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Influence of Age on Guideline-Concordant Cancer Care for Elderly Patients in the United States.

ABSTRACT: To examine the frequency of guideline-concordant cancer care in elderly patients, including "older" elderly (age ?80 years).Using the Surveillance, Epidemiology and End Results-Medicare dataset in patients aged ?66 years diagnosed with nonmetastatic breast cancer (n=55,094), non-small cell lung (NSCLC) (n=36,203), or prostate cancer (n=86,544) from 2006 to 2011, chemotherapy, surgery, and radiation (RT) treatments were identified using claims. Pearson ?2 tested associations between age and guideline concordance.Older patients were less likely to receive guideline-concordant curative treatment: in stage III breast cancer, receipt of postmastectomy RT (70%, 46%, and 21% in patients aged 66-79, 80-89, and ?90 years, respectively; P<.0001); in stage I NSCLC, RT or surgery (89%, 80%, and 64% in age 66-79, 80-89, and ?90 years; P<.0001); in stage III NSCLC, RT or surgery plus chemotherapy (79%, 58%, and 27% in age 66-79, 80-89, and ?90 years; P<.0001); and in intermediate/high-risk prostate cancer, RT or prostatectomy (projected life expectancy >10 years: 85% and 82% in age 66-69 and 70-75 years; and ?10 years: 70%, 42%, and 9% in age 76-79, 80-89, and ?90 years; P<.0001). However, older patients were more likely to receive guideline-concordant de-intensified treatment: in stage I to II node-negative breast cancer, hypofractionated postlumpectomy RT (9%, 16%, and 23% in age 66-79, 80-89, and ?90 years; P<.0001); in stage I estrogen receptor-positive breast cancer, observation after lumpectomy (12%, 42%, and 84% in age 66-79, 80-89, and ?90 years; P<.0001); in stage I NSCLC, stereotactic body RT instead of surgery (7%, 16%, and 25% in age 66-79, 80-89, and ?90 years; P<.0001); and in lower-risk prostate cancer, no active treatment (25%, 54%, and 68% in age 66-79, 80-89, and ?90 years; P<.0001).Actual treatment of older elderly cancer patients frequently diverged from guidelines, especially in curative treatment of advanced disease. Results suggest a need for better metrics than existing guidelines alone to evaluate quality and appropriateness of care in this population.

SUBMITTER: Fang P

PROVIDER: S-EPMC5504701 | biostudies-literature | 2017 Jul

REPOSITORIES: biostudies-literature

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Influence of Age on Guideline-Concordant Cancer Care for Elderly Patients in the United States.

Fang Penny P He Weiguo W Gomez Daniel R DR Hoffman Karen E KE Smith Benjamin D BD Giordano Sharon H SH Jagsi Reshma R Smith Grace L GL

International journal of radiation oncology, biology, physics 20170201 4

<h4>Purpose</h4>To examine the frequency of guideline-concordant cancer care in elderly patients, including "older" elderly (age ≥80 years).<h4>Methods and materials</h4>Using the Surveillance, Epidemiology and End Results-Medicare dataset in patients aged ≥66 years diagnosed with nonmetastatic breast cancer (n=55,094), non-small cell lung (NSCLC) (n=36,203), or prostate cancer (n=86,544) from 2006 to 2011, chemotherapy, surgery, and radiation (RT) treatments were identified using claims. Pearso ...[more]

