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Vasan V, Gilja S, Kapustin D, Yun J, Roof SA, Chai RL, Khan MN, Rubin SJ. The impact of distance to facility on treatment modality, short-term outcomes, and survival of patients with HPV-positive oropharyngeal squamous cell carcinoma. Am J Otolaryngol 2024; 45:104356. [PMID: 38703611 DOI: 10.1016/j.amjoto.2024.104356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE This study compared treatment and outcomes for patients with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) based on their travel distance to treatment facility. MATERIALS AND METHODS Patients with cT1-4, N0-3, M0 HPV-positive OPSCC in the National Cancer Database from 2010 to 2019 were identified and split into four quartiles based on distance to facility, with quartile 4 representing patients with furthest travel distances. Multivariable-adjusted logistic regression and Cox proportional hazards modeling were used to analyze the primary outcome of treatment received, and secondary outcomes of clinical stage, overall survival, surgical approach (i.e., TORS versus other), and 30-day surgical readmissions. RESULTS 17,207 patients with HPV-positive OPSCC were evenly distributed into four quartiles. Compared to patients in quartile 1, patients in quartile 4 were 40 % less likely to receive radiation versus surgery (OR = 0.60; 95 % CI = 0.54-0.66). Among the patients who received surgery, quartile 4 had a higher odds of receiving TORS treatment compared to quartile 1 (4v1: OR = 2.38; 95 % CI = 2.05-2.77), quartile 2 (4v2: OR = 2.31, 95 % CI = 2.00-2.66), and quartile 3 (4v3: OR = 1.75; 95 % CI = 1.54-1.99). Quartile 4 had a decreased odds of mortality compared to Quartile 1 (4v1: OR = 0.87; 95 % CI = 0.79-0.97). There were no differences among the quartiles in presenting stage and 30-day readmissions. CONCLUSIONS This study found that patients with furthest travel distance to facility were more often treated surgically over non-surgical management, with TORS over open surgery, and had better overall survival. These findings highlight potential disparities in access to care for patients with HPV-positive OPSCC.
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Affiliation(s)
- Vikram Vasan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shivee Gilja
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Danielle Kapustin
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun Yun
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Scott A Roof
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raymond L Chai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mohemmed N Khan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel J Rubin
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Farquhar DR, Masood MM, Lenze NR, Tasoulas J, Sheth S, Lumley C, Blumberg J, Yarbrough WG, Zevallos J, Weissler MC, Zanation AM, Hackman TG, Olshan AF. Effect of distance of treatment center on survival for HPV-negative head and neck cancer patients. Head Neck 2023; 45:2981-2989. [PMID: 37767817 DOI: 10.1002/hed.27522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/20/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND In rural states, travel burden for complex cancer care required for head and neck squamous cell carcinoma (HNSCC) may affect patient survival, but its impact is unknown. METHODS Patients with HPV-negative HNSCC were retrospectively identified from a statewide, population-based study. Euclidian distance from the home address to the treatment center was calculated for radiation therapy, surgery, and chemotherapy. Multivariable Cox proportional hazards models were used to examine the risk of 5-year mortality with increasing travel quartiles. RESULTS There were 936 patients with HPV-negative HNSCC with a mean age of 60. Patients traveled a median distance of 10.2, 11.1, and 10.9 miles to receive radiation therapy, surgery, and chemotherapy, respectively. Patients in the fourth distance quartile were more likely to live in a rural location (p < 0.001) and receive treatment at an academic hospital (p < 0.001). Adjusted overall survival (OS) improved proportionally to distance traveled, with improved OS remaining significant for patients who traveled the furthest for care (third and fourth quartile by distance). Relative to patients in the first quartile, patients in the fourth had a reduced risk of mortality with radiation (HR 0.59, 95% CI 0.42-0.83; p = 0.002), surgery (HR 0.47, 95% CI 0.30-0.75; p = 0.001), and chemotherapy (HR 0.56, 95% CI 0.35-0.91; p = 0.020). CONCLUSION For patients in this population-based cohort, those traveling greater distances for treatment of HPV-negative HNSCC had improved OS. This analysis suggests that the benefits of coordinated, multidisciplinary care may outweigh the barriers of travel burden for these patients.
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Affiliation(s)
- Douglas R Farquhar
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Maheer M Masood
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Nicholas R Lenze
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jason Tasoulas
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Siddharth Sheth
- Department of Hematology/Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Catherine Lumley
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jeffrey Blumberg
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Wendell G Yarbrough
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jose Zevallos
- Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mark C Weissler
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Adam M Zanation
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Trevor G Hackman
- Department of Otolaryngology/Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Andrew F Olshan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Otolaryngology/Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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McIntire RK, Keith SW, Nowlan T, Butt S, Cambareri K, Callaghan J, Halstead T, Chandrasekar T, Kelly WK, Leader AE. Predictors of consenting to participate in a clinical trial among urban cancer patients. Contemp Clin Trials 2023; 125:107061. [PMID: 36567059 DOI: 10.1016/j.cct.2022.107061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/09/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patient participation in clinical trials is influenced by demographic and other individual level characteristics. However, there is less research on the role of geography and neighborhood-level factors on clinical trial participation. This study identifies the demographic, clinical, geographic, and neighborhood predictors of consenting to a clinical trial among cancer patients at a large, urban, NCI-designated cancer center in the Mid-Atlantic region. METHODS We used demographic and clinical data from patients diagnosed with cancer between 2015 and 2017. We geocoded patient addresses and calculated driving distance to the cancer center. Additionally, we linked patient data to neighborhood-level educational attainment, social capital and cancer prevalence. Finally, we used generalized linear mixed-effects conditional logistic regression to identify individual and neighborhood-level predictors of consenting to a clinical trial. RESULTS Patients with higher odds of consenting to trials were: Non-Hispanic White, aged 50-69, diagnosed with breast, GI, head/neck, hematologic, or certain solid tumor cancers, those with cancers at regional stage, never/former tobacco users, and those with the highest neighborhood social capital index. Patients who lived further from the cancer center had higher odds of consenting to a trial. With every 1-km increase in residential distance, there was a 4% increase in the odds that patients would consent to a trial. Neither of the additional neighborhood-level variables predicted consenting to a clinical trial. CONCLUSIONS This study identifies important demographic, patient-level, and geographic factors associated with consenting to cancer clinical trials, and lays the groundwork for future research exploring the role of neighborhood-level factors in clinical trial participation.
