Estimating the economic burden of status epilepticus to the health care system.

PURPOSE: Status epilepticus (SE) is a major neurological condition associated with significant morbidity and mortality. No studies to evaluate the cost burden of SE have been performed to date. This study estimates the direct cost related to an inpatient admission for SE in an urban academic medical center. METHODS: Cases of SE were defined based on a standard 30 min or greater seizure duration. The inpatient claims data were analyzed for 192 patients admitted with SE from 1 July 1993 through 30 June 1994. Patient demographic and clinical characteristics associated with increased cost were identified using multiple regression. The direct costs for SE were compared with other common DRGs. RESULTS: The median reimbursement for a patient with SE was dollar 8417. The average length of stay for all SE patients was 12.9 days. Age groups (17-45 and 46-64) and etiology (acute CNS) were the only patient factors significantly associated with increased cost. SE patients had 30-60% higher reimbursements than patients admitted for other acute health problems including acute myocardial infarction or congestive heart failure. CONCLUSIONS: The direct inpatient costs for SE are high compared with the direct costs of admissions for other major conditions such as acute myocardial infarction or congestive heart failure. Data from this study were used to estimate a dollar 4 billion annual direct cost for inpatient admissions for SE. Given the incidence and the high costs, further more detailed evaluation of these costs may be useful in assessing the adequacy of reimbursement for this subset of patients with epilepsy.

Review of a pilot quality-assessment program for interpretative comments.

BACKGROUND: Interpretative commenting constitutes an important aspect of the post-analytical phase in chemical pathology, but has only recently been the subject of quality assessment. The Royal College of Pathologists of Australasia (RCPA)-Australasian Association of Clinical Biochemists (AACB) Chemical Pathology Patient Report Comments Program is currently in its third year, having started in 2000 as a pilot program. We present a review of the pilot program. METHODS: The program is aimed at individuals rather than laboratories. Two cases were circulated to participants of the Chemical Pathology Quality Assurance Program every month over a 6-month period. The case report contained the age and sex of the patient, together with brief clinical notes, the biochemistry results for commenting and other information of relevance. Three lines of space were given for the comment. The comments received from participants were broken down into their components and translated into common key phrases for the purpose of summarization and analysis. A histogram of the frequency of use of the common key phrases was generated. The comments or the key phrases were not given scores or marks, nor was any other indication given as to the appropriateness of their comments. RESULTS: This approach of simple peer-group comparison of comments without any assessment of the appropriateness of the comments was found to be inadequate; thus, when the program continues, key phrases will be classified according to degree of appropriateness and a suggested comment for each case will be proposed by an 'expert' panel. CONCLUSIONS: The program can serve a useful role in continuing education. Clinical biochemists and trainees who add interpretative comments to results produced by their laboratory, or give interpretative advice over the telephone, may potentially benefit from participating in this program.

The impact of disease management on outcomes and cost of care: a study of low-income asthma patients.

An asthma disease management program designed specifically for low-income patients experiencing significant adverse events can improve health outcomes substantially, while lowering costs. The Virginia Health Outcomes Partnership aimed to help physicians in a fee-for-service primary care case management program manage asthma in Medicaid recipients. Approximately one-third of physicians treating asthma in an area designated as the intervention community volunteered to participate in training on disease management and communication skills. This large-scale study discovered that the rate of emergency visit claims for patients of participating physicians who received feedback reports dropped an average of 41% from the same quarter a year earlier, compared to only 18% for comparison community physicians. Although only a third of the intervention community physicians participated in the training, emergency visit rates for all intervention community physicians nonetheless declined by 6% relative to the comparison community among moderate-to-severe asthma patients when data for participating and nonparticipating physicians were combined. At the same time, the dispensing of some reliever drugs recommended for asthma increased 25% relative to the comparison community. A cost-effectiveness analysis projected direct savings to Medicaid of $3 to $4 for every incremental dollar spent providing disease management support to physicians. The results of this study demonstrate the potential this program offers, especially for Medicaid programs in other states that want to improve the care of their primary care case management networks and, at the same time, manage costs.

