and B; enrolled in a health maintenance organization; received a diagnosis of atrial fibrillation, any SVT, or stroke; or died. RESULTS: Receipt of intravenous bisphosphonates was modestly associated with an increased risk for atrial fibrillation (hazard ratio [HR] = 1.30; 95% CI, 1.18 to 1.43), all SVT (HR = 1.28; 95% CI, 1.19 to 1.38), and stroke (HR = 1.30; 95% CI, 1.09 to 1.54). The risk for all SVT increased 7% for each increase of five bisphosphonate dose equivalents (HR = 1.07; 95% CI, 1.02 to 1.12). CONCLUSION: Clinicians who treat patients with cancer who have received intravenous bisphosphonates should be aware of the possible cardiovascular adverse events associated with this treatment.

Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease.

BACKGROUND: Readmissions in patients with chronic obstructive pulmonary disease (COPD) are common and costly. We examined the effect of early follow-up visit with patient's primary care physician (PCP) or pulmonologist following acute hospitalization on the 30-day risk of an emergency department (ER) visit and readmission. METHODS: We conducted a retrospective cohort study of fee-for-service Medicare beneficiaries with an identifiable PCP who were hospitalized for COPD between 1996 and 2006. Three or more visits to a PCP in the year prior to the hospitalization established a PCP for a patient. We performed a Cox proportional hazard regression with time-dependent covariates to determine the risk of 30-day ER visit and readmission in patients with or without a follow-up visit to their PCP or pulmonologist. RESULTS: Of the 62 746 patients admitted for COPD, 66.9% had a follow-up visit with their PCP or pulmonologist within 30 days of discharge. Factors associated with lower likelihood of outpatient follow-up visit were longer length of hospital stay, prior hospitalization for COPD, older age, black race, lower socioeconomic status, and emergency admission. Those receiving care at nonteaching, for-profit, and smaller-sized hospitals were more likely to have a follow-up visit. In a multivariate, time-dependent analysis, patients who had a follow-up visit had a significantly reduced risk of an ER visit (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.83-0.90) and readmission (HR, 0.91; 95% CI, 0.87-0.96). CONCLUSION: Continuity with patient's PCP or pulmonologist after an acute hospitalization may lower rates of ER visits and readmission in patients with COPD.

Dissecting racial disparities in the treatment of patients with locoregional pancreatic cancer: a 2-step process.

BACKGROUND: Previous studies have demonstrated that black patients with pancreatic cancer are less likely to undergo resection and have worse overall survival compared with white patients. The objective of this study was to determine whether these disparities occur at the point of surgical evaluation or after evaluation has taken place. METHODS: The authors used the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2002) to compare black patients and white patients with locoregional pancreatic cancer in univariate models. Logistic regression was used to determine the effect of race on surgical evaluation and on surgical resection after evaluation. Cox proportional hazards models were used to identify which factors influenced 2-year survival. RESULTS: Nine percent of 3777 patients were black. Blacks were substantially less likely than whites to undergo evaluation by a surgeon (odds ratio, 0.57; 95% confidence interval, 0.42-0.77) when the model was adjusted for demographics, tumor characteristics, surgical evaluation, socioeconomic status, and year of diagnosis. Patients who were younger and who had fewer comorbidities, abdominal imaging, and a primary care physician were more likely to undergo surgical evaluation. Once they were seen by a surgeon, blacks still were less likely than whites to undergo resection (odds ratio, 0.64; 95% confidence interval, 0.49-0.84). Although black patients had decreased survival in an unadjusted model, race no longer was significant after accounting for resection. CONCLUSIONS: Twenty-nine percent of black patients with potentially resectable pancreatic cancers never received surgical evaluation. Without surgical evaluation, patients cannot make an informed decision and will not be offered resection. Attaining higher rates of surgical evaluation in black patients would be the first step to eliminating the observed disparity in the resection rate.

Correlates of bacterial pneumonia hospitalizations in elders, Texas border.

