A First Step on the Journey to High-Quality Chronic Illness Care.

The Atlantic Healthcare Collaboration (AHC) conducted a quality improvement initiative to improve chronic disease prevention and management for the four Atlantic provinces and their regional health authorities. Leaders and front-line teams carried out a range of projects, each suited to the needs of that region. This initiative helped build the case for improvement, increased the motivation to change, exposed participants to proven ideas for improvement and supported participating organizations in developing the capacity and culture to test, implement and spread improvements. The AHC also created a politically safe learning community with the potential to support and sustain the work of chronic care improvement over time. In carrying this initiative forward, the greatest challenge will be the magnitude of work to be done.

Do depressed newly diagnosed cancer patients differentially benefit from nurse navigation?

OBJECTIVE: To examine whether the effects of a nurse navigator intervention for cancer vary with baseline depressive symptoms. METHOD: Participants were enrolled in a randomized controlled trial of a nurse navigation intervention for patients newly diagnosed with lung, breast or colorectal cancer (N=251). This exploratory analysis used linear regression models to estimate the effect of a nurse navigator intervention on patient experience of care. Models estimated differential effects by including interactions between randomization group and baseline depressive symptoms. Baseline scores on the 9-item Patient Health Questionnaire (PHQ) were categorized into 3 groups: no depression (PHQ=0-4, N=138), mild symptoms of depression (PHQ=5-9, N=76) and moderate to severe symptoms (PHQ=10 or greater, N=34). Patient experience outcomes were measured by subscales of the Patient Assessment of Chronic Illness Care (PACIC) and subscales from an adaptation of the Picker Institute's patient experience survey at 4-month follow-up. RESULTS: With the exception of the PACIC subscale of delivery system/practice design, interaction terms between randomization group and PHQ-9 scores were not statistically significant. CONCLUSIONS: The intervention was broadly useful; we found that it was equally beneficial for both depressed patients and patients who were not significantly depressed in the first 4 months postdiagnosis. However, because of the small sample size, we cannot conclude with certainty that patients with depressive symptoms did not differentially benefit from the intervention.

A differential item function analysis of somatic symptoms of depression in people with cancer.

BACKGROUND: The overlap of somatic symptoms of depression with symptoms of cancer treatment is widely acknowledged and studied. However, this literature provides little guidance for clinicians as to whether these items should be used in assessing depression. The current study examined the appropriateness of using somatic items for assessment of depression in people with cancer. METHODS: People with newly diagnosed breast, lung or colorectal cancer (n=251) completed the Patient Health Questionnaire-9 (PHQ9) shortly after cancer diagnosis but before cancer treatment (baseline), 4 months later, typically during or shortly after treatment, and 12 months later. Pharmacy data was used to classify participants as having low somatic symptoms or high somatic symptoms. Differential item function (DIF) compared the functioning of the somatic items of the PHQ9 in the low vs. high symptom groups and the chemotherapy vs. no chemotherapy groups at the 4-month assessment. RESULTS: Significant DIF was not found on any of the four somatic items of the PHQ9 and differences in the item parameters of the somatic items were not consistent across the groups. However, fatigue and sleep indicated only mild depression. Only removing the fatigue item greatly affected the number screening positive for depression at 4 months (8.3%) but removing the other somatic items did not have as large an effect. Only one participant at baseline screened positive for depression by somatic symptoms alone (no psychological symptoms) and no participants screened positive by somatic symptoms alone at 4 months and 12 months. LIMITATIONS: The sample size was small for DIF and consisted of mostly women with breast cancer. CONCLUSIONS: Somatic symptoms of depression can continue to be administered to people with cancer, however the fatigue and sleep items should be used with caution.

Advanced imaging among health maintenance organization enrollees with cancer.

