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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