Consolidation of Cancer Registry and Administrative Claims Data on Cancer Diagnosis and Treatment in the US Military Health System.

PURPOSE: Linked cancer registry and medical claims data have increased the capacity for cancer research. However, few efforts have described methods to select information between data sources, which may affect data use. We developed a systematic process to evaluate and consolidate cancer diagnosis and treatment information between the linked Department of Defense Central Cancer Registry (CCR) and Military Health System Data Repository (MDR) administrative claims database, called Military Cancer Epidemiology Data System (MilCanEpi). METHODS: MilCanEpi contains information on cancer diagnosis and treatment of patients receiving care from 1998 to 2014. We used an iterative process guided by knowledge of data features, current literature, and logical comparisons between the CCR and MDR data to evaluate and consolidate cancer diagnosis and treatment received (yes or no) and their dates. We applied the processes to breast cancer data as an example. Agreement between diagnosis and treatment dates in the two data sources was evaluated using Cohen's κ with 95% CIs. RESULTS: In MilCanEpi, we identified 15,965 patients with a breast cancer diagnosis and 15,145 patients who underwent breast cancer surgery; 97.9% and 84.1% of patients had records in both CCR and MDR for diagnosis and surgery, respectively. Exact agreement was 13.7% for diagnosis dates (Cohen's κ = 0.14; 95% CI, 0.13 to 0.14) and 68.9% for surgery dates (Cohen's κ = 0.69; 95% CI, 0.68 to 0.70) between the two data sources. After applying systematic processes, 98.1% of patients with a breast cancer diagnosis and 99.7% of patients with surgery had information selected for analytic data sets. CONCLUSION: The developed processes resulted in high consolidation rates of breast cancer data in MilCanEpi and may serve as a data selection template for other tumor sites and linked data sources.

Racial Comparisons in Timeliness of Colon Cancer Treatment in an Equal-Access Health System.

BACKGROUND: Non-Hispanic black (NHB) adults with cancer may have longer time-to-treatment than non-Hispanic whites (NHW) in the United States. Unequal access to medical care may partially account for this racial disparity. This study aimed to investigate whether there were racial differences in time-to-treatment and in treatment delays for patients diagnosed with colon cancer in the equal-access Military Health System (MHS). METHODS: Patients age 18-79 years diagnosed with colon adenocarcinoma between January 1, 1998, and December 31, 2014, were identified in the Department of Defense Central Cancer Registry and the MHS Data Repository-linked databases. Median time-to-treatment (surgery and chemotherapy) and 95% confidence intervals were compared between NHBs and NHWs in multivariable quantile regression models. Odds ratios and 95% confidence intervals of receiving delayed treatment defined by guidelines for NHBs relative to NHWs were estimated using multivariable logistic regression. RESULTS: Patients (n = 3067) had a mean age at diagnosis of 58.4 (12.2) years and the racial distribution was 76.7% NHW and 23.3% NHB. Median adjusted time-to-treatment was similar for NHB compared to NHW patients. The likelihood of receiving delayed treatment was similar between NHB and NHW patients. CONCLUSIONS: In the MHS, there was no evidence of treatment delays for NHBs compared to NHWs, suggesting the role of equal access to medical care and insurance coverage in reducing racial disparities in colon cancer treatment.

Factors related to re-excision procedures following primary breast-conserving surgery for women with breast cancer in the U.S. Military Health System.

BACKGROUND AND OBJECTIVES: Re-excision surgery is undertaken to obtain clear margins after breast-conserving surgery (BCS) for localized breast cancer. This study examines patient and tumor characteristics related to re-excision surgery in the universal-access Military Health System (MHS). METHODS: Retrospective analysis of patients with pathologically confirmed stage I-III breast cancer between 1998 and 2014 in the Department of Defense Central Cancer Registry and MHS Data Repository-linked databases who received primary BCS. Multivariable stepwise logistic regression methods identified characteristics associated with re-excision surgery (lumpectomy and mastectomy) and conversion to mastectomy, given as adjusted odds ratios (AOR) and 95% confidence intervals (CIs). RESULTS: Of 7637 women receiving BCS, 26.3% had a re-excision and 9.9% converted to mastectomy. Tumor location, larger tumor size (≥4 cm), and regional lymph node involvement were associated with a greater likelihood of re-excision and mastectomy conversion. Pathology before BCS (AOR, 0.39; 95% CI, 0.35, 0.44 for re-excision) and neoadjuvant treatment (AOR, 0.50; 95% CI, 0.36, 0.69 for re-excision) were associated with a decreased likelihood of these outcomes. Additionally, age, tumor histology, and military-specific variables were associated with mastectomy conversion. CONCLUSION: Comprehensive preoperative workup, including tumor pathology, may better inform surgical decision-making and reduce re-excision rates.

