Download Patterns of Care in Breast Cancer

Patterns of Care in Breast Cancer: On Care
Coordination in Underserved Populations and the Use
of Health Claims Data.
Roger Anderson, Ph.D.
Professor
Health Services Research Core
Penn State Cancer Institute
Penn State Hershey Medical College
Research Roundtable Appalachia Community Cancer Network
September 28, 2007
Hershey, PA
Research team
PSU:
Duke:
Fabian Camacho, M.S.
Gary Chase, Ph.D.
Wenke Hwang, Ph.D.
Kristie Long-Foley, Ph.D.
Gretchen Kimmick, M.D.
CCR:
Karen Knight
NCHS:
Tim Whitmire, Ph.D.
WFU:
North Eastern North Carolina
Counties
60
50
Age
adjusted
Breast
Cancer
Death rate
per 100,000
40
30
20
10
0
Source, North Carolina Cancer Registry, 2005,; SEER, National Cancer Institute, 2005
Gates
Herford
Pasquotank
Perquimans
Camden
North Carolina
US
Objectives
 Describe assembly of linked-Medicaid- North
Carolina cancer registry data.
 Describe the use of this dataset to identify unmet
needs in cancer prevention and control
 Discuss applicability to ACCN
 Discuss health services research implications
Medicaid and Rural Health
Medicaid is an important source of health insurance
coverage for both rural residents and rural providers.
Rural residents are more likely to live in poverty than
urban residents, and are less likely to have employer
sponsored health insurance coverage.
Rural residents are more likely to be covered by
Medicaid than are urban residents.
Percent Residents with Medicaid Coverage During the
Past Year in Urban and Rural Counties.
CPS, 2004-2005
State
Rural
Urban
Kentucky
17.4
12.1
Maryland
16.8
8.6
New York
17.4
18.3
Ohio
11.2
12.3
Pennsylvania
12.0
11.3
Virginia
11.5
6.9
West Virginia
18.2
11.3
North Carolina Project
NC Tumor Registry
+
 Incident cases
 Clinical data
 1st course of Tx
(FORDS)
 Hospital Registrars
 Other facilities
 Merged data
 CDC proficiency
testing
NC Medicaid Claims
 All medical services*
(ICD-9/10, CPT)
 Pharmacy (NDC)
 [monthly eligibility]
 [no clinical data]
* Variable by state
Database
1998-99 Medicaid Claims for North Carolina.
 N=1,401 female breast cancer (single primary, all
stages, 20% all cases)
Caveats of Medicaid claims:
•
•
•
•
•
Managed care organizations omitted
Dual eligibility - Medicare
Continuous enrollment - pre-and-post diagnosis.
Bundling of claims (date/services)
Completeness of claims (unbilled services?)
Data Sources
Caveats of Hospital Registry data:
• First course of treatment may be defined as 4-months
post diagnosis.
• Treatment in physician offices may go unreported.
• Out-of state services often missing
• May exclude VHA cases
• Comorbidity – added in 2003
• Non-registry (mid-size) hospitals lower quality data
Data Sources
Caveats of Medicaid data:
• 9- 12 months of continuous eligibility is generally
needed.
• Medicare files m,ay be needed for dually insured.
• Policies on covered services may vary by state.
Methods
 Test Population (1998-99 cases): 1,401 cases
single primary breast cancer in NC registry years
1998 - 1999.
 Test sample: 845 (60%) cases enrolled in
Medicaid 1 month prior and 12 months post
registry date of diagnosis
 Approach:
• 1) Assume registry data is accurate if treatment is listed
as provided (not missing or indeterminate).
• 2) Else, replace data with Medicaid claims (if
discordant).
• 3) Validate by performing record review on sample of
cases.