Causes of death in elderly prostate cancer patients and in a comparison nonprostate cancer cohort.

BACKGROUND: Prostate cancer tends to affect older men and to progress relatively slowly. Since the prevalence of comorbidity increases with advancing age, competing causes of death are important contributors to death rates among prostate cancer patients. Accurate determination of the underlying causes of death in older men dying with prostate cancer may thus also be more difficult. METHODS: We compared the distribution of underlying causes of death in decedents from a population-based cohort of elderly prostate cancer patients to that from a population-based comparison cohort of elderly men without prostate cancer. Among decedents from the prostate cancer patient cohort, we examined associations of patient demographics, disease stage, and initial treatment, with assignment of a prostate cancer underlying cause of death (versus any other cause) by use of multivariable logistic regression. In the subgroup of prostate cancer patient decedents having underlying causes of death other than prostate cancer, the underlying cause distribution was compared with that in nonprostate cancer cohort decedents. RESULTS: Prostate cancer was the underlying cause for 39% (95% confidence interval [CI] = 36.3-41.9) of the decedents in the prostate cancer cohort. Causes of death among prostate cancer patients not dying of prostate cancer were similar to those among the nonprostate cancer cohort decedents. However, in those who were aggressively treated, the adjusted odds of other cancer causes of death were 51% higher (odds ratio [OR] = 1.51; 95% CI = 1.08-2.10) than that in nonprostate cancer patient decedents, while in those treated with watchful waiting the adjusted odds were 34% lower (OR = 0.66; 95% CI = 0.47-0.93). CONCLUSIONS: Initial treatment may influence the underlying cause of death reported in vital statistics for prostate cancer patients.

A sociodemographic and economic comparison of breast reconstruction, mastectomy, and conservative surgery.

BACKGROUND: There are a variety of surgical choices for women with early-stage breast cancer, including breast-conserving surgery, mastectomy, or mastectomy plus reconstructive surgery. This report examines some of the factors that affect these choices and the costs of the various treatment options. METHODS: Data from the Virginia Cancer Registry were linked to insurance claims from the Trigon Blue Cross and Blue Shield Company for women with local and regional staged breast cancer from 1989 to 1991 in Virginia. Multivariate analyses and cost studies were performed. RESULTS: There were 592 women who underwent breast-conserving surgery (BCS, 26%), mastectomy (58%), or mastectomy plus reconstruction (16%). Increasing age reduced the use of reconstruction. The choice of reconstruction was not affected by tumor size, nodal status, or race. Sixty percent of women had immediate breast reconstruction at the time of mastectomy; the majority had the implant procedure. The cost of BCS ($21,582) was higher than that of mastectomy ($16,122, P < .01). The costs for BCS and mastectomy were significantly lower than for mastectomy plus reconstruction ($31,047, P < .05). The 2-year cost for immediate reconstruction was $8200 less than for delayed procedures and was similar to the cost of BCS. CONCLUSIONS: Age was the driving force in reconstruction decisions. Clinical factors such as tumor size and nodal status were more important for the choice between BCS and mastectomy. There are significant cost differences between the various procedures. For a similar cosmetic outcome, BCS is less expensive than breast reconstruction. When reconstruction is required, a simultaneous procedure is less expensive.

Monitoring the health status and impact of treatment on Americans: the Medicare Beneficiary Health Status Registry.