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Affiliation(s)
- Russell K McIntire
- Jefferson College of Population Health, Thomas Jefferson University, 901 Walnut St., 10(th) Floor, Philadelphia, PA 19107, United States of America.
| | - Scott W Keith
- Division of Biostatistics, Department of Pharmacology, Physiology, & Cancer Biology, Thomas Jefferson University, 130 S 9(th) St., 17(th) Floor, Philadelphia, PA 19107, United States of America
| | - Thomas Nowlan
- Jefferson College of Population Health, Thomas Jefferson University, 901 Walnut St., 10(th) Floor, Philadelphia, PA 19107, United States of America
| | - Seif Butt
- Jefferson College of Population Health, Thomas Jefferson University, 901 Walnut St., 10(th) Floor, Philadelphia, PA 19107, United States of America
| | - Katherine Cambareri
- Jefferson College of Population Health, Thomas Jefferson University, 901 Walnut St., 10(th) Floor, Philadelphia, PA 19107, United States of America
| | - Joseph Callaghan
- Jefferson College of Population Health, Thomas Jefferson University, 901 Walnut St., 10(th) Floor, Philadelphia, PA 19107, United States of America
| | - Tiara Halstead
- Jefferson College of Population Health, Thomas Jefferson University, 901 Walnut St., 10(th) Floor, Philadelphia, PA 19107, United States of America
| | - Thenappan Chandrasekar
- Department of Urology, Thomas Jefferson University, 1025 Walnut Street, Suite 1112, Philadelphia, PA 19107, United States of America
| | - Wm Kevin Kelly
- Division of Solid Tumor Oncology, Department of Medical Oncology, Thomas Jefferson University, 925 Chestnut Street, Suite 220A, Philadelphia, PA 19107, United States of America
| | - Amy E Leader
- Division of Population Science, Department of Medical Oncology, Thomas Jefferson University, 834 Chestnut St., Benjamin Franklin House, Suite 320, Philadelphia, PA 19107, United States of America
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Gill AS, Beswick DM, Mace JC, Menjivar D, Ashby S, Rimmer RA, Ramakrishnan VR, Soler ZM, Alt JA. Evaluating Distance Bias in Chronic Rhinosinusitis Outcomes. JAMA Otolaryngol Head Neck Surg 2022; 148:507-514. [PMID: 35511170 PMCID: PMC9073660 DOI: 10.1001/jamaoto.2022.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The distance traveled by patients for medical care is associated with patient outcomes (ie, distance bias) and is a limitation in outcomes research. However, to date, distance bias has not been examined in rhinologic studies. Objective To evaluate the association of distance traveled by a cohort of patients with chronic rhinosinusitis with baseline disease severity and treatment outcomes. Design, Setting, and Participants A total of 505 patients with chronic rhinosinusitis were prospectively enrolled in a multi-institutional, cross-sectional study in academic tertiary care centers between April 2011 and January 2020. Participants self-selected continued appropriate medical therapy or endoscopic sinus surgery. The 22-item Sinonasal Outcome Test (SNOT-22) and Medical Outcomes Study Short Form 6-D (SF-6D) health utility value scores were recorded at enrollment and follow-up. Data on the distances traveled by patients to the medical centers, based on residence zip codes, and medical comorbid conditions were collected. Exposures Distance traveled by patient to obtain rhinologic care. Main Outcomes and Measures SNOT-22 and SF-6D scores. Scores for SNOT-22 range from 0 to 110; and for SF-6D, from 0.0 to 1.0. Higher SNOT-22 total scores indicate worse overall symptom severity. Higher SF-6D scores indicate better overall health utility; 1.0 represents perfect health and 0.0 represents death. Results The median age for the 505 participants was 56.0 years (IQR, 41.0-64.0 years), 261 were men (51.7%), 457 were White (90.5%), and 13 were Hispanic or Latino (2.6%). These categories were collected according to criteria described and required by the National Institutes of Health and therefore do not equal the entire cohort. Patients traveled a median distance of 31.6 miles (50.6 km) (IQR, 12.2-114.5 miles [19.5-183.2 km]). Baseline (r = 0.00; 95% CI, 0.00-0.18) and posttreatment (r = 0.01; 95% CI, -0.07 to 0.10) SNOT-22 scores, as well as baseline (r = -0.12; 95% CI, -0.21 to -0.04) and posttreatment (r = 0.07; 95% CI, -0.02 to 0.16) SF-6D scores, were not associated with distance. There was no clinically meaningful correlation between distance traveled and mean comorbidity burden. Nevertheless, patients with a history of endoscopic sinus surgery were more likely to travel longer distances to obtain care (Cliff delta = 0.28; 95% CI, 0.19-0.38). Conclusions and Relevance Although this cross-sectional study found that some patients appear more willing to travel longer distances for chronic rhinosinusitis care, results suggest that distance traveled to academic tertiary care centers was not associated with disease severity, outcomes, or comorbidity burden. These findings argue for greater generalizability of study results across various cohorts independent of distance traveled to obtain rhinologic care. Trial Registration ClinicalTrials.gov Identifier: NCT02720653.
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Affiliation(s)
- Amarbir S Gill
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City
| | - Daniel M Beswick
- Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles
| | - Jess C Mace
- Division of Rhinology and Sinus Surgery/Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, Portland
| | - Dennis Menjivar
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City
| | - Shaelene Ashby
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City
| | - Ryan A Rimmer
- Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Vijay R Ramakrishnan
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis
| | - Zachary M Soler
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Jeremiah A Alt
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City
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Mehta N, Lavoie-Gagne OZ, Cohn MR, Michalski J, Fitch A, Yanke AB, Cole BJ, Verma NN, Forsythe B. Travel Distance Does Not Affect Outcomes After Arthroscopic Rotator Cuff Repair. Arthrosc Sports Med Rehabil 2022; 4:e511-e517. [PMID: 35494309 PMCID: PMC9042758 DOI: 10.1016/j.asmr.2021.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 10/24/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Nabil Mehta
- Address correspondence to Nabil Mehta, M.D., Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612, U.S.A.
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The Impact of Socioeconomic Determinants on the Quality of Life of Moroccan Breast Cancer Survivors Diagnosed Two Years Earlier at the National Institute of Oncology in Rabat. Obstet Gynecol Int 2021; 2021:9920007. [PMID: 34257668 PMCID: PMC8249154 DOI: 10.1155/2021/9920007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/11/2021] [Indexed: 01/30/2023] Open
Abstract
Introduction The objective of this study was to investigate the impact of socioeconomic determinants on the quality of life of Moroccan women with breast cancer two years after their diagnosis who are followed up at the National Institute of Oncology (INO) in Rabat. Methods This is a cross-sectional study that was conducted between May 2019 and September 2020. The sample size was 304 women. Data were collected using the EORTC QLQ-C30 and EORTC QLQ-BR 23 questionnaires in the Moroccan dialect. Results The mean age of participants was 53.5 ± 12.4 years, where the majority resided in urban areas and more than half were illiterate. Moreover, three-quarters of the survivors were not working, and almost all have basic medical coverage. Nearly one-third of the respondents had experienced discrimination from those around them, and nearly half attributed the decrease in income to their state of health. In addition, 38.2 percent of participants stated that they had great difficulty living on their monthly income after the illness, whereas more than half of the survivors had a good quality of life in terms of overall health (GHS/QOL). Besides, social function obtained the highest score, while emotional function obtained the lowest score. Furthermore, financial difficulty was the most distressing symptom. Indeed, income adjustment after the disease, discrimination, distance between home and treatment center, professional status, and medical coverage were correlated with GHS/QOL. Regression analysis revealed that income adjustment after illness and discrimination were significant predictors of GHS/QOL. Conclusion The data suggest establishing a financial support program and the development of education and awareness-raising policies to combat discrimination.
