Regional Variation in Spending and Survival for Older Adults With Advanced Cancer

Brooks, Gabriel A.; Li, Ling; Sharma, Dhruv; Weeks, Jane C.; Hassett, Michael J.; Yabroff, K. Robin; Schrag, Deborah

doi:10.1093/jnci/djt025

Cited by 92 publications

(94 citation statements)

References 32 publications

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“…Clinicians face considerable uncertainty in choosing appropriate treatment approaches for patients with advanced cancer, and previous work has shown that there is substantial regional variation in per capita Medicare spending for this population. Furthermore, regional variation in advanced cancer spending was not associated with survival differences in elderly patients with advanced cancer,[8] supporting the conclusion that the marginal value of high-intensity practice patterns in the advanced cancer setting is low. Here, we examine regional variation in Medicare spending for elderly patients (ages sixty-five and older) with advanced cancer, with spending claims broken down into thirteen distinct cancer-relevant service categories.…”

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confidence: 71%

Acute Hospital Care Is The Chief Driver Of Regional Spending Variation In Medicare Patients With Advanced Cancer

et al. 2014

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The root causes of regional variation in medical spending are poorly understood and vary by clinical condition. To identify drivers of regional spending variation for Medicare patients with advanced cancer, we used linked Surveillance, Epidemiology, and End Results (SEER) program–Medicare data from 2004–10. We broke down Medicare spending into thirteen cancer-relevant service categories. We then calculated the contribution of each category to spending and regional spending variation. Acute hospital care was the largest component of spending and the chief driver of regional spending variation, accounting for 48 percent of spending and 67 percent of variation. In contrast, chemotherapy accounted for 16 percent of spending and 10 percent of variation. Hospice care comprised 5 percent of spending; however variation in hospice spending was fully offset by opposing variation in other categories. Our analysis suggests that the strategy with the greatest potential to improve the value of care for patients with advanced cancer is to reduce reliance on acute hospital care for this patient population.

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confidence: 71%

Acute Hospital Care Is The Chief Driver Of Regional Spending Variation In Medicare Patients With Advanced Cancer

et al. 2014

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“…3 Despite advances in tumor profiling and drug development, improvements in health outcomes have been limited, and many new drugs are associated with both adverse effects and high costs. [19][20][21] Thus, for patients with metastatic cancer, the expected benefits of chemotherapy must be weighed against the possibility of treatment-related toxicities. 6,22 In our analysis of a population-based cohort of older adults with advanced cancer, chemotherapy was associated with increased risk of hospitalization, and a considerable proportion of admissions were attributable to likely chemotherapy-related toxicities.…”

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confidence: 99%

ReCAP: Hospitalizations in Older Adults With Advanced Cancer: The Role of Chemotherapy

O'Neill

Atoria

O'Reilly

et al. 2016

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CONTEXT AND QUESTION ASKED: In patients with metastatic cancer, chemotherapy may provide symptom control, prevent complications, prolong life, or improve quality of life. Except in rare cases, however, patients with metastatic disease will not be cured. In older patients with metastatic cancer, hospitalization for treatment toxicity may reduce the quality of an already limited life expectancy. We evaluated the association between chemotherapy for metastatic cancer and risk of hospitalization. MAIN CONCLUSION:Hospitalizations are common in patients with incurable advanced malignancies and are more likely among those who receive chemotherapy. APPROACH:In the linked SEER-Medicare dataset, we identified Medicare beneficiaries aged 66 years or older with a primary diagnosis of metastatic breast, colorectal, ovarian, bladder, lung, pancreas, esophageal, stomach, or prostate cancer between 2001 and 2009 who died by the end of 2010. Chemotherapy recipients and nonrecipients were pairmatched by age, sex, race, comorbidity, geographic region and survival duration. The primary endpoint was hospital admission, identified in inpatient claims between cancer diagnosis and the first of hospice admission or death. We also identified the subset of admissions associated with a primary or secondary diagnosis code suggestive of an adverse effect of chemotherapy. The association between chemotherapy and hospitalization was estimated in separate multivariable Cox proportional-hazards regression models for each cancer site, accounting for the matched-pairs design and controlling for unmatched demographic and disease characteristics. RESULTS:Of 18,486 patients who received chemotherapy for metastatic cancer, 92% were hospitalized at least once for any reason, including 51% hospitalized for a likely toxicity. The corresponding rates among matched non-recipients were 83% and 34% ( Figure). In nearly all cancers, chemotherapy recipients had a greater risk of hospitalization for a likely toxicity or for any cause. Chemotherapy recipients had substantially higher hospitalization for infection or fever (21% v 15%), hematologic complications (11% v 3%), dehydration (13% v 6%), and PE or DVT (9% v 4%) compared with nonrecepients. Chemotherapy was associated with a significantly increased risk of likely toxicity-related hospitalization in nearly all cancers, controlling for sociodemographic characteristics and other treatment. The association was greatest in patients with metastatic esophageal cancer (adjusted hazard ratio, 2.00; 95% CI, 1.11 to 3.60) and smallest in patients with metastatic prostate cancer (adjusted hazard ratio, 1.22; 95% CI, 1.01 to 1.47). 151Original Contribution CARE DELIVERY Original Contribution CARE DELIVERY INTERPRETATION: Older patients receiving chemotherapy for incurable advanced cancers are at high risk of hospitalization, of which a non-negligible proportion is likely attributable to adverse effects of treatment. Infection, fever, dehydration, and hematologic complications constitute a large proportion of these ev...

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“…7,8 Other research has demonstrated variation in the use of inpatient services for patients with advanced cancer at the regional level but not doi: 10 at the practice level. 9 Some pilot projects have reported reductions in inpatient utilization through enhanced care management. 10,11 Stakeholders have emphasized opportunities to produce savings by supporting poorly reimbursed aspects of care, such as care planning, care coordination, and enhanced outpatient services to prevent costly inpatient admissions.…”

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Wide Variation In Payments For Medicare Beneficiary Oncology Services Suggests Room For Practice-Level Improvement

et al. 2015

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In recent years many policy makers have recommended alternative payment models in medical oncology in order to reduce costs and improve patient outcomes. Yet information on how oncology practices differ in their use of key service categories is limited. We measured annual payments for key service categories delivered to fee-for-service Medicare beneficiaries receiving care from 1,534 medical oncology practices in 2011-12. In 2012, differences in payments per beneficiary at the seventy-fifth-percentile practice compared to the twenty-fifth-percentile practice were $3,866 for chemotherapy (including administration and supportive care drugs), $1,872 for acute medical hospitalizations, and $439 for advanced imaging. Supportive care drugs, bevacizumab, and positron-emission tomography accounted for the greatest percentage of variation. Average practice payments for service categories were highly correlated across years but not correlated with each other, which suggests that service categories may be affected by different physician practice characteristics. These differences, even when clinical guidelines exist, demonstrate the potential for quality improvement that could be accelerated through alternative payment models.

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Regional Variation in Spending and Survival for Older Adults With Advanced Cancer

Abstract: There is substantial regional variation in Medicare spending for advanced cancer, yet no consistent association between mean regional spending and survival.

Cited by 92 publications

References 32 publications

Acute Hospital Care Is The Chief Driver Of Regional Spending Variation In Medicare Patients With Advanced Cancer

Acute Hospital Care Is The Chief Driver Of Regional Spending Variation In Medicare Patients With Advanced Cancer

ReCAP: Hospitalizations in Older Adults With Advanced Cancer: The Role of Chemotherapy

Wide Variation In Payments For Medicare Beneficiary Oncology Services Suggests Room For Practice-Level Improvement

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