PURPOSE: Fee-for-service (FFS) Medicare expenditures for advanced imaging studies (defined as computed tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET] scans, and nuclear medicine studies [NM]) rapidly increased in the past two decades for patients with cancer. Imaging rates are unknown for patients with cancer, whether under or over age 65 years, in health maintenance organizations (HMOs), where incentives may differ. MATERIALS AND METHODS: Incident cases of breast, colorectal, lung, prostate, leukemia, and non-Hodgkin lymphoma (NHL) cancers diagnosed in 2003 and 2006 from four HMOs in the Cancer Research Network were used to determine 2-year overall mean imaging counts and average total imaging costs per HMO enrollee by cancer type for those under and over age 65. RESULTS: There were 44,446 incident cancer patient cases, with a median age of 75 (interquartile range, 71-81), and 454,029 imaging procedures were performed. The mean number of images per patient increased from 7.4 in 2003 to 12.9 in 2006. Rates of imaging were similar across age groups, with the exception of greater use of echocardiograms and NM studies in younger patients with breast cancer and greater use of PET among younger patients with lung cancer. Advanced imaging accounted for approximately 41% of all imaging, or approximately 85% of the $8.7 million in imaging expenditures. Costs were nearly $2,000 per HMO enrollee; costs for younger patients with NHL, leukemia, and lung cancer were nearly $1,000 more in 2003. CONCLUSION: Rates of advanced imaging appear comparable among FFS and HMO participants of any age with these six cancers.

Performance of claims-based algorithms for identifying heart failure and cardiomyopathy among patients diagnosed with breast cancer.

BACKGROUND: Cardiotoxicity is a known complication of certain breast cancer therapies, but rates come from clinical trials with design features that limit external validity. The ability to accurately identify cardiotoxicity from administrative data would enhance safety information. OBJECTIVE: To characterize the performance of clinical coding algorithms for identification of cardiac dysfunction in a cancer population. RESEARCH DESIGN: We sampled 400 charts among 6460 women diagnosed with incident breast cancer, tumor size ≥ 2 cm or node positivity, treated within 8 US health care systems between 1999 and 2007. We abstracted medical records for clinical diagnoses of heart failure (HF) and cardiomyopathy (CM) or evidence of reduced left ventricular ejection fraction. We then assessed the performance of 3 different International Classification of Diseases, 9th Edition (ICD-9)-based algorithms. RESULTS: The HF/CM coding algorithm designed a priori to balance performance characteristics provided a sensitivity of 62% (95% confidence interval, 40%-80%), specificity of 99% (range, 97% to 99%), positive predictive value (PPV) of 69% (range, 45% to 85%), and negative predictive value (NPV) of 98% (range, 96% to 99%). When applied only to incident HF/CM (ICD-9 codes and gold standard diagnosis both occurring after breast cancer diagnosis) in patients exposed to anthracycline and/or trastuzumab therapy, the PPV was 42% (range, 14% to 76%). CONCLUSIONS: Claims-based algorithms have moderate sensitivity and high specificity for identifying HF/CM among patients with invasive breast cancer. As the prevalence of HF/CM among the breast cancer population is low, ICD-9 codes have high NPV but only moderate PPV. These findings suggest a significant degree of misclassification due to HF/CM overcoding versus incomplete clinical documentation of HF/CM in the medical record.

Perspectives of cancer survivors on the role of different healthcare providers in an integrated delivery system.

PURPOSE: The purpose of this paper is to describe patient perspectives on survivorship care 1 year after cancer diagnosis. METHODS: The study was conducted at an integrated healthcare delivery system in western Washington State. Participants were patients with breast, colorectal, and lung cancer who had enrolled in a randomized control trial (RCT) of oncology nurse navigation to improve early cancer care. Those alive and enrolled in the healthcare system 1 year after diagnosis were eligible for this analysis. Participants completed surveys by phone. Questions focused on receipt of treatment summaries and care plans; discussions with different providers; patient opinions on who does and should provide their care; and patient perspectives primary care providers' (PCP) knowledge and skills related to caring for cancer survivors RESULTS: Of the 251 participants in the RCT, 230 (91.6%) responded to the 12-month phone survey and were included in this analysis; most (n = 183, 79.6%) had breast cancer. The majority (84.8%) considered their cancer specialist (e.g., medical, radiation, surgical or gynecological oncologist) to be their main provider for cancer follow-up and most (69.4%) had discussed follow-up care with that provider. Approximately half of patients were uncertain how well their PCP communicated with the oncologist and how knowledgeable s/he was in caring for cancer survivors. CONCLUSIONS: One year after diagnosis, cancer survivors continue to view cancer specialists as their main providers and are uncertain about their PCP's skills and knowledge in managing their care. Our findings present an opportunity to help patients understand what their PCPs can and cannot provide in the way of cancer follow-up care. IMPLICATIONS FOR CANCER SURVIVORS: Additional research on care coordination and delivery is necessary to help cancer survivors manage their care between primary care and specialty providers.