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Liu GG, Tang C, Liu Y, Bu T, Tang D. Will high-speed railway influence the healthcare seeking behaviour of patients? Quasi-experimental evidence from China. Health Policy Plan 2021; 36:1633-1643. [PMID: 34058009 DOI: 10.1093/heapol/czab018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 11/13/2022] Open
Abstract
This study examines the impacts of high-speed railway (HSR) transportation on the healthcare-seeking behaviour of patients along newly integrated areas of Sichuan province, China. The opening of the Cheng-Mian-Le intercity HSR is considered as quasi-experimental evidence from China, and we make a propensity score matching the difference in differences research design, using data from the monthly report database of the Sichuan Province health statistical data collection and Decision Support System from 2014 to 2015. We find that, first, the opening of the HSR resulted in significant healthcare-seeking behaviour with great heterogeneity. Second, patients are more likely to go to areas with high-density healthcare resources, in which case HSR may mitigate the diagnostic inaccuracies that patients face locally. Third, the 'distance enhancement effect' was present, and its marginal effect is more significant for long-distance patients. Fourth, the tiered-network healthcare policy has no significant restrictive impact on patients seeking high-level medical services. Our results show that HSR establishment has a substantial impact on the behaviour of people seeking medical treatment and medicine. Furthermore, we discuss the results' policy implications for the allocation and integration of China's healthcare market, and the accessibility of medical and health services.
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Affiliation(s)
- Gordon G Liu
- Institute for Global Health and Development, Peking University, Beijing 100871, China
| | - Chengxiang Tang
- Institute for Global Health and Development, Peking University, Beijing 100871, China.,Public Administration School, Guangzhou University, Guangzhou 510006, China
| | - Yahong Liu
- School of Economics and Management, Beijing Jiaotong University, Beijing 100044, China
| | - Tao Bu
- School of Economics and Management, Beijing Jiaotong University, Beijing 100044, China
| | - Daisheng Tang
- School of Economics and Management, Beijing Jiaotong University, Beijing 100044, China
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Harris JA, Hunter WP, Hanna GJ, Treister NS, Menon RS. Rural patients with oral squamous cell carcinoma experience better prognosis and long-term survival. Oral Oncol 2020; 111:105037. [DOI: 10.1016/j.oraloncology.2020.105037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
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Jayakrishnan TT, Bakalov V, Chahine Z, Lister J, Wegner RE, Sadashiv S. Disparities in the enrollment to systemic therapy and survival for patients with multiple myeloma. Hematol Oncol Stem Cell Ther 2020; 14:218-230. [PMID: 33069693 PMCID: PMC7546959 DOI: 10.1016/j.hemonc.2020.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/02/2020] [Accepted: 09/21/2020] [Indexed: 01/16/2023] Open
Abstract
Background Disparities driven by socioeconomic factors have been shown to impact outcomes for cancer patients. We sought to explore this relationship among patients with multiple myeloma (MM) who were not considered for hematopoietic stem cell transplant in the first-line setting and how it varied over time. Methods We queried the National Cancer Database for patients diagnosed with MM between 2004 and 2016 and included only those who received systemic therapy as the first-line treatment. Enrollment rates for therapy were calculated as receipt of systemic therapy as the incident event of interest (numerator) over time to initiation of therapy (denominator) and used to calculate incident rate ratios that were further analyzed using Poisson regression analysis. A multivariate Cox proportional hazards model was constructed for survival analysis, and differences were reported as hazard ratios (HRs). Results We identified 56,102 patients for enrollment analysis and 50,543 patients for survival analysis. Therapy enrollment in a multivariate model was significantly impacted by race and sex (p < .005). Advanced age, earlier year of diagnosis, lack of insurance or Medicaid, and higher comorbidity were associated with poor survival (HR > 1), whereas female sex, non-Hispanic black race, higher income, and treatment at an academic center were associated with improved survival (HR < 1). Conclusion Disparities in treatment of MM exist and are caused by a complex interplay of multiple factors, with socioeconomic factor playing a significant role. Studies exploring such determinants may help in equitable distribution of resources to overcome such differences.
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Affiliation(s)
| | - Veli Bakalov
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Zena Chahine
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - John Lister
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Santhosh Sadashiv
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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Dhakal P, Lyden E, Muir KLE, Al-Kadhimi ZS, Maness LJ, Gundabolu K, Bhatt VR. Effects of Distance From Academic Cancer Center on Overall Survival of Acute Myeloid Leukemia: Retrospective Analysis of Treated Patients. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2020; 20:e685-e690. [PMID: 32660903 PMCID: PMC9413366 DOI: 10.1016/j.clml.2020.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/17/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Patients living farther away from academic centers may not have easy access to resources for management of acute myeloid leukemia (AML). We aimed to analyze the effect of distance traveled on overall survival (OS) of AML patients treated at an academic center. PATIENTS AND METHODS AML patients diagnosed at the University of Nebraska Medical Center were divided into 4 groups according to the shortest distance between the cancer center and patients' residence (<25, 25-50, 50-100, and > 100 miles). Chi-square test and ANOVA were used to examine the association of distance with patient characteristics. OS, defined as the time from diagnosis of AML to death from any cause, was determined by the Kaplan-Meier method. Comparison of survival curves was done by the log-rank test. Multivariable analysis using Cox regression was performed to detect the survival effect of distance from the cancer center. RESULTS The total number of patients was 449. Median distance was 85 miles (interquartile range, 20-180). OS at 1 year for < 25, 25-50, 50-100, and > 100 miles was 45%, 55%, 38%, and 40% respectively (P = .6). In a Cox regression analysis, distance from treatment center, as a continuous variable, was not a significant factor for death (hazard ratio, 1.001; 95% confidence interval, 1.000-1.001). Multivariable analysis showed nonsignificant trend of increased mortality for patients traveling > 100 miles to a cancer center. CONCLUSION This study did not demonstrate an association between distance from an academic cancer center and OS in AML. This finding should provide some assurance to patients who live farther away from academic centers.
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Affiliation(s)
- Prajwal Dhakal
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE.
| | - Elizabeth Lyden
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE
| | - Kate-Lynn E Muir
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Zaid S Al-Kadhimi
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
| | - Lori J Maness
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
| | - Krishna Gundabolu
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
| | - Vijaya Raj Bhatt
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE
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Smith JB, Shew M, Karadaghy OA, Nallani R, Sykes KJ, Gan GN, Brant JA, Bur AM. Predicting salvage laryngectomy in patients treated with primary nonsurgical therapy for laryngeal squamous cell carcinoma using machine learning. Head Neck 2020; 42:2330-2339. [PMID: 32383544 PMCID: PMC10601023 DOI: 10.1002/hed.26246] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 03/06/2020] [Accepted: 04/22/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Machine learning (ML) algorithms may predict patients who will require salvage total laryngectomy (STL) after primary radiotherapy with or without chemotherapy for laryngeal squamous cell carcinoma (SCC). METHODS Patients treated for T1-T3a laryngeal SCC were identified from the National Cancer Database. Multiple ML algorithms were trained to predict which patients would go on to require STL after primary nonsurgical treatment. RESULTS A total of 16 440 cases were included. The best classification performance was achieved with a gradient boosting algorithm, which achieved accuracy of 76.0% (95% CI 74.5-77.5) and area under the curve = 0.762. The most important variables used to construct the model were distance from residence to treating facility and days from diagnosis to start of treatment. CONCLUSION We can identify patients likely to fail primary radiotherapy with or without chemotherapy and who will go on to require STL by applying ML techniques and argue for high-quality, multidisciplinary regionalized care.
