Managed care and cancer outcomes for Medicare beneficiaries with disabilities.

OBJECTIVE: To determine if the type of insurance arrangement, specifically health maintenance organization (HMO) vs fee-for-service (FFS), affects cancer outcomes for Medicare beneficiaries with disabilities. STUDY DESIGN: Retrospective cohort. METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare linked dataset to identify beneficiaries older and younger than 65 years entitled to Medicare benefits because of disability (Social Security Disability Insurance) who subsequently were diagnosed as having breast cancer (n = 6839) or non-small cell lung cancer (n = 10,229) from 1988 through 1999. We categorized persons according to Medicare insurance arrangement (continuous FFS, continuous HMO, or mixed FFS/HMO) during the periods 12 months before diagnosis and 6 months after diagnosis. Using a retrospective cohort design, we examined stage at diagnosis, cancer-directed treatments, and survival. RESULTS: Women with continuous HMO insurance had earlier-stage breast cancer diagnosis (adjusted relative risk, 0.77; 95% confidence interval, 0.65-0.91) and were more likely to receive radiation therapy following breast-conserving surgery (adjusted relative risk, 1.11; 95% confidence interval, 1.03-1.19). Women having continuous HMO insurance had better breast cancer survival, primarily resulting from earlier-stage diagnosis. Among persons with non-small cell lung cancer, those having mixed FFS/HMO insurance were more likely to receive definitive surgery for early-stage disease (adjusted odds ratio, 1.23; 95% confidence interval, 1.02-1.49) and to have better overall survival but not significantly better lung cancer survival. CONCLUSION: When diagnosed as having breast cancer or non-small cell lung cancer, some Medicare beneficiaries with disabilities fare better with managed care compared with FFS insurance plans.

Clinical trials and tribulations: lessons learned from recruiting pregnant ex-smokers for relapse prevention.

The development of smoking cessation and relapse prevention interventions for pregnant and postpartum women is a public health priority. However, researchers have consistently reported substantial difficulty in recruiting this population into clinical trials. The problem is particularly acute for relapse prevention studies, which must recruit women who have already quit smoking because of their pregnancy. Although these individuals are an important target for tobacco control efforts, they represent an extremely small subgroup of the general population. This paper describes multiple recruitment strategies used for a clinical trial of a self-help relapse prevention program for pregnant women. The effectiveness of the strategies and the direct expense per participant recruited are provided. A proactive recruitment strategy (telephoning women whose phone numbers were purchased from a marketing firm) was ultimately much more successful than a variety of reactive strategies (advertisements, press releases, direct mail, Web placement, health care provider outreach). We found few differences between proactively and reactively recruited participants on baseline variables. The primary difference was that the former had smoked fewer cigarettes per day and reported lower nicotine dependence prior to quitting. Strengths and limitations of the recruitment strategies are discussed.

Cost disparities in lung cancer treatment by disability status, sex, and race.

BACKGROUND: The recent literature contains numerous reports of disparities in the diagnosis, treatment, and outcomes of lung cancer across a growing list of population subgroups, including disability status. A common assumption is that disparities stem mainly from variations in the level and type of treatment resources available to specific subgroups. Few studies, however, have directly measured resource differentials. Since policy makers identify reducing health disparities as a critical priority, this study examined whether cumulative Medicare costs (resource consumption) for lung cancer treatment differ across eight patient subgroups defined by disability status, sex, and race. HYPOTHESIS: Treatment disparities across the eight subgroups will be reflected in variations in the cumulative cost profiles of those subgroups, controlling for other plausible cost drivers. Failure to detect statistically significant differentials in these cost profiles implies that treatment disparities stem from factors other than access to, and utilization of, health care services. METHODS: Linked SEER-Medicare data were used to construct cost profiles by service type and treatment phase for roughly 80,000 incident lung cancer cases in patients aged 45 to 85 years at diagnosis. Multiple regression models then tested for cost differentials across the eight subgroups, controlling for various patient and disease characteristics. RESULTS: Significant cost differentials were detected, some unanticipated. Women tended to have higher treatment costs than men; they also had more favorable survivals. Nonwhites also tended to have higher treatment costs than whites, although they had significantly shorter survivals. On average, men with disabilities consumed the fewest treatment resources and had the shortest survivals. Mixed results were obtained for women with disabilities. CONCLUSIONS: Among others, the findings suggest that reducing disparities will take more than just improving access to health care. Special attention must be paid to lung cancer patients with disabilities by both policy makers and clinicians.

