Abstract Session C3: Cancer Research Moderator: Neeraja B. Peterson, MD Discussant: Karla Kerlikowske, MD, SGIM 2014 Distinguished Professor in Cancer Research CARE FRAGMENTATION AND SURVIVAL FOR PATIENTS WITH STAGE III COLON CANCER Tanvir Hussain 1,2 ; Hsien-Yen Chang 2 ; Christine M. Veenstra 3 ; Craig E. Pollack 1,2 . 1 Johns Hopkins University School of Medicine, Baltimore, MD; 2 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; 3 University of Michigan Health Systems, Ann Arbor, MI. (Tracking ID #1939909) BACKGROUND: Cancer care can be complex and fragmented, spanning many settings and providers. Though the Institute of Medicine cites fragmentation as a priority for improving cancer care, little is known about aspects of fragmentation that affect cancer outcomes. We examine two features which may have different implications for improving care delivery: receiving surgical and medical oncologic care from providers affiliated with different hospitals; and receiving care from a surgeon-oncologist pair who infrequently shares patients with one another. We focus on stage III colon cancer patients as guidelines recommend both surgery and chemotherapy. METHODS: Patients with stage III colon cancer diagnosed between 2000-2005 were identified from SEER- Medicare data. Patients were assigned to their operative surgeon and the medical oncologist who billed for the plurality of their visits in the year following diagnosis. Surgeons and oncologists were linked to the hospital where they billed most for inpatient care. Patients were classified as experiencing "hospital fragmentation" if their surgeon and oncologist were assigned to different hospitals (versus the same hospital). We determined the number of patients each surgeon-oncologist pair shared; patients were classified as having "high patient- sharing" physicians if their oncologist and surgeon shared many patients (top quartile of the shared patients distribution versus lower three). Patient-sharing has been validated as a measure of collaboration and information exchange between physicians. Our primary outcome was all cause mortality (censor date 12/31/2007). Secondary outcomes included timely receipt of chemotherapy (9 months of diagnosis) and cost of care [total claims using MEDPAR (Part A), NCH (Part B), and Outsaf files)] in the 12 months following diagnosis. We used Cox proportional hazard and regression models, adjusted for patient demographics, socioeconomic status, comorbidities, SEER site; surgeon's yearly procedure volume, oncologist patient panel size; and hospital characteristics (volume; NCI, for-profit, and academic status). Generalized estimating equations and robust standard errors were used to account for hierarchical data and clustering. RESULTS: Our sample included 7443 patients. Median survival was 3.04 years. One-third (N=2471) received care from surgeons and oncologists associated with different hospitals. No difference in morality was associated with hospital fragmentation (adjusted HR=1.00, 95% CI: 0.93-1.07). We observed an increased risk of death among patients whose surgeons and medical oncologists shared few patients (lower three quartiles of shared patients) compared to those whose doctors were in the top quartile (HR=1.15, 1.06-1.25). No statistical interaction between the two predictors was noted in the final model (Wald's test, p=0.324). Neither hospital fragmentation nor patient-sharing predicted timely receipt of chemotherapy or 12 month costs of care. CONCLUSIONS: Receiving care from physicians associated with the same hospital did not improve survival for stage III colon cancer patients, whereas receiving care from physicians sharing many patients with another did. These results suggest that efforts to improve care fragmentation need to examine the informal relationships between physicians that may be reflected by patient-sharing. Further, cancer survival, quality, and costs may not be improved by delivery redesign which addresses fragmentation solely by consolidating options for care to one institution.
PROSTATE CANCER PATIENTS: THE RELATIONSHIP WITH RACE/ETHNICITY AND HEALTH LITERACY Celia P. Kaplan 1,2 ; Anna Napoles 1,2 ; Steven Gregorich 1 ; Tung T. Nguyen 1,2 ; Jennifer Livaudais-Toman 1 ; Eliseo J. Perez- Stable 1,2 ; Eric J. Small 1,2 ; Mack Roach 2,3 . 1 University of California San Francisco, San Francisco, CA; 2 University of California San Francisco, San Francisco, CA; 3 University of California San Francisco, San Francisco, CA. (Tracking ID #1935608) BACKGROUND: Clinical trials provide the foundation for advances in cancer diagnostics and therapeutics and are the major channel for translating treatment-related discoveries in cancer care into clinical practice. To ensure that the benefits and burdens of this research are distributed fairly among all cancer patients and that research findings are generalizable, it is important that minorities participate in clinical trials. However, enrollment of African Americans and Latinos remains lower than that of non-Latino whites. Limited health literacy, more common among minorities than whites, is a key barrier to clinical trial recruitment. We sought to examine the association between race/ethnicity, health literacy and stated willingness to participate in clinical trials among prostate cancer patients. METHODS: Potential participants consisted of men diagnosed with prostate cancer in 2008 between the ages of 18 and 75, recruited through the California Cancer Registry, living within 60 miles of a site offering access to one or more clinical trials in eight California counties: Alameda, Contra Costa, Marin, Monterey, San Francisco, Santa Clara, Santa Cruz and Los Angeles Counties. Between November 2011 and November 2012, we identified all cases of prostate cancer in African American, Latino and Asian American patients and a random sample of prostate cancer cases in white men. Participants completed a 30-minute telephone interview in English, Spanish or Chinese (Mandarin or Cantonese) to assess their attitudes, knowledge and willingness to participate in prostate cancer clinical trials. Health literacy was assessed with a 3-item previously validated scale that asked about comfort reading hospital materials, filling out medical forms, and understanding written information (scale scores ranged from 1- 5, dichotomized as <3.5 = low literacy, ≥3.5 = medium - high literacy). In multivariable analyses, logistic regression was used to estimate effects of ethnicity and health literacy on willingness to participate. We estimated odds ratios [OR] and 95% confidence intervals [CI]. RESULTS: A total of 1,869 men were contacted and the final sample included 855 men for a response rate of 46%. More than half (52%) were age 65 years or older. The ethnically diverse sample included white (42%), Latino (24%), African American (19%) and Asian American men (15%). More than 50% completed college. Nearly 70% were born in the U.S. The majority of men (98%) were insured and 81% had medium to high health literacy (composite score≥3.5). Only 17% believed that "clinical trials are beneficial" but 75% believed that "clinical trials are important", while only 38% expressed a willingness to participate in clinical trials. Bivariate and multivariable analysis results are presented in Table 1. CONCLUSIONS: Among men with prostate cancer, African American and Latino men expressed a greater willingness to participate in prostate cancer clinical trials than non-Latino white men. Health literacy was not associated with willingness to participate. Given lower rates of clinical trial participation in these racial/ethnic groups, our findings suggest that factors other than willingness to participate affect actual participation and need to be explored. Table 1. Bivariate and multivariable analyses: Willingness to participate in prostate cancer clinical trials Willing to participate % OR (95% CI) aOR* (95% CI) Race/Ethnicity Non-Latino white 34% Ref Ref African American 44% 1.31 (0.89-1.92) 1.69 (1.01-2.82)° Asian 30% 0.85 (0.55-1.32) 0.86 (0.46-1.61) Latino 55% 2.21 (1.55-3.14)° 1.75 (1.01-3.05)° Health Literacy Low (score<3.5) 48% Ref Ref Medium to High (score≥3.5) 39% 0.75 (0.53-1.07) 1.34 (0.77-2.34) *Analysis is also adjusted for age, marital status, education, nationality, employment, health insurance, prior research participation, knowledge of clinical trials, attitudes towards clinical trials, and Gleason score. °p<0.05
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