Assessing Willingness of Patients with Diabetes to Attend Pharmacist-Led Structured and Patient Specific Diabetes Self-Management Education.

Background: The American Diabetes Association recommends that people with diabetes should participate in diabetes self-management education, however data shows that many patients do not attend educational classes. Objectives: To examine the views of patients with diabetes who utilize services at an independent pharmacy in Richmond, Virginia regarding their (1) interest in attending diabetes self-management education and support (DSMES) services, (2) perceptions of a pharmacist leading DSMES services, (3) willingness to pay for DSMES services, and (4) relationship between self-reported diabetes management status with their willingness to attend DSMES services. Methods: A qualitative survey was administered over five months to patients with diabetes at an independent community pharmacy in Richmond, VA. The survey included 35 questions in a mixed format of Likert scale, dichotomous, and fill in the blank. Survey data was analyzed using univariate, bivariate, and/or multivariate analysis using SAS 9.4. Results: Twenty seven surveys were completed, 15% response rate. Patients were female (56.7%) with an average age of 69 ± 10.8 years. Caucasian race accounted for 90% of patients, 6.7% reported Black or African American, the remainder responded "other". Patients agreed they were interested in attending individual virtual and in person DSMES sessions with a rate of 52% and 87%, respectively. When asked about the full service of 9 group sessions, 33% responded disagree and 30% reported agree. 52% of patients reported belief that pharmacists had the knowledge to lead sessions. When asked about willingness to pay, patients mostly selected the lowest cost option ($25 - $35). Conclusion: Patients with diabetes are willing to participate in DSMES services and believe pharmacists can lead the sessions. It is important to continue to advocate for DSMES services so patients can understand the full benefits of the program and receive the best possible care.

Effect of community pharmacist-provided patient education of partial fill availability for acute opioid prescriptions.

BACKGROUND: More than 191 million opioid prescriptions were filled in the United States during 2017, and studies have shown that patients often have leftover medication. OBJECTIVES: To (1) measure the percentage filled as partial quantities and the percentage subsequently filled to completion; (2) determine which medications are filled as partial, completion, and full fills; and (3) identify patient reasons and demographics for partial, completion, and full fills. PRACTICE DESCRIPTION: Two pharmacies of a national community pharmacy chain in Richmond, VA. PRACTICE INNOVATION: Virginia law allows prescriptions to be filled in partial quantities as long as the total quantity does not exceed the written quantity and the remaining portions are filled within 30 days of the written date. Pharmacists developed an intervention to educate patients about the option to fill opioid prescriptions as a partial quantity. EVALUATION METHODS: Retrospective analysis of drug utilization reports to identify the impact of the pharmacist intervention for acute, nonmaintenance opioid prescriptions filled as partial, completion, or full fill during a 5-month period. Patient demographics and reasons for choosing a partial or full fill were collected using surveys completed at prescription pickup. RESULTS: A total of 25.6% of included prescriptions were partially filled, and of these, only 31.9% were filled to completion. Hydrocodone-acetaminophen was the most common prescription, 35.8% full, 28.3% partial, and 36.4% completion fills. Patients' motivation was driven by the pharmacist's suggestion (48.5%) for partial fill and desire to have the medication if needed (36.6%) for full fill. CONCLUSION: Pharmacist offer of partial filling of acute opioid prescriptions may lead patients to partially fill prescriptions, and patients cited the pharmacist suggestion as a motivator.

Intravenous Versus Oral Acetaminophen Use in Febrile Neurocritical Care Patients.