Evaluation of breast cancer care under Puerto Rico's Health Care Reform.

Puerto Rico has implemented Health Care Reform legislation that shifted medically indigent and underserved persons from direct care by public sector institutions to managed care arrangements through the private sector. Our aim is to assess how previously underserved women with breast cancer have fared during the first three years of the Reform. Medical claims data were obtained on breast cancer cases in San Juan who were either enrolled in the capitated Reform plan or in a commercial policy offered by the same insurer. A set of indicators reflecting initial therapy, use of key services, and cumulative utilization rates of various medical procedures were constructed. Statistical tests were conducted to assess whether these indicators differed between Reform- and commercially-insured patients. Failure to reject null hypotheses of indicator differences were then used to judge Reform progress. We found some differences, but they were neither pervasive nor unidirectional. On balance, we conclude that previously underserved women are being treated for breast cancer roughly on par with other patients. This conclusion, however, is preliminary and subject to important qualifications.

Cancer stage at diagnosis and survival among persons with Social Security Disability Insurance on Medicare.

OBJECTIVE: To examine stage at diagnosis and survival for disabled Medicare beneficiaries diagnosed with cancer under age 65 and compare their experiences with those of other persons diagnosed under age 65. DATA SOURCES: Surveillance, Epidemiology, and End Results (SEER) Program data and SEER-Medicare linked data for 1988-1999. SEER-11 Program includes 11 population-based tumor registries collecting information on all incident cancers in catchment areas. Tumor registry and Medicare data are linked for persons enrolled in Medicare. STUDY DESIGN: 307,595 incident cases of non-small cell lung (51,963), colorectal (52,092), breast (142,281), and prostate (61,259) cancer diagnosed in persons under age 65 from 1988 to 1999. Persons who qualified for Social Security Disability Insurance and had Medicare (SSDI/Medicare) were identified from Medicare enrollment files. Ordinal polychotomous logistic regression and Cox proportional hazards regression were used to estimate adjusted associations between disability status and later-stage diagnoses and mortality (all-cause and cancer-specific). PRINCIPAL FINDINGS: Persons with SSDI/Medicare had lower rates of Stages III/IV diagnoses than others for lung (63.3 versus 69.5 percent) and prostate (25.5 versus 30.8 percent) cancers, but not for breast or colorectal cancers. After adjustment, they remained less likely to be diagnosed at later stages for lung and prostate cancers. Nevertheless, persons with SSDI/Medicare experienced higher all-cause mortality for each cancer. Cancer-specific mortality was higher among persons with SSDI/Medicare for breast and colorectal cancer patients. CONCLUSIONS: Disabled Medicare beneficiaries are diagnosed with cancer at similar or earlier stages than others. However, they experience higher rates of cancer-related mortality when diagnosed at the same stage of breast and colorectal cancer.

Disparities in breast cancer treatment and survival for women with disabilities.

