Gladys Ting

Validating Billing/Encounter Codes as Indicators of Lung, Colorectal, Breast, and Prostate Cancer Recurrence Using 2 Large Contemporary Cohorts

Background:A substantial proportion of cancer-related mortality is attributable to recurrent, not de novo metastatic disease, yet we know relatively little about these patients. To fill this gap, investigators often use administrative codes for secondary malignant neoplasm or chemotherapy to identify recurrent cases in population-based datasets. However, these algorithms have not been validated in large, contemporary, routine care cohorts. Objective:To evaluate the validity of secondary malignant neoplasm and chemotherapy codes as indicators of recurrence after definitive local therapy for stage I–III lung, colorectal, breast, and prostate cancer. Research Design, Subjects, and Measures:We assessed the sensitivity, specificity, and positive predictive value (PPV) of these codes 14 and 60 months after diagnosis using 2 administrative datasets linked with gold-standard recurrence status information: CanCORS/Medicare (diagnoses 2003–2005) and HMO/Cancer Research Network (diagnoses 2000–2005). Results:We identified 929 CanCORS/Medicare patients and 5298 HMO/CRN patients. Sensitivity, specificity, and PPV ranged widely depending on which codes were included and the type of cancer. For patients with lung, colorectal, and breast cancer, the combination of secondary malignant neoplasm and chemotherapy codes was the most sensitive (75%–85%); no code-set was highly sensitive and highly specific. For prostate cancer, no code-set offered even moderate sensitivity (⩽19%). Conclusions:Secondary malignant neoplasm and chemotherapy codes could not identify recurrent cancer without some risk of misclassification. Findings based on existing algorithms should be interpreted with caution. More work is needed to develop a valid algorithm that can be used to characterize outcomes and define patient cohorts for comparative effectiveness research studies.

High-Cost Imaging in Elderly Patients with Stage IV Cancer

BACKGROUND Medicare expenditures for high-cost diagnostic imaging have risen faster than those for total cancer care and have been targeted for potential cost reduction. We sought to determine recent and long-term patterns in high-cost diagnostic imaging use among elderly (aged ≥65 years) patients with stage IV cancer. METHODS We identified claims within the Surveillance, Epidemiology, and End Results (SEER)-Medicare database with computed tomography, magnetic resonance imaging, positron emission tomography, and nuclear medicine scans between January 1994 and December 2009 for patients diagnosed with stage IV breast, colorectal, lung, or prostate cancer between January 1995 and December 2006 (N = 100,594 patients). The proportion of these patients imaged and rate of imaging per-patient per-month of survival were calculated for each phase of care in patients diagnosed between January 2002 and December 2006 (N = 55,253 patients). Logistic regression was used to estimate trends in imaging use in stage IV patients diagnosed between January 1995 and December 2006, which were compared with trends in imaging use in early-stage (stages I and II) patients with the same tumor types during the same period (N = 192,429 patients). RESULTS Among the stage IV patients diagnosed between January 2002 and December 2006, 95.9% underwent a high-cost diagnostic imaging procedure, with a mean number of 9.79 (SD = 9.77) scans per patient and 1.38 (SD = 1.24) scans per-patient per-month of survival. After the diagnostic phase, 75.3% were scanned again; 34.3% of patients were scanned in the last month of life. Between January 1995 and December 2006, the proportion of stage IV cancer patients imaged increased (relative increase = 4.6%, 95% confidence interval [CI] = 3.7% to 5.6%), and the proportion of early-stage cancer patients imaged decreased (relative decrease = -2.5%, 95% CI = -3.2% to -1.9%). CONCLUSIONS Diagnostic imaging is used frequently in patients with stage IV disease, and its use increased more rapidly over the decade of study than that in patients with early-stage disease.

Interinstitutional variation in management decisions for treatment of 4 common types of cancer: A multi-institutional cohort study.

