Paul Abrahamse

Underascertainment of radiotherapy receipt in Surveillance, Epidemiology, and End Results registry data.

Surveillance, Epidemiology, and End Results (SEER) registry data have been used to suggest underuse and disparities in receipt of radiotherapy. Prior studies have cautioned that SEER may underascertain radiotherapy but lacked adequate representation to assess whether underascertainment varies by geography or patient sociodemographic characteristics. The authors sought to determine rates and correlates of underascertainment of radiotherapy in recent SEER data.

Patterns and Correlates of Adjuvant Radiotherapy Receipt After Lumpectomy and After Mastectomy for Breast Cancer

PURPOSE To use patient self-report to provide more valid estimates of whether radiotherapy (RT) is underutilized than possible with registry data, as well as to evaluate for disparities and the influence of preferences and provider interactions. METHODS We considered 2,260 survey respondents who had nonmetastatic breast cancer, were age 20 to 79 years, were diagnosed between July 2005 and February 2007 in Detroit and Los Angeles, and reported to Surveillance, Epidemiology and End Results (SEER) registries (72% response rate). Survey responses were merged with SEER data. We assessed rates and correlates of RT receipt among all patients with invasive cancer receiving breast-conserving surgery (BCS) and among patients undergoing mastectomy with indications for RT (ie, positive lymph nodes or T3-4 tumors). RESULTS Among 904 patients undergoing BCS with strong indications for RT, 95.4% received RT, and 77.6% received RT among the 135 patients undergoing mastectomy with strong indications (P < .001). Among 114 patients undergoing BCS with weaker indications (ie, elderly) for RT, 80.0% received treatment, and 47.5% received RT among the 164 patients undergoing mastectomy with weaker indications (T1N1, T2N1, or T3N0 disease; P < .001). On multivariate analysis, surgery type (P < .001), indication strength (P < .001), age (P = .005), comorbidity (P < .001), income (P = .03), patient desire to avoid RT (P < .001), level of surgeon involvement in decision to have radiation (P < .001), and SEER site (P < .001) were significantly associated with likelihood of RT receipt. CONCLUSION RT receipt was consistently high across sociodemographic subgroups after BCS but was lower after mastectomy, even among patients with strong indications for treatment, in whom clinical benefit is similar. Surgeon involvement had a strong influence on RT receipt.

Factors associated with receipt of breast cancer adjuvant chemotherapy in a diverse population-based sample

PURPOSE Disparities in receipt of adjuvant chemotherapy may contribute to higher breast cancer fatality rates among black and Hispanic women compared with non-Hispanic whites. We investigated factors associated with receipt of chemotherapy in a diverse population-based sample. PATIENTS AND METHODS Women diagnosed with breast cancer between August 2005 and May 2007 (N = 3,252) and reported to the Detroit, Michigan, or Los Angeles County Surveillance, Epidemiology, and End Results (SEER) registry were recruited to complete a survey. Multivariable analyses examined factors associated with chemotherapy receipt. RESULTS The survey was sent to 3,133 patients; 2,290 completed a survey (73.1%), and 1,403 of these patients were included in the analytic sample. In multivariable models, disease characteristics were significantly associated with the likelihood of receiving chemotherapy. Low-acculturated Hispanics were more likely to receive chemotherapy than non-Hispanic whites (odds ratio [OR], 2.00; 95% CI, 1.31 to 3.04), as were high-acculturated Hispanics (OR, 1.43; 95% CI, 1.03 to 1.98). Black women were less likely to receive chemotherapy than non-Hispanic whites, but the difference was not significant (OR, 0.83; 95% CI, 0.64 to 1.08). Increasing age (even in women age < 50 years) and Medicaid insurance were associated with lower rates of chemotherapy receipt. CONCLUSION In this population-based sample, disease characteristics were strongly associated with receipt of chemotherapy, indicating that clinical benefit guides most treatment decisions. We found no compelling evidence that black women and Hispanics receive chemotherapy at lower rates. Interventions that address chemotherapy use rates according to age and insurance status may improve quality of systemic treatment.

