Philip Pantoja

Perinatal substance abuse intervention in obstetric clinics decreases adverse neonatal outcomes.

OBJECTIVE: To evaluate the effect of Early Start, a managed care organizations obstetric clinic-based perinatal substance abuse treatment program, on neonatal outcomes.STUDY DESIGN: Study subjects were 6774 female Kaiser Permanente members who delivered babies between July 1, 1995 and June 30, 1998 and were screened by completing prenatal substance abuse screening questionnaires and urine toxicology screening tests. Four groups were compared: substance abusers screened, assessed, and treated by Early Start (“SAT,” n=782); substance abusers screened and assessed by Early Start who had no follow-up treatment (“SA,” n=348); substance abusers who were only screened (“S,” n=262); and controls who screened negative (“C,” n=5382).RESULTS: Infants of SAT women had assisted ventilation rates (1.5%) similar to control infants (1.4%), but lower than the SA (4.0%, p=0.01) and S groups (3.1%, p=0.12). Similar patterns were found for low birth weight and preterm delivery.CONCLUSION: Improved neonatal outcomes were found among babies whose mothers received substance abuse treatment integrated with prenatal care. The babies of SAT women did as well as control infants on rates of assisted ventilation, low birth weight, and preterm delivery. They had lower rates of these three neonatal outcomes than infants of either SA or S women.

Using the Census Bureau’s surname list to improve estimates of race/ethnicity and associated disparities

Commercial health plans need member racial/ethnic information to address disparities, but often lack it. We incorporate the U.S. Census Bureau’s latest surname list into a previous Bayesian method that integrates surname and geocoded information to better impute self-reported race/ethnicity. We validate this approach with data from 1,921,133 enrollees of a national health plan. Overall, the new approach correlated highly with self-reported race-ethnicity (0.76), which is 19% more efficient than its predecessor (and 41% and 108% more efficient than single-source surname and address methods, respectively, P < 0.05 for all). The new approach has an overall concordance statistic (area under the Receiver Operating Curve or ROC) of 0.93. The largest improvements were in areas where prior performance was weakest (for Blacks and Asians). The new Census surname list accounts for about three-fourths of the variance explained in the new estimates. Imputing Native American and multiracial identities from surname and residence remains challenging.

The Quality of Supportive Cancer Care in the Veterans Affairs Health System and Targets for Improvement

IMPORTANCE Characterizing the quality of supportive cancer care can guide quality improvement. OBJECTIVE To evaluate nonhospice supportive cancer care comprehensively in a national sample of veterans. DESIGN, SETTING, AND PARTICIPANTS Using a retrospective cohort study design, we measured evidence-based cancer care processes using previously validated indicators of care quality in patients with advanced cancer, addressing pain, nonpain symptoms, and information and care planning among 719 veterans with a 2008 Veterans Affairs Central Cancer Registry diagnosis of stage IV colorectal (37.0%), pancreatic (29.8%), or lung (33.2%) cancer. MAIN OUTCOMES AND MEASURES We abstracted medical records from diagnosis for 3 years or until death among eligible veterans (lived ≥ 30 days following diagnosis with ≥ 1 Veterans Affairs hospitalization or ≥ 2 Veterans Affairs outpatient visits). Each indicator identified a clinical scenario and an appropriate action. For each indicator for which a veteran was eligible, we determined whether appropriate care was provided. We also determined patient-level quality overall and by pain, nonpain symptoms, and information and care planning domains. RESULTS Most veterans were older (mean age, 66.2 years), male (97.2%), and white (74.3%). Eighty-five percent received both inpatient and outpatient care, and 92.5% died. Overall, the 719 veterans triggered a mean of 11.7 quality indicators (range, 1-22) and received a mean 49.5% of appropriate care. Notable gaps in care were that inpatient pain screening was common (96.5%) but lacking for outpatients (58.1%). With opioids, bowel prophylaxis occurred for only 52.2% of outpatients and 70.5% of inpatients. Few patients had a timely dyspnea evaluation (15.8%) or treatment (10.8%). Outpatient assessment of fatigue occurred for 31.3%. Of patients at high risk for diarrhea from chemotherapy, 24.2% were offered appropriate antidiarrheals. Only 17.7% of veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63.7% had timely discussion of goals following intensive care unit admission. Most decedents (86.4%) were referred to palliative care or hospice before death. Single- vs multiple-fraction radiotherapy should have been considered in 28 veterans with bone metastasis, but none were offered this option. CONCLUSIONS AND RELEVANCE These care gaps reflect important targets for improving the patient and family experience of cancer care.

