Oncologists' perspectives on post-cancer treatment communication and care coordination with primary care physicians.

Post-treatment cancer care is often fragmented and of suboptimal quality. We explored factors that may affect cancer survivors' post-treatment care coordination, including oncologists' use of electronic technologies such as e-mail and integrated electronic health records (EHRs) to communicate with primary care physicians (PCPs). We used data from a survey (357 respondents; participation rate 52.9%) conducted in 2012-2013 among medical oncologists caring for patients in a large US study of cancer care delivery and outcomes. Oncologists reported their frequency and mode of communication with PCPs, and role in providing post-treatment care. Seventy-five per cent said that they directly communicated with PCPs about post-treatment status and care recommendations for all/most patients. Among those directly communicating with PCPs, 70% always/usually used written correspondence, while 36% always/usually used integrated EHRs; telephone and e-mail were less used. Eighty per cent reported co-managing with PCPs at least one post-treatment general medical care need. In multivariate-adjusted analyses, neither communication mode nor intensity were associated with co-managing survivors' care. Oncologists' reliance on written correspondence to communicate with PCPs may be a barrier to care coordination. We discuss new research directions for enhancing communication and care coordination between oncologists and PCPs, and to better meet the needs of cancer survivors post-treatment.

International comparison of performance measures for screening mammography: can it be done?

OBJECTIVE: Published screening mammography performance measures vary across countries. An inter-national study was undertaken to assess the comparability of two performance measures: the recall rate and positive predictive value (PPV). These measures were selected because they do not require identification of all cancers in the screening population, which is not always possible. SETTING: The screening mammography programs or data registries in 25 member countries of the International Breast Cancer Screening Network (IBSN). METHODS: In 1999 an assessment form was distributed to IBSN country representatives in order to obtain information on how screening mammography was performed and what specific data related to recall rates and PPV were collected. Participating countries were then asked to provide data to allow calculation of recall rates, PPV and cancer detection rates for screening mammography by age group for women screened in the period 1997-1999. RESULTS: Twenty-two countries completed the assessment form and 14 countries provided performance data. Differences in screening mammography delivery and data collection were evident. For most countries, recall rates were higher for initial than for subsequent mammograms. There was no consistent relationship of initial to subsequent PPV, although PPV generally decreased as the recall rate increased. Recall rates decreased with increasing age, while PPV increased as age increased. CONCLUSION: Similar patterns for mammography performance measures were evident across countries.However, the development of a more standardized approach to defining and collecting data would allow more valid international comparisons, with the potential to optimize mammography performance. At present, international comparisons of performance should be made with caution due to differences in defining and collecting mammography data.

Quality assurance for screening mammography data collection systems in 22 countries.

OBJECTIVES: To document the mammography data that are gathered by the organized screening programs participating in the International Breast Cancer Screening Network (IBSN), the nature of their procedures for data quality assurance, and the measures used to assess program performance and impact. METHODS: A detailed questionnaire covering multiple aspects of quality assurance in screening mammography was mailed to IBSN representatives in 23 countries. RESULTS: Countries collect a wealth of screening mammography data, much of it computerized. Most countries have designated staff for data quality assurance. All provide staff training, and most have documentation requirements for data collection. Nearly all have one or more procedures to maintain data confidentiality. Countries are heterogeneous in collecting and assessing data to monitor screening program performance and impact. CONCLUSIONS: Demonstrating that population-based screening mammography reduces breast cancer mortality requires collection of high-quality data on key aspects of the multi-step screening process. Assuring the quality of data collection systems for screening mammography programs is an important and evolving area for IBSN countries.

Development of a comorbidity index using physician claims data.

Important comorbidities recorded on outpatient claims in administrative datasets may be missed in analyses when only inpatient care is considered. Using the comorbid conditions identified by Charlson and colleagues, we developed a comorbidity index that incorporates the diagnostic and procedure data contained in Medicare physician (Part B) claims. In the national cohorts of elderly prostate (n = 28,868) and breast cancer (n = 14,943) patients assessed in this study, less than 10% of patients had comorbid conditions identified when only Medicare hospital (Part A) claims were examined. By incorporating physician claims, the proportion of patients with comorbid conditions increased to 25%. The new physician claims comorbidity index significantly contributes to models of 2-year noncancer mortality and treatment received in both patient cohorts. We demonstrate the utility of a disease-specific index using an alternative method of construction employing study-specific weights. The physician claims index can be used in conjunction with a comorbidity index derived from inpatient hospital claims, or employed as a stand-alone measure.

Stage at diagnosis and treatment patterns among older women with breast cancer: an HMO and fee-for-service comparison.

