Laura Mae Baldwin

Do medicare patients with disabilities receive preventive services? A population-based study

OBJECTIVE To compare health maintenance procedure rates of Medicare patients with different levels of disability. STUDY DESIGN Observational study analyzing data from the 1995 Medicare Current Beneficiary Survey (MCBS, n = 15,590). Self-reported Pap smears, mammograms, and influenza and pneumococcal vaccinations were compared between groups with different levels of health-related difficulties in six activities of daily living (ADL). RESULTS Compared to those without disabilities, the most severely disabled women (limitations in 5 or 6 ADL) reported fewer Pap smears (age < or =70, 23% vs 41%, p < .001) and mammograms (age > or = 50, 13% vs 44%, p < .001). In a controlled analysis, individuals with this high level of disability were 57% (95% confidence interval [CI], 33% to 72%) and 56% (95% CI, 43% to 76%) less likely to report receiving Pap smears and mammograms, respectively, compared with able-bodied women, regardless of their age, whether they were in an HMO, or whether they lived in a long-term care facility. Functional limitations were not a deterrent to receiving vaccinations. In general, patients in HMOs reported more procedures than those in fee-for-service, while those in long-term care facilities reported fewer procedures than those living in the community. CONCLUSIONS Disability among Medicare patients is a significant, independent risk factor for not receiving mammograms and Pap smears. Efforts should be made to identify the most severely disabled because they are at particular risk.

In search of the perfect comorbidity measure for use with administrative claims data : Does it exist?

Background:Numerous measures of comorbidity have been developed for health services research with administrative claims. Objective:We sought to compare the performance of 4 claims-based comorbidity measures. Research Design and Subjects:We undertook a retrospective cohort study of 5777 Medicare beneficiaries ages 66 and older with stage III colon cancer reported to the Surveillance, Epidemiology, and End Results Program between January 1, 1992 and December 31, 1996. Measures:Comorbidity measures included Elixhauser’s set of 30 condition indicators, Klabunde’s outpatient and inpatient indices weighted for colorectal cancer patients, Diagnostic Cost Groups, and the Adjusted Clinical Group (ACG) System. Outcomes included receipt of adjuvant chemotherapy and 2 year noncancer mortality. Results:For all measures, greater comorbidity significantly predicted lower receipt of chemotherapy and higher noncancer death. Nested logistic regression modeling suggests that using more claims sources to measure comorbidity generally improves the prediction of chemotherapy receipt and noncancer death, but depends on the measure type and outcome studied. All 4 comorbidity measures significantly improved the fit of baseline regression models for both chemotherapy receipt (baseline c-statistic 0.776; ranging from 0.779 after adding ACGs and Klabunde to 0.789 after Elixhauser) and noncancer death (baseline c-statistic 0.687; ranging from 0.717 after adding ACGs to 0.744 after Elixhauser). Conclusions:Although some comorbidity measures demonstrate minor advantages over others, each is fairly robust in predicting both chemotherapy receipt and noncancer death. Investigators should choose among these measures based on their availability, comfort with the methodology, and outcomes of interest.

How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies.

Objectives: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. Methods: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the “gold standard.” Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. Results: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. Conclusions: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Predictors of comprehensive surgical treatment in patients with ovarian cancer

Providing appropriate surgical treatment for women with ovarian cancer is one of the most effective ways to improve ovarian cancer outcomes. In this study, the authors identified factors that were associated with a measure of comprehensive surgery, so that interventions may be targeted appropriately to improve surgical care.

Access to Cancer Services for Rural Colorectal Cancer Patients

CONTEXT Cancer care requires specialty surgical and medical resources that are less likely to be found in rural areas. PURPOSE To examine the travel patterns and distances of rural and urban colorectal cancer (CRC) patients to 3 types of specialty cancer care services--surgery, medical oncology consultation, and radiation oncology consultation. METHODS Descriptive cross-sectional study using linked Surveillance, Epidemiology, and End Results (SEER) cancer registry and Medicare claims data for 27,143 individuals ages 66 and older diagnosed with stages I through III CRC between 1992 and 1996. FINDINGS Over 90% of rural CRC patients lived within 30 miles of a surgical hospital offering CRC surgery, but less than 50% of CRC patients living in small and isolated small rural areas had a medical or radiation oncologist within 30 miles. Rural CRC patients who traveled outside their geographic areas for their cancer care often went great distances. The median distance traveled by rural cancer patients who traveled to urban cancer care providers was 47.8 miles or more. A substantial proportion (between 19.4% and 26.0%) of all rural patients bypassed their closest medical and radiation oncology services by at least 30 miles. CONCLUSIONS Rural CRC patients often travel long distances for their CRC care, with potential associated burdens of time, cost, and discomfort. Better understanding of whether this travel investment is paid off in improved quality of care would help rural cancer patients, most of whom are elderly, make informed decisions about how to use their resources during their cancer treatment.

