Manchester Center, VT, United States
Manchester Center, VT, United States

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Davies L.,VA Outcomes Group | Davies L.,Dartmouth Institute for Health Policy and Clinical Practice
Otolaryngology - Head and Neck Surgery (United States) | Year: 2012

Objective. To describe time trends in total laryngectomy health services utilization across the United States, such as rates of surgery, cost, length of stay, and insurance payer, and to compare this to important milestones in recommendations for laryngeal cancer treatment. Study Design. Population-based cohort study Setting. Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) 1997-2008: stratified sample of all US hospital discharges. Subjects and Methods. All patients with the principal procedure of complete laryngectomy. The unit of analysis was the discharge. Results. Between 1997 and 2008, the number of laryngectomies done in the United States decreased by 48%. New cases of laryngeal cancer decreased 33% during the same time. The proportion of patients older than 65 years decreased from 48% to 43%. Mortality for the procedure was 1.4% in 1997 and 1.1% in 2008. Mean length of stay over the study period increased from 13 days to 14 days. Mean hospital charges rose from $58,000 in 1997 to $109,000 in 2008, consistent with the overall rise in US health care costs. Medicare was the dominant insurer throughout. Home health was ordered in 50% of 2008 discharges but only 32% in 1997. Conclusions. The rate of total laryngectomy has dropped more than the incidence of laryngeal cancer has dropped, consistent with the trend toward nonsurgical treatment. Lower surgical volumes and/or salvage laryngectomy surgeries are hypothesized to play a role in longer length of stay, stable mortality rates despite younger patient age, and increased need for home services after discharge. © 2012 American Academy of Otolaryngology - Head and Neck Surgery Foundation.


Messina C.R.,State University of New York at Stony Brook | Lane D.S.,State University of New York at Stony Brook | Anderson J.C.,University of Connecticut | Anderson J.C.,VA Outcomes Group
Cancer Epidemiology | Year: 2012

Background: Overweight/obese women and men are at increased risk for colorectal cancer (CRC) incidence and mortality. Research examining body mass index (BMI) and CRC screening has had mixed results. A clearer understanding of the extent to which high-BMI subgroups are screened for CRC is needed to inform planning for CRC screening promotions targeting BMI. Methods: Data were obtained from a random, population-based sample of women and men at average-risk for CRC (aged 50-75 years) during 2004 (n= 1098). Multiple logistic regression analyses were conducted to evaluate whether BMI category was significantly associated with the probability of reporting recent CRC screening and with the probability of agreeing with statements denoting attitudes/perceptions about CRC and screening. Attitudes/perceptions about CRC and screening were evaluated as potential mediators and moderators of the association between BMI category and CRC screening. Results: After controlling for characteristics associated with CRC screening, overweight and obese women were each 40% less likely to have CRC screening than women with normal-BMI (OR = 0.6, 95% CI:0.4-0.9 and OR = 0.6, 95% CI:0.3-0.9). BMI category was unrelated to screening among men. Obese women (but not men) were less aware than normal-BMI women that obesity increased risk for CRC (OR = 0.5, 95% CI:0.3-0.9) and less worried about CRC (OR = 0.5, 95% CI:0.3-0.8). However, findings suggest that attitudes/perceptions about CRC and screening did not mediate or moderate the association between BMI category and CRC screening. Conclusion: Overweight/obese women are at increased risk for CRC because of their greater BMI and their propensity not to screen for CRC. Study findings suggest that potentially modifiable perceptions, e.g., lack of awareness of risk for CRC and less worry about CRC, in this subgroup may not explain the relationship between BMI category and reduced screening. © 2012 Elsevier Ltd.


Thomas B.,Dartmouth Hitchcock Medical Center | Stedman M.,U.S. National Cancer Institute | Davies L.,Dartmouth Hitchcock Medical Center | Davies L.,Dartmouth Institute for Health Policy | Davies L.,VA Outcomes Group
Laryngoscope | Year: 2014