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Affiliation(s)
- Joshua B. Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Matthew Shew
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Omar A. Karadaghy
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Rohit Nallani
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Kevin J. Sykes
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Gregory N. Gan
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas
| | - Jason A. Brant
- Department of Otorhinolaryngology-Head and Neck Surgery, Hospitals of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrés M. Bur
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas
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Impact of Race and Socioeconomic Status on Psychologic Outcomes in Childhood Cancer Patients and Caregivers. J Pediatr Hematol Oncol 2019; 41:433-437. [PMID: 30629003 DOI: 10.1097/mph.0000000000001405] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Complex relationships between race and socioeconomic status have a poorly understood influence on psychologic outcomes in pediatric oncology. The Family Symptom Inventory was used to assess symptoms of depression and anxiety in pediatric patients with cancer and their caregivers. Separate hierarchical linear regression models examined the relationship between demographic variables, cancer characteristics, socioeconomic status, and access to care and patient or caregiver depression/anxiety. Participants included 196 pediatric patients with cancer (mean age, 11.21 y; 49% African American) and their caregivers. On average, caregivers reported low levels of depression/anxiety. Symptoms of depression and anxiety in patients were correlated with poorer mental health in caregivers (r=0.62; P<0.01). Self-reported financial difficulty (β=0.49; P<0.001) and brain cancer diagnosis for their child (β=0.42; P=0.008) were significantly associated with depression and anxiety in caregivers. Analysis did not reveal significant associations between race, household income, or access to care and patient or caregiver depression/anxiety. Perception of financial hardship can adversely impact mental health in caregivers of children with cancer. Psychosocial assessment and interventions may be especially important for caregivers of patients with brain tumors and caregivers who report feeling financial difficulty.
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Simpson RE, Wang CY, House MG, Zyromski NJ, Schmidt CM, Nakeeb A, Ceppa EP. Travel distance affects rates and reasons for inpatient visits after pancreatectomy. HPB (Oxford) 2019; 21:818-826. [PMID: 30595461 DOI: 10.1016/j.hpb.2018.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/10/2018] [Accepted: 10/26/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Centralization of complex surgical care leads to increased travel distances for patients. We sought to determine if increased travel distance to the index hospital altered inpatient Visit rates following pancreatectomy. METHODS Pancreatectomies from 2013-2016 were reviewed retrospectively from a single high-volume institution. Travel distance for 936 patients was determined, and patients were grouped by 50-mile increments. Visits (Observations or Readmissions) and corresponding reasons were gathered. RESULTS 222 patients (23.7%) had a Visit to any hospital (AH) within 90 days postoperative; 195 (87.8%) were to the index hospital (IH). The <50 miles group had the highest Visit rate to AH (28.6% vs. 17.8% vs. 24.6%; P = 0.008) and the IH (26.9% vs. 15.2% vs. 20.6%; P = 0.002) compared to 50-100 and > 100 miles. This trend was statistically significant for Observations, but not Readmissions. Gastrointestinal (GI) complaints alone led to 20.7% patients requiring Visits to AH at 90-days, mostly in <50miles group for Visits and Observations at AH and IH. CONCLUSIONS Patients closest to the IH had the highest Visit and Observation rate following pancreatectomy without affecting Readmission rate, with GI complaints as a driving factor. Inpatient education and outpatient symptom management may reduce repeat hospitalization.
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Affiliation(s)
- Rachel E Simpson
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Christine Y Wang
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Michael G House
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, 550 University Blvd., Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN, 46202, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, 550 University Blvd., Indianapolis, IN, 46202, USA.
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Evaluating the urban-rural paradox: The complicated relationship between distance and the receipt of guideline-concordant care among cervical cancer patients. Gynecol Oncol 2018; 152:112-118. [PMID: 30442384 DOI: 10.1016/j.ygyno.2018.11.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/31/2018] [Accepted: 11/06/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Urban-rural health disparities are often attributed to the longer distances rural patients travel to receive care. However, a recent study suggests that distance to care may affect urban and rural cancer patients differentially. We examined whether this urban-rural paradox exists among patients with cervical cancer. METHODS We identified individuals diagnosed with cervical cancer from 2004 to 2013 using a statewide cancer registry linked to multi-payer, insurance claims. Our primary outcome was receipt of guideline-concordant care: surgery for stages IA1-IB1; external beam radiation therapy (EBRT), concomitant chemotherapy, and brachytherapy for stages IB2-IVA. We estimated risk ratios (RR) using modified Poisson regressions, stratified by urban/rural location, to examine the association between distance to nearest facility and receipt of treatment. RESULTS 62% of 999 cervical cancer patients received guideline-concordant care. The association between distance and receipt of care differed by type of treatment. In urban areas, cancer patients who lived ≥15 miles from the nearest surgical facility were less likely to receive primary surgical management compared to those <5 miles from the nearest surgical facility (RR: 0.77, 95% CI: 0.60-0.98). In rural areas, patients living ≥15 miles from the nearest brachytherapy facility were more likely to receive treatment compared to those <5 miles from the nearest brachytherapy facility (RR: 1.71, 95% CI: 1.14-2.58). Distance was not associated with the receipt of chemotherapy or EBRT. CONCLUSIONS Among cervical cancer patients, there is evidence supporting the urban-rural paradox, i.e., geographic distance to cancer care facilities is not consistently associated with treatment receipt in expected or consistent ways. Healthcare systems must consider the diverse and differential barriers encountered by urban and rural residents to improve access to high quality cancer care.
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Valle JA, Glorioso TJ, Maddox TM, Armstrong EJ, Waldo SW, Bradley SM, Ho PM. Impact of Patient Distance From Percutaneous Coronary Intervention Centers on Longitudinal Outcomes. Circ Cardiovasc Qual Outcomes 2018; 11:e004623. [DOI: 10.1161/circoutcomes.118.004623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Javier A. Valle
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.)
| | - Thomas J. Glorioso
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora (T.J.G.)
| | - Thomas M. Maddox
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Current address for Dr Maddox: Division of Cardiology, Washington University School of Medicine, St. Louis, MO
| | - Ehrin J. Armstrong
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.)
| | - Stephen W. Waldo
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.)
| | - Steven M. Bradley
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Current address for Dr Bradley: Minneapolis Heart Institute, Minneapolis, MN
| | - P. Michael Ho
- Cardiology Section, Veterans Affairs Rocky Mountain Regional Medical Center, Aurora (J.A.V., T.J.G., T.M.M., E.J.A., S.W.W., S.M.B., P.M.H.)
- Division of Cardiology, University of Colorado School of Medicine, Aurora (J.A.V., E.J.A., S.W.W., P.M.H.)
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Kelly C, Hulme C, Farragher T, Clarke G. Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open 2016; 6:e013059. [PMID: 27884848 PMCID: PMC5178808 DOI: 10.1136/bmjopen-2016-013059] [Citation(s) in RCA: 292] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To investigate whether there is an association between differences in travel time/travel distance to healthcare services and patients' health outcomes and assimilate the methodologies used to measure this. DESIGN Systematic Review. We searched MEDLINE, Embase, Web of Science, Transport database, HMIC and EBM Reviews for studies up to 7 September 2016. Studies were excluded that included children (including maternity), emergency medical travel or countries classed as being in the global south. SETTINGS A wide range of settings within primary and secondary care (these were not restricted in the search). RESULTS 108 studies met the inclusion criteria. The results were mixed. 77% of the included studies identified evidence of a distance decay association, whereby patients living further away from healthcare facilities they needed to attend had worse health outcomes (eg, survival rates, length of stay in hospital and non-attendance at follow-up) than those who lived closer. 6 of the studies identified the reverse (a distance bias effect) whereby patients living at a greater distance had better health outcomes. The remaining 19 studies found no relationship. There was a large variation in the data available to the studies on the patients' geographical locations and the healthcare facilities attended, and the methods used to calculate travel times and distances were not consistent across studies. CONCLUSIONS The review observed that a relationship between travelling further and having worse health outcomes cannot be ruled out and should be considered within the healthcare services location debate.