Nurse navigators in early cancer care: a randomized, controlled trial.

PURPOSE: To determine whether a nurse navigator intervention improves quality of life and patient experience with care for people recently given a diagnosis of breast, colorectal, or lung cancer. PATIENTS AND METHODS: Adults with recently diagnosed primary breast, colorectal, or lung cancer (n = 251) received either enhanced usual care (n = 118) or nurse navigator support for 4 months (n = 133) in a two-group cluster randomized, controlled trial with primary care physicians as the units of randomization. Patient-reported measures included the Functional Assessment of Cancer Therapy-General (FACT-G) Quality of Life scale, three subscales of the Patient Assessment of Chronic Illness Care (PACIC), and selected subscales from a cancer adaptation of the Picker Institute's patient experience survey. Self-report measures were collected at baseline, 4 months, and 12 months. Automated administrative data were used to assess time to treatment and total health care costs. RESULTS: There were no significant differences between groups in FACT-G scores. Nurse navigator patients reported significantly higher scores on the PACIC and reported significantly fewer problems with care, especially psychosocial care, care coordination, and information, as measured by the Picker instrument. Cumulative costs after diagnosis did not differ significantly between groups, but lung cancer costs were $6,852 less among nurse navigator patients. CONCLUSION: Compared with enhanced usual care, nurse navigator support for patients with cancer early in their course improves patient experience and reduces problems in care, but did not differentially affect quality of life.

An oncology nurse navigator program designed to eliminate gaps in early cancer care.

Although the burden of a cancer diagnosis for patients is profound, healthcare systems often fail to address patients' and families' psychosocial, information, and care coordination needs. The authors of this article designed an oncology nurse navigator program to proactively address these care gaps and tested the program's effectiveness in providing high-quality cancer care through a randomized, controlled trial. The program's model was informed by research synthesizing the perspectives of patients, families, clinicians, and experts throughout the country. The authors systematically incorporated feedback from participating clinical departments to improve the effectiveness of the program. This article details the intervention to help inform other systems interested in implementing an oncology nurse navigator program.

Risk of heart failure in breast cancer patients after anthracycline and trastuzumab treatment: a retrospective cohort study.

BACKGROUND: Clinical trials demonstrated that women treated for breast cancer with anthracycline or trastuzumab are at increased risk for heart failure and/or cardiomyopathy (HF/CM), but the generalizability of these findings is unknown. We estimated real-world adjuvant anthracycline and trastuzumab use and their associations with incident HF/CM. METHODS: We conducted a population-based, retrospective cohort study of 12,500 women diagnosed with incident, invasive breast cancer from January 1, 1999 through December 31, 2007, at eight integrated Cancer Research Network health systems. Using administrative procedure and pharmacy codes, we identified anthracycline, trastuzumab, and other chemotherapy use. We identified incident HF/CM following chemotherapy initiation and assessed risk of HF/CM with time-varying chemotherapy exposures vs no chemotherapy. Multivariable Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) with adjustment for age at diagnosis, stage, Cancer Research Network site, year of diagnosis, radiation therapy, and comorbidities. RESULTS: Among 12 500 women (mean age = 60 years, range = 22-99 years), 29.6% received anthracycline alone, 0.9% received trastuzumab alone, 3.5% received anthracycline plus trastuzumab, 19.5% received other chemotherapy, and 46.5% received no chemotherapy. Anthracycline and trastuzumab recipients were younger, with fewer comorbidities than recipients of other chemotherapy or none. Compared with no chemotherapy, the risk of HF/CM was higher in patients treated with anthracycline alone (adjusted HR = 1.40, 95% CI = 1.11 to 1.76), although the increased risk was similar to other chemotherapy (adjusted HR = 1.49, 95% CI = 1.25 to 1.77); the risk was highly increased in patients treated with trastuzumab alone (adjusted HR = 4.12, 95% CI = 2.30 to 7.42) or anthracycline plus trastuzumab (adjusted HR = 7.19, 95% CI = 5.00 to 10.35). CONCLUSIONS: Anthracycline and trastuzumab were primarily used in younger, healthier women and associated with increased HF/CM risk compared with no chemotherapy. This population-based observational study complements findings from clinical trials on cancer treatment safety.

