CERCIT Project 2: Assessing the Quality of Cancer Treatment in Texas. Sharon Giordano

Transcription

1 CERCIT Project 2: Assessing the Quality of Cancer Treatment in Texas Sharon Giordano October 21, 2011

2 Specific Aims 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 Determine the variation in quality of cancer treatment acrossgeographic regions of Texas and assess how variation in the availability of cancer specialists influences the quality of care

3 Specific Aims 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 Determine the variation in quality of cancer treatment acrossgeographic regions of Texas and assess how variation in the availability of cancer specialists influences the quality of care

4 Registries May Under Ascertain Malin et al, JNCI 2002 N=304 California Cancer Registry vs medical record, Surgery: sensitivity 95% for mastectomy and lumpectomy (k=0.9) Radiation: sensitivity 72% (k=0.7); specificity 99% Chemotherapy: sensitivity 56% (k=0.6); specificity 99% Sensitivity decreased with stage, no difference by age

5 Under Ascertainment May Vary by SES 2290 Survey respondents compared radiotherapy use vs SEER % under ascertained (32% LA, 11% Detroit) Associated with later stage, low income, non ACS certified hospital Jagsi et al, Cancer 2011

6 SEER Medicare Comparisons Radiation in Medicare, not SEER 4.7% breast, 8.5% lung, 3% prostate ( Virnig 2002) 18% breast (Du and Goodwin) Chemotherapy POC and Medicare sensitivity of Medicare 88 95%; no info on specificity (Warren, 2002) Surgery: K statistic

7 Endpoints Use Medicare as gold standard d Calculated sensitivity, specificity, percent agreement, kappa statistics Percent of patients with TCR no treatment, Medicare treatment (true under ascertaiment?) Logistic regression (TCR=no, Medicare=Yes)

8 Data Sources Linkages of TCR Medicare Linkage of TCR Medicaid id Linkage of TCR Private Insurance

9 Patient Cohort Definitions Texas residents Age 66+ Year of diagnosis i Not diagnosed by autopsy or death certificate First Primary Cancer and no 2nd within 12 mo Histology confirmation Continuous coverage A&B/no HMO +/ 12 mo

10 Overall Cohorts Overall Breast Lung Colorectal Prostate Pancreatic Total N 112,959 23,992 31,871 21,742 30,083 5,271 Med.Age White 77% 79% 80% 75% 73% 72% Black 8% 7% 8% 9% 8% 10% Hispanic 13% 12% 10% 14% 15% 17% Other 2% 1% 1% 2% 4% 2% Male 53% <1% 54% 47% 100% 44% Female 47% 99% 46% 53% 0% 56% Big Metro 47% 51% 46% 47% 47% 48% Metro 28% 27% 28% 29% 28% 29% Urban 7% 6% 8% 7% 7% 7% Less Urban 16% 13% 15% 15% 15% 14% Rural 2% 2% 2% 2% 2% 2%

11 Percent Treatment Colorectal N=21,742 Prostate N=30,083 Lung N=31,871 Pancreas N=5271 Breast N=23,992 Radiation Med 4mo Radiation Med 12mo Radiation TCR Chemo Med 4 mo Chemo Md12 Med mo Chemo TCR Surgery 4mo Surgery 12mo Surgery TCR

12 Surgery Whole Cohort Sensitivity: 92% Specificity: i 92% Kappa statistic: 0.86 TCR=No, Medicare=Yes: 3.8%

13 HRR Definition Hospital referral regions (HRRs) represent regional health care markets for tertiary medical care that generally requires the services of a major referral center. The regions were defined by determining where patients were referred for major cardiovascular surgical procedures and for neurosurgery. Each hospital service area (HSA) was examined to determine where most of its residents went for these services. The result was the aggregation of the 3,436 hospital service areas into 306 HRRs. Each HRR has at least one city where both major cardiovascular surgical procedures and neurosurgery are performed.

