RESUMO
PURPOSE: Efforts to curb the rising costs of cancer care while improving quality include alternative payment models (APMs), which offer incentives to reduce avoidable spending and provide high-quality and cost-efficient care. The impact of proposed APMs has not been quantified in real-world practice. In this study, we evaluated ASCO's Patient-Centered Oncology Payment (PCOP) model in existing fee-for-service (FFS) Medicare beneficiaries to understand the magnitude of potential cost savings. MATERIALS AND METHODS: SEER-Medicare data were used to identify women with advanced ovarian cancer diagnosed between 2000 and 2012 who either (1) underwent primary debulking surgery followed by chemotherapy or (2) received neoadjuvant chemotherapy followed by surgery. Medicare payments in each cohort were used to compare FFS and PCOP and to estimate the potential for cost savings across health care services received, including outpatient emergency department visits, hospitalizations, and imaging. RESULTS: Three thousand seven hundred seventy-seven primary debulking surgery and 866 neoadjuvant chemotherapy patients were included in the study, with mean total costs of $75,433 and $95,138 in 2016 US$, respectively Most costs were related to chemotherapy or hospitalization. Additional PCOP-related payments would be offset if hospitalizations could be reduced by 11.6% or imaging claims by 88%. CONCLUSION: APMs have the potential to reduce costs of current FFS reimbursement via either a large reduction in imaging or a modest reduction in hospitalizations during treatment of ovarian cancer. PCOP is a reasonable payment structure for oncologists if the additional payments can provide the necessary resources to invest in improved coordination of care.
Assuntos
Análise Custo-Benefício/economia , Oncologia/economia , Neoplasias Ovarianas/terapia , Assistência Centrada no Paciente/economia , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Planos de Pagamento por Serviço Prestado/economia , Feminino , Gastos em Saúde , Hospitalização/economia , Humanos , Medicare/economia , Estadiamento de Neoplasias , Neoplasias Ovarianas/economia , Neoplasias Ovarianas/epidemiologia , Estados Unidos/epidemiologiaRESUMO
This group-randomized controlled trial examines the effects of a school garden intervention on availability of fruits and vegetables (FV) in elementary school children's homes. Within each region, low income U.S. schools in Arkansas, Iowa, New York, and Washington State were randomly assigned to intervention group (nâ¯=â¯24) or waitlist control group (nâ¯=â¯22). Children were in grades 2, 4, and 5 at baseline (nâ¯=â¯2768). The garden intervention consisted of both raised-bed garden kits and a series of grade-appropriate lessons. FV availability at home was measured with a modified version of the GEMS FJV Availability Questionnaire. The instrument was administered at baseline (Fall 2011) and throughout the intervention (Spring 2012, Fall 2012, Spring 2013). Analyses were completed using general linear mixed models. The garden intervention led to an overall increase in availability of low-fat vegetables at home. Among younger children (2nd grade at baseline), the garden intervention led to greater home availability of vegetables, especially, low-fat vegetables. Moreover, for the younger group, garden intervention fidelity (GIF) or robustness predicted home availability of fruit, vegetables, and low-fat vegetables. School gardens have potential to affect FV availability in the home environment.
Assuntos
Frutas , Jardins , Promoção da Saúde , Instituições Acadêmicas , Verduras , Criança , Feminino , Preferências Alimentares , Humanos , Estudos Longitudinais , Masculino , Pobreza , Estudantes/psicologia , Estudantes/estatística & dados numéricos , Inquéritos e Questionários , Estados UnidosRESUMO
OBJECTIVE: Although older patients represent the most rapidly growing segment of the oncology population, clinical care is guided by very little data on patient-reported outcomes, particularly satisfaction with healthcare. Using a large cancer center registry, we sought to describe factors associated with satisfaction with care for older and younger oncology patients. METHODS: Data were collected through the University of North Carolina Health Registry Cancer Survivorship Cohort. Satisfaction was measured with the Patient Satisfaction Questionnaire Short Form. Quality of life (QOL) measures included were the Promis Global short form and the Functional Assessment of Cancer Therapy General (FACT-G). RESULTS: A total of 2385 patients were included. 460 (20%) were aged 70 and above (older group). Older patients reported significantly higher levels of satisfaction in domains of time spent with doctor (scores 3.84 versus 3.73 p=0.03) and financial aspects (scores 4.03 versus 3.44 p<0.001) compared to younger patients. In multivariable analysis, higher QOL scores and higher self-reported ECOG performance status were associated with higher satisfaction scores. African American race was associated with lower satisfaction scores in all age groups. QOL was more closely correlated with satisfaction in older patients compared to younger patients. CONCLUSIONS: Older patients with cancer report higher levels of satisfaction with care, in part due to lesser financial burden of care. Better QOL is associated with satisfaction with care in older patients. Use of patient-reported outcomes such as patient satisfaction may help improve patient-centered geriatric oncology care.