Accuracy of Radiation data in BCS sample
BCS sample
Sensitivity
Specificity
Registry
84%
100%
Claims
95%
93%
Combined
97%
98%
Table 3. Adjusted Odds of Registry Codes for Radiation and
Chemotherapy when Medicaid Claims are Present
CCR Agreement on Radiation
CCR Agreement on
Chemotherapy
# with radiation claims: 279
# with chemotherapy claims: 236
Caucasian vs Other
0.89 (0.48, 1.66)
0.57 (0.31, 1.05)
Dually Eligible No vs Yes
0.72 (0.37,1.40)
2.33 (1.24, 4.41)
N/A vs 5 + cm
1.10 (0.36,3.31)
0.62 (0.17,2.35)
0-1 cm vs 5+ cm
2.39 (0.67, 8.54)
0.27 (0.05,1.65)
1-2 cm vs 5+ cm
1.71 (0.60, 4.84)
0.65 (0.18,2.27)
2-5 cm vs 5+ cm
0.74 (0.29,1.94)
0.35 (0.12,1.09)
1.15 (0.58,2.25)
0.94 (0.45,1.95)
5.27 (0.54,51.14)
7.74 (1.22,49.09)
0.11
0.35)
7.77 (0.037,
(2.80,21.58)
0.43
4.31(0.18,1.05)
(2.08,8.94)
0.989 (0.985,0.993)
0.994 (0.988, 0.998)
Tumor Size
Sample N
Lymph Nodes Removed
Class of Case 1 or 2 present 4
Registry Facility
Days to first claims since dx
(Rad column, Chem column)
Examples of Application to Answer Patterns of Care
And Outcomes Research Questions
Correlates of Under Use of Radiation Treatment with BCS in North Carolina Medicaid
Total
Radiation
No Radiation
p
N= 344
N=242
(70.4%)
N=102
(30.0%)
Age group at time of diagnosis
65+ years
<65 years
159 (46.2%)
185 (53.8%)
58.49
80.54
41.51
19.46
<.0001
Race/ethnicity
White
Other
175 (50.9%)
169 (49.1%)
69.71
71.01
30.29
28.99
0.7931
Charlson Comorbidity Score (Excluding Cancer
dx)
0
1
2
166 (48.26%)
52 (15.12%)
126 (36.63%)
75.90
65.38
65.08
24.10
34.62
34.92
0.0931
Patient County of Residence
Non-metropolitan county
Metropolitan county
116 (33.7%)
228 (66.3%)
64.66
73.25
35.34
26.75
0.0991
County Medicaid Density
High (> 50 percentile)
Low
Assisted Living1
Yes
No
167 (48.55)
177 (51.45)
68.26
72.32
31.74
27.68
0.4107
80 (23.3%)
264 (76.7%)
52.50
75.76
47.50
24.24
0.0001
Hospital Size2
Large / Medium
Small
302 (72.52%)
42 (12.21%)
72.52
54.76
27.48
45.24
0.0182
301 (87.50%)
72.43
55.81
27.57
44.19
0.0257
43 (12.50%)
312 (90.70%)
32 (9.30%)
72.44
50.00
27.56
50.00
0.0081
Surgery Hospital Volume3
High/Medium (> 5000 patients discharges)
Low
Breast cancer patient volume (Medicaid)4
Higher >50%
Lower ≤ 50%
1. Based on presence of any paid claims from nursing home (location of service=T), home healthcare services (Q) or skilled nursing facility (cos = 35,36).
2. Tertile distribution of number of beds reported by American Hospital Directory.
3. Based on patient discharges reported by American Hospital Directory
4. Median split of all breast cancer cases with Medicaid enrollment.
Table 3. Interaction Graph showing unadjusted proportions of Radiation Treatment in
BCS patients by Metropolitan Status and Hospital Size
% BCS who received radiation
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
L/M
Hospital Size
Metro
NonMetro
S
0.00
0.25
0.50
0.75
1.00
Kaplan-Meier Survival Curves of All-Cause Mortality by Radiotherapy
Treatment
0
500
1000
1500
2000
Days since diagnosis
No Radiation
Radiation
2500
Cormorbidity among Women with Breast Cancer in NC Medicaid
N= 1,401
●
55 % had at least one other comorbid condition defined in Charlson
comorbidity index
● Among those with comorbidity, > 50% had multiple conditions.
● The top three comorbid conditions were:
Diabetes (26%)
Congestive heart failure (18%),
Chronic pulmonary disease (11%).
North Carolina Medicaid enrollees with a diagnosis of
diabetes with and without breast cancer:
Medication Possession Ratio: diabetes medicines/ insulin products
12 month days supply
mean days (SD)
____________________________________________________
Women without cancer
With breast cancer
300 (19)
205 (95)
Hormone Medication Persistence. NC Medicaid Breast Cancer
Monali Bhosle OSU
Cumulative nonpersistence rate based on number with + ER status who started
therapy.
No significant association between race and medication persistence adjusting for a
type of index therapy and other confounders (hazard ratio (SE) [95%CI]: 1.13 (0.30)
[0.68-1.89].
Current Multi-Site Study
● CDC Patterns of Care Study (Breast and
Prostate CA)
7 States + PSU
Registry data + CMS
Centralized data processing (5 sites).
Pooled data analysis
Model
NCCN guideline concordant care
Health system and patient characteristics
Care coordination
Proposal
● Develop set of cancer prevention and control outcomes consistent
with CDC pattern of care studies.
● Seek funding to link 7 ACCN States Registry data to
Medicaid/Medicare.
● PSCI Health Services Research Core serve as Data and Support
Center to provide:
IRB templates
Data acquisition and linkage
Archive
Analysis support