Kaijun Liao

Prior experiences of racial discrimination and racial differences in health care system distrust.

Purpose:Factors contributing to racial differences in health care system distrust (HCSD) are currently unknown. Proposed potential contributing factors are prior experiences of racial discrimination and racial residential segregation. Methods:Random digit dialing survey of 762 African American and 1267 white adults living in 40 US metropolitan statistical areas. Measures included the Revised Health Care System Distrust scale, the Experiences of Discrimination scale, metrics of access to care, sociodemographic characteristics, and the level of racial residential segregation in the city (using the isolation index). Results:In unadjusted analyses, African Americans had higher levels of HCSD, particularly values distrust, and greater experiences of discrimination. Experience of discrimination was also strongly associated with HCSD. Adjusting for sociodemographic characteristics, health care access, and residential segregation had little effect on the association between African American race and overall HCSD or values distrust. In contrast, adjusting for experiences of racial discrimination reversed the association so that distrust was lower among African Americans than whites (odds ratio 0.53; 95% confidence interval, 0.33–0.85 for the overall measure). The Sobel test for mediation was strongly significant (P<0.001). Conclusions:Higher HCSD among African Americans is explained by a greater burden of experiences of racial discrimination than whites. Reasons for higher distrust among whites after adjusting for experiences of racial discrimination are not known. Efforts to eliminate racial discrimination and restore trust given prior discrimination are needed.

Outcomes After Intensity-Modulated Versus Conformal Radiotherapy in Older Men With Nonmetastatic Prostate Cancer

PURPOSE There is little evidence comparing complications after intensity-modulated (IMRT) vs. three-dimensional conformal radiotherapy (CRT) for prostate cancer. The study objective was to test the hypothesis that IMRT, compared with CRT, is associated with a reduction in bowel, urinary, and erectile complications in elderly men with nonmetastatic prostate cancer. METHODS AND MATERIALS We undertook an observational cohort study using registry and administrative claims data from the SEER-Medicare database. We identified men aged 65 years or older diagnosed with nonmetastatic prostate cancer in the United States between 2002 and 2004 who received IMRT (n = 5,845) or CRT (n = 6,753). The primary outcome was a composite measure of bowel complications. Secondary outcomes were composite measures of urinary and erectile complications. We also examined specific subsets of bowel (proctitis/hemorrhage) and urinary (cystitis/hematuria) events within the composite complication measures. RESULTS IMRT was associated with reductions in composite bowel complications (24-month cumulative incidence 18.8% vs. 22.5%; hazard ratio [HR] 0.86; 95% confidence interval [CI], 0.79-0.93) and proctitis/hemorrhage (HR 0.78; 95% CI, 0.64-0.95). IMRT was not associated with rates of composite urinary complications (HR 0.93; 95% CI, 0.83-1.04) or cystitis/hematuria (HR 0.94; 95% CI, 0.83-1.07). The incidence of erectile complications involving invasive procedures was low and did not differ significantly between groups, although IMRT was associated with an increase in new diagnoses of impotence (HR 1.27, 95% CI, 1.14-1.42). CONCLUSION IMRT is associated with a small reduction in composite bowel complications and proctitis/hemorrhage compared with CRT in elderly men with nonmetastatic prostate cancer.

Physician Social Networks and Variation in Prostate Cancer Treatment in Three Cities

OBJECTIVE To examine whether physician social networks are associated with variation in treatment for men with localized prostate cancer. DATA SOURCE 2004-2005 Surveillance, Epidemiology and End Results-Medicare data from three cities. STUDY DESIGN We identified the physicians who care for patients with prostate cancer and created physician networks for each city based on shared patients. Subgroups of urologists were defined as physicians with dense connections with one another via shared patients. PRINCIPAL FINDINGS Subgroups varied widely in their unadjusted rates of prostatectomy and the racial/ethnic and socioeconomic composition of their patients. There was an association between urologist subgroup and receipt of prostatectomy. In city A, four subgroups had significantly lower odds of prostatectomy compared with the subgroup with the highest rates of prostatectomy after adjusting for patient clinical and sociodemographic characteristics. Similarly, in cities B and C, subgroups had significantly lower odds of prostatectomy compared with the baseline. CONCLUSIONS Using claims data to identify physician networks may provide an insight into the observed variation in treatment patterns for men with prostate cancer.