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Neoplasias/psicologia , Satisfação do Paciente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/economia , Neoplasias/epidemiologia , Qualidade de Vida , Sistema de Registros , Autorrelato , Fatores de Tempo , Adulto JovemRESUMO
PURPOSE: Large randomized trials have established the noninferiority of shorter courses of "hypofractionated" radiation therapy (RT) to the whole breast compared to conventional courses using smaller daily doses in the adjuvant treatment of selected breast cancer patients undergoing lumpectomy. Hypofractionation is more convenient and less costly. Therefore, we sought to determine uptake of hypofractionated breast RT over time. METHODS AND MATERIALS: In the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database, we identified 16,096 women with node-negative breast cancer and 4269 with ductal carcinoma in situ (DCIS) who received lumpectomy followed by more than 12 fractions of RT between 2004 and 2010. Based on Medicare claims, we determined the number of RT treatments given and grouped patients into those receiving hypofractionation (13-24) or those receiving conventional fractionation (≥25). We also determined RT technique (intensity modulated RT or not) using Medicare claims. We evaluated patterns and correlates of hypofractionation receipt using bivariate and multivariable analyses. RESULTS: Hypofractionation use was similar in patients with DCIS and those with invasive disease. Overall, the use of hypofractionation increased from 3.8% in 2006 to 5.4% in 2007, to 9.4% in 2008, and to 13.6% in 2009 and 2010. Multivariable analysis showed increased use of hypofractionation in recent years and in patients with older age, smaller tumors, increased comorbidity, higher regional education, and Western SEER regions. However, even in patients over the age of 80, the hypofractionation rate in 2009 to 2010 was only 25%. Use of intensity modulated RT (IMRT) also increased over time (from 9.4% in 2004 to 22.7% in 2009-2010) and did not vary significantly between patients receiving hypofractionation and those receiving traditional fractionation. CONCLUSIONS: Hypofractionation use increased among low-risk older US breast cancer patients with publication and maturation of evidence from randomized trials, but overall use of this cost-saving approach remained low. This contrasts with the more rapid rate of adoption of IMRT in the same time period, a costly innovation supported by less strong evidence of benefit.
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Neoplasias da Mama/radioterapia , Carcinoma Intraductal não Infiltrante/radioterapia , Fracionamento da Dose de Radiação , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/patologia , Carcinoma Intraductal não Infiltrante/cirurgia , Feminino , Humanos , Modelos Logísticos , Mastectomia Segmentar , Análise Multivariada , Radioterapia Adjuvante/métodos , Radioterapia Adjuvante/estatística & dados numéricos , Radioterapia Adjuvante/tendências , Radioterapia de Intensidade Modulada/economia , Radioterapia de Intensidade Modulada/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Programa de SEER/estatística & dados numéricos , Carga TumoralRESUMO
IMPORTANCE: Routine cancer screening has unproven net benefit for patients with limited life expectancy. OBJECTIVE: To examine the patterns of prostate, breast, cervical, and colorectal cancer screening in the United States in individuals with different life expectancies. DESIGN, SETTING, AND PARTICIPANTS: Data from the population-based National Health Interview Survey (NHIS) from 2000 through 2010 were used and included 27 404 participants aged 65 years or older. Using a validated mortality index specific for NHIS, participants were grouped into those with low (<25%), intermediate (25%-49%), high (50%-74%), and very high (≥75%) risks of 9-year mortality. MAIN OUTCOMES AND MEASURES: Rates of prostate, breast, cervical, and colorectal cancer screening. RESULTS: In participants with very high mortality risk, 31% to 55% received recent cancer screening, with prostate cancer screening being most common (55%). For women who had a hysterectomy for benign reasons, 34% to 56% had a Papanicolaou test within the past 3 years. On multivariate analysis, very high vs low mortality risk was associated with less screening for prostate (odds ratio [OR], 0.65 [95% CI, 0.50-0.85]), breast (OR, 0.43 [95% CI, 0.35-0.53]), and cervical (OR, 0.50 [95% CI, 0.36-0.70]) cancers. There was less screening for prostate and cervical cancers in more recent years compared with 2000, and there was no significant interaction between calendar year and mortality risk for any cancer screening (P > .05 for all cancers). Our sensitivity analysis showed that screening was also common in individuals with less than 5-year life expectancy. CONCLUSIONS AND RELEVANCE: A substantial proportion of the US population with limited life expectancy received prostate, breast, cervical, and colorectal cancer screening that is unlikely to provide net benefit. These results suggest that overscreening is common in both men and women, which not only increases health care expenditure but can lead to net patient harm.
