Jinn-Ing Liou

Adjuvant Chemotherapy for Stage II Colon Cancer With Poor Prognostic Features

PURPOSE Adjuvant chemotherapy is typically considered for patients with stage II colon cancer characterized by poor prognostic features, including obstruction, perforation, emergent admission, T4 stage, resection of fewer than 12 lymph nodes, and poor histology. Despite frequent use, the survival advantage conferred on patients with stage II disease by chemotherapy is yet unproven. We sought to determine the overall survival benefit of chemotherapy among patients with stage II colon cancer having poor prognostic features. PATIENTS AND METHODS A total of 43,032 Medicare beneficiaries who underwent colectomy for stage II and III primary colon adenocarcinoma diagnosed from 1992 to 2005 were identified from the Surveillance, Epidemiology, and End Results (SEER) -Medicare database. χ(2) and two-way analysis of variance were used to assess differences in patient- and disease-related characteristics. Five-year overall survival was examined using Kaplan-Meier survival analysis and Cox proportional hazards regression with propensity score weighting. RESULTS Of the 24,847 patients with stage II cancer, 75% had one or more poor prognostic features. Adjuvant chemotherapy was received by 20% of patients with stage II disease and 57% of patients with stage III disease. After adjustment, 5-year survival benefit from chemotherapy was observed only for patients with stage III disease (hazard ratio[HR], 0.64; 95% CI, 0.60 to 0.67). No survival benefit was observed for patients with stage II cancer with no poor prognostic features (HR, 1.02; 95% CI, 0.84 to 1.25) or stage II cancer with any poor prognostic features (HR, 1.03; 95% CI, 0.94 to 1.13). CONCLUSION Among Medicare patients identified with stage II colon cancer, either with or without poor prognostic features, adjuvant chemotherapy did not substantially improve overall survival. This lack of benefit must be considered in treatment decisions for similar older adults with colon cancer.

Readmission after colectomy for cancer predicts one-year mortality.

Objectives:Early hospital readmission is a common and costly problem in the Medicare population. In 2009, the Centers for Medicaid and Medicare Services began mandating hospital reporting of disease-specific readmission rates. We sought to determine the rate and predictors of readmission after colectomy for cancer, as well as the association between readmission and mortality. Methods:Medicare beneficiaries who underwent colectomy for stage I to III colon adenocarcinoma from 1992 to 2002 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Multivariate logistic regression identified predictors of early readmission and 1-year mortality. Odds ratios were adjusted for multiple factors, including measures of comorbidity, socioeconomic status, and disease severity. Results:Of 42,348 patients who were discharged, 4662 (11.0%) were readmitted within 30 days. The most common causes of rehospitalization were ileus/obstruction and infection. Significant predictors of readmission included male gender, comorbidity, emergent admission, prolonged hospital stay, blood transfusion, ostomy, and discharge to nursing home. Readmission was inversely associated with hospital procedure volume, but not surgeon volume. After adjusting for potential confounding variables, the predicted probability of 1-year mortality was 16% for readmitted patients, compared with 7% for those not readmitted. This difference in mortality was significant for all stages of cancer. Conclusions:Early readmission after colectomy for cancer is common and due in part to modifiable factors. There is a remarkable association between readmission and 1-year mortality. Early readmission is therefore an important quality-of-care indicator for colon cancer surgery. These findings may facilitate the development of targeted interventions that will decrease readmissions and improve patient outcomes.

Rehospitalization and survival for stroke patients in managed care and traditional Medicare plans.

Background:Stroke affects more than 500,000 older persons each year in the United States, but no studies have compared older stroke patients in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) after recent changes in FFS reimbursement. Objectives:We sought to compare utilization and outcomes after stroke in Medicare HMO and FFS. Design:We reviewed administrative data in 11 regions from Medicare and a large national health plan. Subjects:We studied Medicare beneficiaries 65 years and older discharged with ischemic stroke during 1998–2000, ie, 4816 HMO patients and a random sample of 4187 FFS patients from 422 hospitals. Measures:We measured survival, rehospitalization, length of stay, discharge destination, and warfarin use. Results:Overall, HMO patients were younger, male, non-Caucasian, and had fewer comorbid conditions. When compared with FFS patients, HMO patients were more likely to be rehospitalized within 30 days for a primary diagnosis of ischemic stroke (Adjusted Hazard Ratio = 1.45, 95% Confidence Interval [CI] 1.14–1.83) or ill-defined conditions (eg, rehabilitation services) (2.87, 95% CI 1.85–4.46) and less likely to be rehospitalized for fluid and electrolyte disorders (0.54, 95% CI 0.34–0.87) or circulatory/respiratory problems (0.77, 95% CI 0.60–0.98). There were no consistent differences in 30-day mortality or in 1-year rehospitalization or mortality for 30-day survivors. HMO patients also were much less likely to be discharged to rehabilitation facilities, slightly less likely to be discharged to skilled nursing facilities and to have a shorter length of stay, and did not differ in the use of home care services or warfarin use when compared with FFS patients. Conclusions:Traditional measures of quality such as 30-day rehospitalization may not be valid when comparing HMO and FFS patients if differences might reflect an alternative service mix. Utilization of postacute care for FFS patients appears similar to HMO patients except for discharge to rehabilitation facilities.

