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NAACCR 2007 Conference Determining Quality of Cancer Care Using Cancer Registry Data Patterns of Care Analysis Using SEER-Medicare Data Nancy Baxter St Michael’s Hospital, University of Toronto Financial Relationships None to Disclose Overview Patterns of care - why do we care? Use of SEER-Medicare data Alternatives for patterns of care Examples Advantages and disadvantages Examples Advantages and disadvantages Impact and Interpretation Quality of care? Patterns of Care Provides a snap shot to evaluate practice Evaluate trends over time Identify important variations Determine need for knowledge translation interventions and quality improvement strategies Opportunity for feedback Regional variations in care Variations in care based on patient factors Variations in care based on provider factors Creates an environment of “watchful concern” SEER-Medicare Data Tremendously rich data for patterns of care studies Quality and completeness of SEER data in terms of case identification and staging Medicare Data Able to enrich SEER data wrt first course of treatment Provides information on long-term care of cancer patients – can evaluate patterns of care for surveillance, screening of survivors etc. Snap Shot in Time Variations in Reconstruction After Radical Cystectomy Gore JL Cancer 2006; 107:729-37 Premise Removal of the bladder for bladder ca is highly morbid Reconstruction with neobladder is thought to improve quality of life above standard ileoconduit Patterns of care in this area unknown Series in expert centers unlikely to reflect care in the population Methods Patients in SEER areas with a bladder malignancy (identified through SEER) diagnosed 1992 through 1999 Underwent radical cystectomy by 2000 as defined by ICD-9 and CPT codes for radical cystectomy Method of reconstruction determined using ICD-9 and CPT codes Also evaluated patient and provider factors and the influence of these factors on choice of reconstruction Results 3611 patients with bladder cancer identified who underwent cystectomy 20% had neobladder 80% had ileoconduit Age, sex, race, income, and education all important determinants of reconstruction Provider factors important Conclusions Majority of older patients with bladder cancer do not receive what is considered optimal treatment Patient and provider factors associated with type of bladder reconstruction, many that should have no impact on eligibility for a neobladder Regionalization might promote increased use of neobladder reconstruction Time Trends Radiation Therapy After Mastectomy Between 1991 and 1999 in Elderly Women: Response to Clinical Trial Information Punglia et al JCO 2006; 24:3474-82 Premise Post-mastectomy irradiation recommended for women at high risk of recurrence Did care change in response to presentation / publication of evidence? 1994 – abstract presented from Danish study – benefit in premenopausal but not significant in postmenopausal 1997 – 2 RCT’s published (Danish and British Columbia) demonstrating benefit in premenopausal 1999 – Danish study reported for postmenopausal demonstrating benefit Methods Used SEER-Medicare data Women with Stage I and II breast cancer diagnosed 1991 – 1999 who underwent mastectomy as defined by SEER or Medicare data ge 65, continuously enrolled in Medicare Part A and B, not enrolled in an HMO Results 19,699 women identified, 11% underwent irradiation Multivariate Analysis After adjusting for covariates, postmastectomy irradiation increased over time Odds of RT in 1999 (vs 1991) = 1.8 (95% CI 1.4-2.2) Also found significant differences in rates depending on type of institution and region of the country Variations in Care Effect of Distance to Radiation Treatment Facility on the Use of Radiation after Mastectomy in Elderly Women Punglia et al, Int J Radiat Oncol Biol Phys 2006; 66:56-63 Premise Many small communities lack radiation facilities Radiation treatment requires daily therapy Lack of access to transportation may be a critical factor in delivery of irradiation May be a particular issue in the elderly Methods Used SEER-Medicare data Women with Stage I and II breast cancer diagnosed 1991 – 1999 who underwent mastectomy as defined by SEER or Medicare data ge 65, continuously enrolled in Medicare Part A and B, not enrolled in an HMO Determined latitude and longitude of 1,197 facilities offering radiation Determined latitude and longitude of patient residence based on Zip code Results 19,787 women identified, 11% had irradiation Median distance to RT center = 4.8 miles (IQR = 2.7-10.8) Distance from facility associated with receipt of RT in multivariate analysis Interpretation RT was associated with distance from center However only decreased with > 25 miles away Only 13% of patients lived this distance from center SEER regions more urban than general US population 1 This effect was primarily for node negative patients – when evaluated separately, no effect of distance for node positive patients most likely to benefit Warren Med Care 2002; 40:IV 3-18 SEER-Medicare Data Powerful