The use of intravenous (IV) acetaminophen (APAP) for fever has not been thoroughly studied in neurocritical care (NCC) patients, in whom a temperature of ≥38°C is associated with poor outcomes and treatment to normothermia is common practice. This retrospective study evaluated NCC patients admitted between May 1, 2012, and April 30, 2013, and received at least one dose of IV or oral (PO) APAP for a body temperature of ≥38°C. The primary aim of this study was to compare the reduction in body temperature (RIT) between IV and PO APAP, calculated as the change in temperature before and 0.5, 1, 2, 3, and 6 hours after administration. Descriptive statistics were used to assess use characteristics, and Kruskal-Wallis and Mann-Whitney U tests were used for between-group differences. There were 142 NCC patients who received a total of 405 IV APAP and 253 PO APAP doses. Seventy percent of all APAP doses resulted in a temperature of <38°C within 6 hours. The median oral body temperature before APAP was 38.8°C and 38.6°C for IV and PO APAP, respectively (p < 0.01). The median RIT at 0.5 (IV 0.25°C vs. PO 0.2°C), 1 (IV 0.4°C vs. PO 0.2°C), 2 (IV 0.7°C vs. PO 0.5°C), 3 (IV 0.9°C vs. PO 0.6°C), and 6 (IV 1°C vs. PO 0.8°C) hours was significantly greater for IV APAP than for PO APAP at all time points (p < 0.05). Patients with an acute ischemic stroke and patients with an intracerebral hemorrhage had a statistically significantly greater RIT with IV APAP therapy. IV APAP administered to febrile NCC patients was associated with a significantly greater RIT than PO, but 70% of all APAP doses resulted in a body temperature of <38°C within 6 hours. Further prospective studies are needed to determine if IV APAP improves clinical outcomes.

Over-the-counter medication use in residents of senior living communities: A survey study.

BACKGROUND: Self-medication with over-the-counter (OTC) products is common among older adults. Although OTC self-medication is a convenient way to manage some health issues, older persons may be at higher risk of experiencing medication-related problems. This study examines the prevalence, practices, and preferences associated with OTC medication use in older adult residents of senior living communities. OBJECTIVES: The study aimed to examine the characteristics of OTC medication users and to quantify the prevalence, attitudes, perceptions, preferences, and practices regarding OTC medication use and decision-making in 2 senior living communities in central Virginia. METHODS: The study used survey methodology. A 51-item semistructured questionnaire was designed by the research team of geriatrics specialists, and mixed-methods and evaluation researchers. The questionnaire was administered in-person to participants (N = 88). Descriptive analyses were conducted using SAS 9.4. Characteristics of those using OTC medications as directed by a health professional were compared with those of whom were self-medicating with OTC medications. RESULTS: Most of the sample were women (55%), black (61%) and had less than or equal to a high school education (55%). Analgesics were the most (76%) prevalent OTC therapeutic category used, and aspirin was the most (65%) prevalent OTC medication. A greater (82%) proportion of respondents reported self-recommended OTC medication use (self-medication with OTC medications) rather than physician recommended use (18%). A high (41%) prevalence of inappropriate use of OTC medications was observed in this sample of older adults. Most (80%) considered OTC medications safe and effective. The pharmacy was the most (93%) commonly reported purchase location to buy an OTC medication. Physicians were the most (90%) commonly reported information source for OTC medications. CONCLUSION: Considering the high percentage of self-reported self-medication, inappropriate use, and experiences of adverse effects, steps should be taken to develop consumer education and relationships with pharmacists to encourage the responsible use of OTC medications in this population.

Economic burden of pediatric prescription opioid poisonings in the United States.

BACKGROUND: Among the different drugs involved in pediatric exposures and poisonings, opioids are the most important, given their rise in nonmedical use. Opioid poisonings in children can result in serious symptoms or complications, including respiratory disorders such as apnea, respiratory failure, and respiratory depression; psychiatric or nervous system disorders such as agitation, seizures, and coma; and cardiac disorders such as tachycardia, bradycardia, and cardiac arrest. Opioid poisonings in children can have delayed onset of symptoms as well as severe and prolonged toxic effects. Many studies have examined the economic burden of opioid poisoning in the general population, but very little is known about the pediatric population. OBJECTIVE: To estimate the economic burden associated with pediatric prescription opioid poisonings. METHODS: This study examined opioid poisonings in pediatric patients, defined as patients aged less than 18 years, for the 2012 base year. Costs were estimated using the 2012 Nationwide Emergency Department Sample (NEDS), Kids' Inpatient Database (KID), Multiple Cause-of-Death (MCOD) file, and other published sources, while applying a societal perspective. The Bottom Up approach was used to estimate the total cost of pediatric prescription opioid poisonings. Direct costs included costs associated with emergency department (ED) visits, hospitalizations, and ambulance transports. Indirect costs were estimated using the human capital method and included productivity costs due to caregivers' absenteeism and premature mortality among children. Descriptive statistics were employed in calculating costs. RESULTS: The total costs of pediatric prescription opioid poisonings and exposure in the United States were $230.8 million in 2012. Total direct costs were estimated to be over $21.1 million, the majority resulting from prescription opioid poisoning-related inpatient stays. Total indirect (productivity) costs were calculated at $209.7 million, and 98.6% of these costs were attributed to opioid poisoning-related mortality. Pediatric prescription opioid poisoning-related ED visits, inpatient stays, and deaths were most common in patients aged 13-17 years and those in mid to large urban areas. Most were unintentional. CONCLUSIONS: Pediatric prescription opioid poisonings resulted in direct and indirect costs of $230.8 million in 2012. While these costs are low in comparison with the costs of prescription opioid poisoning in the general population, the number of pediatric poisonings represents only a small fraction of total poisonings. Quantified costs associated with pediatric prescription opioid poisonings can help decision makers to understand the economic trade-offs in planning interventions. DISCLOSURES: This research had no external funding but was funded by an unrestricted research grant made to the Department of Pharmacotherapy & Outcomes Science by kaléo Pharma, maker of a naloxone product. The authors declare no conflicts of interest or financial interests. Portions of this study were presented as an abstract at the 22nd Annual ISPOR Meeting; May 22, 2017; Boston, MA.