BACKGROUND: Breast-conserving surgery combined with axillary lymph node dissection and radiotherapy or mastectomy are definitive treatments for women with early-stage breast cancer. Little is known about breast cancer treatment for women with disabilities. OBJECTIVE: To compare initial treatment for early-stage breast cancer between women with and without disabilities and to examine the association of treatment differences and survival. DESIGN: Retrospective cohort study. SETTING: 11 Surveillance, Epidemiology, and End Results (SEER) Program tumor registries. PARTICIPANTS: 100,311 women who received a diagnosis of stage I to IIIA breast cancer at 21 to 64 years of age from 1988 to 1999. Women who qualified for Social Security Disability Insurance (SSDI) and Medicare at breast cancer diagnosis were considered disabled. MEASUREMENTS: Receipt of breast-conserving surgery versus mastectomy. For women who had breast-conserving surgery (n = 49 166), the authors examined receipt of radiotherapy and axillary lymph node dissection. Survival was measured from diagnosis until death or until 31 December 2001. RESULTS: Women with SSDI and Medicare coverage had lower rates of breast-conserving surgery than other women (43.2% vs. 49.2%; adjusted relative risk, 0.80 [95% CI, 0.76 to 0.84]). Among women who had breast-conserving surgery, women with SSDI and Medicare coverage were less likely than other women to receive radiotherapy (adjusted relative risk, 0.83 [CI, 0.77 to 0.90]) and axillary lymph node dissection (adjusted relative risk, 0.81 [CI, 0.74 to 0.90]). Women with SSDI and Medicare coverage had lower survival rates than those of other women in all-cause mortality (adjusted hazard ratio, 2.02 [CI, 1.88 to 2.16]) and breast cancer-specific mortality (adjusted hazard ratio, 1.31 [CI, 1.18 to 1.45]). Results were similar after adjustment for treatment differences. LIMITATIONS: Findings are limited to women who qualified for SSDI and Medicare. No data on adjuvant chemotherapy and hormonal therapy were available, and details about the underlying disability were lacking. CONCLUSIONS: Women with disabilities had higher breast cancer mortality rates and were less likely to undergo standard therapy after breast-conserving surgery than other women. Differences in treatment did not explain the differences in breast cancer mortality rates.

Effect of concomitant use of benzodiazepines and other drugs on the risk of injury in a veterans population.

BACKGROUND: Benzodiazepines comprise a class of drugs that when used as monotherapy are generally acknowledged to pose a risk for injury by increasing the likelihood of falls, fall-related injuries, adverse drug events and car accidents. Benzodiazepines may also be used concomitantly with other high risk medications that may further exacerbate the risk of injury. The aim of this study is to examine the occurrence of the concomitant use of benzodiazepines and other drugs and then quantify the indirect effect of these drug combinations on the likelihood of an injury-related health care episode. METHODS: A multivariate model was specified that included outpatient prescription data and inpatient/outpatient medical utilisation records for 13,745 patients at a Veterans Administration hospital system over a 3-year period (1999-2001). We analysed 1,33,872 outpatient benzodiazepine prescriptions and >1.5 million non-benzodiazepine prescriptions for the study population. Micromedex software was used to identify combinations of benzodiazepines and other drugs that are likely to result in 'major' interactions. We then further restricted our focus to the use of these drug combinations within a 30-day period prior to an injury-related medical event. The adjusted odds ratio on a variable characterising concomitant use of a benzodiazepine and another drug within this period was used to quantify the relative risk of injury. The principal outcome was the estimated risk of an injury-related health care episode within a 30-day period when taking both a benzodiazepine and another drug with a 'major' severity rating as defined by Micromedex. The risk of injury was adjusted for comorbidities, hospital discharges, marital status, age, mean arterial pressure and body mass index, as well as the dose of benzodiazepine (converted to diazepam equivalents) and duration of benzodiazepine treatment. RESULTS: Of the 1,110 unique individuals who experienced an injury, 790 (71.2%) patients had used a benzodiazepine in combination with another drug. Furthermore, only 4.3% (320/7522) of the patients taking benzodiazepines who did not have concomitant drug use experienced an injury. The occurrence of this concomitant use increased the odds of an injury >2-fold in the model. Dose and duration of benzodiazepine use, as well as certain comorbidities, were also associated with an increased risk for injury, whereas being married reduced the risk. CONCLUSIONS: This is the first large-scale study to quantify the impact of concomitant use of benzodiazepines and other drugs on the risk of injury in a population of Veterans Administration patients. It demonstrates the utility of expanding the focus of inappropriate medication usage to include analyses that link potentially inappropriate drug use with health care utilisation for injuries.