PMID: 28366580

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Project description:ObjectivesElderly carry a disproportionate burden of lung cancer in the US. Therefore, its important to ensure that these patients receive quality cancer care. Timeliness of care is an important dimension of cancer care quality but its impact on prognosis remains to be explored. This study evaluates the variations in guideline-concordant timely lung cancer care and prognosis among elderly in the US.Materials and methodsUsing the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2002-2007), we identified elderly patients with lung cancer (n=48,850) and determined time to diagnosis and treatment. We categorized patients by receipt of timely care using guidelines from the British Thoracic Society and the RAND Corporation. Hierarchical generalized logistic model was constructed to identify variables associated with receipt of timely care. Kaplan-Meier analysis and Log Rank test was used for estimation and comparison of the three-year survival. Multivariable Cox proportional hazards model was constructed to estimate lung cancer mortality risk associated with receipt of delayed care.ResultsTime to diagnosis and treatment varied significantly among the elderly. However, majority of them (77.5%) received guideline-concordant timely lung cancer care. The likelihood of receiving timely care significantly decreased with NSCLC disease, early stage diagnosis, increasing age, non-white race, higher comorbidity score, and lower income. Paradoxically, survival outcomes were significantly worse among patients receiving timely care. Adjusted lung cancer mortality risk was also significantly lower among patients receiving delayed care, relative to those receiving timely care (Hazard ratio (HR)=0.68, 95% Confidence interval (CI)=(0.66-0.71); p ≤ 0.05).ConclusionThis study highlights the critical need to address disparities in receipt of guideline-concordant timely lung cancer care among elderly. Although timely care was not associated with better prognosis in this study, any delays in diagnosis and treatment should be avoided, as it may increase the risk of disease progression and psychological stress in patients. Furthermore, given that lung cancer diagnostic and management services are covered under the Medicare program, observed delays in care among Medicare beneficiaries is also a cause for concern.

Project description:PurposeWe identified the frequency of racial disparities in guideline-concordant cancer care for select common disease sites in the United States and the impact of guideline concordance on mortality disparities.Methods and materialsUsing Surveillance, Epidemiology, and End Results Medicare data, we evaluated patients age >65 years of black or non-Hispanic white race who were diagnosed with stage III breast (n = 3607), stage I (n = 14,605) or III (n = 15,609) non-small cell lung, or stage III prostate (n = 3548) cancer between 2006 and 2011. Chemotherapy, surgery, and radiation therapy (RT) treatments were identified using claims data. Pearson χ2 was used to test the associations between race and guideline concordance on the basis of National Comprehensive Cancer Network curative treatment guidelines. Mortality risks were modeled using Cox proportional hazards.ResultsBlack patients were less likely to receive guideline-concordant curative treatment than non-Hispanic white patients for stage III breast cancer postmastectomy RT (53% black, 61% white; P = .0014), stage I non-small cell lung cancer stereotactic radiation or surgery (61% black, 75% white; P < .0001), stage III non-small cell lung cancer chemotherapy in addition to RT or surgery (36% black, 41% white; P = .0001), and stage III prostate cancer RT or prostatectomy (82% black, 95% white; P < .0001). Disparities in guideline concordance impacted racial mortality disparities. Specifically, hazard ratios that demonstrated elevated all-cause mortality risks in black patients were lowered (and more closely approached hazard ratio of 1.00) after adjusting for guideline concordance. A similar impact for cause-specific mortality was observed.ConclusionsRacial disparities in the receipt of curative cancer therapy impacted racial mortality disparities across multiple cancer sites. Benchmarking adherence to guideline-concordant care could represent an opportunity to stimulate improvements in disparities in cancer treatment and survival.