Evidence gaps in advanced cancer care: community-based clinicians' perspectives and priorities for comparative effectiveness research.

PURPOSE: Although much effort has focused on identifying national comparative effectiveness research (CER) priorities, little is known about the CER priorities of community-based practitioners treating patients with advanced cancer. CER priorities of managed-care-based clinicians may be valuable as reflections of both payer and provider research interests. METHODS: We conducted mixed methods interviews with 10 clinicians (five oncologists and five pharmacists) at five health plans within the Health Maintenance Organization Cancer Research Network. We asked, "What evidence do you most wish you had when treating patients with advanced cancer?" and questioned participants on their impressions and knowledge of CER and pragmatic clinical trials (PCTs). We conducted qualitative analyses to identify themes across interviews. RESULTS: Ninety percent of participants had heard of CER, 20% had heard of PCTs, and all rated CER/PCTs as highly relevant to patient and health plan decision making. Each participant offered between three and 10 research priorities. Half (49%) involved head-to-head treatment comparisons; another 20% involved comparing different schedules or dosing regimens of the same treatment. The majority included alternative outcomes to survival (eg, toxicity, quality of life, noninferiority). Participants cited several limitations to existing evidence including lack of generalizability, funding biases, and rapid development of new treatments. CONCLUSION: Head-to-head treatment comparisons remain a major evidence need among community-based oncology clinicians, and CER/PCTs are highly valued methods to address the limitations of traditional randomized trials, answer questions of cost-effectiveness or noninferiority, and inform data-driven dialogue and decision making by all stakeholders.

Evidence gaps in advanced cancer care: community-based clinicians' perspectives and priorities for CER.

OBJECTIVES: Although much effort has focused on identifying national comparative effectiveness research (CER) priorities, little is known about the CER priorities of community-based practitioners treating patients with advanced cancer. CER priorities of managed care-based clinicians may be valuable as reflections of both payer and provider research interests. METHODS: We conducted mixed methods interviews with 10 clinicians (5 oncologists and 5 pharmacists) at 5 health plans within the Health Maintenance Organization Cancer Research Network. We asked, "What evidence do you most wish you had when treating patients with advanced cancer" and questioned participants on their impressions and knowledge of CER and pragmatic clinical trials (PCTs). We conducted qualitative analyses to identify themes across interviews. RESULTS: Ninety percent of participants had heard of CER, 20% had heard of PCTs, and all rated CER/PCTs as highly relevant to patient and health plan decision making. Each participant offered between 3 and 10 research priorities. Half (49%) involved head-to-head treatment comparisons; another 20% involved comparing different schedules or dosing regimens of the same treatment. The majority included alternative outcomes to survival (eg, toxicity, quality of life, noninferiority). Participants cited several limitations to existing evidence, including lack of generalizability, funding biases, and rapid development of new treatments. CONCLUSION: Head-to-head treatment comparisons remain a major evidence need among community- based oncology clinicians, and CER/PCTs are highly valued methods to address the limitations of traditional randomized trials, answer questions of cost-effectiveness or noninferiority, and inform data-driven dialogue and decision making by all stakeholders.

Improving modern cancer care through information technology.

The cancer care system is increasingly complex, marked by multiple hand-offs between primary care and specialty providers, inadequate communication among providers, and lack of clarity about a "medical home" (the ideal accountable care provider) for cancer patients. Patients and families often cite such difficulties as information deficits, uncoordinated care, and insufficient psychosocial support. This article presents a review of the challenges of delivering well coordinated, patient-centered cancer care in a complex modern healthcare system. An examination is made of the potential role of information technology (IT) advances to help both providers and patients. Using the published literature as background, a review is provided of selected work that is underway to improve communication, coordination, and quality of care. Also discussed are additional challenges and opportunities to advancing understanding of how patient data, provider and patient involvement, and informatics innovations can support high-quality cancer care.