BACKGROUND: Immunization preventable bacterial pneumonia is an Agency for Healthcare Research and Quality (AHRQ) prevention quality indicator of health care. This study explored associations of individual and county correlates with bacterial pneumonia hospitalization rates for elders residing in 32 Texas counties bordering Mexico. METHODS: We estimated baseline rates from Texas Health Care Information Collection's hospital discharge data for 1999-2001, and population counts from the 2000 U.S. Census. RESULTS: The rate among the total Texas border population was 500/10,000, three times the national rate. Elders 75+, males, and Latinos had the highest rates. An increase of 1 primary care physician per 1000 population is associated with a decrease in pneumonia-related hospitalization rates by 33%, while each 10% increase in Latinos is associated with a 0.1% rate increase. DISCUSSION: This baseline bacterial pneumonia hospitalization study demonstrates a systematic approach to estimate county rates, a process that could lead to improved outcomes through effective community interventions. Methodology demonstrates how publicly available hospital discharge data can be used by communities to better measure and improve quality of health care.

Readmission after pancreatectomy for pancreatic cancer in Medicare patients.

OBJECTIVE: The objective of this study was to use a population-based dataset to evaluate the number of readmissions and reasons for readmission in Medicare patients undergoing pancreatectomy for pancreatic cancer. METHODS: We used Surveillance, Epidemiology, and End Results-Medicare linked data (1992-2003) to evaluate the initial hospitalization, readmission rates within 30 days (early), and between 30 days and 1 year (late) after initial discharge and reasons for readmission in patients 66 years and older undergoing pancreatectomy. RESULTS: We identified 1,730 subjects who underwent pancreatectomy for pancreatic cancer. The in-hospital mortality was 7.5%. The overall Kaplan-Meier readmission rate was 16% at 30 days and 53% at 1 year, accounting for 15,409 additional hospital days. Early readmissions were clearly related to operative complications in 80% of cases and unrelated diagnoses in 20% of cases. Late readmissions were related to recurrence in 48%, operative complications in 25%, and unrelated diagnoses in 27% of cases. In a multivariate analysis, only distal pancreatic resection (P = 0.02) and initial postoperative length of stay > or =10 days (P = 0.03) predicted early readmission. When compared to patients not readmitted, patients readmitted early had worse median survival (11.8 vs.16.5 months, P = 0.04), but the 5-year survival was identical (18%). Late readmission was associated with worse median and 5-year survival (19.4 vs. 12.1 months, 12% vs. 21%, P < 0.0001). CONCLUSIONS: Our study demonstrates overall 30-day and 1-year readmission rates of 16% and 53%. The majority of early readmissions were related to postoperative complications but not related to patient and tumor characteristics. Complications causing early readmission are a cause of early mortality and are potentially preventable. Conversely, late readmissions are related to disease progression and are a marker of early mortality and not the cause.

Continuity of outpatient and inpatient care by primary care physicians for hospitalized older adults.

CONTEXT: Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization. OBJECTIVES: To describe continuity of care in older hospitalized patients, change in continuity over time, and factors associated with discontinuity. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 3,020,770 hospital admissions between 1996 and 2006 using enrollment and claims data for a 5% national sample of Medicare beneficiaries older than 66 years. Data files were constructed to include the patients' demographic and enrollment information (denominator file) and claims for hospital stays (MEDPAR file) and physician services (carrier claims file). Characteristics of the hospitals were included in annual provider of services files. Being seen by a physician was defined as when a physician had submitted a bill for evaluation and management services for that patient. MAIN OUTCOME MEASURES: Percentage of patients who during hospitalization were seen by any outpatient physician they had visited in the year before hospitalization (continuity with any outpatient physician) or by their primary care physician (PCP) (continuity with a PCP). RESULTS: In 1996, 50.5% (95% confidence interval [CI], 50.3%-50.7%) of hospitalized patients were seen by at least 1 physician that they had visited in an outpatient setting in the prior year, and 44.3% (95% CI, 44.1%-44.6%) of patients with an identifiable PCP were seen by that physician while hospitalized. These percentages decreased to 39.8% (95% CI, 39.6%-40.0%) and 31.9% (95% CI, 31.6%-32.1%), respectively, in 2006. Greater absolute decreases in continuity with any outpatient physician between 1996 and 2006 occurred in patients admitted on weekends (13.9%; 95% CI, 12.9%-14.7%) and those living in large metropolitan areas (11.7%; 95% CI, 11.1%-12.3%) and in New England (16.2%; 95% CI, 14.4%-18.0%). In multivariable multilevel models, increasing involvement of hospitalists was associated with approximately one-third of the decrease in continuity of care between 1996 and 2006. CONCLUSION: Between 1996 and 2006, physician continuity from outpatient to inpatient settings decreased in the Medicare population.