Economic burden of renal cell carcinoma among older adults in the targeted therapy era.

OBJECTIVE: This study examined the economic burden of renal cell carcinoma (RCC) among older adults. The study also examined healthcare costs by types of resources used and stage at which RCC was diagnosed. METHODS: The study analyzed the Surveillance Epidemiology and End Result-Medicare linked data. We included a prevalent cohort of RCC patients from 2013, diagnosed and continuously enrolled in Medicare from 2005 to 2013. RCC patients were matched to controls selected from a 5% sample of noncancer beneficiaries using propensity score matching to calculate incremental costs. Total healthcare costs (THC) were calculated using a phase-based approach, which classified patients into early, continuing, and late phases of care. Costs were also examined by types of resources used and stage at which RCC was diagnosed. Generalized linear models estimated annual incremental costs per patient. The number of older RCC patients was calculated using SEER-Stat and ProjPrev software. The average incremental THC was multiplied by the estimated number of RCC patients to calculate the total economic burden of RCC among older adults. RESULTS: The study included 10,392 each of RCC and control patients. The average annual THC associated with RCC was $7,419 for all phases, $22,752 for the initial phase, $4,860 for the continuing phase, and $13,232 for the late phase of care. The average THC was $4,584 for patients diagnosed at stage I, $4,727 for stage II, $9,331 for stage III, and $31,637 for stage IV. For patients diagnosed at stages I to III, hospital cost (approximately $1,500-$3,400) was the largest component of THC. For stage IV patients, prescription drug cost ($11,747) was the largest component of THC. The projected number of older RCC patients in 2015 was 204,256. The annual economic burden of RCC after weighting for proportion of patients diagnosed at various stages was estimated to be $2.1 billion. CONCLUSIONS: RCC was associated with a significant economic burden on Medicare. Healthcare costs associated with RCC varied substantially between early stage and metastatic patients. This research provided a baseline that can be used to assess the economic value of emerging therapies among older RCC patients.

Prevalence and Characteristics of Pediatric Opioid Exposures and Poisonings in the United States.

OBJECTIVE: To examine the prevalence and characteristics of pediatric opioid exposures and poisonings in the US. STUDY DESIGN: This was a retrospective, cross-sectional analysis using the National Poison Data System from January 1, 2010 to December 31, 2014. Records of children aged <18 years with exposure to opioid-containing medications were identified. Standardized prevalence rates were calculated, and the annual trend was examined. Pediatric opioid exposures were characterized descriptively, and logistic regression was performed to estimate the association between various clinical and sociodemographic characteristics and exposures with serious (ie, moderate, major, or death) outcomes. The association of pediatric opioid exposures and area-level socioeconomic status factors at 5-digit ZIP code level was examined descriptively. RESULTS: The prevalence of opioid exposures was 22.6 per 100 000 children and was particularly high among ≤5-year-olds. Prevalence declined from 25.5 to 20 per 100 000 children from 2010 to 2014. There were 83 418 pediatric opioid exposures over the 5-year period and nearly one-half resulted in poisoning. Over 60% of exposures were among children ≤5 years of age, 73.4% were unintentional, and over 90% occurred at home. One in every 2 pediatric opioid exposures was evaluated in a healthcare facility. Annually 4912 children aged ≤5 years were treated in the emergency department or admitted for care. Older age, nonaccidental intent, and single-substance opioid, especially buprenorphine and methadone, were associated with serious outcomes (P < .05). Positive correlations were observed for area-level socioeconomic status factors including proportion of adults and pediatric opioid exposures. CONCLUSIONS: Pediatric opioid exposures and poisonings decreased from 2010 to 2014 but morbidity remains high. The epidemiology of opioid exposures differed considerably by age.