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Affiliation(s)
- Charlotte Kelly
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Institute for Transport Studies, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Tracey Farragher
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Wasif N, Chang YH, Pockaj BA, Gray RJ, Mathur A, Etzioni D. Association of Distance Traveled for Surgery with Short- and Long-Term Cancer Outcomes. Ann Surg Oncol 2016; 23:3444-3452. [PMID: 27126630 DOI: 10.1245/s10434-016-5242-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The influence of distance traveled for treatment on short- and long-term cancer outcomes is unclear. METHODS Patients with colon, esophageal, liver, and pancreas cancer from 2003 to 2006 were identified from the National Cancer Data Base (NCDB). Distance traveled for surgical treatment was estimated using zip code centroids. Propensity scores were generated for probability of traveling farther for treatment. Mixed effects logistic regression for 90-day mortality and Cox regression for 5-year mortality were compared between patients treated regionally and those traveling from farther away. RESULTS The mean distance traveled for all patients for surgical resection was 30.0 ± 227 miles, with a median distance of 7.5 (interquartile range 14.4) miles. Patients who were aged ≥80 years, on Medicaid, or African American were less likely to be in the fourth quartile of distance (Q4) traveled for surgery. Patients who were in Q4 had a lower risk-adjusted 90-day mortality compared to Q1 for colon [odds ratio (OR) 0.89, 95 % confidence interval (CI) 0.82-0.96], liver (OR 0.49, 95 % CI 0.3-0.78), and pancreatic (OR 0.74, 95 % CI 0.56-0.98) cancer. Similarly, patients in Q4 for all tumor types had a lower risk-adjusted 5-year mortality compared to patients in Q1; colon (hazard ratio (HR) 0.96, 95 % CI 0.93-0.99), esophagus (HR 0.84, 95 % CI 0.75-0.94), liver (HR 0.75, 95 % CI 0.62-0.89), and pancreas (HR 0.87, 95 % CI 0.80-0.95). CONCLUSIONS Greater travel distance for surgical resection of gastrointestinal cancers is associated with lower 90-day and 5-year mortality outcomes. This distance bias has implications for regionalization and reporting of cancer outcomes.
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Affiliation(s)
- Nabil Wasif
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA. .,Surgical Outcomes Division, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Arizona, Phoenix, USA.
| | - Yu-Hui Chang
- Department of Biostatistics, Mayo Clinic Arizona, Phoenix, AZ, USA.,Surgical Outcomes Division, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Arizona, Phoenix, USA
| | - Barbara A Pockaj
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA
| | - Richard J Gray
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA
| | - Amit Mathur
- Division of Transplant Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA.,Surgical Outcomes Division, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Arizona, Phoenix, USA
| | - David Etzioni
- Division of Colorectal Surgery, Department of Surgery, Mayo Clinic Arizona, Phoenix, USA.,Surgical Outcomes Division, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic Arizona, Phoenix, USA
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18
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Zheng C, Habermann EB, Shara NM, Langan RC, Hong Y, Johnson LB, Al-Refaie WB. Fragmentation of Care after Surgical Discharge: Non-Index Readmission after Major Cancer Surgery. J Am Coll Surg 2016; 222:780-789.e2. [PMID: 27016905 DOI: 10.1016/j.jamcollsurg.2016.01.052] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Despite national emphasis on care coordination, little is known about how fragmentation affects cancer surgery outcomes. Our study examines a specific form of fragmentation in post-discharge care-readmission to a hospital different from the location of the operation-and evaluates its causes and consequences among patients readmitted after major cancer surgery. STUDY DESIGN We used the State Inpatient Database of California (2004 to 2011) to identify patients who had major cancer surgery and their subsequent readmissions. Logistic models were used to examine correlates of non-index readmissions and to assess associations between location of readmission and outcomes, measured by in-hospital mortality and repeated readmission. RESULTS Of 9,233 readmissions within 30 days of discharge after major cancer surgery, 20.0% occurred in non-index hospitals. Non-index readmissions were associated with emergency readmission (odds ratio [OR] = 2.63; 95% CI, 2.26-3.06), rural residence (OR = 1.81; 95% CI, 1.61-2.04), and extensive procedures (eg hepatectomy vs proctectomy; OR = 2.77; CI, 2.08-3.70). Mortality was higher during non-index readmissions than index readmissions independent of patient, procedure, and hospital factors (OR = 1.31; 95% CI, 1.03-1.66), but was mitigated by adjusting for conditions present at readmission (OR = 1.24; 95% CI, 0.98-1.58). Non-index readmission predicted higher odds of repeated readmission within 60 days of discharge from the first readmission (OR = 1.16; 95% CI, 1.02-1.32), independent of all covariates. CONCLUSIONS Non-index readmissions constitute a substantial proportion of all readmissions after major cancer surgery. They are associated with more repeated readmissions and can be caused by severe surgical complications and increased travel burden. Overcoming disadvantages of non-index readmissions represents an opportunity to improve outcomes for patients having major cancer surgery.
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Affiliation(s)
- Chaoyi Zheng
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Elizabeth B Habermann
- Division of Health Care Research and Policy and Robert D and Patricia E Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, MN
| | - Nawar M Shara
- MedStar Health Research Institute, Washington, DC; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC
| | - Russell C Langan
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Young Hong
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Lynt B Johnson
- Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC
| | - Waddah B Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
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19
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Nwachukwu BU, Dy CJ, Burket JC, Padgett DE, Lyman S. Risk for Complication after Total Joint Arthroplasty at a Center of Excellence: The Impact of Patient Travel Distance. J Arthroplasty 2015; 30:1058-61. [PMID: 25639857 DOI: 10.1016/j.arth.2015.01.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/02/2015] [Accepted: 01/11/2015] [Indexed: 02/01/2023] Open
Abstract
Healthcare reorganization and bundled payment schemes have resulted in increased patient travel distances in orthopedics. Travel distance has been previously associated with increased complication risk but has yet to be studied in orthopedics. We analyzed the impact of patient travel distance on short-term complications. We reviewed 38,887 TJAs performed between 2008 and 2011 and identified 1606 complications in 1110 procedures. There was no significant association between complication risk and patient travel distance. Complication risk was associated with age, ASA class, Medicare and Medicaid status (P<0.0001 for all). Regional centers of excellence appear to be a viable model in healthcare reorganization however continued attention should be paid to attenuating the individual patient factors associated with complication at these institutions.