CONTEXT: Few studies have compared patterns of care in health maintenance organization (HMO) and fee-for-service (FFS) settings. OBJECTIVE: To examine breast cancer stage at diagnosis and, for those at an early stage, treatment patterns for elderly women in HMO and FFS settings. DESIGN: Cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked to Medicare enrollment records. SETTINGS AND PARTICIPANTS: Women aged 65 years or older residing in 11 geographic areas who were newly diagnosed as having breast cancer between 1988 and 1993. MAIN OUTCOME MEASURES: Standardized percentage of cases diagnosed at late stages for HMO vs FFS; standardized percentage of early-stage cases undergoing initial treatment with breast-conserving surgery (BCS); and, among BCS cases, standardized percentage receiving adjuvant radiation therapy. Standardization was achieved through logistic regression, controlling for patient demographics, cancer history, county of residence, year of diagnosis, and educational attainment at the census tract level. Analyses of treatment patterns were controlled for stage at diagnosis and tumor size. RESULTS: The HMO enrollees were less likely to have breast cancer diagnosed at late stages than FFS patients (HMO, 7.6%; FFS, 10.8%; difference, -3.2% [95% confidence interval (CI), -4.2% to -2.2 %]). Among early-stage cases, the percentages undergoing BCS were similar in HMO and FFS settings overall (HMO, 38.4%; FFS, 36.8%; difference, 1.6% [95% CI, 0.0%-3.2%]); percentages varied markedly at the individual plan level. Among women undergoing BCS, HMO enrollees were significantly more likely to receive radiation therapy but, again, results varied by plan (HMO, 69.0%; FFS, 63.7%; difference, 5.3% [95% CI, 2.9%-7.7%]). In general, use of BCS and radiation therapy was substantially higher than that found in an earlier study examining cases diagnosed between 1985 and 1989. CONCLUSIONS: Treatment of early-stage breast cancer in HMOs often differs from local FFS patterns, but not in a consistent way. During the period of our study, elderly HMO enrollees did not appear to have systematic access problems with adjuvant radiation therapy following BCS compared with women in an FFS setting.

Factors influencing enrollment in clinical trials for cancer treatment.

BACKGROUND: Recruitment of cancer patients to clinical trials is an ongoing challenge. In this study, we assess factors that may influence enrollment in clinical trials for cancer treatment. METHODS: Between June 1997 and January 1998, data were collected on all adult cancer patients evaluated for enrollment in National Cancer Institute-sponsored clinical trials at 15 medical facilities in the southeastern United States. RESULTS: More than 2,300 cancer patients were evaluated; 7% were enrolled. Neither patient sex nor race predicted enrollment. Patients with fee-for-service coverage were more than twice as likely to be enrolled compared with patients with other types of coverage, including managed care. Patient refusal accounted for the nonenrollment of nearly 40% of those clinically eligible. CONCLUSIONS: Although multiple factors influence enrollment in clinical trials for cancer treatment, results suggest that insurance coverage plays a role. Patient refusal, a substantial reason for nonenrollment, points to the need for continued efforts to educate physicians and the public in the value of clinical trials.

Trends and black/white differences in treatment for nonmetastatic prostate cancer.

OBJECTIVES: Controversy and uncertainty surround use of radical prostatectomy, radiation therapy, and conservative symptomatic management in treating elderly men with nonmetastatic prostate cancer. Prior studies have demonstrated variations in use of these therapies by patient age, race, and geographic region. This study examined trends in treatment for nonmetastatic prostate cancer in black and white men aged 65 and older during the period 1986 to 1993. The study also explored factors related to use of initial therapies in these men. METHODS: A cohort of 52,915 men (48,410 white; 4,505 black) obtained from the linked SEER-Medicare dataset was used in an observational design. Various sociodemographic and clinical measures were incorporated in the analysis. RESULTS: For both races, use of aggressive therapy had increased with time, although this trend appears to be slowing. Black men were less likely to undergo radical prostatectomy than were white men, but use of radiation therapy did not differ markedly by race. High socioeconomic status and a lack of comorbid conditions were among the factors predictive of aggressive therapy receipt. The relation between race and receipt of aggressive therapy was dependent on whether prostate cancer was detected by transurethral resection of the prostate. Sociodemographic and clinical characteristics explained approximately half the difference between black men and white men in radical prostatectomy use. CONCLUSIONS: This study documents racial differences and changing practice patterns in the treatment of nonmetastatic prostate cancer in elderly men. Further research is required to more fully understand reasons for racial differences, as well as to promote rational use of health care resources.

Trends and outcomes of outpatient mastectomy in elderly women.

