ACE-27 with Dr. Piccirillo from Washington University St. Louis. August 18, 2009

Transcription

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2 ACE-27 with Dr. Piccirillo from Washigto Uiversity St. Louis August 18, 2009

3 Itroductio Patiets with cacer ofte have other diseases, illesses, or coditios i additio to their idex cacer These other coditios are geerally referred to as comorbidities Although ot a feature of the cacer itself, comorbidity is a importat attribute of the patiet Comorbidity has direct impact o the care of patiets, cacer statistics, ad the assessmet of the quality of care

4 Observatioal Research Majority (>95%) of cacer patiets i this coutry are ot erolled i cliical trials Receive care at local hospitals based o commuity stadards ad guidelies developed by atioal specialty orgaizatios Federal law ad professioal licesig board requiremets madate that local hospitals collect ad maitai importat demographic, tumor, treatmet, ad follow-up iformatio about cacer patiets This detailed iformatio is collected at the hospital level by traied cacer registrars ad is maitaied withi hospital-based tumor registries

5 Cacer registry systems provide a outstadig opportuity to study importat aspects of cacer care, icludig studies of treatmet effectiveess, outcomes, ad quality of care (IOM Report) However, adjustmet methods are essetial to cotrol for o-radom assigmet To improve the performace of risk-adjustmet methodologies, importat therapeutic ad progostic characteristics of the patiet must be available for aalysis Istitute of Medicie Report, Natioal Cacer Policy Board. Esurig Quality Cacer Care

6 Give the fact that the severity of comorbidity may impact o selectio ad outcomes of treatmet, it is imperative to measure ad iclude comorbidity assessmet whe usig data from observatioal research Ufortuately, o tumor registry system collects comorbidity iformatio o a regular basis

7 Comorbidity Istrumets Several istrumets have bee developed to classify differet comorbid diseases ad to quatify the severity of the overall comorbid coditio These istrumets have bee used to classify comorbidity i several types of cacers ad have performed well Few of the istrumets were specifically desiged to study comorbidity i cacer patiets

8 Chart-Based Record Review Kapla-Feistei Idex J Chro Dis. 1974;27: Charlso Comorbidity Idex J Chro Dis 1987;40(5): The Idex of Co-Existet Disease Med Care 1993;31(2): Adult Comorbidity Evaluatio-27 J Reg Maagemet 2001;28:

9 Claims-Based Assessmet Modificatios of Charlso Dartmouth-Maitoba ICD-9 coversio algorithm J Cli Epidemiol 1993;46: Deyo et al J Cli Epidemiol 1992;45: Elixhauser Model Med Care 1998;36:8-27 Klabude et al -- i ad out-patiet claims J Cli Epidemiol 2000;53: Vo Korff et al chroic disease score from automated pharmacy records J Cli Epidemiol 1992;45:

10 Compariso of Comorbidity Collectio Methods Chart-Based Approach Advatages Score ca be assiged to the majority of patiets Very accurate assessmet of comorbidity Disadvatages Additioal work effort Claims-Based Approach Advatages Available i may states for may people Less expesive alterative Disadvatages Iformatio may ot be available for all patiets i a tumor registry Less complete ad accurate assessmet

11 Commissio O Cacer Iitiative COC madated that begiig Jauary 1, 2003 all ew cases must iclude comorbidity ad complicatios These elemets are to be coded usig the ICD-9-CM codes Preset program madated by the CoC will lead to iaccurate ad misleadig comorbidity ad complicatio iformatio J Reg Maagemet 2003;30:

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13 Adult Comorbidity Evaluatio item comorbidity idex for patiets with cacer Developed through modificatio of the Kapla-Feistei Comorbidity Idex (KFI) Modificatios were made through discussios with cliical experts ad a review of the literature Validated i study of 19,268 cacer patiets treated at Bares-Jewish Hospital JAMA 2004;291:

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15 Example Cogestive Heart Failure Mild Exertioal or paroxysmal dyspea which has respoded to treatmet Moderate Hospitalized more tha six moths ago Severe Hospitalized withi last 6 moths or ejectio fractio < 20%

16 Overall Comorbidity Score Noe, Mild, Moderate, or Severe Algorithm developed by Kapla ad Feistei Highest raked sigle ailmet I cases where two or more Moderate ailmets occur i differet orga systems, the Overall comorbidity Score should be desigated as Severe

17 Example Coditio Myocardial Ifarct more tha 6 moths ago DBP mm Hg History of alcohol abuse, but ot presetly drikig Overall Comorbidity Score Decompesatio Moderate Mild Mild

18 Example Coditio Myocardial Ifarct more tha 6 moths ago DBP mm Hg History of alcohol abuse, but ot presetly drikig Overall Comorbidity Score Decompesatio Moderate Mild Mild Moderate

