Project 1: Evaluation of Cancer Screening Practices | PI: James S. Goodwin, MD
Despite considerable research on the underutilization of appropriate cancer screening focusing on the patient, physician, and health system factors that contribute to screening disparities very little similar work has been performed on overutilization of screening and inappropriate screening. Such work is important because reductions in overutilization can free up resources to remedy the underutilization of cancer screening in disadvantaged populations. Texas is an ideal state to examine both underutilization and overutilization of testing, because it is large, ethnically, and economically diverse, and has dramatic contextual variations in overall per-patient Medicare expenditures.
For three screening modalities (PSA, mammography, and colonoscopy) addressed the following:
- Systematically described the use of cancer screening in Texas.
- Investigated patient, provider, medical system, geographical, and time factors (2001 through 2012) that predict optimal utilization (vs. over or underutilization) of cancer screening.
- Investigated outcomes of screening, focusing on benefits and harms associated with optimal utilization vs. overutilization or underutilization of cancer screening.
With PSA we concentrated on overutilization by evaluating its use in men with an average life expectancy of fewer than 10 years based on age and comorbidity. With colonoscopy, we assessed both underutilization and overutilization. Overutilization of colonoscopy is defined as shorter than recommended intervals between screening and also by screening in populations with less than a ten-year life expectancy. With mammography we also assessed both overutilization and underutilization, studying its use in women aged 40 and older stratified into cohorts of different average life expectancies.
Project 2: Assessing the Quality of Cancer Treatment in Texas | PI: Sharon Giordano, MD, MPH
No data source currently exists for measuring the quality of cancer treatment in Texas. Although the Texas Cancer Registry collects some treatment information, the focus is on cancer incidence, staging, and survival. As with most cancer registries, treatment data are often missing and of unknown accuracy and completeness. However, these treatment data can be supplemented and completed using other data sources. We proposed to link the Texas Cancer Registry with Medicare, Medicaid, and private insurance databases to assess treatment patterns for patients in Texas. From Medicare, Medicaid, and insurance claims records, we are able to evaluate the use and type of surgery, chemotherapy, and radiotherapy for Texas patients with cancer.
Our specific aims were:
- Determine the agreement of the Texas Cancer Registry and claims databases for the rates of surgery, chemotherapy, and radiotherapy use for patients in Texas with colorectal, lung, breast, prostate, and pancreatic cancer.
- Evaluate the quality of cancer treatment in the state of Texas by studying adherence to evidence-based treatment guidelines for patients with colorectal, lung, breast, prostate, and pancreatic cancer.
- Determine the variation in the quality of cancer treatment across geographic regions of Texas and assess how variation in the availability of cancer specialists influences the quality of care.
The information learned from this study increases the completeness of the data in the Texas Cancer Registry, provides information on patterns of cancer treatment in Texas and identifies potential gaps in the quality of cancer treatment in Texas. We are able to identify areas of Texas where cancer patients are underserved due to a lack of specialists. Previous studies have shown profound variation in cancer care by geography, provider, and patient. Therefore, these data on cancer care in Texas are essential to target resources and policies to the populations and geographic areas that would benefit the most.
Project 3: Quality of Post-Treatment Surveillance of Cancer Patients in Texas | PI: Hemalkumar B. Mehta, PhD
The primary goal of surveillance following curative treatment for cancer, regardless of site, is to detect local recurrence or distant disease at a time when survival can be prolonged by interventions designed to cure or at least treat the disease more effectively than when discovered later. Evidence-based recommendations regarding surveillance can decrease variations in care, limit unnecessary care, and serve to facilitate the delivery of necessary care. The availability of evidence-based recommendations varies significantly among different cancer types. Based on randomized, controlled data, the surveillance recommendations for breast and colorectal cancer are clear. In contrast, few to no evidence-based recommendations exist for post-treatment surveillance for cancers such as lung and pancreas. In national studies using both administrative data and single-institution data, we and others have identified wide variation in post-treatment surveillance with respect to evidence-based recommendations. Despite clear recommendations, surveillance practices vary significantly by patient demographics, cancer type, and the type and number of physicians (primary care physicians vs. specialists) performing the surveillance.
We initially used the Texas Cancer Registry and linked Medicare, Medicaid, and private insurance claims data from 2000-2012 to address the following specific aims:
- Describe the patterns of surveillance testing after curative treatment for breast and colorectal cancer patients compared to available evidence-based recommendations and describe the cost of guideline adherent and non-adherent post-treatment surveillance.
- Describe the patterns of surveillance testing after curative treatment for non-small cell lung and pancreatic cancer patients.
- Describe physician visits after curative-intent cancer treatment, including the proportion of patients with regular visits to primary care physicians, surgeons, medical oncologists, and/or radiation oncologists, as well as the proportion of patients who see multiple provider types for each of the four cancers.
- Assess the effects of patient characteristics, provider characteristics, health care delivery factors, and time on guideline-adherent surveillance testing, overuse of testing, and underuse of testing.
Our analysis allows us to examine the reasons for both overuse and underuse of surveillance tests and will yield important information to guide state-level decision-making and allocation of resources to optimize post-treatment cancer surveillance in Texas. We ask questions including, but not limited to, the following: Is there significant ethnic variation in post-treatment surveillance? Does the overuse of post-treatment surveillance correlate with high per capita Medicare spending in different geographic regions? How do surveillance patterns differ by physician specialty? Does care by multiple providers lead to repetitive or duplicative testing? Given the lack of evidence-based recommendations, we cannot evaluate the overuse or underuse of post-treatment surveillance in lung and pancreatic cancer. However, studying the patterns of post-treatment surveillance for these unstudied cancers will allow us to describe current patterns and identify potential overuse, such as repetitive testing.
Project 4: Quality of Supportive Cancer Care in Texas | PI: Linda Elting, DrPH
High-quality cancer care is a priority for the nation owing to cancer’s high prevalence and mortality. Over the last three decades, many treatments and care strategies have shown promise for improving cancer outcomes and quality of care. Most efforts to measure and improve the quality of cancer care have focused on the entire US. We proposed to link cancer-specific information from the Texas Cancer Registry (TCR) to Medicare, Medicaid, and private insurance claims, creating a unique resource for quality measurement for Texas. We use these data to assess the quality of supportive cancer care of Texans and to target knowledge translation activities to populations that will benefit.
Our goal is to conduct actionable, policy-relevant quality of cancer care research about Texas to inform our integrated knowledge translation plan. To accomplish this goal we identify gaps in quality in which we can intervene to improve quality. Interventions could be directly targeted at providers or patients (providing feedback on adherence and outcomes for the state or regions, predefined order sets, electronic guidelines, or patient guides), or through policy (identifying gaps in insurance coverage of supportive care). A secondary goal is to develop methods and experience with the new data sets that can be generalized to future studies of the comparative effectiveness and quality of cancer care.
We focus on 5 indicators of quality supportive care across the cancer care continuum: emesis prevention and infection prevention during initial cancer treatment, surveillance of bone health and cardiac health during and after treatment, and appropriate delivery of hospice/palliative care at the end of life.
- Describe the quality of supportive cancer care among Texas residents and changes in quality of care over time (2001-2012).
- Quality of care will be measured as adherence to national guidelines for emesis and infection prevention, surveillance for bone and cardiac health, and delivery of end of life care.
- Describe variation in guideline adherence related to patient or provider demographic factors, provider specialty and experience, practice environment, and geographic region of Texas.
- Compare the clinical outcomes (effectiveness) and the average cost of care of patients with guideline adherent and non-adherent care overall and changes over time.