Multilevel factors associated with inequities in multidisciplinary cancer consultation

Disparities across the continuum of lung cancer care: a review of recent literature

PURPOSE OF REVIEW

Lung cancer remains the leading cause of cancer mortality worldwide. Health disparities have long been noted in lung cancer incidence and survival and persist across the continuum of care. Understanding the gaps in care that arise from disparities in lung cancer risk, screening, treatment, and survivorship are essential to guiding efforts to achieve equitable care.

RECENT FINDINGS

Recent literature continues to show that Black people, women, and people who experience socioeconomic disadvantage or live in rural areas experience disparities throughout the spectrum of lung cancer care. Contributing factors include structural racism, lower education level and health literacy, insurance type, healthcare facility accessibility, inhaled carcinogen exposure, and unmet social needs. Promising strategies to improve lung cancer care equity include policy to reduce exposure to tobacco smoke and harmful pollutants, more inclusive lung cancer screening eligibility criteria, improved access and patient navigation in lung cancer screening, diagnosis and treatment, more deliberate offering of appropriate surgical and medical treatments, and improved availability of survivorship and palliative care.

SUMMARY

Given ongoing disparities in lung cancer care, research to determine best practices for narrowing these gaps and to guide policy change are an essential focus of future lung cancer research.

Elevated Mortality Rate in Patients With Functional Seizures After Diagnosis and Referral

Background and Objectives

To evaluate the standardized mortality ratio (SMR) of patients in the United States referred to a multidisciplinary clinic for treatment of functional seizures.

Methods

We identified patients who had or had not died based on automated retrospective review of electronic health records from a registry of patients referred to a single-center multidisciplinary functional seizures treatment clinic. We calculated an SMR by comparing the number of observed deaths with the expected number of deaths in an age-matched, sex-matched, and race-matched population within the same state, and year records were available.

Results

A total of 700 patients with functional seizures (mean age 37 years, 78% female) were followed up for 1,329 patient-years for a median of 15 months per patient (interquartile range 6-37 months). We observed 11 deaths, corresponding to a mortality rate of 8.2 per 1,000 patient-years and an SMR of 2.4 (95% confidence interval: 1.17-4.22). Five of 9 patients with identified circumstances around their death were in hospice care when they passed. None of the identified causes of death were related to seizures directly.

Discussion

These data provide further evidence of elevated mortality in functional seizures soon after diagnosis and referral to treatment. These data from the decentralized health care system of the United States build on the findings from other countries with large-scale health registries.

Disparities in Access to Multidisciplinary Cancer Consultations and Treatment for Patients With Early-Stage Non-Small Cell Lung Cancer: A SEER-Medicare Analysis

PURPOSE

Disparities in access to a multidisciplinary cancer consultation (MDCc) persist, and the role of physician relationships remains understudied. This study examined the extent to which multilevel factors, including patient characteristics and patient-sharing network measures reflecting the structure of physician relationships, are associated with an MDCc and receipt of stereotactic body radiation therapy versus surgery among patients with early-stage non-small cell lung cancer (NSCLC).

METHODS AND MATERIALS

In this cross-sectional study, we analyzed Surveillance, Epidemiology, and End Results (SEER)-Medicare data for patients diagnosed with stage I-IIA NSCLC from 2016 to 2017. We assembled patient-sharing networks and identified cancer specialists who were locally unique for their specialty, herein referred to as linchpins. The proportion of linchpin cancer specialists for each hospital referral region (HRR) was calculated as a network-based measure of specialist scarcity. We used multilevel multinomial logistic regression to estimate associations between study variables and receipt of an MDCc and multilevel logistic regression to examine the relationship between patient receipt of an MDCc and initial treatment.

RESULTS

Our study included 6120 patients with stage I-IIA NSCLC, of whom 751 (12.3%) received an MDCc, 1729 (28.3%) consulted only a radiation oncologist, 2010 (32.8%) consulted only a surgeon, and 1630 (26.6%) consulted neither specialist within 2 months of diagnosis. Compared with patients residing in an HRR with a low proportion of linchpin surgeons, those residing in an HRR with a high proportion of linchpin surgeons had a 2.99 (95% CI, 1.87-4.78) greater relative risk of consulting only a radiation oncologist versus receiving an MDCc and a 2.70 (95% CI, 1.68-4.35) greater relative risk of consulting neither specialist versus receiving an MDCc. Patients who received an MDCc were 5.32 times (95% CI, 4.27-6.63) more likely to receive stereotactic body radiation therapy versus surgery.

CONCLUSIONS

Physician networks are associated with receipt of an MDCc and treatment, underscoring the potential for leveraging patient-sharing network analysis to improve access to lung cancer care.

Neighborhood and racial influences on triple negative breast cancer: evidence from Northeast Ohio

PURPOSE

Triple negative breast cancer (TNBC) is an aggressive subtype of breast cancer (BC) with higher recurrence rates and poorer prognoses and most prevalent among non-Hispanic Black women. Studies of multiple health conditions and care processes suggest that neighborhood socioeconomic position is a key driver of health disparities. We examined roles of patients' neighborhood-level characteristics and race on prevalence, stage at diagnosis, and mortality among patients diagnosed with BC at a large safety-net healthcare system in Northeast Ohio.

METHODS

We used tumor registry to identify BC cases from 2007 to 2020 and electronic health records and American Community Survey for individual- and area-level factors. We performed multivariable regression analyses to estimate associations between neighborhood-level characteristics, measured by the Area Deprivation Index (ADI), race and comparative TNBC prevalence, stage at diagnosis, and total mortality.