OBJECTIVE: A major new survey program, the Medicare Beneficiary Health Status Registry (MBHSR), has been proposed to improve the monitoring of the health status of Medicare beneficiaries. The MBHSR would collect data by mail with telephone follow up of nonrespondents to permit economical assessment of a total Registry of approximately 200,000 Medicare beneficiaries, approximately 54,000 of whom would be surveyed in any given year. (Surveys would be conducted of samples of new enrollees who would be reinterviewed every five years.) METHOD: To assess the feasibility of that approach, a field test was conducted with a probability sample (n = 1,922) that comprised approximately equal numbers of new Medicare enrollees (aged, 65) and current beneficiaries (age range, 76-80). The field test was designed to assess the quality of the data that this design would produce. FINDINGS: Results indicate that the proposed design of the MBHSR could achieve response rates of approximately 80% among both age cohorts using a survey instrument that took 30 minutes to complete. Internal reliability of Activities of Daily Living, Instrumental Activities of Daily Living, Mobility, Mental Health Index, General Health, and Prostate Symptomatology scales ranged from 0.77 to 0.93. When measurements were repeated approximately 30 days after the initial survey, moderate to high levels of cross temporal correlation (range, 0.64-0.96) were found for most indexes, with the exception of prostate symptomatology. In addition, an earlier comparison of survey responses in the MBHSR field test to Medicare payment records indicated that the MBHSR field test obtained highly accurate reports of most of the major surgeries that were recorded in Medicare claims files. CONCLUSION: The design proposed for the MBHSR is feasible. If implemented, it should produce acceptably high rates of response and data quality.

Predictors of Medicare costs in elderly beneficiaries with breast, colorectal, lung, or prostate cancer.

BACKGROUND: Determining the apportionment of costs of cancer care and identifying factors that predict costs are important for planning ethical resource allocation for cancer care, especially in markets where managed care has grown. DESIGN: This study linked tumor registry data with Medicare administrative claims to determine the costs of care for breast, colorectal, lung and prostate cancers during the initial year subsequent to diagnosis, and to develop models to identify factors predicting costs. SUBJECTS: Patients with a diagnosis of breast (n = 1,952), colorectal (n = 2,563), lung (n = 3,331) or prostate cancer (n = 3,179) diagnosed from 1985 through 1988. RESULTS: The average costs during the initial treatment period were $12,141 (s.d. = $10,434) for breast cancer, $24,910 (s.d. = $14,870) for colorectal cancer, $21,351 (s.d. = $14,813) for lung cancer, and $14,361 (s.d. = $11,216) for prostate cancer. Using least squares regression analysis, factors significantly associated with cost included comorbidity, hospital length of stay, type of therapy, and ZIP level income for all four cancer sites. Access to health care resources was variably associated with costs of care. Total R2 ranged from 38% (prostate) to 49% (breast). The prediction error for the regression models ranged from < 1% to 4%, by cancer site. CONCLUSIONS: Linking administrative claims with state tumor registry data can accurately predict costs of cancer care during the first year subsequent to diagnosis for cancer patients. Regression models using both data sources may be useful to health plans and providers and in determining appropriate prospective reimbursement for cancer, particularly with increasing HMO penetration and decreased ability to capture complete and accurate utilization and cost data on this population.

A comparison of patterns of care of nonsmall cell lung carcinoma patients in a younger and Medigap commercially insured cohort.

BACKGROUND: The objective of this study was to examine and compare lifetime treatment patterns and hospitalization of incident nonsmall cell lung carcinoma (NSCLC) between pre-Medicare eligible (age < 65 years) and supplemental Medigap (age > or = 65 years) enrollees in a commercially insured cohort using insurance claims. METHODS: Claims from Virginia Blue Cross and Blue Shield beneficiaries with NSCLC submitted between 1989-1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, disease stage, and type of tumor. Initial treatment categories were stratified using Physicians' Current Procedural Terminology codes. RESULTS: There were 1706 incident NSCLC patients; 349 were age < or = 64 years ("younger") and 1212 were age > or = 65 years ("elderly"). Having commercial insurance was not associated with any survival advantage compared with national averages at 2 years. In comparison with elderly patients, younger patients more often were treated with surgery for local disease (80.2% vs. 54.8%) and surgery alone or in combination with radiation for regional disease (51.9% vs. 32.0%). Radiation was used more often in elderly patients compared with younger patients with local disease (30.5% vs. 14.0%) but less often in patients with distant disease (76.2% vs. 54.9%). Compared with elderly patients, younger patients presenting with distant disease received more chemotherapy (18.8% vs. 5.1%; P <0.001); late palliative use of chemotherapy or radiation occurred in only 4-8% of younger patients. Compared with elderly patients, younger patients with regional or distant disease spent more days in the hospital (compared with national averages at 2 years: regional disease, 30.0 vs. 23.9 days; distant disease, 33.0 vs. 21.4 days; P <0.0001). CONCLUSIONS: The results of this study show that more comprehensive health insurance is not associated with better outcomes in patients with NSCLC. Age specific trends for greater use of surgery, radiation, and total hospitalization in younger patients is consistent with other reports. Commercial health care claims supplemented by clinical staging from cancer registries can address long term practice patterns in patients with cancer.