19 Example Coditio Chroic exertioal agia Major depressio cotrolled with medicatio Diabetes requirig isuli Decompesatio Moderate Mild Moderate Overall Comorbidity Score

20 Example Coditio Chroic exertioal agia Major depressio cotrolled with medicatio Diabetes requirig isuli Overall Comorbidity Score Decompesatio Moderate Mild Moderate Severe

21 Adult Comorbidity Evaluatio-27 Coget comorbid ailmet Grade 3 Severe Decompesatio Grade 2 Moderate Decompesatio Grade 1 Mild Decompesatio Cardiovascular System Myocardial Ifarct MI 6 moths MI > 6 moths ago Old MI by ECG oly, age udetermied Agia / Coroary Artery Disease Cogestive Heart Failure (CHF) Ustable agia Hospitalized for CHF withi past 6 moths Ejectio fractio < 20% Chroic exertioal agia Recet ( 6 moths) Coroary Artery Bypass Graft (CABG) or Percutaeous Traslumial Coroary Agioplasty (PTCA) Recet ( 6 moths) coroary stet Hospitalized for CHF >6 moths prior CHF with dyspea which limits activities Arrhythmias Vetricular arrhythmia 6 moths Vetricular arrhythmia > 6 moths ago Chroic atrial fibrillatio or flutter Pacemaker Hypertesio Veous Disease Peripheral Arterial Disease DBP>130 mm Hg Severe maligat papilledema or other eye chages Ecephalopathy Recet PE ( 6 mos.) Use of veous filter for PE s Bypass or amputatio for gagree or arterial isufficiecy < 6 moths ago Utreated thoracic or abdomial aeurysm (>6 cm) DBP mm Hg Secodary cardiovascular symptoms: vertigo, epistaxis, headaches DVT cotrolled with Coumadi or hepari Old PE > 6 moths Bypass or amputatio for gagree or arterial isufficiecy > 6 moths Chroic isufficiecy ECG or stress test evidece or catheterizatio evidece of coroary disease without symptoms Agia pectoris ot requirig hospitalizatio CABG or PTCA (>6 mos.) Coroary stet (>6 mos.) CHF with dyspea which has respoded to treatmet Exertioal dyspea Paroxysmal Noctural Dyspea (PND) Sick Sius Sydrome DBP mm Hg DBP <90 mm Hg while takig atihypertesive medicatios Old DVT o loger treated with Coumadi or Hepari Itermittet claudicatio Utreated thoracic or abdomial aeurysm (< 6 cm) s/p abdomial or thoracic aortic aeurysm repair

22 Web-Based Comorbidity Educatio Program

23 Web-Based Comorbidity Educatio Program

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25 Prevalece of Comorbidity Across the Age Groups

26 Methods Prospective observatioal cohort study 22,620 adult cacer patiets 10,851 age 65 (48%) Treated at 8 US hospitals Critical Reviews Ocology-Hematology 2008;76(2):

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28 Chagig Prevalece of Comorbidity Across Age Groups All Comorbidities (N=22,260)

29 Chagig Prevalece of Idividual Comorbid Ailmets Hypertesio (N=7198) Pulmoary (N=2838) Solid Tumor (N=2752) Diabetes Mellitus (N=2691)

30 Chagig Prevalece of Idividual Comorbid Ailmets Cogestive Heart Failure (N=793) Vascular Disease (N=457)

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32 Impact of Comorbidity Therapy Progosis Assessmet of Quality of Care

33 Comorbidity Impact o Therapy The use of preferred therapy might be cotraidicated due to the presece of comorbid ailmets There are two distict ways that comorbid ailmets might impact o type of therapy

34 The comorbid ailmet(s) may reder a overall progosis so poor for the patiet that she may be deied a otherwise desirable treatmet for the idex cacer A particular type of comorbid ailmet(s) may affect the patiet's ability to tolerate a particular type of therapy

35 Prostate Cacer Example Desch et al studied treatmet recommedatios for local or regioal prostate cacer As comorbidity icreased, the proportio of me receivig o treatmet rose correspodigly Fewer tha 30% of me with the most sigificat level of comorbidity received surgery, radiatio therapy, or combiatios of aggressive therapy as compared with almost 55% of me who had o comorbid ailmets Med Care 1996;34:

36 Breast Cacer Example Greefield et al coducted a retrospective review to examie whether physicias provided less vigorous treatmet for elderly patiets with breast cacer Sample icluded wome with breast carcioma who received their primary cacer maagemet at oe of seve hospitals i Souther Califoria Appropriate treatmet defied accordig to criteria map that icorporated widely accepted practice stadards JAMA 1987;257:

37 Relatioship of the Comorbidity Idex (CI) to Physicia Maagemet of Breast Cacer Number of Patiets With Treatmet CI Score Iappropriate Appropriate Total Noe, Mild 53 (19%) Severe 37 (41%) Total 90 (24%) P<0.001 χ 2 = Yates corrected 231 (81%) 53 (59%) 284 (76%) (100%)