Growth in the care of older patients by hospitalists in the United States.

BACKGROUND: National and population-based information on the increase in patient care by hospitalists in the United States is lacking. METHODS: Using a 5% sample of Medicare beneficiaries in 1995, 1997, 1999, and the period from 2001 through 2006, we identified 120,226 physicians in general internal medicine who were providing care to older patients in 5800 U.S. hospitals. We defined hospitalists as general internists who derived 90% or more of their Medicare claims for evaluation-and-management services from the care of hospitalized patients. We then calculated the percentage of all inpatient Medicare services provided by hospitalists and identified patient and hospital characteristics associated with the receipt of hospitalist services. RESULTS: The percentage of physicians in general internal medicine who were identified as hospitalists increased from 5.9% in 1995 to 19.0% in 2006, and the percentage of all claims for inpatient evaluation-and-management services by general internists that were attributed to hospitalists increased from 9.1% to 37.1% during this same period. Accompanying the increase in care by hospitalists was an increase in the percentage of all hospitalized Medicare patients who were treated by general internists (both hospitalists and traditional, non-hospital-based general internists), from 46.4% in 1995 to 61.0% in 2006. In a multilevel, multivariable analysis controlling for patient and hospital characteristics, the odds of receiving care from a hospitalist increased by 29.2% per year from 1997 through 2006. In 2006, there was marked geographic variation in the rates of care provided by hospitalists, with rates of more than 70% in some hospital-referral regions. CONCLUSIONS: These analyses of data from Medicare claims showed a substantial increase in the care of hospitalized patients by hospitalist physicians from 1995 to 2006.

Ethnic differences in in-hospital place of death among older adults in California: effects of individual and contextual characteristics and medical resource supply.

BACKGROUND: : Substantial ethnic differences have been reported in the probability that death will occur in a hospital setting rather than at home, in a hospice, or in a nursing home. To date, no study has investigated the role of both individual characteristics and contextual characteristics, including local health care environments, to explain ethnic differentials in end-of-life care. OBJECTIVES: : The study purpose is to examine ethnic differences in the association between death as a hospital in-patient and individual and contextual characteristics, as well as medical resource supply. RESEARCH DESIGN: : This study employed a secondary data analysis. SUBJECTS: : We used data from the California Death Statistical Master file for the years 1999-2001, which included 472,382 complete cases. These data were geocoded and linked to data from the US Census Bureau and the American Hospital Association. RESULTS: : Death as an in-patient was most common for Asian (54%) and Hispanic immigrants (49%) and least common for non-Hispanic whites (36%) and US-born Asians (41%). Medical resource supply variables are of considerable importance in accounting for ethnic differentials in the probability of dying in a hospital. Residual differences in in-hospital site of death were largest for immigrant populations. CONCLUSIONS: : There are sizeable ethnic differentials in the probability that a death will occur in a hospital in California. These differences are substantially mediated by sociodemographic characteristics of the decedent and local medical care supply. One implication of these findings is that variation exists in the efficiency and quality of end of life care delivered to ethnic minorities.

Risk of subsequent dementia diagnoses does not vary by types of adjuvant chemotherapy in older women with breast cancer.

