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Yu J.B.,Yale University | Yu J.B.,Public Policy and Effectiveness Research Center | Soulos P.R.,Yale University | Soulos P.R.,Public Policy and Effectiveness Research Center | And 9 more authors.
International Journal of Radiation Oncology Biology Physics | Year: 2012

Purpose: Intensity-modulated radiation therapy (IMRT) requires a high degree of expertise compared with standard radiation therapy (RT). We performed a retrospective cohort study of Medicare patients treated with IMRT compared with standard RT to assess outcomes in national practice. Methods and Materials: Using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database, we identified patients treated with radiation for cancer of the head and neck from 2002 to 2005. We used multivariate Cox models to determine whether the receipt of IMRT was associated with differences in survival. Results: We identified 1613 patients, 33.7% of whom received IMRT. IMRT was not associated with differences in survival: the 3-year overall survival was 50.5% for IMRT vs. 49.6% for standard RT (p = 0.47). The 3-year cancer-specific survival was 60.0% for IMRT vs. 58.8% (p = 0.45). Conclusion: Despite its complexity and resource intensive nature, IMRT use seems to be as safe as standard RT in national community practice, because the use of IMRT did not have an adverse impact on survival. © 2012 Elsevier Inc. All rights reserved.


Gross C.P.,Public Policy and Effectiveness Research Center | Gross C.P.,Yale University | Long J.B.,Public Policy and Effectiveness Research Center | Long J.B.,Yale University | And 9 more authors.
JAMA Internal Medicine | Year: 2013

Background: Little is known about the cost to Medicare of breast cancer screening or whether regionallevel screening expenditures are associated with cancer stage at diagnosis or treatment costs, particularly because newer breast cancer screening technologies, like digital mammography and computer-aided detection (CAD), have diffused into the care of older women. Methods: Using the linked Surveillance, Epidemiology, and End Results-Medicare database, we identified 137 274 women ages 66 to 100 years who had not had breast cancer and assessed the cost to fee-for-service Medicare of breast cancer screening and workup during 2006 to 2007. For women who developed cancer, we calculated initial treatment cost. We then assessed screeningrelated cost at the Hospital Referral Region (HRR) level and evaluated the association between regional expenditures and workup test utilization, cancer incidence, and treatment costs. Results: In the United States, the annual costs to feefor- service Medicare for breast cancer screening-related procedures (comprising screening plus workup) and treatment expenditures were S1.08 billion and S1.36 billion, respectively. For women 75 years or older, annual screening- related expenditures exceeded S410 million. Agestandardized screening-related cost per beneficiary varied more than 2-fold across regions (from S42 to 107 per beneficiary); digital screening mammography and CAD accounted for 65% of the difference in screening-related cost between HRRs in the highest and lowest quartiles of cost. Women residing in HRRs with high screening costs were more likely to be diagnosed as having earlystage cancer (incidence rate ratio, 1.78 [95% CI, 1.40- 2.26]). There was no significant difference in the cost of initial cancer treatment per beneficiary between the highest and lowest screening cost HRRs (S151 vs S115; P=.20). Conclusions: The cost to Medicare of breast cancer screening exceeds S1 billion annually in the fee-forservice program. Regional variation is substantial and driven by the use of newer and more expensive technologies; it is unclear whether higher screening expenditures are achieving better breast cancer outcomes. © 2013 American Medical Association.


Kardos S.V.,Public Policy and Effectiveness Research Center | Gross C.P.,Public Policy and Effectiveness Research Center | Gross C.P.,Yale University | Schulam P.G.,Public Policy and Effectiveness Research Center | And 7 more authors.
BJU International | Year: 2014