BACKGROUND When clinical practice is governed by evidence-based guidelines and there is consensus about their validity, practice variation should be minimal. For areas in which evidence gaps exist, greater variation is expected. OBJECTIVE To systematically assess interinstitutional variation in management decisions for 4 common types of cancer. DESIGN Multi-institutional, observational cohort study of patients with cancer diagnosed between July 2006 through May 2011 and observed through 31 December 2011. SETTING 18 cancer centers participating in the formulation of treatment guidelines and systematic outcomes assessment through the National Comprehensive Cancer Network. PATIENTS 25 589 patients with incident breast cancer, colorectal cancer, lung cancer, or non-Hodgkin lymphoma. MEASUREMENTS Interinstitutional variation for 171 binary management decisions with varying levels of supporting evidence. For each decision, variation was characterized by the median absolute deviation of the center-specific proportions. RESULTS Interinstitutional variation was high (median absolute deviation >10%) for 35 of 171 (20%) oncology management decisions, including 9 of 22 (41%) decisions for non-Hodgkin lymphoma, 16 of 76 (21%) for breast cancer, 7 of 47 (15%) for lung cancer, and 3 of 26 (12%) for colorectal cancer. Forty-six percent of high-variance decisions involved imaging or diagnostic procedures and 37% involved choice of chemotherapy regimen. The evidence grade underpinning the 35 high-variance decisions was category 1 for 0%, 2A for 49%, and 2B/other for 51%. LIMITATION Physician identifiers were unavailable, and results may not generalize outside of major cancer centers. CONCLUSION The substantial variation in institutional practice manifest among cancer centers reveals a lack of consensus about optimal management for common clinical scenarios. For clinicians, awareness of management decisions with high variation should prompt attention to patient preferences. For health systems, high variation can be used to prioritize comparative effectiveness research, patient-provider education, or pathway development. PRIMARY FUNDING SOURCE National Cancer Institute and National Comprehensive Cancer Network.When clinical practice is governed by evidence-based guidelines, variation in care of similar patients should be minimal. This multi-institutional cohort study found that management decisions for p...

Invasive procedures in the elderly after stage IV cancer diagnosis

BACKGROUND Invasive procedures are resource intense and may be associated with substantial morbidity. These harms must be carefully balanced with the benefits gained in life expectancy and quality of life. Prior research has demonstrated an increasing aggressiveness of care in cancer patients at the end-of-life. To better characterize surgical care in this setting, we sought to examine trends in the use of invasive procedures in patients diagnosed with metastatic cancer on presentation. MATERIALS AND METHODS Using Surveillance Epidemiology and End Results -Medicare data, we identified invasive procedure claims from 1994-2009 for patients diagnosed with incident stage IV breast, colorectal, lung, and prostate cancer patients in 1995-2006. We grouped procedures into surgically relevant categories, using an adaptation of the Clinical Classifications Software, and measured utilization and relative changes over time. RESULTS Of stage IV patients diagnosed in 2002-2006, 96% underwent a procedure during the course of their cancer care including 63% after the diagnostic period, and 25% in the last month of life. Between 1996 and 2006, minimal change was observed in utilization during the diagnostic period (+1.5%). However, there were significant increases during continuing care (+20.7%) and the last month of life (+21.5%). Procedures consistent with primary tumor resection decreased, whereas those with probable palliative intent and those unrelated to cancer increased. CONCLUSIONS Nearly all patients who present with metastatic cancer undergo invasive procedures. Although overall utilization is increasing, the specific procedure types indicate that it may be appropriate, enhancing the quality of life in this vulnerable population.

Interinstitutional Variation in Management Decisions for Treatment of 4 Common Types of CancerA Multi-institutional Cohort StudyInterinstitutional Variation in Cancer Management Decisions

BACKGROUND When clinical practice is governed by evidence-based guidelines and there is consensus about their validity, practice variation should be minimal. For areas in which evidence gaps exist, greater variation is expected. OBJECTIVE To systematically assess interinstitutional variation in management decisions for 4 common types of cancer. DESIGN Multi-institutional, observational cohort study of patients with cancer diagnosed between July 2006 through May 2011 and observed through 31 December 2011. SETTING 18 cancer centers participating in the formulation of treatment guidelines and systematic outcomes assessment through the National Comprehensive Cancer Network. PATIENTS 25 589 patients with incident breast cancer, colorectal cancer, lung cancer, or non-Hodgkin lymphoma. MEASUREMENTS Interinstitutional variation for 171 binary management decisions with varying levels of supporting evidence. For each decision, variation was characterized by the median absolute deviation of the center-specific proportions. RESULTS Interinstitutional variation was high (median absolute deviation >10%) for 35 of 171 (20%) oncology management decisions, including 9 of 22 (41%) decisions for non-Hodgkin lymphoma, 16 of 76 (21%) for breast cancer, 7 of 47 (15%) for lung cancer, and 3 of 26 (12%) for colorectal cancer. Forty-six percent of high-variance decisions involved imaging or diagnostic procedures and 37% involved choice of chemotherapy regimen. The evidence grade underpinning the 35 high-variance decisions was category 1 for 0%, 2A for 49%, and 2B/other for 51%. LIMITATION Physician identifiers were unavailable, and results may not generalize outside of major cancer centers. CONCLUSION The substantial variation in institutional practice manifest among cancer centers reveals a lack of consensus about optimal management for common clinical scenarios. For clinicians, awareness of management decisions with high variation should prompt attention to patient preferences. For health systems, high variation can be used to prioritize comparative effectiveness research, patient-provider education, or pathway development. PRIMARY FUNDING SOURCE National Cancer Institute and National Comprehensive Cancer Network.When clinical practice is governed by evidence-based guidelines, variation in care of similar patients should be minimal. This multi-institutional cohort study found that management decisions for p...