Reoperation as a Quality Indicator in Colorectal Surgery: A Population-Based Analysis

Objective:To describe unplanned procedures following colorectal cancer surgery that might be used as intermediate outcome measures, and to determine their association with mortality and length of stay. Summary Background:Variation in the quality of surgical care, especially for common illnesses like colorectal cancer, has received increasing attention. Nonfatal complications resulting in procedural interventions are likely to play a role in poor outcomes but have not been well explored. Methods:Cohort analysis of 26,638 stage I to III colorectal cancer patients in the 1992 to 1996 SEER-Medicare database. Independent variables: sociodemographics, tumor characteristics, comorbidity, and acuity. Primary outcome: postoperative procedural intervention. Analysis: Logistic regression identified patient characteristics predicting postoperative procedures and the adjusted risk of 30-day mortality and prolonged hospitalization among patients with postoperative procedures. Results:A total of 5.8% of patients required postoperative intervention. Patient characteristics had little impact on the frequency of postoperative procedures, except for acute medical conditions, including bowel perforation (relative risk [RR] = 3.0, 95% confidence interval [CI] = 2.5–3.6), obstruction (RR = 1.6; 95% CI = 1.4–1.8), and emergent admission (RR = 1.3; 95% CI = 1.1–1.4). After a postoperative procedure, patients were more likely to experience early mortality (RR = 2.4; 95% CI = 2.1–2.9) and prolonged hospitalization (RR = 2.2; 95% CI = 2.1–2.4). The most common interventions were performed for abdominal infection (31.7%; RR mortality = 2.9; 95% CI = 2.3–3.7), wound complications (21.1%; RR mortality = 0.7; 95% CI = 0.4–1.3), and organ injury (18.7%; RR mortality = 1.6; 95% CI = 1.1–2.3). Conclusions:Postoperative complications requiring additional procedures among colorectal cancer patients correlate with established measures of surgical quality. Prospective tracking of postoperative procedures as complication markers may facilitate outcome studies and quality improvement programs.

The effect of expanding Medicaid prenatal services on birth outcomes.

OBJECTIVES Over 80% of US states have implemented expansions in prenatal services for Medicaid-enrolled women, including case management, nutritional and psychosocial counseling, health education, and home visiting. This study evaluates the effect of Washington States expansion of such services on prenatal care use and low-birthweight rates. METHODS The change in prenatal care use and low-birthweight rates among Washingtons Medicaid-enrolled pregnant women before and after initiation of expanded prenatal services was compared with the change in these outcomes in Colorado, a control state. RESULTS The percentage of expected prenatal visits completed increased significantly, from 84% to 87%, in both states. Washingtons low-birthweight rate decreased (7.1% to 6.4%, P = .12), while Colorados rate increased slightly (10.4% to 10.6%, P = .74). Washingtons improvement was largely due to decreases in low-birthweight rates for medically high-risk women (18.0% to 13.7%, P = .01, for adults; 22.5% to 11.5%, P = .03, for teenagers), especially those with preexisting medical conditions. CONCLUSIONS A statewide Medicaid-sponsored support service and case management program was associated with a decrease in the low-birthweight rate of medically high-risk women.

Residual Treatment Disparities After Oncology Referral for Rectal Cancer

BACKGROUND Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists. METHODS We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided. RESULTS There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy. CONCLUSION Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians†‡

Genetic counseling and testing is recommended for women at high but not average risk of ovarian cancer. National estimates of physician adherence to genetic counseling and testing recommendations are lacking.

Persistent demographic differences in colorectal cancer screening utilization despite Medicare reimbursement.

BackgroundColorectal cancer screening is widely recommended, but often under-utilized. In addition, significant demographic differences in screening utilization exist. Insurance coverage may be one factor influencing utilization of colorectal cancer screening tests.MethodsWe conducted a retrospective analysis of claims for outpatient services for Washington state Medicare beneficiaries in calendar year 2000. We determined the proportion of beneficiaries utilizing screening fecal occult blood tests, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema in the overall population and various demographic subgroups. Multiple logistic regression analysis was used to determine the relative odds of screening in different demographic groups.ResultsApproximately 9.2% of beneficiaries had fecal occult blood tests, 7.2% had any colonoscopy, flexible sigmoidoscopy, or barium enema (invasive) colon tests, and 3.5% had invasive tests for screening indications. Colonoscopy accounted for 41% of all invasive tests for screening indications. Women were more likely to receive fecal occult blood test screening (OR 1.18; 95%CI 1.15, 1.21) and less likely to receive invasive tests for screening indications than men (OR 0.80, 95%CI 0.77, 0.83). Whites were more likely than other racial groups to receive any type of screening. Rural residents were more likely than urban residents to have fecal occult blood tests (OR 1.20, 95%CI 1.17, 1.23) but less likely to receive invasive tests for screening indications (OR 0.89; 95%CI 0.85, 0.93).ConclusionReported use of fecal occult blood testing remains modest. Overall use of the more invasive tests for screening indications remains essentially unchanged, but there has been a shift toward increased use of screening colonoscopy. Significant demographic differences in screening utilization persist despite consistent insurance coverage.