OBJECTIVE: Little is known about long-term cognitive side effects of adjuvant chemotherapy for breast cancer. We thus examined incidence of dementia diagnoses in older women diagnosed with breast cancer, stratified by types of chemotherapy regimen. METHODS: We identified patients with incident dementia diagnoses through Medicare claims linked to the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) tumor registry data. The study population (n = 6,932) consisted of women at least 68 years of age, who were diagnosed with early-stage breast cancer from 1994 through 2002 in one of the SEER areas and received chemotherapy as part of their cancer treatment. Excluded were women with a diagnosis of dementia within the 3 years prior to their cancer diagnosis. RESULTS: Our sample comprised mostly white women. The mean age was 74. Fifty-seven percent were estrogen receptor positive. Over 70% had no comorbidity. The use of taxol and anthracycline-based treatments increased from mid-1990s to early 2000. Increasing age at cancer diagnosis, Black ethnicity, living in a census tract with lower level of education, and increasing number of comorbidities were associated with new claims of dementia diagnoses after chemotherapy. There was no significant association between types of chemotherapy agents and risk of subsequent dementia diagnoses. CONCLUSION: No association was found between types of adjuvant chemotherapy agents for breast cancer and risk of new dementia diagnoses. Our findings suggest that concerns about post-chemotherapy dementia should not be a major factor in determining type of adjuvant chemotherapy regimen to prescribe for older women with breast cancer.

Effect of a dementia diagnosis on survival of older patients after a diagnosis of breast, colon, or prostate cancer: implications for cancer care.

BACKGROUND: Preexisting dementia affects cancer care. Knowledge of how dementia affects survival after a cancer diagnosis may help guide cancer care decisions. We therefore examined the associations between preexisting diagnoses of dementia and survival from breast, colon, and prostate cancer. METHODS: We conducted a retrospective cohort study of 106,061 patients aged 68 years or older diagnosed as having breast, colon, or prostate cancer, using data from the linked Surveillance, Epidemiology and End Results-Medicare database. We assessed the risks of mortality from cancer and noncancer causes, stratified by presence or absence of preexisting dementia diagnoses. Cox proportional hazards regression was used to adjust for confounding variables. RESULTS: Seven percent of our sample had preexisting dementia diagnoses. Survival after a cancer diagnosis was markedly worse in demented than in nondemented patients. Most of the excess deaths came from noncancer causes; 33.3% of those with a dementia diagnosis died within 6 months of a cancer diagnosis, compared with 8.5% of patients without dementia. Less than 17.0% of the excess mortality in patients with dementia who had breast or colon cancer was explained by a more advanced cancer stage at diagnosis. None of the excess deaths in prostate cancer was explained by stage at diagnosis. For all 3 cancers, the presence of preexisting dementia diagnoses attenuated the relationship between stage at diagnosis and survival. CONCLUSIONS: Preexisting dementia diagnoses were associated with high mortality, mostly from noncancer causes. The effect of cancer stage at diagnosis on mortality was significantly reduced in older patients with precancer diagnoses of dementia.

672 patients with acinar cell carcinoma of the pancreas: a population-based comparison to pancreatic adenocarcinoma.

BACKGROUND: Acinar cell carcinoma (ACC) is a rare cancer of the pancreas accounting for approximately 1% of nonendocrine tumors. Because no large series of patients with ACC exist, our understanding of this disease comes mainly from small retrospective reports and anecdotal experience. OBJECTIVE: Our goal was to evaluate a large population-based cohort of patients with ACC and compare their demographic factors and outcomes to those of patients with pancreatic adenocarcinoma (PA). METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2003), we identified all patients with ACC or PA. The demographic factors, tumor characteristics, resection status, and long-term survival were compared between the 2 groups. RESULTS: A total of 672 patients with ACC and 58,526 with PA were identified. The mean age at the time of diagnosis was significantly lower for ACC than PA (56 years vs 70 years, P < .001). Compared with patients with PA, patients with ACC were more likely to be male (54% vs 48%, P = .007) and white (85% vs 81%, P = .03). Based on SEER clinical staging, patients with ACC were less likely to have unstaged disease (8% vs 18%). Of the 616 patients with staged ACC, 16% had localized disease, 26% had regional disease, and 58% had distant disease. In the 47,896 staged patients with PA, 10% had localized disease, 33% had regional disease, and 57% had distant disease (P < .0001 compared to ACC). Based on clinical extent of disease, 81% of patients with locoregional ACC and 70% of patients with locoregional PA were resectable. However, only 69% of ACC patients with locoregional disease and 27% of PA patients with locoregional disease underwent surgical resection. The overall 5-year survival was 42.8% for ACC (median, 47 months) and 3.8% for PA (median, 4 months, P < .0001). Patients with unresected ACC had a 5-year survival rate of 22% compared to 2% in patients with unresected PA (P < .0001). Surgical resection significantly improved survival. The 5-year survival was 72% in resected ACC and 16.3% in resected PA (P < .0001). Multivariate Cox proportional hazards regression model results suggested patients with ACC were less likely to die (hazard ratio = 0.241; 95% confidence interval, 0.22-0.27) than patients with PA after controlling for gender, race, stage, SEER region of diagnosis, and surgical resection status. CONCLUSIONS: Consistent with anecdotal reports and previous retrospective studies, ACC is a more indolent disease than PA. Patients with ACC tend to present at a younger age, are more likely to have resectable disease, and are much more likely to undergo potentially curative resection. The long-term survival for patients with ACC is significantly better when compared to the long-term survival of patients with PA.