Does comorbid disease interact with cancer? An epidemiologic analysis of mortality in a cohort of elderly breast cancer patients.

BACKGROUND: Although widely believed that co-occurring chronic diseases in elderly persons do not act independently in causing death, there has been little empirical research assessing prognostic interrelationships between comorbidities. METHODS: Nonconcurrent prospective follow-up of 3,549 Virginia-resident elderly women diagnosed with a first breast cancer and 2,114 elderly women with no breast cancer history admitted to Virginia hospitals with principal diagnoses of genital prolapse during 1986-1988 was conducted through linkage of cancer registry and Medicare administrative records. Aggregate comorbidity was measured from Medicare claims via the Charlson comorbidity index (CCI). Mortality rates and relative risks were estimated for the breast cancer and non-breast-cancer groups stratified by the presence and level of comorbidity. Proportional hazards models were used to estimate Rothman's synergy index (S) measure of additive interaction. RESULTS: Over full follow-up, the excess mortality rate for women with breast cancer and other comorbidity was 17% greater than expected under the null hypothesis that risks were additive and independent (S = 1.17, p = .12). Stratified analyses revealed a pattern of S estimates across cancer stage subgroups that was biologically sensible, but this pattern was not supported by strong statistical evidence. CONCLUSIONS: This study provides the first empirical estimates of statistical interaction between breast cancer and other chronic comorbidity. S index values tended to be small, but these small effects would translate into substantial numbers of deaths attributable to interaction between cancer and comorbidity. Interactions between breast cancer and comorbid disease should be explored further in large studies that can estimate these effects with increased precision.

Costs of care associated with non-small-cell lung cancer in a commercially insured cohort.

PURPOSE: To examine the cost of incident cases of non-small-cell lung cancer (NSCLC) in a commercially insured cohort. METHODS: Claims from Virginia Blue Cross and Blue Shield (BCBS) beneficiaries with lung cancer from 1989 to 1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, stage, and type of cancer at diagnosis. Costs for all medical care included insurance payment, copayments, and deductibles for 2 years after diagnosis or until death. RESULTS: Three hundred forty-nine incident NSCLC patients were evaluated. The mean 2-year cost for each patient after diagnosis or until death was $47,941 (95% confidence interval, $43,758 to $52,124). Total average costs and hospital days were significantly lower for local disease ($37,514, 21.2 days), but were similar for regional ($52,797, 30.0 days) and distant ($49,382, 33.0 days) disease. Hospital days accounted for 48% and hospital-based claims for 70% of costs. Initial treatments, which included radiation, unadjusted for stage, had the lowest survival rates and the highest costs, and were associated with the most hospital days. Initial stage, race, gender, and age were not predictors of total 2-year costs. The independent predictors of total 2-year costs were type of treatment: any radiation therapy, any surgery, or any chemotherapy (all, P < .001). Inpatient hospital days was only a modest predictor of costs after adjusting for type of treatment. Patients who survived less than 1 year spent 30.5 days in hospital and had an average cost of $47,280. CONCLUSION: The direct health care costs of younger NSCLC patients care are substantial. These results should serve as a benchmark for future comparisons as the United States market shifts to managed care.

Variation in the use of breast-conserving therapy for Medicare beneficiaries in Virginia: clinical, geographic, and hospital characteristics.

