Identifying Smoking Status and Smoking Cessation Using a Data Linkage Between the Kentucky Cancer Registry and Health Claims Data

Development of an Electronic Health Record-Based Algorithm for Predicting Lung Cancer Screening Eligibility in the Population-Based Research to Optimize the Screening Process Lung Research Consortium

PURPOSE

Lung cancer screening (LCS) guidelines in the United States recommend LCS for those age 50-80 years with at least 20 pack-years smoking history who currently smoke or quit within the last 15 years. We tested the performance of simple smoking-related criteria derived from electronic health record (EHR) data and developed and tested the performance of a multivariable model in predicting LCS eligibility.

METHODS

Analyses were completed within the Population-based Research to Optimize the Screening Process Lung Consortium (PROSPR-Lung). In our primary validity analyses, the reference standard LCS eligibility was based on self-reported smoking data collected via survey. Within one PROSPR-Lung health system, we used a training data set and penalized multivariable logistic regression using the Least Absolute Shrinkage and Selection Operator to select EHR-based variables into the prediction model including demographics, smoking history, diagnoses, and prescription medications. A separate test data set assessed model performance. We also conducted external validation analysis in a separate health system and reported AUC, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy metrics associated with the Youden Index.

RESULTS

There were 14,214 individuals with survey data to assess LCS eligibility in primary analyses. The overall performance for assigning LCS eligibility status as measured by the AUC values at the two health systems was 0.940 and 0.938. At the Youden Index cutoff value, performance metrics were as follows: accuracy, 0.855 and 0.895; sensitivity, 0.886 and 0.920; specificity, 0.896 and 0.850; PPV, 0.357 and 0.444; and NPV, 0.988 and 0.992.

CONCLUSION

Our results suggest that health systems can use an EHR-derived multivariable prediction model to aid in the identification of those who may be eligible for LCS.

Development and Demonstration of Tobacco Treatment Measures for Cancer Registries: Novel Metrics for Quality Improvement

BACKGROUND

Individuals undergoing cancer treatment have better outcomes when they discontinue tobacco use. Few cancer centers systematically provide evidence-based cessation services. As part of a national quality improvement initiative [Cancer Center Cessation Initiative (C3i)], we collaborated with our cancer registry to develop and implement two tobacco treatment metrics for tracking the provision of behavioral support and pharmacotherapy.

METHODS

Post-development, the tobacco treatment metrics were integrated into the registry for all future patients. We used means and frequencies to summarize tobacco treatment for cases treated between 2017 and 2019, coinciding with the timeframe of C3i participation.

RESULTS

Of 17,735 cancer cases reviewed, both measures were captured on 17,654 (99.5%) of patients, with 3,091 (17.4%) identified as users of tobacco. Across the 3 years, 557 (18%) of individuals who used tobacco received either tobacco cessation pharmacotherapy or behavioral support; with 478 (15.5%) receiving behavioral counseling, 352 (11.4%) receiving pharmacotherapy, and 273 (8.8%) receiving both-considered gold standard care. Tobacco treatment varied substantially across cancer types. The odds of receiving gold standard care were 2.37 times greater in 2019 compared with 2017. (OR, 2.37; 95% confidence interval, 1.63-3.46; P < 0.0001).

CONCLUSIONS

The new metrics demonstrated high completion rates and their potential to track quality improvement efforts over time. They identified suboptimal treatment reach, but a potential increase in treatment over time and greater treatment among tobacco-related versus nontobacco-related cancers.

IMPACT

Continued tobacco use worsens cancer care outcomes. Integrating measures into cancer registries is a viable option for tracking tobacco treatment and cessation in the context of cancer care.

The association of new-onset diabetes with subsequent diagnosis of pancreatic cancer-novel use of a large administrative database

BACKGROUND

Screening options for pancreatic ductal adenocarcinoma (PDAC) are limited. New-onset type 2 diabetes (NoD) is associated with subsequent diagnosis of PDAC in observational studies and may afford an opportunity for PDAC screening. We evaluated this association using a large administrative database.