Combination therapy with once-weekly glucagon like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes: a case series.

BACKGROUND: National treatment guidelines recommend glucagon-like peptide receptor agonists (GLP-1 RAs) as add-on therapy to oral agents. However, GLP-1 RAs in combination with dipeptidyl peptidase-4 (DPP-4) inhibitors is not recommended due to a lack of evidence. OBJECTIVE: This case series aims to describe the efficacy and safety of once-weekly GLP-1 RAs administered concomitantly with DPP-4 inhibitors in patients with type 2 diabetes. METHODS: A retrospective chart review of electronic medical records at a free health clinic was conducted between July 2014 and September 2016. Patients 18 years and older with type 2 diabetes were included if they received concomitant DPP-4 inhibitor and once-weekly GLP-1 RA therapy with at least one glycated hemoglobin A1c (HbA1c) measurement within three to six months of starting the combination. The primary and secondary outcomes included change in HbA1c and weight, and patient reported adverse events. RESULTS: Out of forty-three patients that received combination DPP-4 inhibitor plus GLP-1 RA therapy, only eighteen received once-weekly GLP-1 RA. At 3 months, the median (IQR) HbA1c and weight change was -0.8% (-4.3 to 2%) and -0.4kg (-4.2 to 5.8 kg) respectively. No patients reached an HbA1c below 7% and only three patients (17%) reached a HbA1c less than 8%. Patient reported adverse effects included gastrointestinal disturbances (28%), hypoglycemic symptoms (17%), and injection site reactions (0.6%). CONCLUSIONS: Concomitant use of once-weekly GLP-1 RAs and DPP-4 inhibitors provides only modest improvement in glycemic control with minimal weight loss benefits, which is similar to monotherapy with either agent. The combination is unlikely to provide synergistic effects and is not cost effective. These data support the current recommendations against use of combined incretin therapy.

A qualitative study to understand over-the-counter medication use and decision-making among residents of senior-living communities.

INTRODUCTION: OTC medications are generally considered safe and convenient to use without requiring a prescription. However, the safety of an OTC medication and the final health outcome depends in part upon consumers' perceptions, beliefs, and their decision-making about OTC medication use. This study uses a qualitative approach to explore the knowledge, beliefs, and practices associated with OTC medication use and decision-making in adults aged 65 years and older. METHODS: A set of focus groups (N = 10) were conducted in a sample of independently living older adult residents of senior apartment buildings (N = 80) using purposeful sampling. All focus groups were recorded, transcribed verbatim, and analyzed qualitatively. RESULTS: Most participants considered OTC medications safe and effective to use if following the drug label instructions appropriately. Brand name products were perceived as equally or more effective compared to generic products by participants. Two approaches to OTC treatment decision-making were observed: 1) a decision to treat their symptoms by themselves (self-recommended) or 2) a decision to ask and/or follow their physician's recommendation (physician-recommended). Each of these treatment approaches may lead to the other depending on the person's financial and healthcare resources, the severity of the symptoms, experiences with the medication, and relationship with the physician. Maximum and fast relief was mentioned as the most important attribute in the final OTC purchase decision, followed by the lower cost, and easy to swallow dosage forms. Aspirin and ibuprofen were the two most frequently reported OTC medications associated with adverse effects and inappropriate use. CONCLUSIONS: Older adults, in general, feel positive about OTC medications and are satisfied with using them. Considering the self-reported malpractices and side effects associated with OTC medications, older adults should be encouraged to make safe and responsible decisions about self-medication.