Objective To evaluate the relationship between partial nephrectomy (PN) and hospital availability of robot-assisted surgery from a population-based cohort in the USA. Methods After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association survey from 2006 to 2008, we identified 21 179 patients who underwent either PN or radical nephrectomy (RN) for renal cell carcinoma (RCC). The primary outcome assessed was the type of nephrectomy performed. Multivariable logistic regression identified the patient and hospital characteristics associated with receipt of PN. Results We identified 4832 (22.8%) and 16 347 (77.2%) patients who were treated for RCC with PN and RN, respectively. On multivariable analysis, patients were more likely to receive PN at academic centres (odds ratio [OR] 2.77; P < 0.001), urban centres (OR 3.66; P < 0.001) and American College of Surgeons (ACOS)-designated cancer centres (OR: 1.10; P < 0.05) compared with non-academic, rural and non-ACOS-designated cancer centre hospitals, respectively. Robot-assisted surgery availability at a hospital was also associated with a higher adjusted odds of PN compared with centres without that availability (OR 1.28; P < 0.001). Conclusions Although academic and urban locations are established factors that affect the receipt of PN for RCC, the availability of robot-assisted surgery at a hospital was also independently associated with higher use of PN. Our results are informative in identifying other key hospital characteristics which may facilitate greater adoption of PN. © 2014 The Authors. BJU International © 2014 BJU International.


Gross C.P.,Public Policy and Effectiveness Research Center | Gross C.P.,Yale University | Fried T.R.,Public Policy and Effectiveness Research Center | Fried T.R.,Yale University | And 12 more authors.
Journal of Geriatric Oncology | Year: 2015

Objective: To understand how older persons with multiple chronic conditions (MCC) approach decisions about cancer screening. Materials and Methods: We conducted interviews with adults >. 65. years old with at least two chronic conditions who were taking ≥. five medications daily. Patients were first asked how age and multimorbidity influence their cancer screening decisions. After showing them an educational prompt that explained the relationship between life expectancy and the benefits of cancer screening, respondents were then asked about screening in the context of specific health scenarios. Using grounded theory, three independent readers coded responses for salient themes. Sample size was determined by thematic saturation. Results: Most respondents (26 of 28) initially indicated that their overall health or medical conditions do not influence their cancer screening decisions. After viewing the educational prompt, respondents described two broad approaches to cancer screening in the setting of increasing age or multi-morbidity. The first was a "benefits versus harms" approach in which participants weighed direct health benefits (e.g. reducing cancer incidence or mortality) and harms (e.g. complications or inconvenience). The second was a heuristic approach. Some heuristics favored screening, such as a persistent belief in unspecified benefits from screening, value of knowledge about cancer status, and not wanting to "give up", whereas other heuristics discouraged screening, such as fatalism or a reluctance to learn about their cancer status. Conclusions: When considering cancer screening, some older persons with MCC employ heuristics which circumvent the traditional quantitative comparison of risks and benefits, providing an important challenge to informed decision making. © 2014 Elsevier Inc.


PubMed | Yale University and Public Policy and Effectiveness Research Center
Type: Journal Article | Journal: Cancer | Year: 2016

Although newer treatments for myelodysplastic syndromes (MDS), particularly hypomethylating agents (HMAs), are expensive, it is unclear whether MDS-related costs of care are associated with overall survival. This study evaluated the relation between MDS-related costs and survival among Medicare beneficiaries with MDS.Eligible patients were identified from the Surveillance, Epidemiology, and End Results-Medicare database with codes for MDS from International Classification of Diseases for Oncology, 3rd edition. The patients were diagnosed between January 1, 2005 and December 31, 2011, were 66 years old or older, and were followed through death or the end of study (December 31, 2012). Medicare payments were used to estimate costs. Cumulative costs in a propensity score-matched group of cancer-free Medicare beneficiaries were subtracted from costs in the MDS cohort in each registry to estimate MDS-related costs. Hazard ratios (HRs) and 95% confidence intervals (CIs) were derived from multivariate Cox proportional hazards models adjusted for patient and disease characteristics.There were 8580 eligible patients, and 1,267 (14.7%) received HMAs. The overall 2-year survival rate was 48.7%, and the 2-year registry-specific MDS-related cost per patient ranged from $40,793 to $78,156 across 16 registries. The 2-year MDS-related cost was not associated with survival in the overall study population (first tertile, reference; second tertile, HR, 0.96; 95% CI, 0.89-1.04; P = .29; third tertile, HR, 0.98; 95% CI, 0.91-1.06; P = .64) or in subgroups of patients who did or did not receive HMAs.Medicare expenditures for elderly patients with MDS varied across registries but were not associated with survival. A lack of an association between costs and outcomes warrants additional research because it may help to identify potential areas for cost-saving interventions without compromising patient outcomes. Cancer 2016;122:1598-607. 2016 American Cancer Society.