METHODS

Patients were identified using claims data from the OptumLabs® Data Warehouse. Adult patients with NoD diagnosis were matched 1:3 with patients without NoD using age, sex and chronic obstructive pulmonary disease (COPD) status. The event of PDAC diagnosis was compared between cohorts using the Kaplan-Meier method. Factors associated with PDAC diagnosis were evaluated with Cox's proportional hazards modeling.

RESULTS

We identified 640 421 patients with NoD and included 1 921 263 controls. At 3 years, significantly more PDAC events were identified in the NoD group vs control group (579 vs 505; P < 0.001). When controlling for patient factors, NoD was significantly associated with elevated risk of PDAC (HR 3.474, 95% CI 3.082-3.920, P < 0.001). Other factors significantly associated with PDAC diagnosis were increasing age, increasing age among Black patients, and COPD diagnosis (P ≤ 0.05).

CONCLUSIONS

NoD was independently associated with subsequent diagnosis of PDAC within 3 years. Future studies should evaluate the feasibility and benefit of PDAC screening in patients with NoD.

Linking the Center for International Blood and Marrow Transplant Research Registry to the California Cancer Registry and California Hospital Patient Discharge Data

Advances in hematopoietic cell transplantation (HCT) have substantially improved patient survival, increasing the importance of studying outcomes and long-term adverse effects in the rapidly growing population of HCT survivors. Large-scale registry data from the Center for International Blood and Marrow Transplant Research (CIBMTR) are a valuable resource for studying mortality and late effects after HCT, providing detailed data reported by HCT centers on transplantation-related factors and key outcomes. This study was conducted to evaluate the robustness of CIBMTR outcome data and assess health-related outcomes and healthcare utilization among HCT recipients. We linked data from the CIBMTR for California residents with data from the population-based California Cancer Registry (CCR) and hospitalization information from the California Patient Discharge Database (PDD). In this retrospective cohort study, probabilistic and deterministic record linkage used key patient identifiers, such as Social Security number, ZIP code, sex, birth date, hematologic malignancy type and diagnosis date, and HCT type and date. Among 22,733 patients registered with the CIBMTR who underwent autologous or allogeneic HCT for hematologic malignancy between 1991 and 2016, 89.0% were matched to the CCR and/or PDD (n = 17,707 [77.9%] for both, n = 1179 [5.2%] for the CCR only, and n = 1342 [5.9%] for the PDD only). Unmatched patients were slightly more likely to have undergone a first autologous HCT than an allogeneic HCT (12.6% versus 9.0%), to have a larger number of missing linkage identifiers, and to have undergone HCT prior to 2010. Among the patients reported to the CIBMTR who matched to the CCR, 85.7% demonstrated concordance of both hematologic malignancy type and diagnosis date across data sources. This linkage presents unparalleled opportunities to advance our understanding of HCT practices and patient outcomes.

Cerebrospinal fluid (CSF) leak after elective lumbar spinal fusion: Who is at risk?

PURPOSE

CSF leaks are a known complication of lumbar fusion surgery. There is a scarcity of literature describing the incidence and risk factors associated with this complication. The aim of this study was to identify patients who are at risk of developing postoperative CSF leak.

METHODS

The Nationwide Inpatient Sample database was used to identify patients who had lumbar fusion in the US from 2002 to 2014. Inpatient outcomes included the incidence and risk of developing CSF leak based on selected patient-specific characteristics. Secondary outcomes included average length of stay, mean costs, and mortality rates. All statistical analyses were conducted based on multivariate regression models using the SPSS software.

RESULTS

A total of 439,220 patients who underwent elective lumbar fusion procedures were identified. Of these patients, 2.6% (11,636 /439,220) were found to have CSF leak. Independent important risk factors for CSF leak development included: older age (OR: 1.025; 95% CI: 1.02-1.03; p < 0.0001), posterior approach (OR: 1.71; 95% CI: 1.59-1.85; p < 0.0001) compared to anterior approach, chronic deficiency anemia (OR: 1.21; 95% CI:1.14-1.30; p < 0.0001), obesity (OR: 1.22; 95% CI: 1.15-1.30; p < 0.0001), and pulmonary circulatory disease (OR: 1.44; 95% CI: 1.18-1.75; p < 0.0001). CSF leak was associated with increased length of stay (5.39 ± 3.86 vs. 3.74 ± 2.55; p < 0.0001), hospitalization costs (120,129.0 ± 88,123.5 vs. 89,226.8 ± 65,350.3; p < 0.0001) and mortality (0.3% vs. 0.1%; p < 0.05).