Project description:Rationale: The level of adherence to lung cancer treatment guidelines in the United States is unclear. In addition, it is unclear whether previously identified disparities by racial or ethnic group and by age persist across all clinical subgroups.Objectives: To assess the level of adherence to the minimal lung cancer treatment recommended by the National Comprehensive Cancer Network guidelines (guideline-concordant treatment) in the United States, and to assess the persistence of disparities by racial or ethnic group and by age across all clinical subgroups.Methods: We evaluated whether 441,812 lung cancer cases in the National Cancer Database diagnosed between 2010 and 2014 received guideline-concordant treatment. Logistic regression models were used to assess possible disparities in receiving guideline-concordant treatment by racial or ethnic group and by age across all clinical subgroups, and whether these persist after adjusting for patient, tumor, and health care provider characteristics.Results: Overall, 62.1% of subjects received guideline-concordant treatment (range across clinical subgroups = 50.4-76.3%). However, 21.6% received no treatment (range = 10.3-31.4%) and 16.3% received less intensive treatment than recommended (range = 6.4-21.6%). Among the most common less intensive treatments for all subgroups was "conventionally fractionated radiotherapy only" (range = 2.5-16.0%), as was "chemotherapy only" for nonmetastatic subgroups (range = 1.2-13.7%), and "conventionally fractionated radiotherapy and chemotherapy" for localized non-small-cell lung cancer (5.9%). Guideline-concordant treatment was less likely with increasing age, despite adjusting for relevant covariates (age ≥ 80 yr compared with <50 yr: adjusted odds ratio = 0.12, 95% confidence interval = 0.12-0.13). This disparity was present in all clinical subgroups. In addition, non-Hispanic black patients were less likely to receive guideline-concordant treatment than non-Hispanic white patients (adjusted odds ratio = 0.78, 95% confidence interval = 0.76-0.80). This disparity was present in all clinical subgroups, although statistically nonsignificant for extensive disease small-cell lung cancer.Conclusions: Between 2010 and 2014, many patients with lung cancer in the United States received no treatment or less intensive treatment than recommended. Particularly, elderly patients with lung cancer and non-Hispanic black patients are less likely to receive guideline-concordant treatment. Patterns of care among those receiving less intensive treatment than recommended suggest room for improved uptake of treatments such as stereotactic body radiation therapy for subjects with localized non-small-cell lung cancer.

Project description:BackgroundSchizophrenia is associated with excess mortality and multimorbidity, which is possibly associated with difficulty in coordinating care for multiple mental and physical comorbidities. We analyzed the receipt by patients with schizophrenia of 11 types of guideline-concordant care and the association of such care with survival.MethodsGuideline-concordant care over an 8-year period (financial years 2002 to 2009) was examined in a nationwide sample of 49,173 male veterans with schizophrenia, who were aged 50 years or older. Administrative databases from the electronic medical record system of the Veterans Health Administration (VA) provided comprehensive measures of patient demographics and medical information. Relying on the 2004 American Psychiatric Association guidelines, patterns in 11 types of care were identified and cluster-analyzed. Care types included cardiovascular, metabolic, weight management, nicotine dependence, infectious diseases, vision, and mental health counseling (individual, family, drugs/alcohol, psychiatric medication, and compensated work therapy). Survival analysis estimated association of care patterns with survival, adjusting for clinical and demographic covariates.ResultsThere was an average of four chronic diseases in addition to schizophrenia in the cohort, notably hypertension (43%) and dyslipidemia (29%). Three longitudinal trajectories (clusters) were identified: 'high-consistent' (averaging 5.4 types of care annually), 'moderate-consistent' (averaging 3.8), and 'poor-decreasing' (averaging 1.9). Most veterans were receiving cardiovascular care (67 to 76%), hepatic and renal function assays (79 to 84%), individual counseling (72 to 85%) and psychiatry consults (66 to 82%), with the proportion receiving care varying by cluster group. After adjustment for age, baseline comorbidity, and other covariates, there was a greater survival rate for those with poor-decreasing care compared with high-consistent care, and for high-consistent compared with moderate-consistent care.ConclusionsRelatively low levels of guideline-concordant care were seen for older VA patients with schizophrenia, and trajectories of care over time were associated with survival in a non-intuitive pattern. The group with the lowest and decreasing levels of care was also the oldest, but nonetheless had the best age-adjusted and other covariate-adjusted survival rates, possibly because they were requiring less care relative to younger, sicker veterans, and thus their comorbidity burden was markedly lower. Notably, in the group with the sickest individuals (that is those with the highest comorbidity scores, who were very disabled), receiving guideline-concordant care was associated with improved survival in adjusted models compared with those patients receiving only moderate levels of care.

