Nina A. Bickell

Referral Patterns for Coronary Artery Disease Treatment: Gender Bias or Good Clinical Judgment?

OBJECTIVE To determine whether a gender bias exists in referral for coronary bypass graft surgery among patients with catheterization-documented coronary artery disease. DESIGN Historical cohort study (1969 to 1984). SETTING A referral medical center. PATIENTS A total of 5795 patients with catheterization-documented coronary artery disease. MEASUREMENTS Surgical referral patterns of men and women grouped by risk for cardiac death and by treatment effectiveness. Time trends were evaluated for three periods: 1969 to 1974, 1975 to 1979, and 1980 to 1984. RESULTS Overall, when no adjustment was made for baseline risk for cardiac death, no statistical difference was found between men and women regarding referral for surgery (46% compared with 44%, respectively). When an adjustment was made for such risk, the male-to-female odds ratio for surgical referral was 1.28 (95% Cl, 1.05 to 1.58) among patients with a low risk for cardiac death. This effect was most evident in the 1980 to 1984 period (odds ratio, 1.73; Cl, 1.29 to 2.31). In the high-risk group, the odds ratio was 0.84 (Cl, 0.68 to 1.04), with little change occurring during the study. Men were more likely to be referred for surgery when surgery offered the least survival benefit relative to medical therapy (odds ratio, 1.29; Cl, 1.08 to 1.54). This effect was most pronounced in the 1980 to 1984 period (odds ratio, 1.63; Cl, 1.27 to 2.10). CONCLUSIONS Women are less likely than men to be referred for coronary bypass graft surgery among patients with a low risk for cardiac death, in whom surgery offers little or no survival benefit over medical treatment. Women are at least as likely as men to be referred for bypass surgery among more symptomatic and more severely diseased patients, in whom surgery offers the greatest survival benefits. These trends were most prominent in the recent years of the study. Based on surgical survival benefits, these referral patterns may represent more appropriate treatment referral for women than men.

Underuse of Breast Cancer Adjuvant Treatment: Patient Knowledge, Beliefs, and Medical Mistrust

PURPOSE Little is known about why women with breast cancer who have surgery do not receive proven effective postsurgical adjuvant treatments. METHODS We surveyed 258 women who recently underwent surgical treatment at six New York City hospitals for early-stage breast cancer about their care, knowledge, and beliefs about breast cancer and its treatment. As per national guidelines, all women should have received adjuvant treatment. Adjuvant treatment data were obtained from inpatient and outpatient charts. Factor analysis was used to create scales scored to 100 of treatment beliefs and knowledge, medical mistrust, and physician communication about treatment. Bivariate and multivariate analyses assessed differences between treated and untreated women. RESULTS Compared with treated women, untreated women were less likely to know that adjuvant therapies increase survival (on a 100-point scale; 66 v 75; P < .0001), had greater mistrust (64 v 53; P = .001), and had less self-efficacy (92 v 97; P < .05); physician communication about treatment did not affect patient knowledge of treatment benefits (r = 0.8; P = .21). Multivariate analysis found that untreated women were more likely to be 70 years or older (adjusted relative risk [aRR], 1.11; 95% CI, 1.00 to 1.13), to have comorbidities (aRR, 1.10; 95% CI, 1.04 to 1.12), and to express mistrust in the medical delivery system (aRR, 1.003; 95% CI, 1.00 to 1.007), even though they were more likely to believe adjuvant treatments were beneficial (aRR, 0.99; 95% CI, 0.98 to 0.99; model c, 0.84; P < or = .0001). CONCLUSION Patient knowledge and beliefs about treatment and medical mistrust are mutable factors associated with underuse of effective adjuvant therapies. Physicians may improve cancer care by ensuring that discussions about adjuvant therapy include a clear presentation of the benefits, not just the risks of treatment, and by addressing patient trust in and concerns about the medical system.