RESULTS

TNBC was more common among non-Hispanic Black (53.7%) vs. non-Hispanic white patients (46.4%). Race and ADI were individually significant predictors of TNBC prevalence, stage at diagnosis, and total mortality. Race remained significantly associated with TNBC subtype, adjusting for covariates. Accounting for TNBC status, a more disadvantaged neighborhood was significantly associated with a worse stage at diagnosis and higher death rates.

CONCLUSION

Our findings suggest that both neighborhood socioeconomic position and race are strongly associated with TNBC vs. other BC subtypes. The burden of TNBC appears to be highest among Black women in the most socioeconomically disadvantaged neighborhoods. Our study suggests a complex interplay of social conditions and biological disease characteristics contributing to racial disparities in BC outcomes.

Clinical Multiteam System Composition and Complexity Among Newly Diagnosed Early-Stage Breast, Colorectal, and Lung Cancer Patients With Multiple Chronic Conditions: A SEER-Medicare Analysis

PURPOSE

Sixty percent of adults have multiple chronic conditions at cancer diagnosis. These patients may require a multidisciplinary clinical team-of-teams, or a multiteam system (MTS), of high-complexity involving multiple specialists and primary care, who, ideally, coordinate clinical responsibilities, share information, and align clinical decisions to ensure comprehensive care needs are managed. However, insights examining MTS composition and complexity among individuals with cancer and comorbidities at diagnosis using US population-level data are limited.

METHODS

Using SEER-Medicare data (2006-2016), we identified newly diagnosed patients with breast, colorectal, or lung cancer who had a codiagnosis of cardiopulmonary disease and/or diabetes (n = 75,201). Zaccaro's theory-based classification of MTSs was used to categorize clinical MTS complexity in the 4 months following cancer diagnosis: high-complexity (≥ 4 clinicians from ≥ 2 specialties) and low-complexity (1-3 clinicians from 1-2 specialties). We describe the proportions of patients with different MTS compositions and quantify the incidence of high-complexity MTS care by patient groups.

RESULTS

The most common MTS composition was oncology with primary care (37%). Half (50.3%) received high-complexity MTS care. The incidence of high-complexity MTS care for non-Hispanic Black and Hispanic patients with cancer was 6.7% (95% CI, -8.0 to -5.3) and 4.7% (95% CI, -6.3 to -3.0) lower than non-Hispanic White patients with cancer; 13.1% (95% CI, -14.1 to -12.2) lower for rural residents compared with urban; 10.4% (95% CI, -11.2 to -9.5) lower for dual Medicaid-Medicare beneficiaries compared with Medicare-only; and 16.6% (95% CI, -17.5 to -15.8) lower for colorectal compared with breast cancer.

CONCLUSION

Incidence differences of high-complexity MTS care were observed among cancer patients with multiple chronic conditions from underserved populations. The results highlight the need to further understand the effects of and mechanisms through which care team composition, complexity, and functioning affect care quality and outcomes.

Acceptance of Simulated Adult Patients With Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis

IMPORTANCE

Although there have been significant increases in the number of US residents insured through Medicaid, the ability of patients with Medicaid to access cancer care services is less well known.

OBJECTIVE

To assess facility-level acceptance of Medicaid insurance among patients diagnosed with common cancers.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional secret shopper study was conducted in 2020 in a random sample of Commission on Cancer-accredited facilities in the United States using a simulated cohort of Medicaid-insured adult patients with colorectal, breast, kidney, and melanoma skin cancer.

EXPOSURES

Telephone call requesting an appointment for a patient with Medicaid with a new cancer diagnosis.

MAIN OUTCOMES AND MEASURES

Acceptance of Medicaid insurance for cancer care. Descriptive statistics, χ2 tests, and multivariable logistic regression models were used to examine factors associated with Medicaid acceptance for colorectal, breast, kidney, and skin cancer. High access hospitals were defined as those offering care across all 4 cancer types surveyed. Explanatory measures included facility-level factors from the 2016 American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services General Information database.

RESULTS

A nationally representative sample of 334 facilities was created, of which 226 (67.7%) provided high access to patients with Medicaid seeking cancer care. Medicaid acceptance differed by cancer site, with 319 facilities (95.5%) accepting Medicaid insurance for breast cancer care; 302 (90.4%), colorectal; 290 (86.8%), kidney; and 266 (79.6%), skin. Comprehensive community cancer programs (OR, 0.4; 95% CI, 0.2-0.7; P = .007) were significantly less likely to provide high access to care for patients with Medicaid. Facilities with nongovernment, nonprofit (vs for-profit: OR, 3.5; 95% CI, 1.1-10.8; P = .03) and government (vs for-profit: OR, 6.6; 95% CI, 1.6-27.2; P = .01) ownership, integrated salary models (OR, 2.6; 95% CI, 1.5-4.5; P = .001), and average (vs above-average: OR, 6.4; 95% CI, 1.4-29.6; P = .02) or below-average (vs above-average: OR, 8.4; 95% CI, 1.5-47.5; P = .02) effectiveness of care were associated with high access to Medicaid. State Medicaid expansion status was not significantly associated with high access.

CONCLUSIONS AND RELEVANCE

This study identified access disparities for patients with Medicaid insurance at centers designated for high-quality care. These findings highlight gaps in cancer care for the expanding population of patients receiving Medicaid.