CONCLUSION

Spine surgeons should be aware of certain patient and procedure-specific characteristics that increase the risk of developing postoperative CSF leak after lumbar fusion in order to improve patient outcomes.

Postoperative Use of Biologics was Less Common among Patients with Crohn's Disease With Emergent/Urgent Versus Elective Intestinal Resection

BACKGROUND & AIMS

Given the risk of intestinal resection for Crohn's disease, postoperative treatment may be informed by several risk factors, including resection type. We compared postoperative treatment strategies for Crohn's disease between emergent/urgent versus elective resection.

METHODS

We identified patients with intestinal resection for Crohn's disease between 2002-2018 using the MarketScan databases. We classified emergent/urgent resections as those occurring after emergency department admission or after the second day of admission. We estimated adjusted risk differences for the association between resection type (emergent/urgent versus elective) and 6-month postoperative medication strategy (biologic monotherapy, biologic combination therapy with an immunomodulator, immunomodulator monotherapy, other non-biologic medication for Crohn's [5-aminosalicylates, antibiotics, corticosteroids], or no medications for Crohn's).

RESULTS

During 6 months after resection among 4,187 patients, 23% received biologic monotherapy, 6% received combination therapy, 16% received immunomodulator monotherapy, and 36% received other non-biologics. Compared to elective resection, emergent/urgent resection was associated with more common use of "other non-biologic" medications (risk difference 6.4%; 95% confidence interval [CI] 2.8%, 10.0%), but less common use of biologic monotherapy (risk difference -3.2%; 95% CI -6.2%, -0.1%) and no medications (risk difference -3.6%; 95% CI -6.6%, -0.6%).

CONCLUSIONS

Although patients with emergent/urgent resection may benefit from more aggressive postoperative therapy, there was evidence that emergent/urgent resection was more associated than elective resection with postoperative use of non-biologics for Crohn's disease. Future studies of treatment patterns and comparative effectiveness of postoperative treatment strategies for Crohn's patients should consider these differences between resection types, which may be important drivers of longer-term outcomes.

Receipt of and Spending on Cessation Medication Among US Adults With Employer-Sponsored Health Insurance, 2010 and 2017

OBJECTIVE

Studies examining the use of smoking cessation treatment and related spending among enrollees with employer-sponsored health insurance are dated and limited in scope. We assessed changes in annual receipt of and spending on cessation medications approved by the US Food and Drug Administration (FDA) among tobacco users with employer-sponsored health insurance from 2010 to 2017.

METHODS

We analyzed data on 439 865 adult tobacco users in 2010 and 344 567 adult tobacco users in 2017 from the IBM MarketScan Commercial Database. We used a negative binomial regression to estimate changes in receipt of cessation medication (number of fills and refills and days of supply). We used a generalized linear model to estimate spending (total, employers', and out of pocket). In both models, covariates included year, age, sex, residence, and type of health insurance plan.

RESULTS

From 2010 to 2017, the percentage of adult tobacco users with employer-sponsored health insurance who received any cessation medication increased by 2.4%, from 15.7% to 16.1% (P < .001). Annual average number of fills and refills per user increased by 15.1%, from 2.5 to 2.9 (P < .001) and days of supply increased by 26.4%, from 81.9 to 103.5 (P < .001). The total annual average spending per user increased by 53.6%, from $286.40 to $440.00 (P < .001). Annual average out-of-pocket spending per user decreased by 70.9%, from $70.80 to $20.60 (P < .001).

CONCLUSIONS

Use of smoking cessation medications is low among smokers covered by employer-sponsored health insurance. Opportunities exist to further increase the use of cessation medications by promoting the use of evidence-based cessation treatments and reducing barriers to coverage, including out-of-pocket costs.