Vest M.T.,Section of Pulmonary and Critical Care Medicine | Herrin J.,Section of Cardiology | Herrin J.,Public Policy and Effectiveness Research Center | Herrin J.,Health Research and Educational Trust | And 11 more authors.
Chest | Year: 2013

Background: Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as videoassisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare benefi - ciaries with stage I NSCLC are unknown. Methods: We used the Surveillance, Epidemiology and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment. Results: The sample comprised 13,458 patients with a mean age of 75.7 years. The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% ( P , .001), although the proportion of patients undergoing VATS increased from 11.3% to 32.0%. Similarly, although the use of new radiation modalities increased from 0% to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgical vs no treatment (OR, 0.12; 95% CI, 0.09-0.16) and more likely to receive radiation vs surgery (OR, 13.61; 95% CI, 9.75-19.0). Conclusion: From 1998 to 2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less-invasive forms of surgery and radiation. CHEST 2013; 143(2):429-435 © 2013 American College of Chest Physicians.


Gancayco J.,Digestive Diseases | Soulos P.R.,General Internal Medicine | Soulos P.R.,Public Policy and Effectiveness Research Center | Khiani V.,Illinois College | And 8 more authors.
Journal of Clinical Gastroenterology | Year: 2013

BACKGROUND:: The use of screening colonoscopy among older persons is controversial due to variability in life expectancy and sex-based differences in colorectal cancer incidence. We assessed the relation between sex, age, and receipt of screening colonoscopy overall and within strata of life expectancy. METHODS:: We used Medicare data to identify beneficiaries during the years 2001 to 2005 who had not undergone a colonoscopy in the prior 3 years. Medicare claims were used to identify screening colonoscopy use; life expectancy was estimated using a life table approach. We used Poisson regression to examine sex and age differences in screening colonoscopy, adjusted for patient demographic characteristics. RESULTS:: Our sample consisted of 161,229 patients (61.9% female; mean age 76.9 y). The screening colonoscopy rates for females and males were 16.9 and 24.4 screening colonoscopies per 1000 person-years, respectively (P<0.001). The screening colonoscopy rate was highest for patients with the longest life expectancy (10 to 15 y: 27.2 screening colonoscopies per 1000 person-years) compared with 3.4 per 1000 person-years in the life expectancy <5-year group. Within specific life expectancy categories, older patients had significantly lower screening rates; in the 10- to 15-year life expectancy category, patients 75 to 79 years old had a lower rate (21.9 screening colonoscopies per 1000 person-years) than patients 68 to 69 years old (34.1 screening colonoscopies per 1000 person-years; P<0.001). CONCLUSIONS:: In a large cohort of Medicare beneficiaries, there was evidence of screening colonoscopy use even among patients with a short life expectancy. After accounting for life expectancy, females and older persons were less likely to undergo screening colonoscopy. Copyright © 2013 by Lippincott Williams & Wilkins.


Yang D.X.,Yale University | Yang D.X.,Public Policy and Effectiveness Research Center | Gross C.P.,Yale University | Gross C.P.,Public Policy and Effectiveness Research Center | And 4 more authors.
Cancer | Year: 2014