Objectives/Hypothesis Historically, histologic grade has not been considered a useful prognostic factor in head and neck squamous cell carcinoma (SCC). However, in other solid tumors, grade is known to affect prognosis. We test the hypothesis that histologic grade is an independent predictor of prognosis in oral cavity SCC. Study Design Population-based cohort study using the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute. Methods Fifteen year cause-specific survival. Multivariate analysis was performed on a subset of patients diagnosed between 2004 and 2008. Results Among patients 20 to 65 years of age with American Joint Committee on Cancer (AJCC) stage I or II cancer, the adjusted risk of death is 2.7 times greater (95% CI 1.72-4.11) if the tumor is poorly differentiated or undifferentiated than it is if the tumor is well differentiated. Among patients 66 to 94 years of age, the risk of death is 3.0 (95% CI 2.02-4.54) times greater. For those over age 65, moderately differentiated tumors also confer an estimated 42% increased risk of death, but this estimate is only borderline significant (P = 0.05). Conclusions There is a strong association between histologic grade and survival in patients with AJCC stage I or II oral cavity SCC. High histologic grade in early stage oral cavity cancer is associated with poorer survival and carries independent prognostic value in addition to tumor size, node status, and presence of distant metastasis (TNM) stage. Thus, histologic grade should be considered clinically when making treatment decisions, and multivariable models of survival should include grade as a covariate to improve prognostic accuracy. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.


Hoang J.K.,Duke University | Nguyen X.V.,Ohio State University | Davies L.,VA Outcomes Group | Davies L.,The Dartmouth Institute for Health Policy and Clinical Practice
Academic Radiology | Year: 2015

Thyroid cancer fulfills the criteria for overdiagnosis by having a reservoir of indolent cancers and practice patterns leading to the diagnosis of incidental cancers from the reservoir. The occurrence of overdiagnosis is also supported by population-based data showing an alarming rise in thyroid cancer incidence without change in mortality. Because one of the activities leading to overdiagnosis is the workup of incidental thyroid nodules detected on imaging, it is critical that radiologists understand the issue of overdiagnosis and their role in the problem and solution. This article addresses 1) essential thyroid cancer facts, 2) the evidence supporting overdiagnosis, 3) the role of radiology in overdiagnosis, 4) harms of overdiagnosis, and 5) steps radiologists can take to minimize the problem. © 2015 AUR.


Pohl H.,VA Outcomes Group | Pohl H.,Dartmouth Hitchcock Medical Center | Wrobel K.,Charite University Hospitals | Bojarski C.,Charite University Hospitals | And 3 more authors.
American Journal of Gastroenterology | Year: 2013

OBJECTIVES:It is assumed that esophageal adenocarcinoma is the end result of a stepwise disease process that transitions through gastroesophageal reflux disease (GERD) and Barrett's esophagus. The aim of this study was to examine at what stage known risk factors exert their influence toward the progression to cancer.METHODS:We enrolled 113 consecutive outpatients without GERD, 188 with GERD, 162 with Barrett's esophagus, and 100 with esophageal adenocarcinoma or high-grade dysplasia (HGD). All patients underwent a standard upper endoscopy and completed a standardized questionnaire about their social history, symptoms, dietary habits, and prescribed medications. We used adjusted logistic regression analysis to assess risk factors between each two consecutive disease stages from the absence of reflux disease to esophageal adenocarcinoma.RESULTS: Overall, male gender, smoking, increased body mass index (BMI), low fruit and vegetable intake, duration of reflux symptoms, and presence of a hiatal hernia were risk factors for cancer/HGD. However, different combinations of risk factors were associated with different disease stages. Hiatal hernia was the only risk factor to be strongly associated with the development of GERD. For GERD patients, male gender, age, an increased BMI, duration of reflux symptoms, and presence of a hiatal hernia were all associated with the development of Barrett's esophagus. Finally, the development of cancer/HGD among patients with Barrett's esophagus was associated with male gender, smoking, decreased fruit and vegetable intake, and a long segment of Barrett's esophagus, but not with age, BMI, or a hiatal hernia.CONCLUSIONS:While some risk factors act predominantly on the initial development of reflux disease, others appear to be primarily responsible for the development of more advanced disease stages. © 2013 by the American College of Gastroenterology.


Davies L.,VA Outcomes Group | Davies L.,Dartmouth College | Davies L.,Dartmouth Institute for Health Policy and Clinical Practice | Welch H.G.,Dartmouth Institute for Health Policy and Clinical Practice
JAMA Otolaryngology - Head and Neck Surgery | Year: 2014