Outcomes following pancreatic resection: variability among high-volume providers.

BACKGROUND: A strong volume-outcome relationship has been demonstrated for pancreatic resection, and regionalization of care to high-volume centers (>11 resections/year) has been recommended. However, it is unclear if volume alone should be the sole criteria for regionalization. The objective of this study is to evaluate variability in outcomes among high-volume hospitals (>11 resections/year). METHODS: We used the Texas Hospital Inpatient Discharge Database from 1999 through 2005 to evaluate variability in outcomes after pancreatic resection among high-volume hospitals in Texas. The outcome variables of interest were mortality, length of stay, discharge to a skilled nursing facility, operation within 24 hours of hospital admission, and total hospital charges. Unadjusted and adjusted models were performed. RESULTS: A total of 12 high-volume hospitals were in Texas. The number of resections at each hospital ranged from 78-608 cases for the 7-year time period studied. In unadjusted models, there was significant variability in mortality (range, 0.7%-7.7%, P < .0001), duration of stay (range of medians, 9-21 days, P < .0001), the need for ongoing nursing care at discharge (range, 0.7%-41.4%, P < .0001), operation within 24 hours of admission (range, 41%-96%, P < .0001), and total hospital charges (median range, $38,318-$110,860, P < .0001). There were significant differences in the demographics, risks of mortality, and illness severity among the 12 high-volume hospitals. Therefore, multivariate models were used to control for age group, sex, race/ethnicity, risk of mortality, illness severity, admission status, diagnosis, procedure, and insurance status. In the multivariate models, the particular hospital at which the pancreatic surgery was performed was a significant independent predictor of every outcome variable except mortality. CONCLUSIONS: For pancreatic resection, there is significant variability in outcomes even among high-volume providers. Individual hospitals likely account for much of the variability not explained by hospital volume. Although the structure measure of hospital volume is easy to measure, these data suggest that it is not a reliable single measure of quality or outcomes after pancreatic surgery.

Reducing the effects of lead-time bias, length bias and over-detection in evaluating screening mammography: a censored bivariate data approach.

Measuring the benefit of screening mammography is difficult due to lead-time bias, length bias and over-detection. We evaluated the benefit of screening mammography in reducing breast cancer mortality using observational data from the SEER-Medicare linked database. The conceptual model divided the disease duration into two phases: preclinical (T(0)) and symptomatic (T(1)) breast cancer. Censored information for the bivariate response vector ( T(0), T(1)) was observed and used to generate a likelihood function. However, the contribution to the likelihood function for some observations could not be calculated analytically, thus, censoring boundaries for these observations were modified. Inferences about the impact of screening mammography on breast cancer mortality were made based on maximum likelihood estimates derived from this likelihood function. Hazard ratios (95% confidence intervals) of 0.54 (0.48-0.61) and 0.33 (0.26- 0.42) for single and regular users (vs. non-users), respectively, demonstrated a protective effect of screening mammography among women 69 years and older. This method reduced the impact of lead-time bias, length bias and over-detection, which biased the estimated hazard ratios derived from standard survival models in favour of screening.

Survival advantage in Medicare patients receiving drug-eluting stents compared with bare metal stents: real or artefactual?