Self-management: Enabling and empowering patients living with cancer as a chronic illness.

With recent improvements in the early detection, diagnosis, and treatment of cancer, people with cancer are living longer, and their cancer may be managed as a chronic illness. Cancer as a chronic illness places new demands on patients and families to manage their own care, and it challenges old paradigms that oncology's work is done after treatment. As a chronic illness, however, cancer care occurs on a continuum that stretches from prevention to the end of life, with early detection, diagnosis, treatment, and survivorship in between. In this article, self-management interventions that enable patients and families to participate in managing their care along this continuum are reviewed. Randomized controlled trials of self-management interventions with cancer patients and families in the treatment, survivorship, and end-of-life phases of the cancer care continuum are reviewed, and the Chronic Care Model is presented as a model of care that oncology practices can use to enable and empower patients and families to engage in self-management. It is concluded that the need for a common language with which to speak about self-management and a common set of self-management actions for cancer care notwithstanding, oncology practices can now build strong relationships with their patients and formulate mutually agreed upon care plans that enable and empower patients to care for themselves in the way they prefer.

The quality of cancer patient experience: perspectives of patients, family members, providers and experts.

BACKGROUND: Anecdotes and limited evidence suggest that a significant percentage of cancer patients encounter troublesome problems in the course of their care. METHODS: The authors collected data about barriers to and facilitators of high-quality cancer care and innovative solutions to improve quality from three sources: focus groups with patients, family members of cancer patients and providers; site visits to cancer care providers and organisations in three American communities; and expert interviews. RESULTS: The authors' respondents consistently described a similar list of problems facing the individual with a suspicion or diagnosis of cancer and his/her family: delays in and lack of coordination of care, patient information gaps and passivity, inadequate attention to emotional and social problems, and difficulty accessing services because of inadequate insurance, limited financial resources or rural residence. The fragmentation and uncertain accountability of cancer care contribute to these issues. Respondents recommended linking patients with a care navigator or manager, using computer technology to better inform and support patients and connect providers, and reforming provider reimbursement to encourage more patient-centred care. CONCLUSIONS: Cancer patients and their families have urgent needs for information and support especially early in their course. To meet these needs, early cancer care must be better organised, integrated, and patient centred. The Institute of Medicine's Model for the Delivery of Psychosocial Services appears to provide a relevant guide to delivering cancer care that better meets patient and family needs.

Accuracy and complexities of using automated clinical data for capturing chemotherapy administrations: implications for future research.

BACKGROUND: Chemotherapy data are important to almost any study on cancer prognosis and outcomes. However, chemotherapy data obtained from tumor registries may be incomplete, and abstracting chemotherapy directly from medical records can be expensive and time consuming. METHODS: We evaluated the accuracy of using automated clinical data to capture chemotherapy administrations in a cohort of 757 ovarian cancer patients enrolled in 7 health plans in the HMO Cancer Research Network. We calculated sensitivity and specificity with 95% confidence intervals of chemotherapy administrations extracted from 3 automated clinical data sources (Health Care Procedure Coding System, National Drug Codes, and International Classification of Diseases) compared with tumor registry data and medical chart data. RESULTS: Sensitivity of all 3 data sources varied across health plans from 79.4% to 95.2% when compared with tumor registries, and 75.0% to 100.0% when compared with medical charts. The sensitivities using a combination of 3 data sources were 88.6% (95% confidence intervals: 85.7-91.1) compared with tumor registries and 89.5% (78.5-96.0) compared with medical records; specificities were 91.5% (86.4-95.2) and 90.0% (55.5-99.7), respectively. There was no difference in accuracy between women aged < 65 and > or = 65 years. Using one set of codes alone (eg, Health Care Procedure Coding System alone) was insufficient for capturing chemotherapy data at most health plans. CONCLUSIONS: While automated data systems are not without limitations, clinical codes used in combination are useful in capturing chemotherapy more comprehensively than tumor registry and without the need for costly medical record abstraction. Key Words: validation of automated clinical data, chemotherapy, medical chart, tumor registry, ovarian cancer.