IMPORTANCE: We have previously reported on a doubling of thyroid cancer incidence-largely due to the detection of small papillary cancers. Because they are commonly found in people who have died of other causes, and because thyroid cancer mortality had been stable, we argued that the increased incidence represented overdiagnosis. OBJECTIVE: To determine whether thyroid cancer incidence has stabilized. DESIGN: Analysis of secular trends in patients diagnosed with thyroid cancer, 1975 to 2009, using the Surveillance, Epidemiology, and End Results (SEER) program and thyroid cancer mortality from the National Vital Statistics System. SETTING: Nine SEER areas (SEER 9): Atlanta, Georgia; Connecticut; Detroit, Michigan; Hawaii; Iowa; New Mexico; San Francisco-Oakland, California; Seattle-Puget Sound, Washington; and Utah. PARTICIPANTS: Men and women older than 18 years diagnosed as having a thyroid cancer between 1975 and 2009 who lived in the SEER 9 areas. INTERVENTIONS: None. MAIN OUTCOMES AND MEASURES: Thyroid cancer incidence, histologic type, tumor size, and patient mortality. RESULTS: Since 1975, the incidence of thyroid cancer has now nearly tripled, from 4.9 to 14.3 per 100 000 individuals (absolute increase, 9.4 per 100 000; relative rate [RR], 2.9; 95%CI, 2.7-3.1). Virtually the entire increase was attributable to papillary thyroid cancer: from 3.4 to 12.5 per 100 000 (absolute increase, 9.1 per 100 000; RR, 3.7; 95%CI, 3.4-4.0). The absolute increase in thyroid cancer in women (from 6.5 to 21.4 = 14.9 per 100 000 women) was almost 4 times greater than that of men (from 3.1 to 6.9 = 3.8 per 100 000 men). The mortality rate from thyroid cancer was stable between 1975 and 2009 (approximately 0.5 deaths per 100 000). CONCLUSIONS AND RELEVANCE: There is an ongoing epidemic of thyroid cancer in the United States. The epidemiology of the increased incidence, however, suggests that it is not an epidemic of disease but rather an epidemic of diagnosis. The problem is particularly acute for women, who have lower autopsy prevalence of thyroid cancer than men but higher cancer detection rates by a 3:1 ratio. Copyright 2014 American Medical Association. All rights reserved.


Wiener R.S.,Boston University | Wiener R.S.,Edith Nourse Rogers Memorial VA Hospital | Gould M.K.,Kaiser Permanente | Woloshin S.,VA Outcomes Group | And 5 more authors.
Chest | Year: 2013

Background: More than 150,000 Americans each year are found to have a pulmonary nodule. Even more will be affected following the publication of the National Lung Screening Trial. Patient-doctor communication about pulmonary nodules can be challenging. Although most nodules are benign, it may take 2 to 3 years to rule out cancer. We sought to characterize patients' perceptions of communication with their providers about pulmonary nodules. Methods: We conducted four focus groups at two sites with 22 adults with an indeterminate pulmonary nodule. Transcripts were analyzed using principles of grounded theory. Results: Patients described conversations with 53 different providers about the pulmonary nodule. Almost all patients immediately assumed that they had cancer when first told about the nodule. Some whose providers did not discuss the actual cancer risk or explain the evaluation plan experienced confusion and distress that sometimes lasted for months. Patients were frustrated when their providers did not address their concerns about cancer or potential adverse effects of surveillance (eg, prolonged uncertainty, radiation exposure), which in some cases led to poor adherence to evaluation plans. Patients found it helpful when physicians used lay terms, showed the CT image, and quantified cancer risk. By contrast, patients resented medical jargon and dismissive language. Conclusions: Patients commonly assume that a pulmonary nodule means cancer. What providers tell (or do not tell) patients about their cancer risk and the evaluation plan can strongly influence patients' perceptions of the nodule and related distress. We describe simple communication strategies that may help patients to come to terms with an indeterminate pulmonary nodule. © 2013 American College of Chest Physicians.


Morris L.G.T.,Sloan Kettering Cancer Center | Sikora A.G.,Mount Sinai School of Medicine | Tosteson T.D.,Leibniz University of Hanover | Davies L.,VA Outcomes Group | Davies L.,Leibniz University of Hanover
Thyroid | Year: 2013