Effect of HIV on survival in patients with non-small-cell lung cancer in the era of highly active antiretroviral therapy: a population-based study.

BACKGROUND HIV-infected patients with lung cancer have been reported to have poorer survival than uninfected patients. Whether this outcome holds true in the era of highly active antiretroviral therapy (HAART) is unclear. We examined the effect of HIV infection on clinical outcome in patients with lung cancer who are also receiving HAART. METHODS Patients diagnosed with non-small-cell lung cancer (NSCLC) from Jan 1, 2000, to Dec 31, 2005, with or without HIV infection were identified by querying the Surveillance, Epidemiology, and End Results registry and the Medicare lung cancer database. Survival analysis by stage and treatment delivered comparing the HIV-infected patients with uninfected controls was done with Kaplan-Meier and Cox models with propensity score adjustments. FINDINGS 71,976 patients with NSCLC were identified as uninfected controls and 322 patients with NSCLC were identified in the HIV group; median age was 75 years for both groups. Median overall survival for all stages was 7·0 months (95% CI 7·0-7·0) for uninfected controls versus 8·0 months (6·0-10·0) for the HIV group (p=0·16); for those with stage I/II disease it was 37·0 months (36·0-39·0) versus 43·0 months (26·0-58·0; p=0·37); for those with stage IIIA/IIIB disease it was 7·0 months (7·0-7·0) versus 3·0 months (2·0-8·0; p=0·051); and for those with stage IV disease it was 3·0 months for both groups (95% CI 3·0-3·0 for controls; 2·0-5·0 for HIV group; p=0·77). After propensity score adjustment, the survival difference in stage IIIA/IIIB was no longer seen (hazard ratio 0·88; 95% CI 0·71-1·09). The median survival for HIV infected patients with stage I or II NSCLC who underwent surgical resection was 58·0 months (95% CI 57·0-60·0) for uninfected controls versus 50·0 months (42·0 to unestimable) for the HIV group (p=0·88). INTERPRETATION We noted no significant difference in clinical outcome between patients with HIV and uninfected controls with NSCLC. Survival after curative surgical resection in early-stage patients was similar in HIV-infected individuals and uninfected controls. These data suggest that HIV status should not affect therapeutic decision making in NSCLC. FUNDING US National Cancer Institute (award number UC2CA148310).

The Influence of Health Care Policies and Health Care System Distrust on Willingness to Undergo Genetic Testing

Purpose:As the potential role of genetic testing in disease prevention and management grows, so does concern about differences in uptake of genetic testing across social and racial groups. Characteristics of how genetic tests are delivered may influence willingness to undergo testing and, if they affect population subgroups differently, alter disparities in testing. Methods:Conjoint analysis study of the effect of 3 characteristics of genetic test delivery (ie, attributes) on willingness to undergo genetic testing for cancer risk. Data were collected using a random digit dialing survey of 128 African American and 209 white individuals living in the United States. Measures included conjoint scenarios, the Revised Health Care System Distrust Scale (including the values and competence subscales), health insurance coverage, and sociodemographic characteristics. The 3 attributes studied were disclosure of test results to the health insurer, provision of the test by a specialist or primary care doctor, and race-specific or race-neutral marketing. Results:In adjusted analyses, disclosure of test results to insurers, having to get the test from a specialist, and race-specific marketing were all inversely associated with willingness to undergo the genetic test, with the greatest effect for the disclosure attribute. Racial differences in willingness to undergo testing were not statistically significant (P=0.07) and the effect of the attributes on willingness to undergo testing did not vary by patient race. However, the decrease in willingness to undergo testing with insurance disclosure was greater among individuals with high values distrust (P=0.03), and the decrease in willingness to undergo testing from specialist access was smaller among individuals with high competence distrust (P=0.03). Conclusions:Several potentially modifiable characteristics of how genetic tests are delivered are associated with willingness to undergo testing. The effect of 2 of these characteristics vary according to the level of health care system distrust, suggesting that policy decisions about delivery of genetic testing may influence differences in uptake across patient subgroups defined by levels of distrust rather than by race.