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Detecção Precoce de Câncer/estatística & dados numéricos , Expectativa de Vida , Neoplasias/prevenção & controle , Procedimentos Desnecessários/estatística & dados numéricos , Adulto , Idoso , Biomarcadores Tumorais/sangue , Neoplasias da Mama/prevenção & controle , Colonoscopia/estatística & dados numéricos , Neoplasias Colorretais/prevenção & controle , Detecção Precoce de Câncer/métodos , Medicina Baseada em Evidências , Feminino , Humanos , Modelos Logísticos , Masculino , Mamografia/estatística & dados numéricos , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Neoplasias/mortalidade , Teste de Papanicolaou/estatística & dados numéricos , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/prevenção & controle , Risco , Estados Unidos/epidemiologia , Procedimentos Desnecessários/efeitos adversos , Procedimentos Desnecessários/economia , Neoplasias do Colo do Útero/prevenção & controleRESUMO
PURPOSE: For patients with a high likelihood of having metastatic disease (high-risk prostate cancer), bone scan is the standard, guideline-recommended test to look for bony metastasis. We quantified the use of bone scans and downstream procedures, along with associated costs, in patients with high-risk prostate cancer, and their use in low- and intermediate-risk patients for whom these tests are not recommended. METHODS AND MATERIALS: Patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed with prostate cancer from 2004 to 2007 were included. Prostate specific antigen (PSA), Gleason score, and clinical T stage were used to define D'Amico risk categories. We report use of bone scans from the date of diagnosis to the earlier of treatment or 6 months. In patients who underwent bone scans, we report use of bone-specific x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) scans, and bone biopsy within 3 months after bone scan. Costs were estimated using 2012 Medicare reimbursement rates. RESULTS: In all, 31% and 48% of patients with apparent low- and intermediate-risk prostate cancer underwent a bone scan; of these patients, 21% underwent subsequent x-rays, 7% CT, and 3% MRI scans. Bone biopsies were uncommon. Overall, <1% of low- and intermediate-risk patients were found to have metastatic disease. The annual estimated Medicare cost for bone scans and downstream procedures was $11,300,000 for low- and intermediate-risk patients. For patients with apparent high-risk disease, only 62% received a bone scan, of whom 14% were found to have metastasis. CONCLUSIONS: There is overuse of bone scans in patients with low- and intermediate-risk prostate cancers, which is unlikely to yield clinically actionable information and results in a potential Medicare waste. However, there is underuse of bone scans in high-risk patients for whom metastasis is likely.
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Neoplasias Ósseas/diagnóstico , Neoplasias Ósseas/secundário , Medicare/economia , Neoplasias da Próstata , Procedimentos Desnecessários/economia , Idoso , Idoso de 80 Anos ou mais , Biópsia/economia , Biópsia/estatística & dados numéricos , Neoplasias Ósseas/economia , Neoplasias Ósseas/epidemiologia , Neoplasias Ósseas/patologia , Osso e Ossos/diagnóstico por imagem , Osso e Ossos/patologia , Análise Custo-Benefício , Humanos , Imageamento por Ressonância Magnética/economia , Imageamento por Ressonância Magnética/estatística & dados numéricos , Masculino , Gradação de Tumores , Próstata/patologia , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/economia , Neoplasias da Próstata/patologia , Risco , Programa de SEER , Tomografia Computadorizada por Raios X/economia , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Estados Unidos , Procedimentos Desnecessários/estatística & dados numéricosRESUMO
BACKGROUND: For patients with adverse pathologic factors (positive surgical margins, extracapsular extension, or seminal vesicle invasion) on prostatectomy pathology, the use and timing of postsurgical treatments are controversial. The goal of the current study was to examine patterns of care in patients with a pathologic indication for postprostatectomy radiotherapy (RT) using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. METHODS: A total of 3460 men treated with radical prostatectomy for localized prostate cancer between 2000 and 2006 with at least 1 adverse pathologic factor and at least 3 years of claims data after surgery were included. Medicare claims through December 31, 2009 were examined. Rates of postprostatectomy hormonal therapy, RT, or both were examined. Logistic regression analysis examined potential factors associated with the receipt and timing of RT. RESULTS: Within 3 years after surgery, 1076 patients (31%) received some form of further therapy, including 850 (25%) who received RT. Receipt of RT was < 35% in all subgroups including every year of study. Fewer than one-half of patients who received RT (43%) did so within 6 months of surgery. On multivariate analysis, pathologic T classification and tumor grade were associated with receipt of RT within 6 months or 3 years of surgery, as were younger age, geographic region, and population density. CONCLUSIONS: Rates of postprostatectomy RT remain low and the timing of RT has not appreciably changed since the publication of the randomized trials supporting the use of adjuvant RT. The use of hormone therapy is almost as common as RT, despite a relative lack of evidence supporting its use in this setting.
