Carol Friedman

Colorectal cancer in U.S. adults younger than 50 years of age, 1998-2001.

Colorectal cancer (CRC) incidence rates are increasing among persons younger than 50 years of age, a population routinely not screened unless an individual has a high risk of CRC. This population‐based study focuses primarily on describing the CRC burden for persons in this age group.

Descriptive epidemiology of colorectal cancer in the United States, 1998-2001.

BACKGROUND. Colorectal cancer (CRC) incidence rates are increasing among persons younger than 50 years of age, a population routinely not screened unless an individual has a high risk of CRC. This population-based study focuses primarily on describing the CRC burden for persons in this age group. METHODS. The data used for this study were derived from the National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) surveillance systems. Age-adjusted incidence rates, rate ratios, and their corresponding 95% confidence intervals were calculated. RESULTS. CRC is ranked among the top 10 cancers occurring in males and females aged 20–49 years regardless of race. Persons younger than 50 years were more likely to present with less localized and more distant disease than do older adults. Among younger adults, age-adjusted incidence rates for poorly differentiated cancers were twice as high as rates for well-differentiated cancers. Incidence rates for poorly differentiated cancers were 60% higher than that for welldifferentiated cancers diagnosed in older adults. Rates were significantly higher for blacks and significantly lower for Asians/Pacific Islanders when compared with that for whites for the most demographic and tumor characteristics examined. CONCLUSIONS. This study confirms the findings of previous population-based studies suggesting that younger patients present with more advanced disease than do older patients. This study also identifies racial and ethnic disparities in CRC incidence in this population. These findings suggest the need for additional studies to understand the behavior and etiology of CRC in blacks. Cancer

Investigation of Postoperative Allograft-Associated Infections in Patients Who Underwent Musculoskeletal Allograft Implantation

BACKGROUND The rate at which allografts are used in surgical procedures has doubled in the United States during the past decade. In 2002, one outpatient surgical center (SC-X) identified a cluster of surgical site infections (SSIs) after anterior cruciate ligament reconstructive surgery (ACLRS). Therefore, we conducted an investigation to determine the extent of the outbreak and to identify risk factors. METHODS Our investigation included retrospective cohort and observational studies. A case patient was defined as any patient who acquired a SSI after undergoing ACLRS at SC-X between February 2000 and June 2002 (the study period). Data collected included demographic characteristics, clinical information, and graft details, such as processing method (i.e., aseptic or sterile). RESULTS Of 331 patients who underwent ACLRS during the study period, 11 (3.3%) met the case definition. All infections occurred at the tibial fixation site of the graft and involved 8 different microorganisms; the median time to a positive culture result was 55 days after ACLRS. The infection rate for patients who received aseptically processed allografts was 4.4% (11 of 250 patients), compared with 0% (0 of 81) for patients who received autografts or sterile allografts (P=.07). Use of a supplementary staple for tibial fixation, compared with other fixation methods that did not involve such staples, increased the risk of infection 10-fold in univariate analysis (relative risk [RR], 10.0; 95% confidence interval [CI], 3.0-32.9) and 9-fold when controlling for tissue processing method (RR, 9.0; 95% CI, 2.8-28.8). CONCLUSIONS The use of sterile allograft tissue appears to be associated with a significant reduction in the risk of postoperative infection, particularly in the presence of adjunctive fixation. Larger clinical studies are necessary to confirm this observation.

The Influence of Year-end Bonuses on Colorectal Cancer Screening

OBJECTIVE To estimate the effect of physician bonus eligibility on colorectal cancer (CRC) screening, controlling for patient and primary care physician characteristics. STUDY DESIGN Retrospective study using managed care plan claims data from 2000 and 2001. METHODS Data on 50-year-old commercially insured patients in a managed care health plan were linked to enrollment and provider files. The data included information on 6749 patients (3058 in 2000 and 3691 in 2001). Multivariate logistic regression models were used to assess the association between CRC screening receipt and physician bonus eligibility. RESULTS From 2000 to 2001, CRC screening use increased from 23.4% to 26.4% (P < .01). Results from the multivariate logistic regression analysis revealed that the probability that a patient received a CRC screening was approximately 3 percentage points higher in the bonus year, 2001 (P < .01). CONCLUSIONS Bonuses targeted at individual physicians were associated with increased use of CRC screening tests. However, more research is needed to examine the effect of performance-based incentives on resource use and the quality of medical care. Specifically, there is a need to determine whether explicit financial incentives are effective in reducing racial disparities in the quality of patient care. This has particular relevance for CRC screening given that black patients are less likely to be screened, they have higher CRC incidence and mortality rates compared with other racial groups, and screening has been shown to be more cost effective in this population.

Does Health Insurance Coverage of Office Visits Influence Colorectal Cancer Testing

Objective: To assess the effect of differing health insurance coverage of physician office visits on the use of colorectal cancer (CRC) tests among an employed and insured population. Method: Cohort study of persons ages 50 to 64 years enrolled in fee-for-service (FFS) or preferred provider organization (PPO) health plans, where FFS plan enrollees bear disproportionate share of office visit coverage, for the period 1995 through 1999. Results: Compared with FFS plans, enrollees in PPO plans were significantly more likely to obtain CRC tests [adjusted relative risk (RRa), 1.27; 95% confidence intervals (CI), 1.21-1.24]. The association was more pronounced among hourly individuals (RRa, 1.43; 95% CI, 1.41-1.45) than among salaried individuals (RRa, 1.09; 95% CI, 1.05-1.10), consistent with a greater differential in office visit coverage among the hourly group. Conclusions: Disproportionate cost-sharing seems to have a negative effect on the use of CRC tests most likely by discouraging nonacute care physician office visits.

Assessing the burden of disease among an employed population: implications for employer-sponsored prevention programs.

Learning ObjectivesList the components of the DALY (disability-adjusted life year) and explain how DALYs are estimated.Recall the disease states that are the most frequent causes of DALYs and note any differences related to gender or employment status (hourly or salaried).Discuss the risk factors underlying the leading causes of DALYs and how they might be modified. Escalating healthcare costs have led employers to identify ways to assess the actual burden of disease among their employees. One such measure is the use of disability-adjusted life-years (DALYs). DALYs were calculated for the General Motors (GM) population for 1994 through 1998 using data from GM’s Mortality Registry, published life tables, and age- and sex-specific disease incidence and disability data from the U.S. Burden of Disease Study. Chronic diseases accounted for 45% (245,844 of 540,450) of total DALYs lost. Ischemic heart disease, stroke, lung cancer, and chronic obstructive pulmonary disease led the list for both men and women and accounted for 39% and 31%, respectively, of the top 10 DALYs lost. Disease burden among employees could be reduced through targeted interventions aimed at the risk factors associated with the leading causes of DALYs.