Pharmacists' comfort level and knowledge about prescribing hormonal contraception in a supermarket chain pharmacy.

OBJECTIVES: To compare community pharmacists' comfort levels and knowledge prescribing hormonal contraception before and after a training session and to identify perceived barriers and resources needed to prescribe hormonal contraception. METHODS: In this pre-post convenience sample survey study, all 350 pharmacists in the Mid-Atlantic Division of Kroger (which spans parts of Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia) were surveyed before and after a training session. The survey consisted of several sections: 1) questions rating comfort, 2) knowledge-based multiple-choice assessment questions, 3) perceptions of barriers and resources needed to prescribe hormonal contraception, and 4) demographics. The training session was a 1-hour continuing education about hormonal contraception. Data were analyzed with the use of univariate and bivariate statistics to compare pre- and post-training survey information. RESULTS: Seventy-eight pharmacists completed both surveys (22.3% response rate). Pharmacists averaged 14 years in pharmacy practice, and 66.6% were female. More pharmacists (31.8%) perceived liability concern as the greatest barrier to pharmacist-initiated contraception. Pharmacist knowledge about hormonal contraception increased in some domains after the training session (P < 0.001). If allowed as a scope of practice in their state, the comfort level of pharmacists in prescribing any type of hormonal contraceptive significantly increased after the training session (P < 0.004). CONCLUSION: Pharmacists have an initial lack of knowledge and perceived lack of comfort with prescribing hormonal contraception if allowed in their state of practice. A training session was identified as an effective tool and intervention to increase pharmacists' comfort levels in prescribing hormonal contraception.

Risk Factors for Serious Prescription Opioid-Induced Respiratory Depression or Overdose: Comparison of Commercially Insured and Veterans Health Affairs Populations.

Objective: To characterize the risk factors associated with overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids in a commercially insured population (CIP) and to compare risk factor profiles between the CIP and Veterans Health Administration (VHA) population. Subjects and Methods: Analysis of data from 18,365,497 patients in the IMS PharMetrics Plus health plan claims database (CIP) who were dispensed a prescription opioid in 2009 to 2013. Baseline factors associated with an event of serious OIRD among 7,234 cases and 28,932 controls were identified using multivariable logistic regression. The CIP risk factor profile was compared with that from a corresponding logistic regression among 817 VHA cases and 8,170 controls in 2010 to 2012. Results: The strongest associations with serious OIRD in CIP were diagnosed substance use disorder (odds ratio [OR] = 10.20, 95% confidence interval [CI] = 9.06-11.40) and depression (OR = 3.12, 95% CI = 2.84-3.42). Other strongly associated factors included other mental health disorders; impaired liver, renal, vascular, and pulmonary function; prescribed fentanyl, methadone, and morphine; higher daily opioid doses; and concurrent psychoactive medications. These risk factors, except depression, vascular disease, and specific opioids, largely aligned with VHA despite CIP being substantially younger, including more females and less chronic disease, and having greater prescribing prevalence of higher daily opioid doses, specific opioids, and most selected nonopioids. Conclusions: Risk factor profiles for serious OIRD among US medical users of prescription opioids with private or public health insurance were largely concordant despite substantial differences between the populations in demographics, clinical conditions, health care delivery systems, and clinical practices.

Pharmacist-physician collaborative care model and time to goal blood pressure in the uninsured population.

Pharmacist-physician collaborative practice models (PPCPMs) improve blood pressure (BP) control, but their effect on time to goal BP is unknown. This retrospective cohort study evaluated the impact of a PPCPM on time to goal BP compared with usual care using data from existing medical records in uninsured patients with hypertension. The primary outcome was time from the initial visit to the first follow-up visit with a BP <140/90 mm Hg. The study included 377 patients (259 = PPCPM; 118 = usual care). Median time to BP goal was 36 days vs 259 days in the PPCPM and usual care cohorts, respectively (P < .001). At 12 months, BP control was 81% and 44% in the PPCPM and usual care cohorts, respectively (P < .001) and therapeutic inertia was lower in the PPCPM cohort (27.6%) compared with usual care (43.7%) (P < .0001). Collaborative models involving pharmacists should be considered to improve BP control in high-risk populations.