Background: The rapidly rising incidence of papillary thyroid cancer may be due to overdiagnosis of a reservoir of subclinical disease. To conclude that overdiagnosis is occurring, evidence for an association between access to health care and the incidence of cancer is necessary. Methods: We used Surveillance, Epidemiology, and End Results (SEER) data to examine U.S. papillary thyroid cancer incidence trends in Medicare-age and non-Medicare-age cohorts over three decades. We performed an ecologic analysis across 497 U.S. counties, examining the association of nine county-level socioeconomic markers of health care access and the incidence of papillary thyroid cancer. Results: Papillary thyroid cancer incidence is rising most rapidly in Americans over age 65 years (annual percentage change, 8.8%), who have broad health insurance coverage through Medicare. Among those under 65, in whom health insurance coverage is not universal, the rate of increase has been slower (annual percentage change, 6.4%). Over three decades, the mortality rate from thyroid cancer has not changed. Across U.S. counties, incidence ranged widely, from 0 to 29.7 per 100,000. County papillary thyroid cancer incidence was significantly correlated with all nine sociodemographic markers of health care access: it was positively correlated with rates of college education, white-collar employment, and family income; and negatively correlated with the percentage of residents who were uninsured, in poverty, unemployed, of nonwhite ethnicity, non-English speaking, and lacking high school education. Conclusion: Markers for higher levels of health care access, both sociodemographic and age-based, are associated with higher papillary thyroid cancer incidence rates. More papillary thyroid cancers are diagnosed among populations with wider access to healthcare. Despite the threefold increase in incidence over three decades, the mortality rate remains unchanged. Together with the large subclinical reservoir of occult papillary thyroid cancers, these data provide supportive evidence for the widespread overdiagnosis of this entity. © Mary Ann Liebert, Inc.


Andrus B.W.,Dartmouth Hitchcock Medical Center | Andrus B.W.,Dartmouth Institute for Health Care Policy and Clinical Practice | Welch H.G.,Dartmouth Institute for Health Care Policy and Clinical Practice | Welch H.G.,VA Outcomes Group
Circulation: Cardiovascular Quality and Outcomes | Year: 2012

Background-Services provided by cardiologists represent a major portion of Medicare expenditures for specialist physicians. The absolute growth and distribution of these services over the past decade have not been well described. Methods and Results-We analyzed fee-for-service Medicare Part B claims for each year from 1999-2008 and selected claims from physicians whose specialty code was cardiology. We then grouped approximately 1000 CPT-9 codes into 45 specific service groups that were then further aggregated into 3 broad service categories: Evaluation and management, noninvasive procedures, and invasive procedures. Our main outcome measures were services and allowed charges per 1000 beneficiaries. Sample size ranged from 30.9 million beneficiaries in 1999 to 31.7 million in 2008. During this 10-year period, the number of claims from cardiologists increased 44% (from 2082-2997 per 1000 beneficiaries) while the allowed charges increased 28% after adjusting for inflation (in 2008 dollars, from $181 397-231 728 per 1000 beneficiaries). Evaluation and management services and invasive procedures contributed relatively little to this growth. Instead, most of the growth involved noninvasive procedures-with a 70% increase in claims. Although the most dramatic increases in noninvasive procedures involved emerging imaging technologies (cardiac CT, MRI, and PET scanning), the bulk of the growth occurred in two established technologies: Resting echocardiograms and stress tests with nuclear imaging. Conclusions-Most of the growth in services provided by cardiologists over the past decade is the result of increased noninvasive imaging. © 2011 American Heart Association, Inc.


Davies L.,VA Outcomes Group | Davies L.,Dartmouth Institute for Health Policy and Clinical Practice | Welch G.,VA Outcomes Group | Welch G.,Dartmouth Institute for Health Policy and Clinical Practice
Archives of Otolaryngology - Head and Neck Surgery | Year: 2010

Objective: To compare the survival rate of people with papillary thyroid cancer limited to the thyroid gland who have not had immediate, definitive treatment for their thyroid cancer with the survival rate of those who have had such treatment. Design: Cohort study of incident cancer cases and initial treatment data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. Data on cause of death was taken from the National Vital Statistics System. Patients: Patients with papillary thyroid cancer limited to the thyroid gland. Main Outcome Measure: Cancer-specific survival. Results: Of all eligible people in the data (n=35 663), 1.2% did not undergo immediate, definitive treatment (n=440). The life table estimate of their 20-year cancerspecific survival rate was 97% (95% confidence interval [CI], 96%-100%). The corresponding estimate for the patients who did receive treatment was 99% (95% CI, 93%-100%). Among those who did not receive immediate, definitive treatment, 6 died from their cancer. This number is not statistically different from the number of thyroid cancer deaths in the treated group over the same period (n=161) (P=.09). Conclusion: Papillary thyroid cancers of any size that are limited to the thyroid gland (no extraglandular extension or lymph node metastases at presentation) have favorable outcomes whether or not they are treated in the first year after diagnosis and whether they are treated by hemithyroidectomy or total thyroidectomy. ©2010 American Medical Association. All rights reserved.

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