Time to Insurance Approval in Private and Public Payers Does Not Influence Survival in Patients Who Undergo Hematopoietic Cell Transplantation.

In the United States, insurance status has been implicated as a barrier to obtaining timely treatment. In this retrospective cohort study of 521 patients who underwent first hematopoietic cell transplantation (HCT), we investigated the association between timeliness of HCT and overall survival. Timeliness was operationally defined in the following 3 ways: (1) payer approval, from request for approval to actual payer approval; (2) transplantation speed, from payer approval to time of actual HCT; and (3) total time, from request for approval to HCT. Patients with private insurance had longer time to payer approval (P < .0001) than those with public payers but shorter time from approval to actual HCT (P < .0001) and total time to HCT (P < .0001). Multivariate Cox regression showed no significant differences in risk of death between slow and fast times in the 3 indices of timeliness in the models that used all patients (n = 509), autologous HCT in lymphoma (n = 278), and autologous HCT in multiple myeloma (n = 121). Additional studies to evaluate the effect of insurance timeliness on all patients for whom HCT is recommended, not just those who undergo HCT, should be conducted.

Persistent Disparities in Adult Hematopoietic Cell Transplantation.

The use of large databases has provided advancements in the understanding of racial, ethnic, and socioeconomic disparities in the field of adult hematopoietic cell transplants (HCT). Disparities exist on individual, institutional, and systemic levels for both allogeneic and autologous HCT. We reviewed the most recent publications that utilized large databases to elucidate disparities in HCT and placed them into historical context of the other major studies in the field. Two emerging themes were identified. These themes are persistent inequalities in both allogeneic HCT and autologous HCT for myeloma and the importance of improving homogeneity of care in HCT. Minimization of inequalities can be achieved only with an understanding of the persistent barriers that exist in the field.

National Survey of Hematopoietic Cell Transplantation Center Personnel, Infrastructure, and Models of Care Delivery.

Hematopoietic cell transplantation (HCT) is a complex procedure that requires availability of adequate infrastructure, personnel, and resources at transplantation centers. We conducted a national survey of transplantation centers in the United States to obtain data on their personnel, infrastructure, and care delivery models. A 42-item web-based survey was administered to medical directors of transplantation centers in the United States that reported any allogeneic HCT to the Center for International Blood and Marrow Transplant Research in 2011. The response rate for the survey was 79% for adult programs (85 of 108 centers) and 82% for pediatric programs (54 of 66 centers). For describing results, we categorized centers into groups with similar volumes based on 2010 total HCT activity (adult centers, 9 categories; pediatric centers, 6 categories). We observed considerable variation in available resources, infrastructure, personnel, and care delivery models among adult and pediatric transplantation centers. Characteristics varied substantially among centers with comparable transplantation volumes. Transplantation centers may find these data helpful in assessing their present capacity and use them to evaluate potential resource needs for personnel, infrastructure, and care delivery and in planning for growth.

Estimating the State-Level Supply of Cancer Care Providers: Preparing to Meet Workforce Needs in the Wake of Health Care Reform.

PURPOSE: This study describes the supply of cancer care providers-physicians, nurse practitioners (NPs), and physician assistants (PAs)-in Nebraska and analyzes changes in the supply over a 5-year period. METHOD: We used workforce survey data for the years 2008 to 2012 from the Health Professions Tracking Service to analyze the cancer care workforce supply in the state of Nebraska. The supply of cancer care providers was analyzed over the 5-year period on the basis of age, sex, specialty, and practice location; distribution of work hours for cancer care physicians was analyzed for 2012. RESULTS: From 2008 to 2012, there was a 3.3% increase in the number of cancer care physicians. Majority of the cancer care physicians (82.5%), NPs (81.1%), and PAs (80%) reported working in urban counties, whereas approximately half of the state's population resides in rural counties (47%). Compared with the national distribution, Nebraska has a lower proportion of medical oncologists, radiation oncologists, and pediatric hematologists/oncologists. The gap between the number of cancer care physicians age ≥ 64 years and the number younger than 40 years is slowly closing in Nebraska, with an increase in those age ≥ 64 years. CONCLUSION: Increasing cancer incidence and improved access to cancer care through the Affordable Care Act could increase demand for cancer care workers. Policymakers and legislators should consider a range of policies based on the best available data on the supply of cancer care providers and the demand for cancer care.