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20
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Smith AK, Shara NM, Zeymo A, Harris K, Estes R, Johnson LB, Al-Refaie WB. Travel patterns of cancer surgery patients in a regionalized system. J Surg Res 2015; 199:97-105. [PMID: 26076685 DOI: 10.1016/j.jss.2015.04.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/19/2015] [Accepted: 04/03/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Regionalization of complex surgeries has increased patient travel distances possibly leaving a substantial burden on those at risk for poorer surgical outcomes. To date, little is known about travel patterns of cancer surgery patients in regionalized settings. To inform this issue, we sought to assess travel patterns of those undergoing a major cancer surgery within a regionalized system. MATERIALS AND METHODS We identified 4733 patients who underwent lung, esophageal, gastric, liver, pancreatic, and colorectal resections from 2002-2014 within a multihospital system in the Mid-Atlantic region of the United States. Patient age, race and/or ethnicity, and insurance status were extracted from electronic health records. We used Geographical Information System capabilities in R software to estimate travel distance and map patient addresses based on cancer surgery type and these characteristics. We used visual inspection, analysis of variance, and interaction analyses to assess the distribution of travel distances between patient populations. RESULTS A total of 48.2% of patients were non-white, 49.9% were aged >65 y, and 54.9% had private insurance. Increased travel distance was associated with decreasing age and those undergoing pancreatic and esophageal resections. Also, black patients tend to travel shorter distances than other racial and/or ethnic groups. CONCLUSIONS These maps offer a preliminary understanding into variations of geospatial travel patterns among patients receiving major cancer surgery in a Mid-Atlantic regionalized setting. Future research should focus on the impact of regionalization on timely delivery of surgical care and other quality metrics.
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Affiliation(s)
- Andrew K Smith
- Department of Surgery, Georgetown University Hospital, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Nawar M Shara
- MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD; The Georgetown-Howard University Center for Clinical and Translational Science, Washington, DC
| | - Alexander Zeymo
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Katherine Harris
- Department of Surgery, Georgetown University Hospital, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Randy Estes
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Lynt B Johnson
- Department of Surgery, Georgetown University Hospital, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD; Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC
| | - Waddah B Al-Refaie
- Department of Surgery, Georgetown University Hospital, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Georgetown University Hospital, Washington, DC; Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD; Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC.
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21
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Fiala MA, Finney JD, Liu J, Stockerl-Goldstein KE, Tomasson MH, Vij R, Wildes TM. Socioeconomic status is independently associated with overall survival in patients with multiple myeloma. Leuk Lymphoma 2015; 56:2643-9. [PMID: 25651424 DOI: 10.3109/10428194.2015.1011156] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Population-based studies suggest that black patients with multiple myeloma (MM) have a higher mortality rate than white patients. However, other studies suggest that this disparity is related to socioeconomic status (SES) rather than race. To provide clarity on this topic, we reviewed 562 patients diagnosed with MM at our institution. Patients with high SES had a median overall survival (OS) of 62.8 months (95% confidence interval [CI] 43.1-82.6 months), compared to 53.7 months (45.2-62.3 months) and 48.6 months (40.4-56.8 months) for middle and low SES, respectively (p = 0.015). After controlling for race, age, year of diagnosis, severity of comorbidities, stem cell transplant utilization and insurance provider, patients with low SES had a 54% increase in mortality rate relative to patients with high SES. To support our findings, we performed a similar analysis of 45,505 patients with MM from the Surveillance, Epidemiology and End Results-18 (SEER) database. Low SES is independently associated with poorer OS in MM.
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Affiliation(s)
- Mark A Fiala
- a Division of Oncology , Washington University School of Medicine , St. Louis , MO , USA
| | - Joseph D Finney
- a Division of Oncology , Washington University School of Medicine , St. Louis , MO , USA
| | - Jingxia Liu
- b Division of Biostatistics, Department of Medicine , Washington University School of Medicine , St. Louis , MO , USA
| | | | - Michael H Tomasson
- a Division of Oncology , Washington University School of Medicine , St. Louis , MO , USA
| | - Ravi Vij
- a Division of Oncology , Washington University School of Medicine , St. Louis , MO , USA
| | - Tanya M Wildes
- a Division of Oncology , Washington University School of Medicine , St. Louis , MO , USA
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22
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Polinski JM, Brookhart MA, Ayanian JZ, Katz JN, Kim SC, Lii J, Tonner C, Yelin E, Solomon DH. Relationships between driving distance, rheumatoid arthritis diagnosis, and disease-modifying antirheumatic drug receipt. Arthritis Care Res (Hoboken) 2014; 66:1634-43. [PMID: 24664991 DOI: 10.1002/acr.22333] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 03/18/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Disease-modifying antirheumatic drugs (DMARDs) are recommended for all patients with rheumatoid arthritis (RA). Some estimate that approximately one-half of patients with RA do not receive DMARDs. We hypothesized that patients with RA living farther from rheumatologists would be less likely to receive RA diagnoses and to receive DMARDs. METHODS US-based Medicare patients ages >65 years were study eligible. We calculated driving distance from patients' homes to the nearest rheumatologist. Using multivariable logistic regression, we assessed relationships between driving distance and RA diagnosis and between driving distance and DMARD receipt. In one set of analyses, distance was divided into quartiles: 0-2, 2.1-5, 5.1-15.9, and ≥16 miles. In a second set of analyses, we used predefined categories: 0-15, 15.1-30, 30.1-60, and >60 miles. RESULTS Among 59,426 Medicare beneficiaries, 918 had diagnosed RA. Compared to the first quartile, increased distance was associated with decreased odds of RA diagnosis (odds ratio [OR] 0.96 [95% confidence interval (95% CI) 0.80-1.16] in second quartile, OR 0.88 [95% CI 0.72-1.07] in third quartile, and OR 0.72 [95% CI 0.56-0.93] in fourth quartile; P < 0.01 for trend). Similar results were observed using predefined categories. Among those with RA, increased distance was associated with increased odds of DMARD receipt across quartiles (OR 1.15 [95% CI 1.06-1.25] in second quartile, OR 1.41 [95% CI 1.29-1.54] in third quartile, and OR 1.32 [95% CI 1.18-1.46] in fourth quartile; P = 0.001 for trend). There was no relationship between predefined categories and DMARD receipt (P = 0.45 for trend). CONCLUSION Increased driving distance to rheumatologists was associated with decreased odds of RA diagnosis. Among those with diagnosed RA, the odds of DMARD receipt rose as distance increased from <2 to 16 miles, but not beyond. Urban residents living closer to rheumatologists may have barriers to DMARD use besides geographic access.
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Affiliation(s)
- Jennifer M Polinski
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Abstract
BACKGROUND A body of research has found that patients who travel a significant distance to obtain medical treatment experience better outcomes, a phenomenon termed "distance bias." This study uses risk-adjusted surgical outcomes data to analyze distance bias in a population of patients treated surgically at a tertiary care institution. METHODS We used risk-adjusted surgical outcomes data from the National Surgical Quality Improvement Project at the Mayo Clinic to calculate observed and expected risk of a severe complication. Operations were stratified into quintiles based on the distance traveled by the patient. RESULTS The average age of patients in our cohort was 56.7 years, and 59.2% were female; patients traveled an average of 226 miles for treatment. Patients living closest to the Mayo Clinic (quintile 1) had lower observed and expected risks of a severe complication relative to patients in quintiles 2-5. Patients from quintile 1 had outcomes which were better than predicted [observed:expected risk ratio of 0.82 (range, 0.63-0.99)]. Patients traveling intermediate distances (quintile 2) had outcomes which were worse than predicted [observed:expected risk ratio of 1.18 (range, 1.00-1.42)]. Operations performed on patients from greater distances (quintiles 3-5) had an observed risk of severe complications which was similar to expected. DISCUSSION The phenomenon of distance bias which has previously been documented in medical and oncologic treatment is not demonstrated in this study. An opposite phenomenon may be more pertinent, where patients who are treated locally are less likely to have a severe complication and have outcomes which are better than predicted.