Project description:Background & aimsThe benefits of hospice care in Medicare recipients with hepatocellular carcinoma (HCC) have not been fully evaluated, which we aimed to study.MethodsWe used nationally representative samples of the Medicare beneficiaries in the USA (2011-2016) to assess the impact of hospice care on the outcomes of patients with HCC. Hospice care benefits on the survival time, length of stay (LOS), 30-day readmissions, and daily charges during the last year and month of life were assessed by logistic regression and generalised linear regression.ResultsAmong 2,230 Medicare beneficiaries with HCC (mean age, 74.9 years; non-Hispanic White 79.1%; male 66.6%), median survival from HCC diagnosis was 68 days; 556 (24.9%) received hospice services; median hospice LOS was 12 days (4-35 days). Hospice users increased from 20.1% to 31.1% over time, driven by enrolment ≤15 days (45.1-59.2%, respectively). In the last year of life, hospice users (vs. no hospice care) had longer median survival time (76.5 vs. 66 days), lower in-hospital mortality (1.1% vs. 25.5%) and lower median daily charges ($951 vs. $1,004) despite more inpatient admissions and higher comorbid diseases. Hospice enrolment was associated with 48.6% reduction in daily charges (95% CI: -54.9% to -41.5%). Longer hospice LOS was associated with lower rates of healthcare utilisation. Patients with chronic liver disease were less likely to enrol in hospice care (odds ratio = 0.18, 95% CI: 0.14-0.24).ConclusionsAlthough hospice provides a significant decrease in healthcare utilisation and some benefit in survival, most care is given in the last 2 weeks of life. Efforts to encourage earlier use of hospice services must continue.Lay summaryThe purpose of hospice care is to provide comfort and lessen suffering at the end of life. Hospice care allows one to die outside the hospital environment which is the wish of most people. However, we found that among persons aged 65 years and older who were diagnosed with liver cancer (which has a poor prognosis), only 25% were enrolled in hospice care and the majority used a hospice only in the last weeks of life. This is a disheartening finding as liver cancer patients with longer hospice enrolment had lower costs and improved survival. We suggest that healthcare practitioners consider discussion of palliative and hospice care routinely with patients suffering from liver cancer.

Project description:BackgroundCulture shapes how people understand illness and death, but few studies examine whether acculturation influences patients' end-of-life treatment preferences and medical care.Methods and findingsIn this multi-site, prospective, longitudinal cohort study of terminally-ill cancer patients and their caregivers (n?=?171 dyads), trained interviewers administered the United States Acculturation Scale (USAS). The USAS is a 19-item scale developed to assess the degree of "Americanization" in first generation or non-US born caregivers of terminally-ill cancer patients. We evaluated the internal consistency, concurrent, criterion, and content validity of the USAS. We also examined whether caregivers' USAS scores predicted patients' communication, treatment preferences, and end-of-life medical care in multivariable models that corrected for significant confounding influences (e.g. education, country of origin, English proficiency). The USAS measure was internally consistent (Cronbach ??=?0.98); and significantly associated with US birthplace (r?=?0.66, P<0.0001). USAS scores were predictive of patients' preferences for prognostic information (AOR?=?1.31, 95% CI:1.00-1.72), but not comfort asking physicians' questions about care (AOR 1.23, 95% CI:0.87-1.73). They predicted patients' preferences for feeding tubes (AOR?=?0.68, 95% CI:0.49-0.99) and wish to avoid dying in an intensive care unit (AOR?=?1.36, 95% CI:1.05-1.76). Scores indicating greater acculturation were also associated with increased odds of patient participation in clinical trials (AOR?=?2.20, 95% CI:1.28-3.78), compared with lower USAS scores, and greater odds of patients receiving chemotherapy (AOR?=?1.59, 95% CI:1.20-2.12).ConclusionThe USAS is a reliable and valid measure of "Americanization" associated with advanced cancer patients' end-of-life preferences and care. USAS scores indicating greater caregiver acculturation were associated with increased odds of patient participation in cancer treatment (chemotherapy, clinical trials) compared with lower scores. Future studies should examine the effects of acculturation on end-of-life care to identify patient and provider factors that explain these effects and targets for future interventions to improve care (e.g., by designing more culturally-competent health education materials).

Dataset Information

Influence of Age on Guideline-Concordant Cancer Care for Elderly Patients in the United States.

Publications

Influence of Age on Guideline-Concordant Cancer Care for Elderly Patients in the United States.

Similar Datasets

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