Variation in colorectal cancer treatment and outcomes in Scotland: real world evidence from national linked administrative health data

Background

Colorectal cancer (CRC) is the fourth most common type of cancer in the United Kingdom and the second leading cause of cancer death. Despite improvements in CRC survival over time, Scotland lags behind its UK and European counterparts. In this study, we carry out an exploratory analysis which aims to provide contemporary, population level evidence on CRC treatment and survival in Scotland.

Methods

We conducted a retrospective population-based analysis of adults with incident CRC registered on the Scottish Cancer Registry (Scottish Morbidity Record 06 (SMR06)) between January 2006 and December 2018. The CRC cohort was linked to hospital inpatient (SMR01) and National Records of Scotland (NRS) deaths records allowing a description of their demographic, diagnostic and treatment characteristics. Cox proportional hazards regression models were used to explore the demographic and clinical factors associated with all-cause mortality and CRC specific mortality after adjusting for patient and tumour characteristics among people identified as early-stage and treated with surgery.

Results

Overall, 32,691 (73%) and 12,184 (27%) patients had a diagnosis of colon and rectal cancer respectively, of whom 55% and 53% were early-stage and treated with surgery. Five year overall survival (CRC specific survival) within this cohort was 72% (82%) and 76% (84%) for patients with colon and rectal cancer respectively. Cox proportional hazards models revealed significant variation in mortality by sex, area-based deprivation and geographic location.

Conclusions

In a Scottish population of patients with early-stage CRC treated with surgery, there was significant variation in risk of death, even after accounting for clinical factors and patient characteristics.

Variation in hospital cost trajectories at the end of life by age, multimorbidity and cancer type

Background

Approximately thirty thousand people in Scotland are diagnosed with cancer annually, of whom a third live less than one year. The timing, nature and value of hospital-based healthcare for patients with advanced cancer are not well understood. The study's aim was to describe the timing and nature of hospital-based healthcare use and associated costs in the last year of life for patients with a cancer diagnosis.

Methods

We undertook a Scottish population-wide administrative data linkage study of hospital-based healthcare use for individuals with a cancer diagnosis, who died aged 60 and over between 2012 and 2017. Hospital admissions and length of stay (LOS), as well as the number and nature of outpatient and day case appointments were analysed. Generalised linear models were used to adjust costs for age, gender, socioeconomic deprivation status, rural-urban (RU) status and comorbidity.

Results

The study included 85,732 decedents with a cancer diagnosis. For 64,553 (75.3%) of them, cancer was the primary cause of death. Mean age at death was 80.01 (SD 8.15) years. The mean number of inpatient stays in the last year of life was 5.88 (SD 5.68), with a mean LOS of 7 days. Admission rates rose sharply in the last month of life. One year adjusted and unadjusted costs decreased with increasing age. A higher comorbidity burden was associated with higher costs. Major cost differences were present between cancer types.

Conclusions

People in Scotland in their last year of life with cancer are high users of secondary care. Hospitalisation accounts for a high proportion of costs, particularly in the last month of life. Further research is needed to examine triggers for hospitalisations and to identify influenceable reasons for unwarranted variation in hospital use among different cancer cohorts.

Cancer Trial Impact: Understanding Implementation of the Short Course Oncology Treatment (SCOT) Trial Findings in colorectal cancer at a National Level

AIMS

The Short Course Oncology Treatment (SCOT) trial indicated that 3 months of adjuvant doublet chemotherapy was non-inferior to 6 months of treatment for patients with colorectal cancer, with considerably less toxicity. The SCOT trial results were disseminated in June 2017. The aim of this study was to understand if SCOT trial findings were implemented in Scotland.

MATERIALS AND METHODS

A retrospective analysis was carried out on a dataset derived from a source population of 5.4 million people. Eligible patients were those with stage II or III colorectal cancer who received adjuvant chemotherapy. Logistic regression was applied to understand the extent of practice change to a 3-month adjuvant chemotherapy duration after the SCOT trial results were disseminated. Interrupted time series analysis was used to visualise differences in prescribing trends before and after June 2017 for the overall cohort, and by SCOT trial eligibility.

RESULTS

In total, 2310 patients were included in the study; 1957 and 353 treated pre- and post-June 2017, respectively. The median treatment duration decreased from 21 weeks (interquartile range 14-24) prior to June 2017 to 12 weeks (interquartile range 12-21 weeks) after June 2017 (P < 0.001). The proportion of patients receiving over 3 months of adjuvant treatment decreased from 75% to 42% (P < 0.001). This change was most noticeable for patients who met the SCOT trial eligibility criteria, and specifically for those with low-risk stage III disease and those treated with capecitabine and oxaliplatin (CAPOX). Although practice change occurred in all locations, there were differences between regions that could be explained by pre-SCOT trial prescribing trends.

DISCUSSION

A significant change in chemotherapy prescribing occurred after dissemination of the SCOT trial results. National, real-world data can be used to capture the extent of implementation of clinical trial results. In this case, implementation was aligned with clinical trial subgroup findings. This type of analysis could be conducted to evaluate the impact of other clinical trials.