The relationship between continuity and patient satisfaction: a systematic review

BACKGROUND Continuity between doctors and patients likely affects patient satisfaction. OBJECTIVE To assess the current evidence on the relationship between continuity and patient satisfaction. METHODS Systematic review of studies of adults in general, family, or internal medicine practices with ongoing, direct, face-to-face contact with their physician. Measures of the relationship between continuity and patient satisfaction were examined. RESULTS A MEDLINE search covering 1984-2007 and a Cumulative Index to Nursing and Allied Health Literature search covering 1981-2007 identified 263 relevant studies and 12 studies met inclusion criteria. There were 12 different continuity measures and 9 different satisfaction measures. CONCLUSIONS Continuity has a variable effect on patient satisfaction.

Physicians' reasons for failing to deliver effective breast cancer care: a framework for underuse.

Objective. Despite numerous randomized trials showing the health benefits of systemic and local therapies for early-stage breast cancer, underuse of these therapies remains a significant quality problem. Little is known about causes of underuse of effective cancer treatments. We sought to understand these causes to design effective interventions to improve care. Research Design. To identify categories of causes of underuse, semistructured interviews were performed with physicians of breast cancer patients who did not receive effective adjuvant care in the 4 years following surgery. Underuse was defined by expert consensus based on evidence-based guidelines. Subjects. Surgeons (n = 13) of all early-stage breast cancer cases who underwent surgical treatment at a tertiary care hospital and had underuse of local or systemic adjuvant therapies. Results. Of all the 275 women with early-stage breast cancer, there were 44 episodes of underuse of effective therapies (16%). In 48% of cases, physicians thought treatment should occur but the treatment failed to take place (32%) or the patient refused (16%). For the other 52% of cases, physicians thought treatment should not occur because evidence did not support treatment in clinical circumstances such as older age (32%), a good prognosis based on tumor size or histology (11%), a second primary breast cancer (5%), or because of comorbidities (5%). All surgeons were aware of the benefits of adjuvant treatments. Conclusions. Causes of underuse can be identified and categorized. Using these categories, a framework of causes of underuse was constructed and interventions targeting the specific causes to improve the quality of care are suggested.

Coordination of Care for Early-stage Breast Cancer Patients*

OBJECTIVE: Little is known about how care is coordinated for patients with diseases requiring multidisciplinary treatments. How complex care is coordinated may affect a patient’s chance of receiving the full complement of care provided by multiple physicians. We sought to describe approaches used to coordinate care for women with early-stage breast cancer, a disease often treated by multiple different disciplines in the outpatient setting. DESIGN: Case studies of 6 hospitals with in-depth semi-structured interviews with providers of breast cancer care and their support staff. SETTING: Five hospitals in downstate New York and 1 hospital in upstate New York. PARTICIPANTS: Sixty-seven interviews were conducted including 35 physicians, 9 nurses, 4 senior clinical or quality directors, 10 administrative assistants, and 9 patient educators and navigators. MEASUREMENTS AND MAIN RESULTS: Content analysis of interviews revealed 7 different coordination mechanisms including tracking of referrals, patient support, regularly-scheduled multidisciplinary meetings, feedback of performance data, use of protocols, computerized systems, and a single physicallocation. No site had any systematic mechanism to track results of referrals or receipt of care provided by other physicians. All physicians used follow-up appointments to check on patients’ receipt of care, but only half of the physicians had an approach to follow up missed appointments. Real-time multidisciplinary meetings with a patient management focus and systematic use of patient support programs, such as patient educators and navigators, were perceived to be valuable. CONCLUSIONS: Numerous coordination mechanisms exist. No site has the ability to systematically track care provided by multiple different specialists. The most valued mechanisms are under the hospital’s aegis. Hospitals should consider implementing coordination mechanisms to improve delivery of multidisciplinary care.

A Tracking and Feedback Registry to Reduce Racial Disparities in Breast Cancer Care