Religiosity, Denominational Affiliation, and Sexual Behaviors Among People With HIV in the United States

Abstract This study sought to describe religiosity and denominational affiliation among the U.S. population living with HIV and to test whether either is associated with HIV-related sexual risk behaviors. A nationally representative sample of 1,421 people in care for HIV, 932 of whom reported recent sexual activity, was used. Religiosity was associated with fewer sexual partners and a lower likelihood of engaging in unprotected sex and in high-risk sex. Catholics were less likely to report unprotected sex than were other Christians, adherents of non-Christian religions, and those reporting no religious affiliation. Catholics were also less likely than other Christians to report high-risk sex and reported fewer sexual partners compared to those of non-Christian religions. We did not observe a difference between Catholics and Evangelicals in the three sexual behaviors investigated. Results suggest that religiosity and some religious teachings may promote safer sex among people with HIV.

Association of Early Patient-Physician Care Planning Discussions and End-of-Life Care Intensity in Advanced Cancer.

BACKGROUND Early patient-physician care planning discussions may influence the intensity of end-of-life (EOL) care received by veterans with advanced cancer. OBJECTIVE The study objective was to evaluate the association between medical record documentation of patient-physician care planning discussions and intensity of EOL care among veterans with advanced cancer. METHODS This was a retrospective cohort study. Subjects were 665 veteran decedents diagnosed with stage IV colorectal, lung, or pancreatic cancer in 2008, and followed till death or the end of the study period in 2011. We estimated the effect of patient-physician care planning discussions documented within one month of metastatic diagnosis on the intensity of EOL care measured by receipt of acute care, intensive interventions, chemotherapy, and hospice care, using multivariate logistic regression models. RESULTS Veterans in our study were predominantly male (97.1%), white (74.7%), with an average age at diagnosis of 66.4 years. Approximately 31% received some acute care, 9.3% received some intensive intervention, and 6.5% had a new chemotherapy regimen initiated in the last month of life. Approximately 41% of decedents received no hospice or were admitted within three days of death. Almost half (46.8%) had documentation of a care planning discussion within the first month after diagnosis and those who did were significantly less likely to receive acute care at EOL (OR: 0.67; p=0.025). Documented discussions were not significantly associated with intensive interventions, chemotherapy, or hospice care. CONCLUSION Early care planning discussions are associated with lower rates of acute care use at the EOL in a system with already low rates of intensive EOL care.

Evaluating the Quality of Supportive Oncology Using Patient-Reported Data

PURPOSE Patient-reported data may provide valuable information for oncology quality measurement. We evaluated applying patient-reported data from the Cancer Care Outcomes Research and Surveillance Consortium national study to quality indicators addressing supportive oncology domains. METHODS We analyzed surveys including validated instruments for symptoms and care planning from 4,174 patients newly diagnosed with lung or colorectal cancer. We adapted existing supportive oncology indicators for use with patient-reported data from Cancer Quality-ASSIST and the American Society of Clinical Oncology Quality Oncology Practice Initiative. Where feasible, we examined indicators using medical record data for comparison purposes. RESULTS Using patient-reported data, the percentage of patients meeting indicator criteria for screening ranged from 74% (significant depressive symptoms) to 93% (pain, nausea/vomiting). The percentage meeting indicator criteria for symptom treatment ranged from 73% (significant depressive symptoms) to 99% (nausea/vomiting). Symptom severity did not affect the results. Using medical record data, the percentage meeting indicator criteria varied between 4% (significant depressive symptoms) and 23% (pain). For information and care planning, 44% met criteria for discussion about resuscitation and 32% for hospice discussion using survey data. Using medical record data, 11% met criteria for goals-of-care discussion in intensive care and 46% for hospice/pain management/palliative care referral before death. CONCLUSION Quality of care for symptoms measured using patient self-report was higher than when including medical record data. Use of patient-reported and medical record data allowed measurement of different perspectives on care planning indicators. Patient-reported data provide a complementary, patient-centered perspective on the quality of supportive oncology care.