30-day survival and rehospitalization for stroke patients according to physician specialty.

Background and Purpose: Stroke patients appear to have improved outcomes when cared for by neurologists, but the mechanism by which improved outcome is achieved is unclear. This study compares 30-day cause-specif ic rehospitalization, 30-day mortality, and specific processes of care for patients treated by a neurologist only, a generalist only, a neurologist and a generalist (i.e., collaborative care), or by another specialist during the index hospitalization.Methods: This study uses Cox regression to analyze claims and enrollment data from 44,099 Medicare beneficiaries 65 years of age and older and discharged with acute ischemic stroke from 1998 to 2000 in 11 US metropolitan regions. Results: Patients seen by neurologists had more severe strokes than patients seen by generalists, though patients seen by generalists had more comorbidities. Patients seen by neurologists (alone or collaboratively) had a 10 and 16% lower risk of 30-day mortality, respectively. Patients seen by a neurologist only had a 12% lower risk of rehospitalization for infections and aspiration pneumonitis. In contrast, patients seen by neurologists had a higher risk of rehospitalization for atherosclerotic (cardiovascular and non-acute cerebrovascular) disease. Patients seen by neurologists were more likely to be discharged to inpatient rehabilitation, had longer lengths of stay, and were more likely to receive warfarin after discharge. Conclusions: Results support the hypothesis that neurologists improve outcomes specifically by reducing the potential for aspiration (through increased swallowing evaluations) or by improving functioning (through use of rehabilitation therapy). Future studies should continue to examine the mechanisms by which neurologists may achieve better outcomes in stroke care.

The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs.

OBJECTIVES: To examine 1‐year mortality and healthcare payments of stroke patients experiencing zero, one and two or more bounce‐backs within 30 days of discharge.

Analysis of Guidelines for Screening Diabetes Mellitus in an Ambulatory Population

OBJECTIVES To compare the case-finding ability of current national guidelines for screening diabetes mellitus and characterize factors that affect testing practices in an ambulatory population. PATIENTS AND METHODS In this retrospective analysis, we reviewed a database of 46,991 nondiabetic patients aged 20 years and older who were seen at a large Midwestern academic physician practice from January 1, 2005, through December 31, 2007. Patients were included in the sample if they were currently being treated by the physician group according to Wisconsin Collaborative for Healthcare Quality criteria. Pregnant patients, diabetic patients, and patients who died during the study years were excluded. The prevalence of patients who met the American Diabetes Association (ADA) and/or US Preventive Services Task Force (USPSTF) criteria for diabetes screening, percentage of these patients screened, and number of new diabetes diagnoses per guideline were evaluated. Screening rates were assessed by number of high-risk factors, primary care specialty, and insurance status. RESULTS A total of 33,823 (72.0%) of 46,991 patients met either the ADA or the USPSTF screening criteria, and 28,842 (85.3%) of the eligible patients were tested. More patients met the ADA criteria than the 2008 USPSTF criteria (30,790 [65.5%] vs 12,054 [25.6%]), and the 2008 USPSTF guidelines resulted in 460 fewer diagnoses of diabetes (33.1%). By single high-risk factor, prediabetes (15.8%) and polycystic ovarian syndrome (12.6%) produced the highest rates of diagnosis. The number of ADA high-risk factors predicted diabetes, with 6 (23%) of 26 patients with 6 risk factors diagnosed as having diabetes. Uninsured patients were tested significantly less often than insured patients (54.9% vs 85.4%). CONCLUSION Compared with the ADA recommendations, the new USPSTF guidelines result in a lower number of patients eligible for screening and decrease case finding significantly. The number and type of risk factors predict diabetes, and lack of health insurance decreases testing.