BACKGROUND: Considerable public attention has focused on the use of outpatient mastectomy and has resulted in numerous legislative proposals to mandate a minimum hospital stay following mastectomy. To date, only limited scientific data are available regarding the use and the outcomes of outpatient mastectomy. The purpose of this study was to provide population-based information on trends and outcomes for outpatient mastectomy in elderly women. METHODS: Medicare data for elderly women with fee-for-service coverage were examined for trends and regional variation in the use of outpatient mastectomy. Logistic regression was used to identify patient and provider characteristics associated with having an outpatient mastectomy, and outcomes were assessed by calculating the risk of being rehospitalized and the reasons for rehospitalization. RESULTS: From 1986 through 1995, the proportion of mastectomies performed on an outpatient basis increased from virtually 0% to 10.8%. Outpatient mastectomies were more likely to be performed on women with no coexisting health problems in hospitals that were for-profit or non-teaching or in large metropolitan statistical areas. Women undergoing outpatient mastectomy had substantially higher rates of rehospitalization within 30 days than women with a 1-day stay in the hospital. Both groups had comparable rates of rehospitalization for complications definitely related to their surgery. The percentage of women who required rehospitalization was low, and the actual number of women rehospitalized was relatively small. CONCLUSIONS: We conclude that the risks from outpatient mastectomy are modest, although ongoing monitoring of outcomes and assessment of patient satisfaction are needed.

Physicians' reactions to change in recommendations for mammography screening.

INTRODUCTION: In December 1993 the National Cancer Institute (NCI) decided to replace its mammography screening guidelines with a Statement of Evidence on Breast Cancer Screening. The Statement of Evidence represented a departure from the institute's previous policy of recommending routine mammography screening in women 40-49 and annual screening in women 50 and over. This study assesses knowledge of and attitudes toward the Statement of Evidence among primary care physicians. In addition, we explore the extent to which physicians changed their individual clinical policies on mammography screening in response to the Statement of Evidence. METHODS: Between October 1994 and June 1995, 545 randomly selected North Carolina primary care physicians completed a mailed questionnaire (overall survey response rate = 42%). RESULTS: Awareness of the Statement of Evidence was high (83%), but attitudes toward it were negative, with a majority of physicians stating that the change in policy was confusing to women and physicians. About 8% of physicians who were aware of the Statement of Evidence changed their practice accordingly. Most physicians reported recommending routine mammography screening in women 40-49 and annual screening in women 50 and over. A majority stated they believe scientific evidence supports these practices. CONCLUSIONS: When faced with a new policy in which guidelines are no longer provided and evidence supporting less use of an established technology is conveyed, physicians demonstrated disinclination to change. The impact of changes in recommendations on physician practice is an important consideration for those who develop and promote screening policies.

Mammography screening under 50: a limited perspective on a multifaceted issue.

Navarro and Kaplan's article on the cost-effectiveness of mammography screening for women under 50 offers a limited perspective on a complex and rapidly evolving issue. They suggest that eliminating mammography benefits for younger women will result in the delivery of other important women's health services, but they provide no data on the cost-effectiveness of these programs compared to mammography. Four other areas of omission significantly limit this article's scope and potential impact. Navarro and Kaplan do not discuss: 1) increasing breast cancer incidence in women under 50, particularly in African-American women; 2) the importance of breast cancer risk in relation to mammography screening; 3) the relevance of meta-analyses of randomized clinical trials done by other investigators; and 4) the heterogeneity of mammography screening recommendations in clinical practice.

Accrual to the Breast Cancer Prevention Trial by participating Community Clinical Oncology Programs: a panel data analysis.

In 1992 patient accrual to the National Cancer Institute-sponsored Breast Cancer Prevention Trial was initiated in the United States and Canada. The Trial will involve 16,000 women who are evaluated to be at high risk of developing breast cancer. Nearly 250 health care organizations are participating in the Trial, including over 40 Community Clinical Oncology Program (CCOP) organizations, which are a component of the NCI's national clinical trials program. A previous NCI-funded evaluation conducted by the University of North Carolina showed the CCOP program to be an effective means of transferring the latest cancer technology, particularly cancer treatments, to the community setting. This paper describes a study designed to evaluate the performance of CCOP organizations in the Breast Cancer Prevention Trial. Using data from the first fifteen months of the Trial, the ability of CCOPs to accrue women is assessed using panel data estimation techniques. An attempt is made to predict accrual by structural, process, and environmental characteristics of participating CCOPs. Factors predictive of accrual include month in which accrual occurred and the extent of competition for trial participants in the CCOP service area. The hypothesized model explains slightly over 19 percent of the variation in accrual performance. The analysis demonstrates the utility of a panel data approach to modeling the dynamics of CCOP participation in a chemoprevention clinical trial.