How is KRAS testing associated with treatment and supportive care for patients with metastatic colorectal cancer? VA national assist project.

64 Background: EGFR monoclonal antibody (mAb) therapies improve quality of life and outcomes for metastatic colorectal cancer (mCRC), but only wild-type KRAS benefit from treatment. We evaluated KRAS testing and pharmacogenetic-guided treatment and supportive and end of life (EOL) care. METHODS Among a national random sample of 265 veterans diagnosed with mCRC in 2008 we evaluated KRAS testing, EGFR mAb therapy, supportive care using the Cancer Quality ASSIST indicators, and healthcare use. Three oncology nurses abstracted charts for care received 2008-2011. We linked chart to VA and Medicare administrative data and compared care received by KRAS testing and results. RESULTS 227/265 (85%) veterans died within 3 years and received an average of 48% of recommended supportive care processes. 96 / 265 (36%) underwent KRAS testing, of whom 41, 42, and 13 had wild-type, mutant, and indeterminant/unknown KRAS. 27/41 (66%) wild-type KRAS patients received an EGFR mAb; 18/45 (40%) patients receiving an EGFR mAb had mutant, indeterminant/unknown, or untested KRAS. KRAS testing was associated with increased systemic therapy but not differences in supportive care or intensity of care at the EOL. KRAS tested vs. not tested received hospice or palliative care (67 vs. 73%, p=0.55); any systemic therapy (96 vs. 40%, p<0.001) including new regimen in last month (0 vs. 6%); any chemotherapy in last 14 days of life (9 vs. 7%); and any acute care in last month of life (28 vs. 32%, p=0.78). CONCLUSIONS KRAS testing was not performed for most veterans with mCRC in 2008, and EGFR mAb therapy was administered to many without wild-type KRAS. KRAS-tested patients were more likely to receive systemic treatments, and testing was not associated with greater intensity or inappropriate EOL care, and rates of such care were low among veterans.

National evaluation of the VA's quality of supportive care.

218 Background: Although known to provide more efficient end-of-life cancer care, the quality of VAs end of life cancer care is unknown. We used Cancer Quality ASSIST to evaluate supportive care comprehensively in a national sample. METHODS We measured ASSIST QIs addressing symptoms, communication, treatment toxicities, and complications among 719 Veterans with a 2008 registry diagnosis of stage IV colorectal (37%), pancreatic (30%), or lung cancer (33%). We abstracted records from diagnosis for 3 years or until death among eligible Veterans (lived >= 30 days following diagnosis with >= 1 VA hospitalization or >=2 VA outpatient visits). We determined patient-level overall and individual QI scores (%delivered/appropriate care) and confirmed reliability on a 5% sample, retaining 39 of 42 QIs. RESULTS Most Veterans were older (mean 66 years) male (97%), and white (68%) with 20% African American, and 3% Hispanic. 85% had >=1 hospitalization and 93% died. Overall, subjects received 48% of recommended care. The average Veteran triggered 13 QIs, and scores ranged from 0-98% (pain 0-96%; dyspnea 11-98%, depression 36-79%, fatigue 4-80%, nausea/vomiting 41-87%, treatment toxicities 13-70%, care planning 18-86%). Notable gaps in care were identified. Inpatient pain screening was common (96%) but lacking for outpatients (58%). With opioids, bowel prophylaxis occurred for only 52% of outpatients and 70% of inpatients. Few patients had timely dyspnea evaluation (16%) or treatment (11%). Outpatient assessment of fatigue occurred for 32%. 24% of patients who received chemotherapy high risk for diarrhea were offered appropriate anti-diarrheals. Only 19% of Veterans had goals of care addressed in the month after a diagnosis of advanced cancer, and 63% of patients had timely discussion of goals following ICU admission. Most decedents (86%) were referred to palliative care or hospice before death. Single vs. multiple fraction radiotherapy should have been considered in 28 Veterans with bone metastasis, but none were offered it. CONCLUSIONS These patient and family-centered supportive care gaps reflect important HRQOL impacts and targets for quality improvement in a system known for excellence in chronic disease care.