14 Surgery by HRR

15 Surgery by Tumor Type Colorectal Prostate Lung Pancreas Breast 0 Sensitivity Specificity

16 Surgery by Tumor Type Kappa TCR=No, Medicare=Yes Colorectal Prostate Lung Pancreas Breast

17 Surgery by Year of Diagnosis Sensitivity Specificity TCR=N0 Kappa Medicare=Yes

18 Surgery Sensitivity Specificity TCR=no, Medicare=Yes Kappa > Big Metro Metro Urban Less Urban Rural Distant In Situ Localized Regional

19 Logistic Regression: Surgery OR CI OR CI Breast 1.0 (ref) Not distant 1.0 (ref) Colorectal Distant Lung Unknown Pancreas NH White 10(ref) 1.0 Prostate Hispanic (ref) Black Other (ref) >

20 Logistic Regression: Surgery OR CI OR CI Houston 1.0 (ref) Longview Abilene Lubbock Amarillo McAllen Austin Odessa Beaumont San Angelo Bryan San Antonio Corpus Temple Christi Dallas Tyler El Paso Victoria Fort Waco Worth Harlingen Wichita Falls

21 Radiation Therapy Whole Cohort Sensitivity: 75.6 Specificity: i Kappa: 0.57 TCR=No, Medicare=Yes: 5.17%

22 Radiation ALL

23 Radiation Therapy by Tumor Type Sensitivity Specificity Kappa TCR=No, Mdi Medicare=Yes

24 Radiation therapy HRR/Tumor Sensitivity Specificity Kappa TCR=No Medicare=Yes

25 Logistic Regression: Radiation OR CI OR CI Breast (ref) (ref) Colorectal Lung Pancreas Prostate NH White 1.0 (ref) Hispanic Age (ref) Black Age Other Age Adjusted for Stage (NS) Age >

26 Logistic Regression: Radiation HRR OR CI OR CI Houston 1.0 (ref) Longview Abilene Lubbock Amarillo McAllen Austin Odessa Beaumont San Angelo Bryan San Antonio Corpus Temple Christi Dallas Tyler El Paso Victoria Fort Waco Worth Harlingen Wichita Falls

27 Chemotherapy Whole Cohort Sensitivity: Specificity: i 88.4 Kappa: 0.45 TCR=No, Medicare=Yes: 8.0%

28 Chemotherapy by HRR

29 Chemotherapy by Tumor Type

30 Chemotherapy HRR/Tumor Type Sensitivity Specificity Kappa TCR No, Medicare Yes Mdi

31 Logistic Regression: Chemotherapy OR CI OR CI Breast 10(ref) 1.0 Not distant 10(ref) 1.0 Colorectal Distant Lung Unknown Pancreas NH White 1.0 (ref) Prostate Hispanic (ref) Black Other (ref) >

32 Logistic Regression: Chemotherapy HRR OR CI HRR OR CI Houston 1.0 (ref) Longview Abilene Lubbock Amarillo McAllen Austin Odessa Beaumont San Angelo Bryan San Antonio Corpus Christi Temple Dallas Tyler El Paso Victoria Fort Worth Waco Harlingen Wichita Falls

33 Issues Medicare not true gold standard Specificity using Medicare as gold standard likely not accurate, military etc. Do cases with Medicare claims, no TCR represent under ascertainment? What to do with data?

34 Conclusions Percentage of patients with reported treatments higher in TCR than Medicare Data missing in sample of Medicare? Sensitivity high: 92% surgery, 76% radiation, 58% chemotherapy Low under ascertainment: surgery 4%, radiation 5%, chemotherapy h 8% Large geographic variation

35 Acknowledgements Jim Goodwin and Linda Elting Vivian Ho, Ben Smith, Yong Fang Kuo Texas Cancer Registry Hoang Nguyen Jiangong Niu Yufeng Zhang Ning Zhang