Cost-effectiveness analysis of a complementary health intervention: the case of smoking relapse prevention.

OBJECTIVES: We assess the cost-effectiveness of smoking relapse prevention interventions designed to keep quitters from resuming the use of cigarettes. Because relapse prevention is complementary to smoking cessation efforts, the appropriate test of its cost-effectiveness is whether it reduces the incremental cost-effectiveness ratio (ICER) of smoking cessation. The major goal of the study is to carry out such a test. METHODS: Data from a randomized trial that ascertained the effectiveness of alternative modes of smoking relapse prevention are combined with ICER estimates of smoking cessation to assess whether relapse prevention is cost-effective. RESULTS: The trial produced convincing evidence that relapse prevention yields statistically significant reductions in the proportion of quitters who are smoking at 24 months postquit. The intervention effects are substantial enough to raise the denominator terms of the smoking cessation ICER and, thereby, offset the amount relapse prevention adds to cost numerator terms. In this sense, smoking relapse prevention tends to pay for itself. CONCLUSIONS: Smoking relapse prevention is a highly cost-effective addition to current efforts to curb cigarette consumption. Complementary health interventions of this sort should be assessed by different methods than those commonly found in the cost-effectiveness literature.

Efficacy and cost-effectiveness of a minimal intervention to prevent smoking relapse: dismantling the effects of amount of content versus contact.

Relapse prevention remains a major challenge to smoking cessation efforts. T. H. Brandon, B. N. Collins, L. M. Juliano, and A. B. Lazev (2000) found that a series of 8 empirically based relapse-prevention booklets mailed to ex-smokers over 1 year significantly reduced relapse. This study dismantled 2 components of that intervention: the amount of content (number of booklets) and the frequency of contact. Content and contact were crossed in a 2 X 2 factorial design. The criteria of at least 1 week of abstinence at baseline was met by 431 participants, 75%-85% of whom returned 12-, 18-, and 24-month follow-up questionnaires. Eight booklets produced consistently higher point-prevalence abstinence rates than did a single booklet, but frequency of contact did not affect outcome. Moreover, the high-content interventions were highly cost-effective.

A randomized controlled trial to increase cancer screening among attendees of community health centers.

BACKGROUND: We assessed the efficacy of the Cancer Screening Office Systems (Cancer SOS), an intervention designed to increase cancer screening in primary care settings serving disadvantaged populations. METHODS: Eight primary care clinics participating in a county-funded health insurance plan in Hillsborough County, Fla, agreed to take part in a cluster-randomized experimental trial. The Cancer SOS had 2 components: a cancer-screening checklist with chart stickers that indicated whether specific cancer-screening tests were due, ordered, or completed; and a division of office responsibilities to achieve high screening rates. Established patients were eligible if they were between the ages of 50 and 75 years and had no contraindication for screening. Data abstracted from charts of independent samples collected at baseline (n = 1,196) and at a 12-month follow-up (n = 1,237) was used to assess whether the patient was up-to-date on one or more of the following cancer-screening tests: mammogram, Papanicolaou (Pap) smear, or fecal occult blood testing (FOBT). RESULTS: In multivariate analysis that controlled for baseline screening rates, secular trends, and other patient and clinic characteristics, the intervention increased the odds of mammograms (odds ratio [OR] = 1.62, 95% confidence interval [CI], 1.07-9.78, P = .023) and fecal occult blood tests (OR = 2.5, 95% CI, 1.65-4.0, P <.0001) with a trend toward greater use of Pap smears (OR = 1.57, 95% CI, 0.92-2.64, P = .096). CONCLUSIONS: The Cancer SOS intervention significantly increased rates of cancer screening among primary care clinics serving disadvantaged populations. The Cancer SOS intervention is one option for providers or policy makers who wish to address cancer related health disparities.

Cost-effectiveness of an intervention to increase cancer screening in primary care settings.