Racial Differences in the Impact of Comorbidities on Survival Among Elderly Men With Prostate Cancer

This study investigates differences in the effects of comorbidities on survival in Medicare beneficiaries with prostate cancer. Medicare data were used to assemble a cohort of 65- to 76-year-old Black (n = 6,402) and White (n = 47,458) men with incident localized prostate cancer in 1999 who survived ≥1 year postdiagnosis. Comorbidities were more prevalent among Blacks than among Whites. For both races, greater comorbidity was associated with decreasing survival rates; however, the effect among Blacks was smaller than in Whites. After adjusting for age, socioeconomic status, and community characteristics, the association between increasing comorbidities and survival remained weaker for Blacks than for Whites, and racial disparity in survival decreased with increasing number of comorbidities. Differential effects of comorbidities on survival were also evident when examining different classes of comorbid conditions. Adjusting for treatment had little impact on these results, despite variation in the racial difference in receipt of prostatectomy with differing comorbidity levels.

Racial disparities in changing to a high-volume urologist among men with localized prostate cancer

Background:Patients who receive surgery from high-volume surgeons tend to have better outcomes. Black patients, however, are less likely to receive surgery from high-volume surgeons. Objective:Among men with localized prostate cancer, we examined whether disparities in use of high-volume urologists resulted from racial differences in patients being diagnosed by high-volume urologists and/or changing to high-volume urologists for surgery. Research Design:Retrospective cohort study from Surveillance, Epidemiology, and End Results-Medicare data. Subjects:A total of 26,058 black and white men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with localized prostate cancer from 1995 to 2005 that underwent prostatectomy. Patients were linked to their diagnosing urologist and a treating urologist (who performed the surgery). Measures:Diagnosis and receipt of prostatectomy by a high-volume urologist, and changing between diagnosing and treating urologist Results:After adjustment for confounders, black men were as likely as white men to be diagnosed by a high-volume urologist; however, they were significantly less likely than white men to be treated by a high-volume urologist [odds ratio 0.76; 95% confidence interval (CI), 0.67–0.87]. For men diagnosed by a low-volume urologist, 46.0% changed urologists for their surgery. Black men were significantly less likely to change to a high-volume urologist (relative risk ratio 0.61; 95% CI, 0.47–0.79). Racial differences appeared to reflect black and white patients being diagnosed by different urologists and having different rates of changing after being diagnosed by the same urologists. Conclusions:Lower rates of changing to high-volume urologists for surgery among black men contribute to racial disparities in treatment by high-volume surgeons.

Physician Social Networks and Variation in Rates of Complications After Radical Prostatectomy

OBJECTIVES Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy. METHODS In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume. RESULTS Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications. CONCLUSIONS Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.

The effect of care setting in the delivery of high-value colon cancer care.

The effect of care setting on value of colon cancer care is unknown.

Hospital Academic Status and Value of Care for Nonmetastatic Colon Cancer

PURPOSE The relationship between oncologic hospital academic status and the value of care for stage II and III colon cancer is unknown. METHODS Retrospective SEER-Medicare analysis of patients age ≥ 66 years with stage II or III colon cancer and seen by medical oncology. Eligible patients were diagnosed 2000 to 2009 and followed through December 31, 2010. Hospitals reporting a major medical school affiliation in the NCI Hospital File were classified as academic medical centers. The association between hospital academic status and survival was assessed using Kaplan-Meier curves and Cox proportional hazards models. The association with mean cost of care was estimated using generalized linear models with log link and gamma family and with cost of care at various quantiles using quantile regression models. RESULTS Of 24,563 eligible patients, 5,707 (23%) received care from academic hospitals. There were no significant differences in unadjusted disease-specific median survival or adjusted risk of colon cancer death by hospital academic status (stage II hazard ratio = 1.12; 95% CI, 0.98 to 1.28; P = .103; stage III hazard ratio = 0.99; 95% CI, 0.90 to 1.08; P = .763). Excepting patients at the upper limits of the cost distribution, there was no significant difference in adjusted cost by hospital academic status. CONCLUSION We found no survival differences for elderly patients with stage II or III colon cancer, treated by a medical oncologist, between academic and nonacademic hospitals. Furthermore, cost of care was similar across virtually the full range of the cost distribution.