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Kristinsson SY, Derolf AR, Edgren G, Dickman PW, Björkholm M. Socioeconomic differences in patient survival are increasing for acute myeloid leukemia and multiple myeloma in sweden. J Clin Oncol 2009; 27:2073-80. [PMID: 19289627 DOI: 10.1200/jco.2008.18.2006] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE An association between socioeconomic status (SES) and survival in acute myeloid leukemia (AML) and multiple myeloma (MM) has not been established in developed countries. We assessed the impact of SES on survival in two large population-based cohorts of AML and MM patients diagnosed in Sweden 1973 to 2005. PATIENTS AND METHODS The relative risk of death (all cause and cause specific) in relation to SES was estimated using Cox's proportional hazards regression. We also conducted analyses stratified by calendar periods (1973 to 1979, 1980 to 1989, 1990 to 1999, and 2000 to 2005). RESULTS We identified a total of 9,165 and 14,744 patients with AML and MM, respectively. Overall, higher white-collar workers had a lower mortality than other SES groups for both AML (P = .005) and MM (P < .005). In AML patients, a consistently higher overall mortality was observed in blue-collar workers compared with higher white-collar workers in the last three periods (hazard ratio [HR], 1.26; 95% CI, 1.05 to 1.51; HR, 1.23; 95% CI, 1.05 to 1.45; HR, 1.28; 95% CI, 1.04 to 1.57, respectively). In MM, no difference was observed in the first two calendar periods. However, in 1990 to 1999, self-employed (HR, 1.18; 95% CI, 1.02 to 1.37), blue-collar workers (HR, 1.18; 95% CI, 1.04 to 1.32), and retired (HR, 1.45; 95% CI, 1.16 to 1.80) had a higher mortality compared to higher white-collar workers. In 2000 to 2005, blue-collar workers had a higher mortality (HR, 1.31; 95% CI, 1.07 to 1.60) compared with higher white-collar workers. CONCLUSION SES was significantly associated with survival in both AML and MM. Most conspicuously, a lower mortality was observed among the highest SES group during more recent calendar periods. Differences in management, comorbidity, and lifestyle, are likely factors to explain these findings.
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Affiliation(s)
- Sigurdur Yngvi Kristinsson
- Division of Hematology, Department of Medicine, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden.
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Abstract
This review of the plasma-cell disorders begins with the definition of monoclonal gammopathy of undetermined significance (MGUS). The prevalence of MGUS in white and black populations is described. MGUS is a common finding in the medical practice of all physicians, and thus it is important to both the patient and the physician to determine whether the monoclonal protein remains stable or progresses to multiple myeloma (MM), Waldenström's macroglobulinemia (WM), primary systemic amyloidosis (AL), or a related disorder. The long-term (almost 40 years) follow-up data of 241 patients in the Mayo Clinic population is provided. In a large study of 1384 patients with MGUS from southeastern Minnesota, the risk of progression to MM, WM, AL, or other disorders was approximately 1% per year. Risk factors for progression are provided. The incidence of MM in Olmsted County, Minnesota, remained stable for the 56-year span 1945-2001. The apparent increase in incidence and mortality rates among patients with MM in many studies is due to improved case ascertainment, especially among the elderly. The incidence and mortality rates of MM in the United States and other countries are presented. The major emphasis is on the cause of MM, which is unclear. Exposure to radiation from atomic bombs, therapeutic and diagnostic radiation, and in workers in the nuclear industry field are addressed. Many studies involving agricultural occupations, exposure to benzene, petroleum products, and engine exhaust and other industrial exposures are discussed. Tobacco use, obesity, diet, and alcohol ingestion are all possible causes of MM. Clusters of MM have been noted. Multiple cases of MM have been found in first-degree relatives.
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Affiliation(s)
- Robert A Kyle
- Laboratory Medicine and Pathology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Stitzenberg KB, Thomas NE, Dalton K, Brier SE, Ollila DW, Berwick M, Mattingly D, Millikan RC. Distance to diagnosing provider as a measure of access for patients with melanoma. ACTA ACUST UNITED AC 2007; 143:991-8. [PMID: 17709657 PMCID: PMC3629703 DOI: 10.1001/archderm.143.8.991] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the effect of travel distance and other sociodemographic factors on access to a diagnosing provider for patients with melanoma. DESIGN Analysis was performed of all incident cases of melanoma in 2000 from 42 North Carolina counties. SETTING Academic research. PARTICIPANTS Patients and providers from 42 North Carolina counties were geocoded to street address. MAIN OUTCOME MEASURES Associations between Breslow thickness and clinical and sociodemographic factors (age, sex, poverty rate, rurality, provider supply, and distance to diagnosing provider) were examined. RESULTS Of 643 eligible cases, 4.4% were excluded because of missing data. The median Breslow thickness was 0.6 mm (range, 0.1-20.0 mm). The median distance to diagnosing provider was 8 miles (range, 0-386 miles). For each 1-mile increase in distance, Breslow thickness increased by 0.6% (P =.003). For each 1% increase in poverty rate, Breslow thickness increased by 1% (P =.04). Breslow thickness was 19% greater for patients aged 51 to 80 years than for those aged 0 to 50 years (P =.02) and was 109% greater for patients older than 80 years than for those aged 0 to 50 years (P < .001). Sex, rurality, and supply of dermatologists were not associated with Breslow thickness. CONCLUSIONS For patients with melanoma, distance to the diagnosing provider is a meaningful measure of access that captures different information than community-level measures of rurality, provider supply, and socioeconomic status. Future work should be targeted at identifying factors that may affect distance to diagnosing provider and serve as barriers to melanoma care.
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Affiliation(s)
- Karyn B Stitzenberg
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, 3010 Old Clinic Bldg, CB 7213, Chapel Hill, NC 27599-7213, USA.
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Rodriguez CP, Baz R, Jawde RA, Rybicki LA, Kalaycio ME, Advani A, Sobecks R, Sekeres MA. Impact of socioeconomic status and distance from treatment center on survival in patients receiving remission induction therapy for newly diagnosed acute myeloid leukemia. Leuk Res 2007; 32:413-20. [PMID: 17727945 DOI: 10.1016/j.leukres.2007.07.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Revised: 07/15/2007] [Accepted: 07/22/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND While socioeconomic status (SES) and the distance patients travel to a treatment center (DTC) impact survival of certain solid tumors, little is known of their influence in acute myeloid leukemia (AML). METHODS We retrospectively reviewed patients receiving remission induction therapy for AML at the Cleveland Clinic between January 1997 and December 2005. Demographic data were obtained from medical records. Income and DTC were determined using online databases. Known prognostic factors (age, WBC count at diagnosis, cytogenetics, AML etiology) were collected and controlled for in Cox proportional hazards analysis. RESULTS Induction chemotherapy was administered to 281 patients; 91% were Caucasian (C), 8% were African American (AA), and 1% were neither (non-AA non-C). The median DTC was 24 miles (range, 0.9-2058), and median annual household income was USD 38,972 (range, USD17,496-143,220). With a median follow up of 22.6 months, the median overall survival (OS) was 11.3 months. In multivariable analyses, age >or=60 years, unfavorable cytogenetics, initial WBC count and secondary AML significantly influenced survival (p<0.001, p<0.001, p=0.035, and p=0.010, respectively). OS was similar for AAs and non-AA non-Cs compared to Cs (HR=1.12, 95% CI=.61-2.07, p=.71, and HR=0.87, CI=0.21-3.62, p=.84, respectively). Neither DTC (HR=1.00, 95%CI=0.98-1.01, p=.96 per 20 mile increment) nor SES (HR=1.02, 95%CI=0.92-1.13, p=.77 per USD10,000 annual income increase) had an impact on OS. CONCLUSION Unlike with many solid tumors, SES and DTC are not predictive of outcome in AML patients.