Contribution Of Care Source To Cancer Treatment Cost Variation In The US Military Health System.

The US Military Health System (MHS) provides universal access to health care for more than nine million eligible beneficiaries through direct care in military treatment facilities or purchased care in civilian facilities. Using information from linked cancer registry and administrative databases, we examined how care source contributed to cancer treatment cost variation in the MHS for patients ages 18-64 who were diagnosed with colon, female breast, or prostate cancer in the period 2003-14. After accounting for patient, tumor, and treatment characteristics, we found the independent contribution of care source to total variation in cost to be 8 percent, 12 percent, and 2 percent for colon, breast, and prostate cancer treatment, respectively. About 20-50 percent of the total cost variance remained unexplained and may be related to organizational and administrative factors.

Time-to-surgery and overall survival after breast cancer diagnosis in a universal health system.

PURPOSE: It is unclear whether time between breast cancer diagnosis and surgery is associated with survival and whether this relationship is affected by access to care. We evaluated the association between time-to-surgery and overall survival among women in the universal-access U.S. Military Health System (MHS). METHODS: Women aged 18-79 who received surgical treatment for stages I-III breast cancer between 1998 and 2010 were identified in linked cancer registry and administrative databases with follow-up through 2015. Multivariable Cox regression models were used to estimate risk of all-cause death associated with time-to-surgery intervals. RESULTS: The study included 9669 women with 93.1% survival during the study period. The hazards ratios (95% confidence intervals) of all-cause death associated with time-to-surgery were 1.15 (0.93, 1.42) for 0 days, 1.00 (reference) for 1-21 days, 0.97 (0.78, 1.21) for 22-35 days, and 1.30 (1.04, 1.61) for ≥ 36 days. The higher risk of mortality associated with time-to-surgery ≥ 36 days tended to be consistent when analyzed by surgery type, age at diagnosis, and tumor stage. CONCLUSIONS: In the MHS, longer time-to-surgery for breast cancer was associated with poorer overall survival, suggesting the importance of timeliness in receiving surgical treatment for breast cancer in relation to overall survival.

Costs for Colon Cancer Treatment Comparing Benefit Types and Care Sources in the US Military Health System.

INTRODUCTION: Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs. MATERIALS AND METHODS: Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18-64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics. RESULTS: The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2-3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment. CONCLUSIONS: In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction.

Cost-Efficiency of Breast Cancer Care in the US Military Health System: An Economic Evaluation in Direct and Purchased Care.

INTRODUCTION: With the rising costs of cancer care, it is critical to evaluate the overall cost-efficiency of care in real-world settings. In the United States, breast cancer accounts for the largest portion of cancer care spending due to high incidence and prevalence. The purpose of this study is to assess the relationship between breast cancer costs in the first 6 months after diagnosis and clinical outcomes by care source (direct or purchased) in the universal-access US Military Health System (MHS). MATERIALS AND METHODS: We conducted a retrospective analysis of data from the Department of Defense Central Cancer Registry and MHS Data Repository administrative records. The institutional review boards of the Walter Reed National Military Medical Center and the Defense Health Agency reviewed and approved the data linkage. We used the linked data to identify women aged 40-64 who were diagnosed with pathologically-confirmed breast cancer between 2003 and 2007 with at least 1 year of follow-up through December 31, 2008. We identified cancer treatment from administrative data using relevant medical procedure and billing codes and extracted costs paid by the MHS for each claim. Multivariable Cox proportional hazards models estimated hazards ratios (HR) and 95% confidence intervals (CI) for recurrence or all-cause death as a function of breast cancer cost in tertiles. RESULTS: The median cost per patient (n = 2,490) for cancer care was $16,741 (interquartile range $9,268, $28,742) in the first 6 months after diagnosis. In direct care, women in the highest cost tertile had a lower risk for clinical outcomes compared to women in the lowest cost tertile (HR 0.58, 95% CI 0.35, 0.96). When outcomes were evaluated separately, there was a statistically significant inverse association between higher cost and risk of death (p-trend = 0.025) for women receiving direct care. These associations were not observed among women using purchased care or both care sources. CONCLUSIONS: In the MHS, higher breast cancer costs in the first 6 months after diagnosis were associated with lower risk for clinical outcomes in direct care, but not in purchased care. Organizational, institutional, and provider-level factors may contribute to the observed differences by care source. Replication of our findings in breast and other tumor sites may have implications for informing cancer care financing and value-based reimbursement policy.