BACKGROUND Black and Hispanic women with early-stage breast cancer are more likely than white women to experience fragmented care and less likely to see medical oncologists to get effective adjuvant treatment. We implemented a tracking and feedback registry to close the referral loop between surgeons and oncologists. METHODS We compared completed oncology consultations and use of adjuvant treatment among a group of 639 women with newly diagnosed stage I or II breast cancer who had undergone surgery at one of six New York City hospitals from 1999 to 2000 with the same outcomes for a different group of 300 women with breast cancer whose surgeries occurred in 2004-2006, after the implementation of the tracking registry. Underuse of adjuvant treatment was defined as no radiotherapy after breast-conserving surgery, no chemotherapy for estrogen receptor (ER)-negative tumors, or no hormonal therapy for ER-positive tumors 1 cm or larger. We used hierarchical modeling to adjust for clustering within hospital and surgeon practice. Odds ratios were converted to adjusted relative risks (aRRs). All statistical tests were two-sided. RESULTS Implementation of the tracking and feedback registry was accompanied by a statistically significant increase in oncology consultations (83% before vs 97% after the intervention; difference = 14%; 95% confidence interval [CI] = 11% to 18%; P < .001) and decrease in underuse of adjuvant treatment (23% before vs 14% after the intervention; difference = -9%, 95% CI = -12% to -6%; P < .001). Underuse declined from 34% to 14% among black women, from 23% to 13% among Hispanic women, and from 17% to 14% among white women (chi-square of change in underuse from before to after among the three racial groups; P = .001). In multivariable models adjusting for clustering by hospital and surgeon, the intervention was associated with increased rates of oncology consultation (aRR = 1.6, 95% CI = 1.3 to 1.8), and reduced underuse of adjuvant treatment (aRR = 0.75, 95% CI = 0.6 to 0.9). Compared with the preintervention findings, minority race was no longer a risk factor for low rates of oncology consultation (aRR = 1.0, 95% CI = 0.7 to 1.3) or for underuse of adjuvant therapy (aRR = 1.0, 95% CI = 0.8 to 1.3). CONCLUSIONS A tracking and feedback registry that enhances completed oncology consultations between surgeons and oncologists also appears to reduce rates of adjuvant treatment underuse and to eliminate the racial disparity in treatment.

A community-centered approach to diabetes in east harlem

AbstractOBJECTIVE: Residents of East Harlem, an impoverished, nonwhite community in New York city (NYC), have up to 5 times the mortality and complication rates of diabetes compared with NYC residents overall. To determine potentially remediable problems underlying this condition, a community-based collaboration of health providers, community advocates, and researchers, surveyed East Harlem residents with diabetes to assess their knowledge, behaviors, barriers to care, and actions taken in response to barriers. DESIGN: Telephone interviews. SETTING: The 3 hospitals and 2 community clinics serving East Harlem. PARTICIPANTS: Nine hundred thirty-nine of the 1,423 persons (66%) with diabetes identified from these 5 healthcare sites with 2 or more ambulatory visits for diabetes during 1998 who lived in East Harlem. RESULTS: While most respondents (90%) said they know how to take their medicines, between 19% and 39% do not understand other aspects of their diabetes management. Many limit their diabetes care due to concerns about money (16% to 40%), and other barriers, such as language and transportation (19% to 22%). In multivariate analyses, Latinos (relative risk [RR]=0.77; 95% confidence interval [95% CI] 0.63 to 0.91) and those who do not keep a diabetic diet due to concerns about money (RR=0.85; 95% CI 0.70 to 0.99) had poorer health status. CONCLUSIONS: A community-based coalition was able to come together, identify areas of concern in diabetes care and assess the needs of adults with diabetes residing and obtaining care in East Harlem. The coalition found that even among those with access to care there remain significant financial barriers to good diabetes care, and a need to address and optimize how individuals with diabetes manage their disease.

The quality of early-stage breast cancer care.

ObjectiveTo assess whether recent practice has improved, the authors created detailed, evidence-based guidelines and assessed the quality of early-stage breast cancer care at four hospitals in the metropolitan New York area. Summary Background DataAdjuvant treatments for early-stage breast cancer have been shown to improve health and longevity. However, reports from the 1980s showed marked underuse of these therapies. MethodsAll 723 women with early-stage breast cancer who had a definitive surgical procedure at four participating hospitals in the Mount Sinai-NYU Health System between April 1994 and August 1996 were included. Inpatient and outpatient records were abstracted. ResultsFifty-nine percent of women underwent breast-conserving surgery, of whom 81% received radiation therapy. Hospital-specific radiation therapy rates varied from 69% to 87%. Seventy-eight percent of women with stage 1B or greater cancer received systemic treatment, with hospital-specific rates varying from 71% to 86%. Between 18% and 33% of women who could have benefited from local or systemic adjuvant treatments did not receive them. The risk of not getting a beneficial adjuvant treatment varied more than twofold by the hospital where the breast cancer surgery was performed. ConclusionsThe hospital where breast cancer surgery is performed is associated with the likelihood that women receive effective local and systemic adjuvant treatments. Surgeons and members of hospital quality improvement programs should encourage multidisciplinary approaches to breast cancer care.