The Association between Sleep Problems, Sleep Medication Use, and Falls in Community-Dwelling Older Adults: Results from the Health and Retirement Study 2010.

Background. Very few studies have assessed the impact of poor sleep and sleep medication use on the risk of falls among community-dwelling older adults. The objective of this study was to evaluate the association between sleep problems, sleep medication use, and falls in community-dwelling older adults. Methods. The study population comprised a nationally representative sample of noninstitutionalized older adults participating in the 2010 Health and Retirement Study. Proportion of adults reporting sleep problems, sleep medication use, and fall was calculated. Multiple logistic regression models were constructed to examine the impact of sleep problems and sleep medication use on the risk of falls after controlling for covariates. Results. Among 9,843 community-dwelling older adults, 35.8% had reported a fall and 40.8% had reported sleep problems in the past two years. Sleep medication use was reported by 20.9% of the participants. Older adults who do have sleep problems and take sleep medications had a significant high risk of falls, compared to older adults who do not have sleep problems and do not take sleep medications. The other two groups also had significantly greater risk for falls. Conclusion. Sleep problems added to sleep medication use increase the risk of falls. Further prospective studies are needed to confirm these observed findings.

Intravenous Versus Oral Acetaminophen for Pain Control in Neurocritical Care Patients.

BACKGROUND: Acetaminophen (APAP) is used in neurocritical care (NCC) patients for analgesia without sedation or antiplatelet activity. Research suggests that intravenous (IV) APAP produces earlier and higher serum levels compared to oral (PO) APAP. This retrospective study evaluates the associated analgesic effects of IV and PO APAP and use of adjunctive opioids in NCC patients with moderate-severe pain. METHODS: Patients admitted to the neuroscience intensive care unit (NSICU) between May 2012 and April 2013 who received ≥1 dose of IV APAP were included in the study. IV and PO APAP doses administered with a predose pain score ≥4 within 1 h of dosing were compared. Pain intensity difference (PID) was calculated as the change between the pain score prior to each dose and scores at 30 min, 1, 2, 3, and 6 h postdose. Pre- and postdose morphine milligram equivalents (MME) were also calculated. RESULTS: 309 NSICU patients received 459 doses of IV and 440 doses of PO APAP meeting our inclusion criteria. The PID at 30 min postdosing was significantly higher among those receiving IV APAP compared to those receiving PO APAP (p = 0.003). No significant difference in PID was seen at 1, 2, 3, and 6 h; and there was no significant difference in pre- or postdose MME between the two groups. CONCLUSION: IV APAP was more effective than PO APAP at relieving pain within 30 min of dosing, but this difference was not sustained over 6 h. Further studies are needed to assess the benefits of this rapid onset of action.

Disparities in Lung Cancer Care and Outcomes among Elderly in a Medically Underserved State Population-A Cancer Registry-Linked Database Study.

Despite availability of guidelines for lung cancer care, variations in lung cancer care among the elderly exist across the nation and are a cause for concern in rural and medically underserved areas. Therefore, the purpose of this study was to evaluate the patterns of lung cancer care and associated health outcomes among elderly residing in a rural and medically underserved area. The authors identified 1924 elderly lung cancer patients from the West Virginia Cancer Registry-Medicare linked database (2002-2007) and categorized them by receipt of guideline-concordant (appropriate and timely) care using guidelines from the American College of Chest Physicians, British Thoracic Society, and the RAND Corporation. Hierarchical generalized logistic models were constructed to identify variables associated with receipt of guideline-concordant care. Kaplan-Meier analysis and log-rank test were used to compare 3-year survival outcomes. Multivariate Cox proportional hazards models were constructed to estimate lung cancer mortality risk associated with nonreceipt of guideline-concordant care. Although guideline-concordant appropriate care was received by fewer than half of all patients (46.5%), of those receiving care, 78.7% received it in a timely manner. Delays in diagnosis and treatment varied significantly. Survival outcomes significantly improved with appropriate care (799 vs. 366 days; P≤0.05), but did not improve with timely care. This study highlights the critical need to address disparities in receipt of guideline-concordant lung cancer care among the elderly residing in rural and medically underserved areas. Although lung cancer diagnostic and management services are covered under the Medicare program, underutilization of these services is a concern. (Population Health Management 2016;19:109-119).