BACKGROUND: Treatment for early-stage breast cancer has evolved significantly in recent years. Breast-conserving therapy (BCT) has been shown to offer equivalent survival compared to traditional mastectomy. However, there is marked variation in the performance of BCT which may not reflect clinical appropriateness or patient preference. Little is known about the factors related to variation in BCT performance in older women with early-stage breast cancer. METHODS: Retrospective claims analysis of 1,512 Medicare patients using part-A data for the years 1992 to 1993, with additional explicit chart review. A clinical algorithm was developed to categorize patients according to their candidacy for BCT and compare this to their treatment. Demographic, clinical, and geographic variables were included in the model. RESULTS: The overall BCT rate in Virginia was 20%, with marked variation among providers of all types. BCT rates ranged from 0% to 44% among hospitals caring for more than 12 cases per year. Twenty-six percent of patients considered good candidates for BCT by current guidelines received this option. Large urban hospitals had significantly higher rates of BCT than smaller hospitals, regardless of the presence of radiation oncology capability. Distance from radiation oncology facilities was a factor in low BCT rates of rural populations, but low BCT rates also were present even in facilities with access to radiation oncology services. CONCLUSIONS: These data present a detailed analysis of the patterns of BCT for Virginia Medicare beneficiaries with early-stage breast cancer. Clinical contraindications to BCT for confirmed early-stage disease were uncommon. Despite similar patient profiles and hospital-reported range of cancer services, marked variation in BCT rates exists. A large number of patients chose traditional mastectomy over BCT due to fears of radiation, but few received radiation oncology consultation. BCT rates were highest in hospitals with radiation oncology facilities on grounds; hospitals with facilities nearby had rates similar to those without access to radiation facilities. Patient preferences are documented poorly. This study provides further evidence that many women are receiving BCT in patterns that may not reflect clinical appropriateness for BCT nor access to necessary facilities.

Perioperative management of colon cancer under Medicare risk programs.

OBJECTIVE: To determine differences in perioperative care and outcomes for patients with colon cancer enrolled in Medicare health maintenance organizations compared with similar fee-for-service nonenrollees. METHODS: Cross-sectional evaluation of hospital care and posthospital outcomes with data obtained from medical records. Nineteen health maintenance organizations representing all model types were selected from 12 states. The nonenrollee sample was drawn from the same areas. The sample included 412 enrollees and 401 nonenrollees, representing 65 hospitals for health maintenance organizations and 61 hospitals for fee-for-service. RESULTS: Nonenrollees were slightly older and had higher preoperative risk. Enrollees had shorter intervals between admission and surgery (enrollees, 1.55 days vs nonenrollees, 2.85 days). Differences in length of stay (enrollees, 10.9 days vs nonenrollees, 14.2 days) persisted even after controlling for preoperative health status. Differences in admissions to intensive care units (enrollees, 36.4% vs nonenrollees, 44.4%) were highly influenced by preoperative health status. Nonenrollees were more significantly likely to receive preoperative antibiotics, postoperative testing (eg, postoperative chest radiographs and electrocardiograms), and postoperative patient-controlled analgesia. Tumor staging was similar for both groups. Enrollees were more likely to be discharged home, while nonenrollees were more likely to be discharged to a nursing home. There were no significant differences in hospital deaths or postdischarge readmissions. CONCLUSIONS: Health maintenance organization enrollees with colon cancer received less clinical services of several types than similar patients in fee-for-service settings, had shorter hospital stays, and were less likely to be discharged to nursing homes. However, there was no evidence that they experienced different outcomes.

Comorbidity measurement in elderly female breast cancer patients with administrative and medical records data.

The inter-rater reliability, cross-source (Medicare claims versus medical record) agreement, and ability to predict all-cause mortality of three aggregate comorbidity indices were evaluated in a group of 404 elderly, incident breast cancer cases identified from the Virginia Cancer Registry and linked to Medicare administrative data files. Comorbidity was based on both medical records and Medicare claims data using indices from Charlson et al (1987), Satariano and Ragland (1994), and Kaplan and Feinstein (1974). Inter-rater agreement was good for all indices (kappas > or = 0.80). Agreement between comorbidity indices measured by claims and medical records was considerably poorer (kappas between 0.30 and 0.40). However, claims-based and medical records-based comorbidity indices were similarly associated with mortality. For the Charlson index, the index best predicting survival, the adjusted relative risk for an increase from a lower to higher comorbidity category was 1.48 (95% confidence interval 1.23, 1.78) based on medical records compared to 1.53 (95% confidence interval 1.23, 1.93) based on Medicare claims. The claims-based Charlson index score still appeared to be associated with survival (relative risk = 1.30; 95% confidence interval = 1.00, 1.70) after controlling for the medical records-based score. This suggests that both comorbidity data sources add valuable prognostic information and, conversely, that the use of either source alone will result in some misclassification of comorbidity.