38 Advaced Head ad Neck Cacer Progostic Comorbidity Iitial Treatmet Radiatio Therapy Oly Abset 100/534 (19%) Preset 38/74 (51%) Total 138/608 (22%) Risk Ratio (95% CI) ( )

39 Poor Quality of Care?

40 Soud Cliical Judgmet?

41 Impact of Comorbidity o Progosis I may cacers, comorbidity progostically more importat tha tumor size or TNM stage Particularly importat for slow growig cacers ad cacers which affect older people Comorbidity ca create sigificat progostic differeces i patiets with the same morphologic ad histologic maifestatios of the idex disease

42 Overall Survival Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Moths After Diagosis

43 Progostic Impact of Comorbidity Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 = , p < Noe Mild Moderate Severe Moths After Diagosis

44 Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Age <50 Log Rak χ 2 =30.45, p< Noe Moderate Mild Severe Moths After Diagosis

45 Moths After Diagosis 50 Age<60 Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =29.86, p< Noe Mild Moderate Severe

46 60 Age<70 Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =65.78, p< Noe Mild Moderate Severe Moths After Diagosis

47 70 Age<80 Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =59.36, p< Noe Moderate Mild Severe Moths After Diagosis

48 Age 80 Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =57.35 p< Moths After Diagosis Noe Mild Moderate Severe

49 Moths After Diagosis Me Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =199.49, p< Noe Mild Moderate Severe

50 Wome Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =177.49, p< Noe Mild Moderate Severe Moths After Diagosis

51 White Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =319.81, p< Moths After Diagosis Noe Mild Moderate Severe

52 Black Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =65.31, p< Noe Mild Moderate Severe Moths After Diagosis

53 Localized Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =243.32, p< Moths After Diagosis Noe Mild Moderate Severe

54 Regioal Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =111.63, p< Moths After Diagosis Noe Mild Moderate Severe

55 Moths After Diagosis Distat Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =73.00, p< Noe Mild Moderate Severe

56 Prostate Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =108.82, p< Moths After Diagosis Noe Mild Moderate Severe

57 Breast Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =29.65, p< Moths After Diagosis Noe Mild Moderate Severe

58 Colorectal Percet Survivig 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Log Rak χ 2 =24.43, p< Moths After Diagosis Noe Mild Moderate Severe

59 PROGNOSTIGRAM Demostratio

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61 Idepedet Progostic Impact Cox Proportioal Hazards Variable Category HR* 95% CI Comorbidity Noe Mild Moderate Severe Ref * Adjusted for age, geder, race, site, ad morphologic stage Log Likelihood χ 2 Square= , p< C Statistic =0.81

62 Quality of Care Assessmet Iclusio of comorbidity iformatio i cacer registries ca improve quality of cacer care assessmet

63 Quality of Care Example Greefield et al studied differeces i mortality rates for 969 patiets with icidet cases of breast, colorectal, ad prostate cacers across seve hospitals i Souther Califoria Of the seve hospitals, the three with the highest mortality had bee pipoited by the Los Ageles Times as high mortality outliers JAMA 1988; 260:

64 The percetage of patiets with severe comorbidity scores raged from 9% to 18% across the seve hospitals (p<0.01) The rakigs of hospitals varied depedig o whether oe adjusted for age, comorbidity level, or cacer stage

65 Quality of Care Example Begg et al used SEER-Medicare liked database to study the relatioship betwee volume of major cacer surgeries performed ad hospital operative mortality rate Comorbidity severity score geerated from Medicare discharge summary from idex hospitalizatio JAMA 1998;280:

66 Higher surgical volume was liked with lower mortality Volume/Mortality relatioship persisted eve after adjustmet for age ad comorbidity Comorbidity iformatio allowed authors to rebut complait that high volume hospitals were selectig less sick patiets

67 Clarify Impact of Other Variables Comorbidity assessmet importat eve whe it is ot idepedetly statistically sigificat Hiller foud decrease likelihood of axillary ode dissectio with icreasig comorbidity After adjustig for age ad size of primary tumor, comorbidity o loger associated with ode dissectio Iclusio of comorbidity allowed for more robust coclusios about age Breast Cacer Research & Treatmet 1996;40:75-86

68 Coclusios Comorbidity is importat The selectio of treatmet Estimates of progosis Evaluatio of quality of care Valid istrumets exist to collect comorbid iformatio Web-based program exists to trai cacer registrars ad other health professioals to code co-morbidity

69 Coclusios Cotiued exclusio of comorbidity impedes the scietific study of cacer ad the humaistic care of patiets Valid comorbidity assessmet should be added as a required data elemet to hospital-based ad cetral cacer registries

70 More Questios? Doria Kallogjeri, MPH

71 Cliical Outcomes Research Web Site

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