Fragmentation of care for frequently hospitalized urban residents

Background:Fragmentation across sites of care may impede efficient healthcare delivery. Objectives:The objectives of this study were to evaluate fragmentation of hospital care for chronically ill New York City (NYC) residents and its association with enrollment in the New York State (NYS) Medicaid program. Research Design:We conducted a cross-sectional study using the NYS Department of Healths Statewide Planning and Research Cooperative System discharge database. We identified 53,031 NYC residents admitted 3 or more times to acute care hospitals between 2000 and 2002 with the same principal diagnosis of a specific chronic illness (diabetes, sickle cell anemia, psychosis, substance abuse, cancer, gastrointestinal disease, chronic obstructive pulmonary disease/asthma, coronary artery disease, or congestive heart failure). We also evaluated a larger cohort of 225,421 patients with ≥3 admissions for a specific chronic illness coded as either the principal or a secondary diagnosis. A generalized logit model was used to examine the relationship between fragmentation and each patients primary insurance adjusted for diagnosis and demographic characteristics. Measures:Fragmentation was characterized as high, moderate, or low based on the number of distinct hospitals a patient visited relative to the patients total number of hospitalizations over the 3-year interval. Results:Among frequently hospitalized NYC residents with select chronic conditions, 17.1% experienced highly fragmented care. This rate was 9.9% for patients with commercial insurance, 24.4% for those with Medicaid, and 9.7% for those with Medicare. The unadjusted odds ratio describing high fragmentation of Medicaid enrollees compared with commercially insured patients was 3.82 (95% confidence interval [CI], 3.50–4.18) and, although attenuated, remained significant after adjustment for demographic characteristics (odds ratio, 1.33; 95% CI, 1.20–1.47). The strongest predictor of fragmentation was a diagnosis of psychosis (OR, 2.81; 95% CI, 2.43–3.25) or substance abuse (OR, 7.58; 95% CI, 6.55–8.77). Conclusions:In NYC, Medicaid enrollment is associated with greater fragmentation of hospital care, but this is largely attributable to the preponderance of Medicaid enrollees with diagnoses of psychosis and substance abuse. Strategies to improve the efficiency of healthcare delivery should focus on patients with mental illness who are frequently admitted to general hospitals.

Racial disparities in the treatment of advanced epithelial ovarian cancer.

OBJECTIVE: To examine whether treatment with guideline-recommended care (surgery and chemotherapy) is associated with mortality differences between black and white women with advanced epithelial ovarian cancer. METHODS: We conducted an observational cohort study using the Surveillance, Epidemiology, and End Results (SEER) linked to Medicare claims for 1995–2007. We evaluated long-term survival for 4,695 black and white women with stage III or stage IV epithelial ovarian cancer with Kaplan-Meier analysis and Cox regression, and then in patients matched by propensity score to create two similar cohorts for comparison. We investigated the association between race, stage, and survival among women who were treated with guideline-recommended care and those who received incomplete treatment. RESULTS: Black women with advanced epithelial ovarian cancer were more likely to die than white women (unadjusted hazard ratio [HR] 1.27; 95% confidence interval [CI] 1.10–1.46). Black women were less likely than white women to receive guideline-recommended care (54% compared with 68%; P<.001), and women who did not receive recommended treatment had lower survival rates than women who received recommended care. Cox proportional hazards models demonstrated no differences in black women compared with white women regarding mortality among women who were treated with guideline-recommended care (adjusted HR 1.04; 95% CI 0.85–1.26), or among women who received incomplete treatment (adjusted HR 1.09; 95% CI 0.89–1.34). The survival analysis of patients matched by propensity score confirmed these analyses. CONCLUSIONS: Differences in rates of treatment with guideline-recommended care are associated with black–white mortality disparities among women with advanced epithelial ovarian cancer. LEVEL OF EVIDENCE: III