Inter-Institutional Variation in Management Decisions for Treatment of Four Common Cancers: A Multi-Institutional Cohort Study

BACKGROUND When clinical practice is governed by evidence-based guidelines and there is consensus about their validity, practice variation should be minimal. For areas in which evidence gaps exist, greater variation is expected. OBJECTIVE To systematically assess interinstitutional variation in management decisions for 4 common types of cancer. DESIGN Multi-institutional, observational cohort study of patients with cancer diagnosed between July 2006 through May 2011 and observed through 31 December 2011. SETTING 18 cancer centers participating in the formulation of treatment guidelines and systematic outcomes assessment through the National Comprehensive Cancer Network. PATIENTS 25 589 patients with incident breast cancer, colorectal cancer, lung cancer, or non-Hodgkin lymphoma. MEASUREMENTS Interinstitutional variation for 171 binary management decisions with varying levels of supporting evidence. For each decision, variation was characterized by the median absolute deviation of the center-specific proportions. RESULTS Interinstitutional variation was high (median absolute deviation >10%) for 35 of 171 (20%) oncology management decisions, including 9 of 22 (41%) decisions for non-Hodgkin lymphoma, 16 of 76 (21%) for breast cancer, 7 of 47 (15%) for lung cancer, and 3 of 26 (12%) for colorectal cancer. Forty-six percent of high-variance decisions involved imaging or diagnostic procedures and 37% involved choice of chemotherapy regimen. The evidence grade underpinning the 35 high-variance decisions was category 1 for 0%, 2A for 49%, and 2B/other for 51%. LIMITATION Physician identifiers were unavailable, and results may not generalize outside of major cancer centers. CONCLUSION The substantial variation in institutional practice manifest among cancer centers reveals a lack of consensus about optimal management for common clinical scenarios. For clinicians, awareness of management decisions with high variation should prompt attention to patient preferences. For health systems, high variation can be used to prioritize comparative effectiveness research, patient-provider education, or pathway development. PRIMARY FUNDING SOURCE National Cancer Institute and National Comprehensive Cancer Network.When clinical practice is governed by evidence-based guidelines, variation in care of similar patients should be minimal. This multi-institutional cohort study found that management decisions for p...

Use of high-cost imaging in elderly patients with metastatic cancer.

6112 Background: Diagnostic imaging is Medicares most rapidly growing service, and increasing rates of imaging have been documented among cancer patients. Like all interventions in patients with metastatic solid tumors, imaging may contribute to palliation but is unlikely to lead to long-term survival. We sought to determine patterns of imaging use in this population and to compare temporal trends with those observed among patients with curable early-stage disease. METHODS We extracted SEER-Medicare claims dated 1999-2007 for patients diagnosed with stage IV breast, colorectal, lung, or prostate cancer in 2000-2005 (n=64,267). High-cost imaging procedures were identified by CPT and/or ICD-9 codes for CT, MRI, PET, and nuclear medicine (NM) studies. Summary statistics were calculated, including percent of patients imaged and number of imaging procedures per patient. Comparable data were generated for patients with stage I-II disease of the same tumor types (n=127,827). Mean rates between groups were compared using the Wilcoxon test. We grouped patients according to year of diagnosis and compared utilization rates for the first and last year of the study period. RESULTS Stage IV patients underwent a mean of 2.4 high cost imaging procedures during the 60 day diagnostic period, compared to 0.8 in early stage patients (p<0.0001). Thereafter, stage IV patients underwent 0.7 high cost scans per month (1 scan every 43 days on average). 41% of stage IV patients were imaged in the last month of life. Over time, overall utilization increased in stage IV patients, while use decreased in early stage patients (Table). CONCLUSIONS Patients with stage IV solid tumors undergo frequent high cost imaging. Imaging rates in this population are increasing over time, in contrast to the observed decrease in those with curable disease. There is an urgent need for studies to determine whether the benefits of these procedures justify the cost, measured in societal resources as well as patient discomfort and anxiety. [Table: see text].