Effect of socioeconomic factors on long-term mortality in men with clinically localized prostate cancer.

OBJECTIVES: To examine the effect of socioeconomic factors on survival in black and white patients with local or regional prostate cancer. METHODS: All cases (n = 2046) of clinically localized prostate cancer diagnosed from 1990 to 2000 at the Henry Ford Health System and the Henry Ford Medical Group, equal access health centers, were included. Data on the stage, grade, age at diagnosis, socioeconomic status, treatment given, comorbidities, and vital statistics were gathered from the Henry Ford Medical Group tumor registry and computerized databases, pathologic reports, patient charts, Surveillance, Epidemiology, and End Results database, and the national death registry. The endpoints were the overall and cancer-specific survival. Survival was calculated using Cox proportional hazards regression models. RESULTS: Of the 2046 cases, 1243 were white and 803 were black. Black patients were more likely to have lower incomes, a greater baseline prostate-specific antigen level, and greater comorbidities. They were also more likely to undergo radiotherapy and less likely to undergo radical prostatectomy. Univariate analysis, with white race as the baseline hazard, showed that black patients had significantly increased cancer-specific (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.01-2.13) and overall (HR 1.29, 95% CI 1.09-1.53) mortality. However, adjusting for insurance status and income on multivariate analysis revealed no significant differences in cancer-specific (HR 1.04, 95% CI 0.66-1.64) and overall (HR 0.96, 95% CI 0.78-1.18) survival. CONCLUSIONS: In this cohort, socioeconomic factors were sufficient to explain the disparity in survival between white and black patients. Survival differences disappeared after adjusting for income status on multivariate analysis.

Understanding high-quality cancer care: a summary of expert perspectives.

BACKGROUND: The Institute of Medicine (IOM) report Crossing the Quality Chasm proposed 6 aims for high-quality healthcare: effective, safe, timely, efficient, equitable, and patient-centered, and emphasized care coordination. Through interviews with nationally recognized experts in healthcare quality, perspectives on barriers and facilitators to achieving these aims for cancer patients were elicited. METHODS: In all, 23 peer-nominated experts with diverse backgrounds in policy, healthcare, patient advocacy, and research were individually interviewed. They were asked about barriers and facilitators to achieving high-quality cancer care, and information technology or other innovations that might improve the quality of cancer diagnosis, treatment, and surveillance. Interviews were tape-recorded and transcribed. Two analysts independently reviewed and coded each transcript using ethnographic software to elucidate key themes. RESULTS: The major perceived barrier to providing high-quality cancer care was unnecessary variation in cancer care because of lack of standardization or adherence to guidelines during diagnosis, treatment, and surveillance. Additional barriers included insufficient teamwork and communication among multidisciplinary care teams, lack of patient awareness and empowerment, diagnostic delays during provider transitions, and excessive reimbursement for treatment. Experts suggested improving cancer patients' experiences by standardizing care, adhering to guidelines, and using "patient navigators" and an interoperable electronic medical record accessible to patients and providers at multiple facilities. CONCLUSIONS: Some of these solutions have been developed and tested, whereas others have not. It is hoped that these suggestions provide impetus for new research, accelerating progress toward achieving the IOM's vision for high-quality cancer care.

Diffusion of aromatase inhibitors for breast cancer therapy between 1996 and 2003 in the Cancer Research Network.