Measuring standards of care for early breast cancer in an insured population.

PURPOSE: To demonstrate the use of a combined data base to evaluate the care for local/regional invasive breast cancer in a large insured population of women aged less than 64 years. PATIENTS AND METHODS: We linked the procedural and hospital claims from Blue Cross Blue Shield (BCBS) of Virginia with clinical stage data from the Virginia Cancer Registry (VCR) from 1989 to 1991. A total of 918 women were assessed with a median age of 50 years; 68% had tumors less than 2 cm, 30% had positive axillary nodes, and 68% were assessed as having local summary stage. A quality-of-care "report card" was used based on standards of care from international Consensus Conferences. RESULTS: Eight percent had a mastectomy as the initial biopsy procedure. Sixty-nine percent of women ultimately underwent mastectomy. Of those women who underwent lumpectomy, 86% had subsequent radiation. Within 3 months of diagnosis, 43% had a bone scan and 20% a computed tomography (CT) scan. Of women with positive axillary lymph nodes, 83% aged less than 51 years and 52% aged 51 to 64 years received chemotherapy. Fifty-six percent of all women had claims from a medical oncologist. Of women having a total mastectomy, 27% had claims from a plastic surgeon. Sixty-six percent to 76% of women had a mammogram, 24% a bone scan, and 14% a CT scan in the 0-18 and 18-36 month intervals following primary treatment. CONCLUSION: This study confirms the feasibility of linking sources of data that provide complementary information needed to develop measurements regarding standards of quality and efficiency of oncologic care. This report should serve as an initial benchmark while we await reports from other populations to define the best practice.

Ability of Medicare claims data and cancer registries to identify cancer cases and treatment.

The objective of this study is to compare the ability of Medicare and cancer registry data to identify incident cancer cases and initial surgical therapy both singly and in combination. Data from the Virginia Cancer Registry (VCR) were linked to Medicare claims files (Medical Provider Analysis and Review File (MEDPAR)) for Virginia residents aged 65 years and over with breast, colorectal, lung, or prostate cancer diagnosed between 1986 and 1989. MEDPAR found 73-83% of cancer cases identified by VCR. Factors significantly associated with MEDPAR missing a case that was reported to VCR included younger age, male gender, living in an urban area, higher social class, in situ disease, and lack of cancer treatment. A total of 70-82% of cancer cases identified through Medicare claims were reported to the VCR. Older age, female gender, nonwhite race, comorbid conditions, no surgical procedures, multiple cancer admissions, and the position of the cancer diagnostic code on the MEDPAR record were factors significantly related to being missed by the VCR. The rate of capturing initial surgical therapies was similar to that of identifying cases. Combining information from VCR and MEDPAR resulted in increasing sensitivity for identifying incident cases to 92-97%. Using combined data from independent sources may improve reporting, increase the accuracy of cancer incidence estimates, and provide an opportunity to identify reasons for missing data.

A prospective, population-based epidemiologic study of status epilepticus in Richmond, Virginia.

This report presents the initial analysis of a prospective, population-based study of status epilepticus (SE) in the city of Richmond, Virginia. The incidence of SE was 41 patients per year per 100,000 population. The frequency of total SE episodes was 50 per year per 100,000 population. The mortality rate for the population was 22%, 3% for children and 26% for adults. Evaluation of the seizure types for adult and pediatric patients demonstrated that both partial and generalized SE occur with a high frequency in these populations. Based on the incidence of SE actually determined in Richmond, Virginia, we project 126,000 to 195,000 SE events with 22,200 to 42,000 deaths per year in the United States. The majority of SE patients had no history of epilepsy. These results indicate that SE is a common neurologic emergency.