dataset to evaluate patterns of care BUT Major limitations to these data for evaluation of patterns of care ?population-based Does not include younger individuals Most studies exclude patients not continuously enrolled in Part A and Part B Most studies excluded anyone enrolled in an Health Maintenance Organization Obviously there are circumstances where care may differ in younger individuals, those in HMOs, or those who do not have continuous enrollment in Part A and B Impact of Age Restriction Treatment of DCIS Age Restricted Gold Med Care 2004; 42:267-75 No Age Restriction Baxter JNCI 2004; 96:443-8 Age is a Major Predictor of RT Exclusion of Patients in HMO Diagnosis and treatment may vary depending on type of health care coverage Differences of how patients are selected for coverage Differences in what health plans offer to their patients Prostate Cancer Treatment and 10-year Survival Among Group/Staff HMO and fee-forservice Medicare Patients Potosky et al Health Serv Res 1999; 34:535-46 Exclusion of Patients in HMO Compared care in 2 major HMO plans in SEER areas (San Francisco–Oakland / Seattle-Puget Sound) to care in patients enrolled in fee for service Medicare Exclusion of Patients in HMO Impact likely differs for different cancers Patterns of care likely differ for various HMO’s Profit status Regional variations Wide regional range of HMO penetration SEER Studies For some studies the exclusivity of SEER-Medicare outweighs the benefits of the richness of the available data Data also more rapidly and freely available But SEER has very limited treatment information SEER-Medicare Patterns of care studies in the past have been potentially outdated when published No chemotherapy No treatment information after first course of therapy Limited patient information No provider information Geographically restricted Alternatives? Combine quality of SEER data with richness of Medicare data Extend to all age groups, regions, and all forms of health care coverage National Cancer Database Joint program of the Commission on Cancer and the American Cancer Society Nationwide outcomes database now covering 75% of all newly diagnosed cancers Care in all states include Currently not available for most researchers Not population based May not be all care received Alternatives Linkages of registry information to other datasets to enrich treatment, patient or provider data The Impact of Highly Active Antiretroviral Therapy on Non-AIDS-Defining Cancers among Adults with AIDS Hessol et al Am J Epidemiol 2007; 165:1143-53 Linked San Francisco AIDS surveillance registry with the California Cancer Registry Alternatives Significantly higher cancer incidence than expected Influence of anti-retroviral therapy on cancer mortality varied Improved survival in lymphoma and lung cancer Potentially worse survival in anal cancer This method may be useful for specific populations Lacks generalizability May be quite difficult to perform the linkages Limited treatment information Canadian Data Single payer system at the province level –detailed treatment information available on virtually all residents from administrative data Drug information also available for individuals over age 65 in Ontario Population-based cancer registries have been linked to admin data in many provinces Lack of stage information greatly limits this work Electronic capture of collaborative staging initiative in Ontario Limitations of POC studies Any dataset used for patterns of care studies lacks information essential to truly evaluate quality Patient preferences Important clinical factors What was delivered vs what was recommended POC studies are an important starting point – potential gaps identified Causes can be explored in further research Reported June 5, 2007 Black Women Shortchanged on Breast Cancer Care (Ivanhoe Newswire) -- Black women with advanced forms of breast cancer may not be getting the same kind of state-of-the-art care white women receive. According to researchers from M.D. Anderson Cancer Center in Houston, TX, the survival rate for white women with the most deadly forms of the disease has risen steadily over the past couple of decades. Survival rates for black women have remained about the same. The research was spurred by a study showing women receiving cutting-edge treatment at M.D. Anderson were surviving longer with advanced forms of the disease. The investigators speculated they'd find the same trend out in the community at large. They were wrong. An analysis of federal data on breast cancer found the median survival for white women with advanced disease was 20 months in the years between 1988 and 1993, jumping to 22 months between 1994 and 1998 and to 27 months between 1999 and 2003. The survival rate languished at around 16-17 months for black women throughout the study periods Summary SEER Medicare data is a rich source of information for patterns of care studies Important to ask questions the data can answer Understand the limitations of the data wrt truly evaluating quality Consider other data sources for specific questions or populations