Tobacco-use Cessation Counseling Service Usage.

Objectives: Tobacco-use is common among elderly lung cancer patients and continued tobacco-use can impact prognosis. This study evaluates patterns of receipt of Tobacco-use Cessation Counseling (TCC) services among these patients. Methods: Using West Virginia Cancer Registry-Medicare linked database (2004-2007), we identified elderly patients with lung cancer (n = 922) and categorized them by receipt of TCC services. Hierarchical generalized logistic model was constructed and survival outcomes were analyzed by Kaplan-Meier analysis, Log-Rank test, and Cox proportional hazards modeling. Results: Majority of patients (76.7%) received TCC services. Unadjusted analysis showed favorable survival outcomes in patients who received TCC services. However, adjusted lung cancer mortality risk was no different between the groups (HR (95% CI) = 1.78 (0.87-3.64)). Conclusion: This study highlights the critical need to address disparities in receipt of TCC services among elderly. Although lung cancer preventive services are covered under the Medicare program, underutilization of these services is a concern.

Guideline-concordant lung cancer care and associated health outcomes among elderly patients in the United States.

OBJECTIVES: In the United States (US), the elderly carry a disproportionate burden of lung cancer. Although evidence-based guidelines for lung cancer care have been published, lack of high quality care still remains a concern among the elderly. This study comprehensively evaluates the variations in guideline-concordant lung cancer care among elderly in the US. MATERIALS AND METHODS: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2002-2007), we identified elderly patients (aged ≥65 years) with lung cancer (n = 42,323) and categorized them by receipt of guideline-concordant care, using evidence-based guidelines from the American College of Chest Physicians. A hierarchical generalized logistic model was constructed to identify variables associated with receipt of guideline-concordant care. Kaplan-Meier analysis and Log Rank test were used for estimation and comparison of the three-year survival. Multivariate Cox proportional hazards model was constructed to estimate lung cancer mortality risk associated with receipt of guideline-discordant care. RESULTS: Only less than half of all patients (44.7%) received guideline-concordant care in the study population. The likelihood of receiving guideline-concordant care significantly decreased with increasing age, non-white race, higher comorbidity score, and lower income. Three-year median survival time significantly increased (exceeded 487 days) in patients receiving guideline-concordant care. Adjusted lung cancer mortality risk significantly increased by 91% (HR = 1.91, 95% CI: 1.82-2.00) among patients receiving guideline-discordant care. CONCLUSION: This study highlights the critical need to address disparities in receipt of guideline-concordant lung cancer care among elderly. Although lung cancer diagnostic and management services are covered under the Medicare program, underutilization of these services is a concern.

Linking Medicare, Medicaid, and cancer registry data to study the burden of cancers in West Virginia.

OBJECTIVE: Develop the WVCR-Linked dataset by combining the West Virginia Cancer Registry (WVCR) with Medicare, Medicaid, and other data sources. Determine health care utilization, costs, and overall burden of four major cancers among the elderly in a rural and medically underserved state population, and to compare them with national estimates. METHOD: We extracted personal identifiers from the West Virginia Cancer Registry (WVCR) data file for individuals ≥ 65 years of age with an incident diagnosis of any cancer between January 1, 2002 and December 31, 2007. We linked the extracted data with Medicare and Medicaid administrative data using deterministic record linkage procedures. We updated missing vital status information by linking the National Death Index (NDI) data file. The updated WVCR-Linked dataset was enriched by links to the U.S. decennial census (2000) file and the Area Resource File. RESULTS: We identified 42,333 individuals, of which 41,574 (98.2%) and 6,031 (14.3%) individuals were matched with Medicare and Medicaid administrative data files, respectively. The NDI data added or updated vital status information for 3,295 (7.8%) individuals in the WVCR-Linked dataset. CONCLUSION: The WVCR-Linked dataset is a comprehensive dataset offering many opportunities to understand factors related to cancer treatment patterns, costs, and outcomes in a rural and medically underserved elderly Appalachian population. Following our example, non-participant states in the Surveillance, Epidemiology and End Results (SEER) program can build a powerful dataset to identify and target cancer disparities, and to improve cancer-related outcomes for their elderly and dual-eligible citizens.