Does It Matter Where You Go for Breast Surgery? Attending Surgeon's Influence on Variation in Receipt of Mastectomy for Breast Cancer

Background:Concerns about the use of mastectomy and breast reconstruction for breast cancer have motivated interest in surgeons influence on the variation in receipt of these procedures. Objectives:To evaluate the influence of surgeons on variations in the receipt of mastectomy and breast reconstruction for patients recently diagnosed with breast cancer. Methods:Attending surgeons (n = 419) of a population-based sample of breast cancer patients diagnosed in Detroit and Los Angeles during June 2005 to February 2007 (n = 2290) were surveyed. Respondent surgeons (n = 291) and patients (n = 1780) were linked. Random-effects models examined the amount of variation due to surgeon for surgical treatment. Covariates included patient clinical and demographic factors and surgeon demographics, breast cancer specialization, patient management process measures, and attitudes about treatment. Results:Surgeons explained a modest amount of the variation in receipt of mastectomy (4%) after controlling for patient clinical and sociodemographic factors but a greater amount for reconstruction (16%). Variation in treatment rates across surgeons for a common patient case was much wider for reconstruction (median, 29%; 5th–95th percentile, 9%–65%) then for mastectomy (median, 18%; 5th–95th percentile, 8% and 35%). Surgeon factors did not explain between-surgeon variation in receipt of treatment. For reconstruction, 1 surgeon factor (tendency to discuss treatment plans with a plastic surgeon prior to surgery) explained a substantial amount of the between-surgeon variation (31%). Conclusion:Surgeons have largely adopted a consistent approach to the initial surgery options. By contrast, the wider between-surgeon variation in receipt of breast reconstruction suggests more variation in how these decisions are made in clinical practice.

Acute exacerbation of chronic bronchitis: disease-specific issues that influence the cost-effectiveness of antimicrobial therapy

Abstract Background: Acute exacerbation of chronic bronchitis (AECB) is a common condition, with substantial associated costs and morbidity. Research efforts have focused on innovations that will reduce the morbidity associated with AECB. Health care payers increasingly expect that the results of evidence-based economic evaluations will guide practitioners in their choice of cost-effective interventions. Objectives: To provide a framework on which to base effective and efficient antimicrobial therapy for AECB, we present a concise clinical review of AECB, followed by an assessment of the available data on the economic impact of this disease. We then address several AECB-specific issues that must be considered in cost-effectiveness analyses of AECB antimicrobial interventions. Methods: Published literature on the clinical and economic impact of AECB was identified using MEDLINE®, pre-MEDLINE®, HealthSTAR, CINAHL, Current Contents/All Editions, EMBASE, and International Pharmaceutical Abstracts databases. Other potential sources were identified by searching for references in retrieved articles, review articles, consensus statements, and articles written by selected authorities. Results: In evaluating cost-effectiveness analyses of AECB antimicrobial therapy it is critical to (1) use the disease-free interval as an outcome measure, (2) evaluate the sequence of multiple therapies, (3) address the impact of both current and future antibiotic resistance, and (4) measure all appropriate AECB-associated costs, both direct and indirect. Conclusions: Incorporating these approaches in economic analyses of AECB antimicrobial therapy can help health care organizations make evidence-based decisions regarding the cost-effective management of AECB.

Understanding the effect of breast augmentation on quality of life: prospective analysis using the BREAST-Q.

Background: The aim of this study was to prospectively evaluate patient satisfaction and quality of life with elective breast augmentation. Methods: Patients with bilateral submuscular breast augmentations prospectively completed the BREAST-Q preoperatively and 6 weeks and 6 months postoperatively; t tests compared preoperative and postoperative scores at 6 weeks and 6 months, and standard indicators of effect sizes were calculated. Logistic regression was used to evaluate the association between patient and surgical factors on satisfaction outcomes. Results: The study sample included 611 female patients with the following characteristics: (1) mean age of 33.5 years; (2) mean body mass index of 21.7; (3) and mean implant volume of 360; with (4) 73 percent having received a silicone implant. Significant improvements were found in patient satisfaction with breasts (p < 0.001), psychosocial well-being (p < 0.001), and sexual well-being (p < 0.001) at 6 weeks and 6 months postoperatively, and all were associated with a very large Kazis effect size of 3.66, 2.39, and 2.56 at 6 months, respectively. However, at both 6 weeks and 6 months postoperatively, physical well-being remained significantly below preoperative baseline scores. In addition, satisfaction with breasts and with the overall surgical experience was significantly lower among older patients (p = 0.01 and 0.02, respectively). Conclusions: Breast augmentation is associated with high patient satisfaction and significant improvements in quality of life. However, physicians should inform patients that submuscular augmentations are associated with a delay in recovery of physical functioning and be aware that older patients may experience diminished satisfaction and should counsel accordingly. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Impact of adjuvant chemotherapy on long‐term employment of survivors of early‐stage breast cancer