BACKGROUND: Ideally, screening detects cancer at a more curable stage and, as a result, decreases the rate of subsequent diagnosis at a late stage. Although it is suggested that some cancer screening tests have led to substantial increases in early-stage incidence with only marginal reductions in late-stage incidence (eg mammography), the association between temporal trends in colorectal cancer screening and its cumulative impact on colorectal cancer incidence is unknown. METHODS: Colorectal cancer incidence data spanning over 3 decades (1976-2009) were collected from the Surveillance, Epidemiology, and End Results database. Data on screening use spanning the period from 1986 to 2010 were collected from the National Cancer Institute Cancer Trends Progress Report, and trends in the incidence of early-stage (in situ, local) and late-stage (regional, distant) colorectal cancer were examined among adults aged ≥50 years. RESULTS: From 1987 to 2010-the years for which screening data were available-the percentage of adults aged ≥50 years who underwent screening rose from 34.8% to 66.1% (which included increases in colonoscopy). During that time, the incidence of late-stage colorectal cancer decreased from 118 to 74 cases per 100,000 population (P<.001). The incidence of early-stage colorectal cancer also decreased, from 77 to 67 cases per 100,000 population (P<.001). After adjusting for underlying trends in cancer incidence, colorectal screening was associated with a reduction of approximately 550,000 cases of colorectal cancer over the past 3 decades in the United States. CONCLUSIONS: There has been a significant decline in the incidence of colorectal cancer in the United States, particularly for late-stage disease, during a time of increasing rates of screening. © 2014 American Cancer Society.


PubMed | Public Policy and Effectiveness Research Center
Type: Journal Article | Journal: Medical care | Year: 2013

Among older women with early-stage breast cancer, patients with a short life expectancy (LE) are much less likely to benefit from adjuvant radiation therapy (RT). Little is known about the impact of physicians and regional factors on the use of RT across LE groups.To determine the relative contribution of patient, physician, and regional factors on the use of RT.Retrospective cohort.Women aged 67-94 years diagnosed with stage I breast cancer between 1998 and 2007 receiving breast-conserving surgery.We evaluated patient, physician, and regional factors for their association with RT across strata of LE using a 3-level hierarchical logistic regression model. Risk-standardized treatment rates (RSTRs) for the receipt of radiation were calculated according to primary surgeon and region.Approximately 43.6% of the 2253 women with a short LE received RT, compared with 90.8% of the 11,027 women with a long LE. Among women with a short LE, the probability of receiving RT varied substantially across primary surgeons; RSTRs ranged from 27.7% to 67.3% (mean, 43.9%). There was less variability across geographic regions; RSTRs ranged from 42.0% to 45.2% (mean, 43.6%). Short LE patients were more likely to receive RT in areas with high radiation oncologist density (odds ratio, 1.59; 95% confidence interval, 1.07-2.36).Although there is a wide variation across geographic regions in the use of RT among women with breast cancer and short LE, the regional variation was substantially diminished after accounting for the operating surgeon.


PubMed | Public Policy and Effectiveness Research Center
Type: Journal Article | Journal: BJU international | Year: 2014

To evaluate the relationship between partial nephrectomy (PN) and hospital availability of robot-assisted surgery from a population-based cohort in the USA.After merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association survey from 2006 to 2008, we identified 21179 patients who underwent either PN or radical nephrectomy (RN) for renal cell carcinoma (RCC). The primary outcome assessed was the type of nephrectomy performed. Multivariable logistic regression identified the patient and hospital characteristics associated with receipt of PN.We identified 4832 (22.8%) and 16347 (77.2%) patients who were treated for RCC with PN and RN, respectively. On multivariable analysis, patients were more likely to receive PN at academic centres (odds ratio [OR] 2.77; P < 0.001), urban centres (OR 3.66; P < 0.001) and American College of Surgeons (ACOS)-designated cancer centres (OR: 1.10; P < 0.05) compared with non-academic, rural and non-ACOS-designated cancer centre hospitals, respectively. Robot-assisted surgery availability at a hospital was also associated with a higher adjusted odds of PN compared with centres without that availability (OR 1.28; P < 0.001).Although academic and urban locations are established factors that affect the receipt of PN for RCC, the availability of robot-assisted surgery at a hospital was also independently associated with higher use of PN. Our results are informative in identifying other key hospital characteristics which may facilitate greater adoption of PN.

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