Racial Differences in Time to Breast Cancer Surgery and Overall Survival in the US Military Health System.

Importance: Racial disparities in time to surgery (TTS) after a breast cancer diagnosis and whether these differences account for disparities in overall survival have been understudied in the US population. Objectives: To compare TTS in non-Hispanic black (NHB) and non-Hispanic white (NHW) women with breast cancer and to examine whether racial differences in TTS may explain possible racial disparities in overall survival in a universal health care system. Design, Setting, and Participants: Retrospective cohort identified from the Department of Defense Central Cancer Registry and Military Health System Data Repository linked databases containing records between January 1, 1998, and December 31, 2008, of 998 NHB women and 3899 NHW women who received a diagnosis of stages I to III breast cancer and underwent breast-conserving surgery (BCS) or mastectomy in the US Military Health System during the study period. Data analyses were conducted from July 5, 2017, to December 29, 2017. Main Outcomes and Measures: The main outcome was time to breast cancer surgery. Non-Hispanic black and NHW women were compared at the 25th, 50th (median), 75th, and 90th percentiles of TTS by using multivariable quantile regression. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs for all-cause death in NHB compared with NHW women after controlling for potential confounders first without and then with TTS. Results: Among the 4887 NHB and NHW women in the cohort, the mean (SD) age was 50.0 (9.4) years. The median TTS was 21 days (95% CI, 20.6-21.4 days) among NHW women and 22 days (95% CI, 20.6-23.4 days) among NHB women. Non-Hispanic black women had a significantly greater estimated TTS at the 75th (3.6 days; 95% CI, 1.6-5.5 days) and 90th (8.9 days; 95% CI, 5.1-12.6 days) percentiles than NHW women in multivariable models. The estimated differences were similar by surgery type. Non-Hispanic black women had a higher adjusted risk for death (HR, 1.45; 95% CI, 1.06-2.01) compared with NHW women among patients receiving breast-conserving surgery. The risks were similar between races among those receiving mastectomy (HR, 1.06; 95% CI, 0.76-1.48). The HRs remained similar after adding TTS to the Cox proportional hazards regression models. Conclusions and Relevance: This study's results indicate that time to breast cancer surgery was delayed for NHB compared with NHW women in the Military Health System. However, the racial differences in TTS did not explain the observed racial differences in overall survival among women who received breast-conserving surgery.

Airway anomalies in patients with craniosynostosis.

OBJECTIVES: 1) Characterize the spectrum of airway anomalies in patients with craniosynostosis, and 2) identify clinical characteristics of these patients that may be associated with the development of airway anomalies. METHODS: This study is a retrospective case series assessing the type and frequency of airway anomalies in all patients with craniosynostosis seen at a tertiary-care children's hospital between 2000 and 2016. Cohort analyses were then performed to identify differences in airway anomalies dependent on syndromic associations, multisutural fusion, and location of suture fusion. Clinical characteristics examined included demographics and additional neurologic and craniofacial abnormalities. RESULTS: Four hundred and ninety-six patients with craniosynostosis (83.5% white, 64.5% male; 33.9% sagittal, 28.8% metopic, 11.5% coronal, 1.2% lambdoid, and 24.6% multisutural) were included. Notable airway anomalies included the following: 13.3% adenotonsillar hypertrophy, 8.9% laryngomalacia, 7.3% tracheomalacia, 7.1% subglottic stenosis, 4.0% bronchomalacia, 3.8% laryngeal cleft, and 1.2% vocal fold paresis. Multisutural craniosynostosis patients (n = 122) were more likely to have obstructive sleep apnea (P = 0.005), adenotonsillar hypertrophy (P = 0.014), tracheomalacia (P = 0.011), subglottic stenosis (P < 0.001), and epiglottic/base of tongue collapse (P = 0.003) and require tracheostomy (P = 0.001) and mechanical ventilation (P = 0.017) compared with single suture craniosynostosis. Syndromic craniosynostosis patients (n = 33) were more likely to have obstructive sleep apnea (P < 0.001), laryngomalacia (P = 0.047), and subglottic stenosis (P = 0.009) compared with nonsyndromic patients. CONCLUSION: Airway anomalies are prevalent in patients with craniosynostosis; patients with multisutural or syndromic types have an increased risk of developing certain abnormalities. There should be a lower threshold for referral for airway evaluation in these populations. LEVEL OF EVIDENCE: 4. Laryngoscope, 129:2594-2602, 2019.