BACKGROUND: Concerns have been raised regarding late mortality, particularly from late stent thrombosis, from drug-eluting stents (DES). Randomized clinical trials have shown that DES decrease restenosis but do not decrease mortality compared with bare metal stents (BMS). These studies utilized well-defined clinical and angiographic subsets. In the "real world" drug-eluting stents are used in a much broader crosssection of patients. We evaluated mortality in the first year after implantation of DES, specifically the sirolimus-eluting stent (SES), Cypher vs. BMS in "real world" older patients using the Medicare claims database. METHODS AND RESULTS: Data for the years 2002 (n = 6,890; pre-DES) and 2003 (n = 7,566; first year of DES use) (May through December of each year) were analyzed. BMS and DES groups had similar baseline characteristics except for small but significant differences with BMS patients being somewhat older, having more males and African Americans, and a higher percentage of peripheral artery disease and heart failure while DES patients had a higher percentage of diabetics and patients with prior revascularization procedures. A significant improvement in mortality using both unadjusted and adjusted analyses was observed for DES (6.0% vs. 11.4%, P < 0.0001; hazard ratio 1.98, 95% CI 1.68-2.34). Controlling for comorbidity, extent of disease, and other characteristics by multivariable analysis or by propensity analysis had little impact on these results. On the other hand, there was no change in overall mortality in all stented patients in 2003 compared with all stented patients in 2002. CONCLUSION: An observed mortality benefit for DES compared with BMS in 2003 was observed, demonstrating the safety of DES, and suggesting the possibility of superiority in outcome in older patients with DES vs. BMS. However, the lack of improved survival from 2002 to 2003 in all stented patients suggests that the mortality advantage with DES finding may be due to unidentified selection biases. Our data suggest that DES in the Medicare population is as safe as, and possibly superior, to BMS for survival over the first year after implantation.

Characteristics of urologists predict the use of androgen deprivation therapy for prostate cancer.

PURPOSE: We previously have reported wide variations among urologists in the use of androgen deprivation for prostate cancer. Using the Surveillance, Epidemiology, and End Results-Medicare linked database, we examined how individual urologist characteristics influenced the use of androgen deprivation therapy. METHODS: Participants included 82,375 men with prostate cancer who were diagnosed from January 1, 1992, through December 31, 2002, and the 2,080 urologists who provided care to them. Multilevel analyses were used to estimate the likelihood of androgen deprivation use within 6 months of diagnosis in the overall cohort, in a subgroup in which use would be of uncertain benefit (primary therapy for localized prostate cancer), and in a subgroup in which use would be evidence-based (adjuvant therapy with radiation for locally advanced disease). RESULTS: In the overall cohort of patients, a multilevel model adjusted for patient characteristics, tumor characteristics, and urologist characteristics (eg, board certification, academic affiliation, patient panel size, years since medical school graduation) showed that the likelihood of androgen deprivation use was significantly greater for patients who saw urologists without an academic affiliation. This pattern also was noted when the analysis was limited to settings in which androgen deprivation would have been of uncertain benefit. Odds ratios for use in that context were 1.66 (95% CI, 1.27 to 2.16) for urologists with no academic affiliation and 1.45 (95% CI, 1.13 to 1.85) for urologists with minor versus major academic affiliations. CONCLUSION: Use of androgen deprivation for prostate cancer varies by the characteristics of the urologist. Patients of non-academically affiliated urologists were significantly more likely to receive primary androgen deprivation therapy for localized prostate cancer, a setting in which the benefits are uncertain.

Mammography use among older Mexican-American women: correcting for over-reports of breast cancer screening.

OBJECTIVES: To determine the accuracy of self-reported mammography use and generate a correction factor that adjusts for reporting errors among Mexican-American women. DESIGN: Self-reported mammography use was compared with a medical chart review. PARTICIPANTS: A random sample of 199 Mexican-American women aged 50-74 in southeast Texas. MAIN OUTCOME MEASURES: Self-reported mammography use for the preceding 2 years and mammography use determined by medical chart review. RESULTS: Positive and negative predictive values of mammography self-reports in the previous 2 years were 73.9 and 86.0%, respectively. The correction factor was 79.6%, or approximately 80% of the self-reported mammograms within the preceding 2 years could be verified through medical chart reviews. CONCLUSIONS: Mammography use rates among Mexican-American women were not as high as self-reports indicated. Estimates need to be adjusted downward by approximately 20%.