Many women with early‐stage breast cancer are working at the time of diagnosis and survive without disease recurrence. The short‐term impact of chemotherapy receipt on employment has been demonstrated, but the long‐term impact merits further research.

Postmastectomy Radiotherapy for Breast Cancer Patterns, Correlates, Communication, and Insights Into the Decision Process

Given accumulating evidence supporting postmastectomy radiotherapy (PMRT) in selected patients, it is important to evaluate patterns and correlates of PMRT utilization, including communication and attitudinal factors.

Coordination of Breast Cancer Care Between Radiation Oncologists and Surgeons: A Survey Study

PURPOSE To assess whether radiation oncologists and surgeons differ in their attitudes regarding the local management of breast cancer, and to examine coordination of care between these specialists. METHODS AND MATERIALS We surveyed attending surgeons and radiation oncologists who treated a population-based sample of patients diagnosed with breast cancer in metropolitan Detroit and Los Angeles. We identified 419 surgeons, of whom 318 (76%) responded, and 160 radiation oncologists, of whom 117 (73%) responded. We assessed demographic, professional, and practice characteristics; challenges to coordinated care; and attitudes toward management in three scenarios. RESULTS 92.1% of surgeons and 94.8% of radiation oncologists indicated access to a multidisciplinary tumor board. Nevertheless, the most commonly identified challenge to radiation oncologists, cited by 27.9%, was failure of other providers to include them in the treatment decision process early enough. Nearly half the surgeons (49.7%) stated that few or almost none of the breast cancer patients they saw in the past 12 months had consulted with a radiation oncologist before undergoing definitive surgery. Surgeons and radiation oncologists differed in their recommendations in management scenarios. Radiation oncologists were more likely to favor radiation than were surgeons for a patient with 3/20 lymph nodes undergoing mastectomy (p = 0.03); surgeons were more likely to favor more widely clear margins after breast conservation than were radiation oncologists (p = 0.001). CONCLUSIONS Despite the widespread availability of tumor boards, a substantial minority of radiation oncologists indicated other providers failed to include them in the breast cancer treatment decision-making process early enough. Earlier inclusion of radiation oncologists may influence patient decisions, and interventions to facilitate this should be considered.

Professional burnout among US plastic surgeons: Results of a national survey

PurposeLittle is known about professional burnout among plastic surgeons. Our purpose is to describe its prevalence among a large national sample of plastic surgeons and identify contributing factors. MethodsA mailed, self-administered survey was sent to 708 plastic surgeons who were randomly sampled from the American Society of Plastic Surgeons national membership (71% response rate). The dependent variable was professional burnout, measured by 3 subscales from the validated Maslach Burnout Inventory-Human Services Survey. “High” scores in either the emotional exhaustion or depersonalization subscale categories predict professional burnout. The independent variables included surgeon sociodemographic and professional characteristics. &khgr;2 was used for the bivariate analyses. ResultsNearly one third (29%) of surgeons scored high in subscale categories predictive of professional burnout. Factors associated with high emotional exhaustion scores included surgeon age, 40–50 years (P = 0.03); fair/poor physician health (P < 0.01); ER call (P < 0.01); >60 work hours per week (P = 0.03); primarily reconstructive practice (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). Factors associated with high depersonalization scores included fair/poor physician health (P= 0.01); ER call (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). ConclusionsNearly one third of plastic surgeons have signs of professional burnout. Middle-aged surgeons and those in poor health are most at risk; along with those who have a reconstructive rather than cosmetic practice, long work hours, ER call responsibility, a nonacademic setting. and group as compared to solo practice. These data have important implications for future workforce shortages and health care quality.