BACKGROUND: The main goal was to conduct a cost-effectiveness analysis of an intervention designed to increase cancer screening rates in primary care settings serving disadvantaged populations. The Cancer Screening Office Systems intervention reminded clinicians whether screening mammography, Pap smears, and/or fecal occult blood tests were up-to-date in eligible patients and then established a division of office responsibilities to ensure that tests were ordered and completed. METHODS: The cost-effectiveness analysis was predicated on data generated from a cluster-randomized controlled trial of Cancer Screening Office Systems conducted at eight clinics participating in a county-funded health insurance plan in Florida. Cost numerators were computed from estimated time inputs of both clinical personnel and patients valued at nationally representative wages as well as expenses for Cancer Screening Office Systems-related materials and overhead. Effectiveness denominators were constructed from net changes in screening rates observed experimentally over a 12-month follow-up. Two types of incremental cost-effectiveness ratios were computed: the cost per extra screening test by type and the cost per life-year saved without and with Cancer Screening Office Systems. RESULTS: Cancer Screening Office Systems produced statistically significant increases in screening rates, and these gains more than outweighed the costs of the intervention viewed from either payer or societal perspectives. CONCLUSIONS: Cancer Screening Office Systems are a cost-effective means of addressing cancer-related health disparities.

Current and evolving strategies for colorectal cancer screening.

BACKGROUND: Colorectal cancer is a major cause of cancer mortality and morbidity. Screening can potentially prevent most colorectal cancers by detection and removal of precursor adenomas. METHODS: The literature and clinical practice guidelines are reviewed, with an emphasis on advances of the last 10 years and evolving screening methods. RESULTS: Colonoscopy has come to be used for screening in persons at average risk for colorectal cancer because of the comparative ineffectiveness of other methods, although these methods continue to be recommended. Virtual colonoscopy and fecal DNA testing are emerging technologies with promise to be more effective than fecal occult blood testing or sigmoidoscopy in selecting those persons who should undergo colonoscopy. Next to age, family history is the most common risk factor for colorectal cancer and one that warrants more aggressive screening and, in some instances, genetic counseling and testing. Hereditary nonpolyposis colorectal cancer accounts for as many as 1 in 20 colorectal cancers, but to take advantage of recent advances in genetic testing for this disorder, a high level of clinical suspicion must be maintained. CONCLUSIONS: If we are to reduce mortality and morbidity from colorectal cancer, practicing clinicians need to be aware of current and evolving strategies for colorectal screening, and assertively recommend the appropriate strategy to their patients.

Appraising the economic efficiency of cancer treatment: an exploratory analysis of lung cancer.

This paper tests whether the measured cost-effectiveness of treating different subgroups of an incident population of lung cancer patients differs significantly and, by implication, whether the provision of care to these patients is tolerably efficient in economic terms. Data from administrative records and Registry follow-up on 544 non-small cell lung cancer patients diagnosed at a single NCI-designated Comprehensive Cancer Center are used to conduct the empirical analysis. The main results show statistically significant differences in cumulative costs and patient outcomes across subgroups differing by disease stage and treatment modality. These findings imply that the delivery of lung cancer care is inefficient. Substantive and methodological implications are discussed.

Breast cancer detection and outcomes in a disability beneficiary population.

Women with disabilities may be at higher risk of late-stage breast cancer. Using the 1991-93 Medicare-Surveillance Epidemiology and End Results (SEER)-linked data set, the authors compared stage at diagnosis and mortality, for Social Security Disability Insurance (SSDI)-qualifying women and similarly aged non-SSDI qualifying women. Disabled patients were diagnosed at a later American Joint Committee on Cancer stage. Disabled patients had higher all-cause mortality rates but had similar breast cancer-specific mortality. Disabled women belonging to Medicare HMOs tended to have earlier stage diagnosis and better survival compared to Medicare fee-for-service (FFS) insurance. In conclusion, disabled patients tended to be diagnosed with breast cancer at a later stage and to have higher mortality. These findings were more pronounced in Medicare FFS than in Medicare HMOs.