Factors that determine the treatment for local and regional prostate cancer.

This article assesses the significance of comorbid and nonclinical factors in type of treatment received by elderly male patients with local-regional stage prostate cancer. Multivariate analysis of data from the Virginia Cancer Registry was linked to Medicare claim files, the Area Resource File, and 1990 Census Data. The type of initial treatment received was studied in 3117 men with local-regional staged prostate cancer diagnosed from 1985 to 1989. The frequency of surgical and radiation therapy for prostate cancer rose between 1985 and 1989 (12.5% to 18.5% for surgery, P < 0.001; 25% to 32% for radiation, P < 0.001). Age was the most important predictor of therapeutic choice; no therapy was given to 26% of men 65 to 69 years old versus 63% of men 85 years or older P < 0.001). Race, residence (rural versus urban), and comorbidity were also strong factors in predicting initial therapy. Using logistic regression, three treatment alternatives were evaluated. Age (odds ratio [OR] .51; 99% confidence interval [CI] = .43, .60), comorbidity (OR .72; 99% CI .63, .82), income (OR 1.14; 99% CI 1.01, 1.28), residence (OR .65; 99% CI .48, .87), diagnosis year (OR 1.15; 99% CI 1.07, 1.23) all were associated independently with treatment versus no treatment. For surgery versus radiation, age (OR .40; 99% CI .27, .57), race (OR 2.92; 99% CI 1.65, 5.15) and education (OR 1.75; 99% CI 1.31, 2.34) were significant factors. For hormonal/orchiectomy versus surgery/radiation, age (OR 5.19; 99% CI 3.84, 7.01), comorbidity (OR 1.28; 99% CI 1.03, 1.58), distance to radiation oncologist (OR .89; 99% CI .80, .99), and diagnosis year (OR .89; 99% CI .79, 1.00) were significant. The number of men receiving surgical and radiation treatments for prostate cancer increased between 1985 and 1989. During that period, age consistently played a significant role in all therapeutic decisions. Other factors, such as comorbidity, race, socioeconomic status, and distance, also were important considerations, depending on the treatment alternative.

The effect of age and comorbidity in the treatment of elderly women with nonmetastatic breast cancer.

BACKGROUND: Increasing age has most often been associated with less aggressive approaches to treatment of nonmetastatic breast cancer in elderly women even after controlling for stage of disease at diagnosis. OBJECTIVE: To examine the influence of patient age on the initial treatment for breast cancer received by elderly women while controlling for the effect of patient comorbidity. METHODS: Cancer registry records for a cohort of 2252 women aged 66 years or older who were diagnosed as having nonmetastatic, invasive breast cancer between 1984 and 1989 and identified through the Virginia Cancer Registry were linked to Medicare Provider and Reimbursement data files. Multivariate models were used to assess the effects of age and comorbidity (as measured by the International Classification of Diseases, Ninth Edition, codes recorded on Medicare claims) on initial treatment approach while adjusting for stage of disease, race, residential location, marital status, and year of diagnosis. RESULTS: In baseline multivariable models, age was negatively associated with any surgical treatment, non-breast-conserving procedures, and radiotherapy following breast-conserving surgery. The odds of women aged 85 years and older receiving surgery were less than one third those of women aged 66 to 74 years (odds ratio, 0.31; 95% confidence interval, 0.16 to 0.60), while odds ratios across the same two age groups for nonbreast-conserving surgery and adjuvant radiotherapy were 0.55 (95% confidence interval, 33 to 92) and 0.03 (confidence interval, 0.01 to 0.13), respectively. With additional adjustment for aggregate comorbidity, odds ratio estimates in these same age-group comparisons were virtually unchanged at 0.31, 0.56, and 0.04. CONCLUSION: Aggregate comorbidity measured by inpatient International Classification of Diseases, Ninth Edition, codes on Medicare inpatient hospital claims does not explain age-related patterns in the initial treatment of elderly patients with breast cancer.