PURPOSE: Clinical trials demonstrated adjuvant aromatase inhibitor treatment is superior for decreasing breast cancer recurrence risk over adjuvant tamoxifen treatment as early as 2001. Yet clinical use for adjuvant treatment was not recommended by the American Society of Clinical Oncology until 2004. Aromatase inhibitor uptake after the first public presentation of randomized trial results but before the release of national guidelines is unclear. We evaluated diffusion of aromatase inhibitor dispensings for breast cancer treatment in integrated healthcare delivery systems across the United States. METHODS: We collected automated data for 13,245 women enrolled at seven integrated healthcare delivery systems in the Cancer Research Network. All women were aged >55 and diagnosed with estrogen receptor positive, invasive breast cancer between 1996 and 2003. We used electronic pharmacy data to identify aromatase inhibitor and tamoxifen dispensings through 2004. We evaluated the proportions of women who received hormone dispensings in two ways: (1) at any point after diagnosis to capture all use, and (2) in the two-year period following diagnosis to approximate adjuvant use. RESULTS: Over time, adjuvant aromatase inhibitor use increased whereas tamoxifen use decreased. Aromatase inhibitor dispensings within 2 years of diagnosis increased from 4.1% among women diagnosed in 2000 to 13% in 2001, 24% in 2002, and 40% in 2003. Tamoxifen use declined starting in 2001 at every system. CONCLUSION: Aromatase inhibitor use rose dramatically after 2001 while tamoxifen use decreased. It appears results from early clinical trials changed practice in these integrated healthcare systems before formal changes in national guidelines.

Delivering effective primary care to older adults: a randomized, controlled trial of the senior resource team at group health cooperative.

OBJECTIVES: To assess the effect of a team of geriatrics specialists on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older. DESIGN: Randomized, controlled trial. SETTING: Two primary care clinics in the Seattle, Washington, area. PARTICIPANTS: Thirty-one PCPs and 874 patients aged 75 and older. INTERVENTION: An interdisciplinary team of geriatrics specialists worked with patients and providers to enhance the geriatric focus of care. MEASUREMENTS: Main outcomes were a practice style reflecting a geriatric orientation and patient scores on the physical and affect subscales of the Arthritis Impact Measurement Scale 2-Short Form. Secondary outcomes were hospitalizations, incident disability in activities of daily living (ADLs), and PCP perceptions of the intervention. Death rates were also assessed. RESULTS: Intervention providers screened significantly more for geriatric syndromes at 12 months, but this finding did not persist at 24 months. There were no significant differences in adequate hypertension control or high-risk prescribing at 12 or 24 months of follow-up. There were no significant differences in patient functioning or significant differences in hospitalization rates at either time point. Meaningful differences were observed in ADL disability at 12 but not 24 months. PCPs viewed the intervention favorably. Seventy-eight participants died over the 24 months of follow-up; the proportion dying was higher in the intervention group (11.4% in intervention group vs 7.1% of controls, P=.03). CONCLUSION: The addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or the use of inpatient care and was associated with greater mortality.

Outcome of follow-up colon examination among a population-based cohort of colorectal cancer patients.

BACKGROUND & AIMS: The benefit of colonoscopy in the follow-up of colorectal cancer survivors is uncertain, and findings of surveillance colonoscopy are not well-characterized. We sought to estimate survival among colorectal cancer patients according to receipt of a follow-up colon examination and to describe the findings of such exams. METHODS: We studied health maintenance organization enrollees with colorectal cancer who underwent surgical resection. Mortality was estimated by using survival analysis, and findings of colon examinations were determined by review of pathology reports. RESULTS: One thousand two patients were eligible for study; 5-year survival was higher (76.8%) for patients who had at least one follow-up exam than for patients who did not undergo follow-up (52.2%, P < .0001). In multivariate analysis, colon examination remained independently associated with improved survival (hazard ratio, 0.58; 95% confidence interval, 0.44-0.75). Twenty patients (3.1%) were diagnosed with a second colorectal cancer, including 9 cancers detected within 18 months of initial cancer diagnosis. Advanced neoplasia was more common (15.5%) among patients followed up between 36-60 months after diagnosis compared with patients followed up within 18 months (6.9%, P = .02). History of adenomas was associated with advanced neoplasia on follow-up (P = .002). Patients with advanced neoplasia on initial follow-up were at high risk for advanced neoplasia on subsequent examinations (13/16, 81%). CONCLUSIONS: After colorectal cancer resection, patients have a high risk of interval cancers, some of which represent missed lesions at initial diagnosis. Therefore, surveillance colonoscopy within 1 year of initial diagnosis is warranted. After adjusting for key variables, endoscopic surveillance is associated with improved survival.