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Medicare/estatística & dados numéricos , Neoplasias da Próstata/radioterapia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Humanos , Masculino , Prostatectomia , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Radioterapia Adjuvante/estatística & dados numéricos , Radioterapia Adjuvante/tendências , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/tendências , Programa de SEER , Terapia de Salvação/estatística & dados numéricos , Terapia de Salvação/tendências , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Timely delivery of care has been identified by the Institute of Medicine as an indicator for quality health care, and treatment delay is a potentially modifiable obstacle that can contribute to the disparities among African American (AA) and Caucasian patients in prostate cancer recurrence and mortality. Using the Surveillance, Epidemiologic and End Results (SEER)-Medicare linked database, we compared time from diagnosis to treatment in AA and Caucasian prostate cancer patients. METHODS: A total of 2506 AA and 21,454 Caucasian patients diagnosed with localized prostate cancer from 2004 through 2007 and treated within 12 months were included. Linear regression was used to assess potential differences in time to treatment between AA and Caucasian patients, after adjusting for sociodemographic and clinical covariates. RESULTS: Time from diagnosis to definitive (prostatectomy and radiation) treatment was longer for AA patients in all risk groups, and most pronounced in high-risk cancer (96 versus 105 days, P < .001). On multivariate analysis, racial differences to any and definitive treatment persisted (ß = 7.3 and 7.6, respectively, for AA patients). Delay to definitive treatment was longer in high-risk (versus low-risk) disease and in more recent years. CONCLUSIONS: AA patients with prostate cancer experienced longer time from diagnosis to treatment than Caucasian patients with prostate cancer. AA patients appear to experience disparities across all aspects of this disease process, and together these factors in receipt of care plausibly contribute to the observed differences in rates of recurrence and mortality among AA and Caucasian patients with prostate cancer.
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Negro ou Afro-Americano/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapia , Tempo para o Tratamento , População Branca/estatística & dados numéricos , Idoso , Antineoplásicos Hormonais/uso terapêutico , Braquiterapia , Humanos , Masculino , Medicare , Análise Multivariada , Prostatectomia , Neoplasias da Próstata/etnologia , Neoplasias da Próstata/mortalidade , Programa de SEER , Estados Unidos/epidemiologiaRESUMO
PURPOSE: We examined whether an increased distance to a urologist is associated with a delayed diagnosis of prostate cancer among black and white patients, as manifested by higher risk disease at diagnosis. MATERIALS AND METHODS: North Carolina Central Cancer Registry data were linked to Medicare claims for patients with incident prostate cancer diagnosed in 2004 to 2005. Straight-line distances were calculated from the patient home to the nearest urologist. Race stratified multivariate ordinal logistic regression was used to examine the association between distance to a urologist and prostate cancer risk group (low, intermediate, high or very high/metastasis) at diagnosis for black and white patients while accounting for age, comorbidity, marital status and diagnosis year. An overall model was then used to examine the distance × race interaction effect. RESULTS: Included in analysis were 1,720 white and 531 black men. In the overall cohort the high risk cancer rate increased monotonically with distance to a urologist, including 40% for 0 to 10, 45% for 11 to 20 and 57% for greater than 20 miles. Correspondingly the low risk cancer rate decreased with longer distance. On race stratified multivariate analysis longer distance was associated with higher risk prostate cancer for white and black patients (p = 0.04 and <0.01, respectively) but the effect was larger in the latter group. The distance × race interaction term was significant in the overall model (p = 0.03). CONCLUSIONS: Longer distance to a urologist may disproportionally impact black patients. Decreasing modifiable barriers to health care access, such as distance to care, may decrease racial disparities in prostate cancer.