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Affiliation(s)
- Cristina P Rodriguez
- Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Center, Cleveland Clinic, 9500 Euclid Avenue R35, Cleveland, OH 44195, USA
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Flowers CR, Glover R, Lonial S, Brawley OW. Racial Differences in the Incidence and Outcomes for Patients with Hematological Malignancies. Curr Probl Cancer 2007; 31:182-201. [PMID: 17543947 DOI: 10.1016/j.currproblcancer.2007.01.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christopher R Flowers
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA
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Kristinsson SY, Landgren O, Dickman PW, Derolf AR, Björkholm M. Patterns of survival in multiple myeloma: a population-based study of patients diagnosed in Sweden from 1973 to 2003. J Clin Oncol 2007; 25:1993-9. [PMID: 17420512 DOI: 10.1200/jco.2006.09.0100] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To define patterns of survival among all multiple myeloma (MM) patients diagnosed in Sweden during a 30-year period. PATIENTS AND METHODS A total of 14,381 MM patients (7,643 males; 6,738 females) were diagnosed in Sweden from 1973 to 2003 (median age, 69.9 years; range 19 to 101 years). Patients were categorized into six age categories and four calendar periods (1973 to 1979, 1980 to 1986, 1987 to 1993, and 1994 to 2003). We computed relative survival ratios (RSRs) as measures of patient survival. RESULTS One-year survival improved (P < .001) over time in all age groups and RSRs were 0.73, 0.78, 0.80, and 0.82 for the four calendar periods; however, improvement in 5-year (P < .001) and 10-year (P < .001) RSR was restricted to patients younger than 70 years and younger than 60 years, respectively. For the first time, in analyses restricted to MM patients diagnosed at age younger than 60 years, we found a 29% (P < .001) reduced 10-year mortality in the last calendar period (1994 to 2003) compared with the preceding calendar period (1987 to 1993). Females with MM had a 3% (P = .024) lower excess mortality than males. CONCLUSION One-year MM survival has increased for all age groups during the last decades; 5-year and 10-year MM survival has increased in younger patients (younger than 60 to 70 years). High-dose melphalan with subsequent autologous stem-cell transplantation, thalidomide, and a continuous improvement in supportive care measures are probably the most important factors contributing to this finding. New effective agents with a more favorable toxicity profile are needed to improve survival further, particularly in the elderly.
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Affiliation(s)
- Sigurdur Yngvi Kristinsson
- Division of Hematology, Department of Medicine, Karolinska Karolinska University Hospital and Institutet, Stockholm, Sweden
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Elliott TE, Elliott BA, Regal RR, Renier CM, Haller IV, Crouse BJ, Witrak MT, Jensen PB. Improving rural cancer patients' outcomes: a group-randomized trial. J Rural Health 2005; 20:26-35. [PMID: 14964925 DOI: 10.1111/j.1748-0361.2004.tb00004.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Significant barriers exist in the delivery of state-of-the-art cancer care to rural populations. Rural providers' knowledge and practices, their rural health care delivery systems, and linkages to cancer specialists are not optimal; therefore, rural cancer patient outcomes are less than achievable. PURPOSE To test the effects of a strategy targeting rural providers and their practice environment on patient travel for care, satisfaction, economic barriers, and health-related quality of life. METHODS A group-randomized trial was conducted with 18 rural communities in the north-central United States. Twelve of these communities were included and defined as the unit of analysis for the patient outcomes portion of the study. The intervention targeted rural providers and their practice environment. The subjects were patients with breast, colorectal, lung, and prostate cancers from the rural communities. The main outcomes were patients' travel to obtain health care, satisfaction with care, perceptions of economic barriers to care, and health-related quality of life. In total, 881 patients were included. RESULTS Group randomization was balanced. Travel for health care was significantly reduced in the community group exposed to the intervention during months 13 to 24 following cancer diagnosis. The mean miles traveled per patient were 1,326 (SE = 306) for the experimental group and 2,186 (SE = 347) for the control group (P = 0.03). No significant differences in satisfaction with care, economic barriers to care, or health-related quality of life were found. CONCLUSIONS The intervention significantly reduced cancer patient travel for health care, which suggests that access to care improved in the experimental group. The results of this study do not allow conclusion that there was no effect on other patient outcomes. The results supported the study's conceptual framework and many of its hypotheses.
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Affiliation(s)
- Thomas E Elliott
- Division of Education and Research, SMDC Health System, 5AV2ME, 503 East Third St, Duluth, MN 55805-1983, USA.
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Lamont EB, Hayreh D, Pickett KE, Dignam JJ, List MA, Stenson KM, Haraf DJ, Brockstein BE, Sellergren SA, Vokes EE. Is patient travel distance associated with survival on phase II clinical trials in oncology? J Natl Cancer Inst 2003; 95:1370-5. [PMID: 13130112 DOI: 10.1093/jnci/djg035] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Prior research has suggested that patients who travel out of their neighborhood for elective care from specialized medical centers may have better outcomes than local patients with the same illnesses who are treated at the same centers. We hypothesized that this phenomenon, often called "referral bias" or "distance bias," may also be evident in curative-intent cancer trials at specialized cancer centers. METHODS We evaluated associations between overall survival and progression-free survival and the distance from the patient residence to the treating institution for 110 patients treated on one of four phase II curative-intent chemoradiotherapy protocols for locoregionally advanced squamous cell cancer of the head and neck conducted at the University of Chicago over 7 years. RESULTS Using Cox regression that adjusted for standard patient-level disease and demographic factors and neighborhood-level economic factors, we found a positive association between the distance patients traveled from their residence to the treatment center and survival. Patients who lived more than 15 miles from the treating institution had only one-third the hazard of death of those living closer (hazard ratio [HR] = 0.32, 95% confidence interval [CI] = 0.12 to 0.84). Moreover, with every 10 miles that a patient traveled for care, the hazard of death decreased by 3.2% (HR = 0.97, 95% CI = 0.94 to 0.99). Similar results were obtained for progression-free survival. CONCLUSION Results of phase II curative-intent clinical trials in oncology that are conducted at specialized cancer centers may be confounded by patient travel distance, which captures prognostic significance beyond cancer stage, performance status, and wealth. More work is needed to determine what unmeasured factors travel distance is mediating.
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Affiliation(s)
- Elizabeth B Lamont
- Department of Medicine and Cancer Research Center, The University of Chicago, Chicago, IL, USA.
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Abstract
METHODS. Social class differences in colon cancer survival were studied in 3147 patients with colon cancer diagnosed in Finland from 1979-1982. Of these patients, 2969 were eligible for survival analysis. RESULTS. A clear social class gradient in colon cancer survival was detected. The difference in the age-adjusted relative risk of death due to colon cancer between the highest (I) and lowest (IV) social class was 19%. Stage of disease at diagnosis accounted for a substantial proportion of differences in survival, and treatment accounted for the rest of them. Differences in treatment by social class were most apparent among patients with advanced or unknown stage of disease at diagnosis. Controlling for the place of residence had little effect on the survival differences. Delay in diagnosis did not account for the observed differences in survival by social class.
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Affiliation(s)
- A Auvinen
- Finnish Centre for Radiation and Nuclear Safety, Helsinki
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