A Case Study of Early-Onset Colorectal Cancer: Using Electronic Health Records to Support Public Health Surveillance on an Emerging Cancer Control Topic

Electronic health records (EHRs) are increasingly being used to support public health surveillance, including in cancer, where many population-based registries can now accept electronic case reporting. Using EHRs to supplement cancer registry data provides the opportunity to examine in more detail emerging issues in cancer control, such as the increasing incidence rates of early onset colorectal cancer (CRC). The purpose of this study was to evaluate the feasibility of a public health organization partnering with a health system to examine risk factors for early-onset CRC in a community cancer setting, and to further understand challenges with using EHRs to address emerging topics in cancer control. We conducted a mixed-methods evaluation using key informant interviews with public health practitioners, researchers, and registry staff to generate insights on how using EHRs and partnering with health systems can improve chronic disease surveillance and cancer control. A data quality assessment of variables representing risk factors for CRC and other clinical characteristics was conducted on all CRC patients diagnosed in 2016 at the participating cancer center. The quantitative assessment of the EHR data revealed that, while most chronic health conditions were well documented, around 25% of CRC patients were missing information on body mass index, alcohol, and tobacco use. Key informants offered ideas and ways to overcome challenges with using EHR data to support chronic disease surveillance. Their recommendations included the following activities: engaging EHR vendors in the development of standards, taking leadership roles on workgroups to address emerging technological issues, participating in pilot studies and task forces, and negotiating with EHR vendors so that clinical decision support tools built to support public health initiatives are freely available to all users of those EHRs. Although using EHR data to support public health efforts is not without its challenges, it soon could be an important part of chronic disease surveillance and cancer control.

EGFR testing and erlotinib use in non-small cell lung cancer patients in Kentucky

This study determined the frequency and factors associated with EGFR testing rates and erlotinib treatment as well as associated survival outcomes in patients with non small cell lung cancer in Kentucky. Data from the Kentucky Cancer Registry (KCR) linked with health claims from Medicaid, Medicare and private insurance groups were evaluated. EGFR testing and erlotinib prescribing were identified using ICD-9 procedure codes and national drug codes in claims, respectively. Logistic regression analysis was performed to determine factors associated with EGFR testing and erlotinib prescribing. Cox-regression analysis was performed to determine factors associated with survival. EGFR mutation testing rates rose from 0.1% to 10.6% over the evaluated period while erlotinib use ranged from 3.4% to 5.4%. Factors associated with no EGFR testing were older age, male gender, enrollment in Medicaid or Medicare, smoking, and geographic region. Factors associated with not receiving erlotinib included older age, male gender, enrollment in Medicare or Medicaid, and living in moderate to high poverty. Survival analysis demonstrated EGFR testing or erlotinib use was associated with a higher likelihood of survival. EGFR testing and erlotinib prescribing were slow to be implemented in our predominantly rural state. While population-level factors likely contributed, patient factors, including geographic location (areas with high poverty rates and rural regions) and insurance type, were associated with lack of use, highlighting rural disparities in the implementation of cancer precision medicine.

Development and Evaluation of a Process to Link Cancer Patients in the SEER Registries to National Medicaid Enrollment Data

Cancer patients receiving Medicaid have worse prognosis. Patients in 14 Surveillance, Epidemiology, and End Results (SEER) cancer registries were linked to national Medicaid enrollment files, 2006-2013, to determine enrollment status during the year before and after diagnosis. A deterministic algorithm based on Social Security number, Medicare Health Insurance Claim number, sex, and date of birth was utilized. Results were compared with an independent linkage of Kentucky-based SEER and Medicaid data. A total 559 484 cancer cases were linked to national Medicaid enrollment files, representing 15-17% of persons with cancer yearly. About 60% of these cases were a complete match on all variables. There was 99% agreement on enrollment status compared with the Kentucky linked data. SEER data were successfully linked to national Medicaid enrollment data. NCI will make the linked data available to researchers, allowing for more detailed assessments of the impact Medicaid enrollment has on cancer diagnosis and outcomes.