Laryngomalacia in Patients With Craniosynostosis.

OBJECTIVE: To characterize differences in the clinical presentation and treatment outcomes of laryngomalacia in patients with and without craniosynostosis. METHODS: A retrospective cohort study was performed comparing all patients with concomitant laryngomalacia and craniosynostosis seen at a tertiary care children's hospital between 2000 and 2016 with a control group of patients with isolated laryngomalacia. Thirty-two patients with craniosynostosis (59% male) and 68 control patients (56% male) were included. There were no significant differences in age of diagnosis or incidence of prematurity. Symptom presentation, disease severity, swallowing function, comorbidities, treatment modalities, and outcomes were examined using logistic regression. RESULTS: Patients with craniosynostosis had increased odds of presenting with stertor (odds ratio [OR] = 3.41, P = .022), increased work of breathing (OR = 18.8, P = .007), obstructive sleep apnea (OR = 8.48, P = .003), dysphagia (OR = 3.40, P = .008), and aspiration (OR = 40.2, P < .001) and decreased odds of presenting with stridor (OR = 0.0804, P < .001) compared with controls. Patients with craniosynostosis had increased odds of severe laryngomalacia (OR = 5.00, P = .031) and other airway anomalies such as tracheomalacia (OR = 5.73, P = .004), bronchomalacia (OR = 15.5, P = .013), and subglottic stenosis (OR = 2.75, P = .028). Treatment of patients with craniosynostosis was more likely to include tracheostomy (OR = 24.8, P < .001) and gastrostomy tube (OR = 88.4, P < .001). There were no significant differences in rates of supraglottoplasty. CONCLUSION: Clinical presentations, comorbidities, and treatments of laryngomalacia are significantly different in the context of craniosynostosis.

Association between Eosinophilic Esophagitis and Esophageal Food Impaction in the Pediatric Population.

Objectives (1) To describe the presentation, management, and outcomes associated with pediatric esophageal food impaction (EFI) at a single tertiary care institution. (2) To identify the key clinical features of pediatric EFI that are associated with a diagnosis of eosinophilic esophagitis (EoE). Study Design Case series with chart review. Setting Tertiary care children's hospital. Subjects and Methods Thirty-five children <18 years of age presenting with EFI between November 1, 2006, and October 31, 2013, were included. Presenting symptoms, medical history, biopsy results, endoscopic findings, and underlying etiology were examined. Fisher exact test, t tests, and logistic regression were used to compare between patients with and without EoE. Results Thirty-five patients had isolated EFI and were included in the study. EoE accounted for 74% (n = 26) of pediatric EFI, with the remaining cases being attributed to neurologic impairment (n = 5, 15%), prior surgeries (n = 1, 3%), reflux esophagitis (n = 1, 3%), or unknown etiologies (n = 2, 6%). EFI was the initial manifestation of EoE in 81% (n = 21) of patients. The most common presenting symptoms were dysphagia (n = 34), choking (n = 26), and vomiting (n = 23). Linear furrowing was the only endoscopic finding that was significantly associated with EoE ( P < .001). Conclusion Most esophageal food impactions in the pediatric population are associated with an underlying diagnosis of EoE and are often the initial manifestation of the disease. EoE must be considered in all pediatric patients with EFI; esophageal biopsies should be strongly considered in these patients at the time of endoscopic management of the EFI.

Predictors of Foreign Body Aspiration in Children.