Cardiac magnetic resonance imaging for the assessment of the myocardium after doxorubicin-based chemotherapy.

OBJECTIVES: Doxorubicin is associated with a cumulative dose-dependent nonischemic cardiomyopathy. Cardiac magnetic resonance imaging (cMRI) is able to examine both structural and functional components of the myocardium. Our aim was to assess the myocardial changes in non-Hodgkin lymphoma patients undergoing doxorubicin-based chemotherapy using cMRI. MATERIALS AND METHODS: cMRI examination was performed before and 3 months after chemotherapy. Experienced investigators interpreted each cMRI, and were blinded to all data. Left ventricular ejection fractions (LVEF), cardiac deformation, and delayed gadolinium enhancement (GD-DE) were quantified for each cMRI. The change between LVEF, GD-GE, and cardiac deformation parameters were compared between the 2 cMRI studies. A Δ LVEF≥10% was considered clinically relevant. The findings of GD-GE or changes in myocardial strain were analyzed as independent variables. RESULTS: All 10 patients enrolled received a cumulative dose of doxorubicin of 300 mg/m. A comparison of pretreatment and posttreatment cMRI demonstrated 5 (50%) patients with a ≥10% decrease in LVEF (median, -8.4%; range, 1% to -17%; P=0.004). Three patients had at least 1 new or progressive segment of GD-DE. The global circumferential strain was significantly lower in patients after treatment, as compared with values before treatment (P=0.018) and to normal controls (P=0.046). Patients after treatment also had significantly lower global longitudinal strain than controls (P=0.035), and longitudinal strain values that tended to decrease compared with pretreatment values (P=0.073). DISCUSSION: Our data suggests that cMRI has the ability to assess both early structural and functional myocardial changes in association with doxorubicin-based chemotherapy.

Insights on practice variations in the management of lymphoma and leukemia.

Clinical practice guidelines are systematically developed statements designed to assist practitioners in making decisions about appropriate healthcare for specific clinical circumstances. Their successful implementation should improve quality of care by decreasing inappropriate variation and expediting the application of effective advances to everyday practice. Despite wide promulgation, guidelines have had limited effect on changing physician behaviors. This two-part review article highlights variations in the current recommended management of lymphoma (Part I) and leukemia (Part II), with some focus on targeted therapies. Focus on variations that may be amenable to educational programs designed for physicians were also considered in the review. For the purpose of this report, "variation" is defined as any deviation in the treatment or management of a particular hematologic malignancy where practice guidelines exist. Specific studies that demonstrate factors that may cause variations in clinical outcomes of hematologic malignancies and may contribute to variations in practice are featured.

Race and socioeconomic status influence outcomes of unrelated donor hematopoietic cell transplantation.

Success of hematopoietic cell transplantation (HCT) can vary by race, but the impact of socioeconomic status (SES) is not known. To evaluate the role of race and SES, we studied 6207 unrelated-donor myeloablative (MA) HCT recipients transplanted between 1995 and 2004 for acute or chronic leukemia or myelodysplastic syndrome (MDS). Patients were reported by transplant center to be White (n = 5253), African American (n = 368), Asian/Pacific-Islander (n = 141), or Hispanic (n = 445). Patient income was estimated from residential zip code at time of HCT. Cox regression analysis adjusting for other significant factors showed that African American (but not Asian or Hispanic) recipients had worse overall survival (OS) (relative-risk [RR] 1.47; 95% confidence interval [CI] 1.29-1.68, P < .001) compared to Whites. Treatment-related mortality (TRM) was higher in African Americans (RR 1.56; 95% CI 1.34-1.83, P < .001) and in Hispanics (RR 1.30; 95% CI 1.11-1.51, P = .001). Across all racial groups, patients with median incomes in the lowest quartile (<$34,700) had worse OS (RR 1.15; 95% CI 1.04-1.26, P = .005) and higher risks of TRM (RR 1.21; 1.07-1.36, P = .002). Inferior outcomes among African Americans are not fully explained by transplant-related factors or SES. Potential other mechanisms such as genetic polymorphisms that have an impact on drug metabolism or unmeasured comorbidities, socioeconomic factors, and health behaviors may be important. Low SES, regardless of race, has a negative impact on unrelated donor HCT outcomes.