Functional impairment and the economic consequences of female breast cancer.

Recent trends in breast cancer diagnosis and mortality suggest that long-term survivors are now more likely to be functionally impaired and, hence, more likely to experience adverse economic outcomes. This study tests whether women who have survived breast cancer for at least five years exhibit more, or more severe, functional impairments than otherwise similar women without breast cancer. It also tests whether women with more severe impairments experience poorer economic outcomes attributable to their functional status. A group of 105 breast cancer survivors was interviewed to obtain data on health and economic changes in the five-year period since diagnosis and initial treatment. An age- and work-matched group of 105 women without cancer was also interviewed to obtain the same data over the same time period. Key changes in the functional status of the subjects as well as economic outcomes such as changes in market earnings, household income, and insurance coverage were measured. Whether impairment is more severe in the breast cancer group than the comparison group was then tested statistically; whether economic outcomes are more adverse in more impaired than less impaired women regardless of their breast cancer status was also tested. The analysis turned up statistically significant evidence in regard to each of these relationships. Breast cancer survivors were more likely than controls to be functionally impaired at the five-year benchmark. Impaired women, in turn, were more likely to reduce work effort and experience downturns in market earnings, among other things. Policy and research implications are discussed.

Indirect economic effects of long-term breast cancer survival.

PURPOSE: The indirect morbidity/disability costs of breast cancer may be rising as a consequence of the growth in the population of long-term survivors. This study was conducted to test whether women who have survived breast cancer for at least 5 years experience long-lasting or continuing economic consequences that are attributable to their disease. DESCRIPTION OF STUDY: A group of 105 women who initially had been treated for breast cancer approximately 5 years before were interviewed to obtain data on economic, demographic, and health changes in the period since diagnosis. An age-matched and work-matched group of 105 women without cancer also was interviewed to obtain the same data for the same time period. Key changes in the economic position of subjects and their families were measured, including changes in work effort, pay rates, and annual earnings of working women and changes in household earnings, income, and assets of all women. RESULTS: These preliminary empirical findings suggest that breast cancer exacts an economic toll from long-term survivors. In particular, survivors who were working at the time of their diagnosis experienced significantly larger reductions in annual market earnings over the 5-year study period than did working control subjects. These losses appear to arise mostly from reduced work effort, not changes in pay rates. Also, changes in total household earnings were lower for survivors, suggesting the presence of family adjustments to the disease. However, no significant differences were detected between the groups in changes in total income or assets over the study period. CLINICAL IMPLICATIONS: Clinicians and policy makers must seek ways to minimize the indirect economic losses that are attributable to breast cancer.

Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy.

PURPOSE: Professionally administered psychosocial interventions have been shown to improve the quality of life of cancer patients undergoing chemotherapy. The present study sought to improve access to psychosocial interventions during chemotherapy treatment by evaluating the efficacy and costs of a patient self-administered form of stress management training that requires limited professional time or experience to deliver. PATIENTS AND METHODS: Four hundred eleven patients about to start chemotherapy were randomly assigned to receive usual psychosocial care only, a professionally administered form of stress management training, or a patient self-administered form of stress management training. Quality-of-life assessments were conducted before randomization and before the second, third, and fourth treatment cycles. Intervention costs were estimated from both payer and societal perspectives. RESULTS: Compared with patients who received usual care only, patients receiving the self-administered intervention reported significantly (P < or = .05) better physical functioning, greater vitality, fewer role limitations because of emotional problems, and better mental health. In contrast, patients who received the professionally administered intervention fared no better in terms of quality of life than patients receiving usual care only. Costs of the self-administered intervention were estimated to be 66% (from a payer perspective) to 68% (from a societal perspective) less than the average costs of professionally administered psychosocial interventions for patients starting chemotherapy. CONCLUSION: Evidence regarding the efficacy and favorable costs of self-administered stress management training suggests that this intervention has the potential to greatly improve patient access to psychosocial intervention during chemotherapy treatment.