OBJECTIVES: To examine the sensitivity and specificity of history, physical examination, and radiologic studies as predictors of foreign body aspiration in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Medical records were reviewed for 102 children who presented to our institution from 2006 to 2013 with suspected foreign body aspiration and who underwent endoscopy. Data included symptoms, physical examination, radiologic, and endoscopy findings. Descriptive statistics, sensitivity and specificity, and univariate and multivariable analyses were performed. RESULTS: A total of 102 patients were included (62% male). The mean age was 3.3 years (SD, 3.7). A foreign body was identified on endoscopy in 69 cases (68%). The most common presenting symptoms were cough (88%), choking/gagging (67%), and wheezing (57%). Decreased breath sounds and wheezing on examination were independently associated with increased odds of foreign body. The most common abnormal radiographic finding was air trapping (33%). The most frequent items retrieved were fragments of seeds and nuts (49%). There were no serious complications related to endoscopy. The sensitivity and specificity of any finding on history, physical examination, and imaging were 100% and 3%, 90% and 33%, 61% and 77%, respectively. Having a positive history, examination, and chest radiograph combined was 46% sensitive and 79% specific. CONCLUSIONS: Patients with airway foreign bodies have varied presentations. The presence of any radiologic finding suggests that endoscopy should be performed, as a foreign body is probable. The absence of any history or physical examination finding was associated with a low likelihood of a foreign body.

Diagnosis of Pediatric Foreign Body Ingestion: Clinical Presentation, Physical Examination, and Radiologic Findings.

OBJECTIVES: (1) To describe clinical and radiologic findings in patients with esophageal foreign bodies. (2) To examine the sensitivity and specificity of history, physical examination, and radiologic studies in children with suspected foreign body ingestion. METHODS: A retrospective cohort study was performed evaluating all children who underwent esophagoscopy for suspected foreign body ingestion at our institution from 2006 to 2013. RESULTS: Five hundred forty-three patients were included (54% male). Average age was 4.7 years (SD = 4.1 years). Foreign bodies were identified on esophagoscopy in 497 cases (92%). Ingestion was witnessed in 23% of cases. Most common presenting symptoms were choking/gagging (49%), vomiting (47%), and dysphagia/odynophagia (42%). Most patients with foreign bodies had a normal exam (76%). Most foreign bodies were radiopaque (83%). In 59% of patients with normal chest radiographs, a foreign body was present. Sensitivity and specificity of 1 or more findings on history, physical examination, and imaging were 99% and 0%, 21% and 76%, and 83% and 100%, respectively. CONCLUSIONS: Most patients with esophageal foreign bodies are symptomatic. Although many patients will have a normal physical examination, an abnormal exam should increase suspicion for a foreign body. Most esophageal foreign bodies are radiopaque, but a normal chest radiograph cannot rule out a foreign body.

The role of tympanostomy tubes in surgery for acquired retraction pocket cholesteatoma.

OBJECTIVE: 1. To determine whether intraoperative tympanostomy tubes (TT) during surgery for acquired retraction pocket cholesteatoma (ARPC) can decrease recurrence of ARPC and retraction pockets (RP). 2. To determine the need for subsequent TT in children that did not initially receive TT. STUDY DESIGN: Retrospective review of children who underwent primary surgery for ARPC. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Audiometry, operative reports, office findings, and recurrence of ARPC and RP were analyzed. Univariate analysis with Fisher's exact test, Wilcoxon rank-sum and t test, as well as multivariate analysis with logistical regression, were used for statistical analyses. RESULTS: 21 patients had TT at initial surgery and 34 patients did not. The recurrence of ARPC was 24% for the TT Group versus 44% for the no TT group (p=0.09). The incidence of RP was 33% in the TT group versus 41% in the no TT groups (p=0.35). 35% of the no TT group subsequently required TT. Audiometric outcomes were not different between groups. TT placement did not significantly affect the odds of recurrent ARPC and RP (95% CI 0.12-1.83, p=0.28 for ARPC and 95% CI 0.30-4.60, p=0.82 for RP). However, the odds of recurrent ARPC and RP were significantly increased in children with stapes and malleus erosion by cholesteatoma. Children with stapes and malleus involvement had 5.28 and 11.8 times higher odds of recurrent ARPC compared to those without ossicular erosion (95% CI 1.09-25.6, p=0.04 stapes and 95% CI 1.58-88.3, p=0.02 malleus). Similarly, children with malleus involvement had an 18.6 times higher odds of recurrent RP (95% CI 1.62-214, p=0.02) compared to those who did not. Incus erosion was not a significant predictor for recurrent ARPC and RP. CONCLUSION: There was no statistical difference in recurrence or audiometric outcomes between patients who underwent TT versus those who did not during initial surgery for ARPC. However malleus and stapes erosion were significantly associated with recurrent ARPC and RP. These findings suggest that TT at initial ARPC surgery did not play a role in preventing recurrence, but malleus and incus erosion, was predictive of recurrent disease. A larger, prospective study of TT at initial surgery for ARPC is needed.