Long-term survival in older critically ill patients with acute ischemic stroke*

Objectives: To compare survival in older patients with acute ischemic stroke admitted to intensive care units (ICUs) with those not requiring ICU care and to assess the impact of mechanical ventilation (MV) and percutaneous gastrostomy tubes (PEG) on long-term mortality. Design: Multicentered retrospective cohort study. Setting: Administrative data from the Centers for Medicare and Medicaid Services covering 93 metropolitan counties primarily in the eastern half of the United States. Patients: 31,301 patients discharged with acute ischemic stroke in 2000. Interventions: None. Measurements and Main Results: Mortality from the time of index hospitalization up to the end of the follow-up period of 12 months. Information was also gathered on use of mechanical ventilation, percutaneous gastrostomy, sociodemographic variables and a host of comorbid conditions. Of all patients with acute ischemic stroke, 26% required ICU admission. The crude death rate for ICU stroke patients was 21% at 30 days and 40% at 1-yr follow-up. At 30 days, after adjustment of sociodemographic variables and comorbidities, ICU patients had a 29% higher mortality hazard compared with non-ICU patients. MV was associated with a five-fold higher mortality hazard (hazard ratio 5.59, confidence interval [CI] 4.93–6.34). The use of PEG was not associated with mortality at 30 days. By contrast, at 1-yr follow up in 30-day survivors, ICU admission was not associated with mortality hazard (hazard ratio 1.01, 95% CI 0.93–1.09). MV still had a higher risk of death (hazard ratio 1.88, 95% CI 1.57–2.25), and PEG patients had a 2.59-fold greater mortality hazard (95% CI 2.38–2.82). Conclusions: Both short-term and long-term mortality in older patients with acute ischemic stroke admitted to ICUs is lower than previously reported. The need for MV and PEG are markers for poor long-term outcome. Future research should focus on the identification of clinical factors that lead to increased mortality in long-term survivors and efforts to reduce those risks.

Predictors of Hospice Utilization among Acute Stroke Patients who Died within Thirty Days

BACKGROUND Hospice is considered to be underutilized, particularly among patients with noncancer diagnoses such as stroke. The highest mortality among stroke patients occurs within the first 30 days; however, we know little about the hospice enrollment decision for this population during this critical time frame. OBJECTIVES To determine hospice enrollment rates and to describe sociodemographic and clinical predictors of hospice utilization among patients who die within 30 days of their stroke. DESIGN Retrospective analysis of administrative data. SUBJECTS Medicare beneficiaries 65 years and older discharged with ischemic stroke from 422 hospitals and 11 metropolitan regions during the year 2000 who died within 30 days of their stroke. MEASURES Hospice utilization within 30 days. RESULTS The overall hospice enrollment rate in our study was 23%. Using multivariable logistic regression, factors predicting increased hospice enrollment included older age, female gender, health management organization (HMO) membership, length of stay more than 3 days, and dementia. Factors predicting decreased enrollment included African American race, mechanical ventilation, gastrostomy tube placement, uncomplicated diabetes mellitus, and valvular disease. When in-hospital deaths were excluded, overall enrollment increased to 44%, and mechanical ventilation and dementia ceased to predict enrollment. CONCLUSIONS Hospice enrollment rates among patients who die within the first 30 days of their stroke, particularly among those who survive to discharge, are much higher than prior estimates suggest. Although overall enrollment rates were higher than anticipated, there remain important sociodemographic and clinical characteristics unique to this population that predict low hospice utilization that should serve as targets for further research and intervention.

Discharge Destination's Effect on Bounce-Back Risk in Black, White, and Hispanic Acute Ischemic Stroke Patients

OBJECTIVE To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30 d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination. DESIGN Retrospective analysis of administrative data. SETTING Four hundred twenty-two hospitals, southern/eastern United States. PARTICIPANTS All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay. RESULTS Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9-22.8], Hispanic=19% [17.1-21.7] vs whites=16% [15.5-16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6-29.3], Hispanics=28% [25.4-31.6] vs whites=33% [31.8-35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2-28.6], Hispanics=28% [24-32.6] vs whites=21% [20.3-21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3-17] vs blacks=20% [18.4-22.2], whites=18% [16.8-18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk. CONCLUSIONS Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect.

Insurance Disruption due to Spousal Medicare Transitions: Implications for Access to Care and Health Care Utilization for Women Approaching Age 65

OBJECTIVE To assess whether a husbands Medicare transition leads to insurance disruptions for his wife that impact her perceived access to care, health care utilization, or health status. DATA SOURCES/STUDY SETTING Respondents were married women under age 65 from the 2003-2005 round of the Wisconsin Longitudinal Study (N=655). STUDY DESIGN Instrumental variable (IV) linear and IV-probit analyses provided unbiased estimates of the effect of an insurance disruption on study outcomes. The instrument was the husbands age: (1) women with husbands who transitioned to Medicare within the previous year (age 65-66); (2) women with husbands who did not transition (60<age<65). DATA COLLECTION/EXTRACTION METHODS Respondents were surveyed via telephone and mail. PRINCIPAL FINDINGS After adjustment, women who experienced an insurance disruption due to their husbands Medicare transition had a greater probability of experiencing a change in usual clinic/provider (71 percent), delaying filling or taking fewer medications than prescribed because of cost (75 percent), going to the emergency room (52 percent), and had lower average mental health scores than women who did not experience an insurance disruption. CONCLUSIONS Despite consistent insurance coverage, the insurance disruption that accompanies a spouses Medicare transition has adverse access and health care utilization consequences for women.