Methodological and logistical considerations to study design and data collection in racial/ethnic minority populations evaluating outcome disparity in hematopoietic cell transplantation.

Outcome disparity associated with race or ethnicity in the United States has been observed in hematopoietic cell transplantation (HCT). The underlying reasons for such disparity are not known. In the United States, an optimal study of health care disparity by race or ethnicity involves consideration of both biologic and psychosocial determinants, which requires an adequately powered, prospective cohort study design. To better characterize the nature and quantify the magnitude of the many impediments relevant to conducting a successful prospective study involving racial or ethnic minorities in HCT, we conducted a feasibility study to help guide planning of a larger scale outcome and disparity study in HCT. The primary questions to be addressed in the study were: (1) can we establish a racially or ethnically diverse patient sample that will respond to a survey focused on sociodemographic, economic, health insurance, cultural, spiritual, and religious well-being, and social support information? (2) What is the retention rate in the study over time? (3) What is the quality of the data collected from the patients over time? The challenges we faced in conducting this multicenter feasibility study are summarized in this report. Despite the difficulty in conducting disparity studies in racial and ethnic minorities, such studies are essential to ensure that people of all ethnic and racial backgrounds have the best chance possible of benefiting from HCT.

Individual physician practice variation in hematopoietic cell transplantation.

PURPOSE: Previous studies have evaluated practice variation in hematopoietic cell transplantation (HCT) among transplant centers and countries. There are no studies investigating individual physician practice variation in HCT. METHODS: An international Internet-based survey of transplant physicians collected data on medical decisions made by adult and pediatric HCT physicians. Multivariable analyses identified practitioner and transplant center characteristics predictive of medical decision making. RESULTS: Analysis of 526 assessable respondents showed a wide variation in management approaches to specific clinical scenarios. Pediatric and adult transplant physicians differed significantly in their management strategies for chronic myeloid leukemia, acute and chronic graft-versus-host disease, and choice of graft source for patients with aplastic anemia. Among adult transplant physicians, there was little agreement on the patient factors favoring reduced intensity conditioning or myeloablative conditioning. CONCLUSION: These results emphasize the heterogeneity of worldwide transplant practices. Local preferences or biases likely result in similar patients being offered different transplant and treatment procedures. The degree of practice variation also highlights the need for clinical trials to clarify areas of controversy. Where clinical trials are not feasible, data from observational studies may be the best available evidence to guide practice.

Quality of life assessment in nonmelanoma cervicofacial skin cancer.

OBJECTIVES/HYPOTHESIS: Health-related quality of life (QOL) assessment of patients with nonmelanoma skin cancer is poorly understood. The objectives of the study were to determine the general QOL of patients with cervicofacial skin cancer and to identify patient, clinical, and preventive behavior variables associated with patients' QOL. STUDY DESIGN: Cross-sectional study of 121 consecutive patients (65 female and 56 male patients) presenting to a dermatological Mohs surgery clinic with nonmelanoma skin cancer of the head and neck. METHODS: Quality of life assessment was performed before counseling or treatment. Measures included the Medical Outcomes Study Short Form 36-item Health Survey (SF-36) and the Functional Assessment of Cancer Therapy-General (FACT-G). RESULTS: Both instruments demonstrated good internal consistency as measured by Cronbach's alpha (SF-36, alpha = 0.45-0.91; FACT-G, alpha = 0.61-0.90). The SF-36 scores were similar to historical norms. Bivariate analysis indicated significant correlation coefficients between QOL and patients' coexisting illnesses and medical risk factors. Sun-protective behaviors were associated with better QOL. The relationship appeared to be minimally influenced by patients' sociodemographic characteristics and disease-related variables (size, location, extent). CONCLUSIONS: Sun-protective behaviors were positively associated with certain QOL subscale scores in the population in the study. General QOL instruments demonstrated minimal impact of nonmelanoma skin cancer on patients at initial diagnosis. However, general measures may not be sensitive to the impact of nonmelanoma skin cancer. The development of a more disease-specific instrument may be necessary to evaluate this disease process.