Analytical considerations when using the Scottish and English Cancer Registries for applied research: the case of colorectal cancer

In this paper, we carry out a retrospective analysis of the Scottish and English cancer registries for the case of colorectal cancer. We aim to assess the comparability of variable coding between the datasets and create derived variables and open access code for use by researchers working with linked Scottish and English cancer registry data. We bring together the national data dictionaries for the Scottish and English cancer registries and define a list of targeted variables. We establish the consistency of variable coding across the two registries, identifying fully complete, near complete, partial, composite and impossible matched variables. In the case of near complete, partial and composite matches, we create derived variables between the two registries. We liaise with NHS staff working within the retrospective registry teams to validate the derivations. Finally, we produce corresponding documentation for the dissemination and preservation of final data items. We considered 63 variables for analysis. Preliminary results show that there is a high degree of similarity between the Scottish and English cancer registries. In particular, 82% of variables were fully, nearly or partially matched, with the remaining 12% and 6% composite matches and impossible matches respectively. The session with the respective cancer registry teams will take place in May 2022. At which point we will present our existing results and seek their input into the final derived data items. Following this, we will publish documentation detailing the derived variables and associated code, to be made available to other researchers working with the Scottish and English cancer registries. This study provides a useful starting point for any researchers seeking to use the linked Scottish and English cancer registry data for applied research. Whilst our analysis has focused on colorectal cancer, the majority of variables are applicable for any cancer. Future research should extend this work to include staging variables for other cancers.

The use of social care services by individuals aged 50 and over diagnosed with colorectal cancer in Scotland: a linked data study

The objective of this paper is to explore how a colorectal cancer (CRC) diagnosis influences an individual’s use of social care services in Scotland. In particular, we aim to compare this use to individual’s diagnosed with other cancers and to those without a cancer diagnosis. We use a linked health and social care dataset of the Scottish population aged 50 and over in the financial year 2015/16. Our approach involves several methods to estimate the effect of a CRC diagnosis on social care use. Firstly, we conduct difference in means tests. Secondly, we estimate two-part models of the utilisation of social care for the CRC, other cancer and non-cancer groups. Lastly, we use propensity score matching. Models are estimated for those diagnosed during 2015/16 and for those diagnosed during 2015/16 or with an historical diagnosis. Preliminary results reveal that the likelihood of receipt of social care services is higher for those diagnosed with CRC compared to those without a cancer diagnosis. Further, individuals with a non-CRC cancer diagnosis are more likely to receive social care services compared to those without a cancer diagnosis, but they are less likely to receive social care compared to those with a CRC diagnosis. Further, the likelihood of care receipt for the CRC and other cancer group increases as the number of years since a cancer diagnosis increases. In terms of the number of services received, CRC patients and those with other types of cancer receive fewer services when compared to those without a cancer diagnosis. Our paper has demonstrated that a CRC diagnosis has a significant impact on an individual’s use of social care services. However, conditional on receiving social care, the number of services received is lower for individuals with CRC. Further research is required to understand whether the needs of those individuals are being met.

International Evidence on the COVID-19 Deaths of People Who Live in Long-Term Care Facilities

The COVID-19 pandemic has had a disproportionate impact, in terms of mortality, on people who live in Long-Term Care Facilities (LTCFs). This study involved compiling data on number of deaths of people who live in LTCFs and analyzing the extent to which differences between countries could be attributed to measures taken to control the spread of COVID-19 to LTCFs or to other factors. The study found that differences in how the data is collected make international comparisons difficult but that there is a clear correlation between number of COVID-19 deaths of residents in LTCFs and number of COVID-19 deaths of people living in the community. The study also found that countries that experienced a particularly high number of deaths in LTCFs during the first COVID-19 wave tended to have lower relative mortality in LTCFs in the subsequent waves, which potentially could be attributed to learning from the initial shock.

Health economic studies of colorectal cancer and the contribution of administrative data: A systematic review

INTRODUCTION

Several forces are contributing to an increase in the number of people living with and surviving colorectal cancer (CRC). However, due to the lack of available data, little is known about the implications of these forces. In recent years, the use of administrative records to inform research has been increasing. The aim of this paper is to investigate the potential contribution that administrative data could have on the health economic research of CRC.

METHODS

To achieve this aim, we conducted a systematic review of the health economic CRC literature published in the United Kingdom and Europe within the last decade (2009-2019).

RESULTS

Thirty-seven relevant studies were identified and divided into economic evaluations, cost of illness studies and cost consequence analyses.

CONCLUSIONS

The use of administrative data, including cancer registry, screening and hospital records, within the health economic research of CRC is commonplace. However, we found that this data often come from regional databases, which reduces the generalisability of results. Further, administrative data appear less able to contribute towards understanding the wider and indirect costs associated with the disease. We explore several ways in which various sources of administrative data could enhance future research in this area.

Patterns and costs of hospital-based cancer care in the last year of life: A national data linkage study in Scotland

e18732

Background: Approximately thirty thousand people in Scotland are diagnosed with cancer each year, of whom 10,000 live less than one year. Hospital is the most common place of death for people with cancer, despite most expressing a preference for community-based care. There is inadequate understanding of the nature and value of hospital-based care for people with advanced cancer. This study aimed to describe patterns of hospital-based healthcare use and associated costs for cancer decedents in their last year of life. Methods: A population-wide administrative data linkage study of hospital-based healthcare use for cancer decedents aged 60+ at death who died between 2012 and 2017 was conducted in Scotland. Linkage was established between the Scottish Morbidity Record, Scottish Cancer Registry and the National Records of Scotland. Hospital admissions, length of stay (LoS), number and nature of outpatient and day case appointments were extracted. Associated costs were estimated using generalised linear models, adjusted for age, gender, primary cause of death, socioeconomic deprivation status, rural-urban (RU) status and comorbidity. Results: The study population included 85,732 decedents with a cancer diagnosis, for whom 64,553 (75.3%) cancer was the underlying cause of death. Mean age at death was 84 years. The mean number of inpatient stays in the last year of life was 5.88 (SD 5.68), with a mean LoS of 7 days. Mean total 1-year inpatient, outpatient and day-case costs per patient were £10,261, £1,275 and £977 respectively. People who died of haematological cancers had the most hospital admissions (mean 11.8). Admission rates rose sharply in the last month of life and were most common in those who died of haematological and lung cancers. One year adjusted and unadjusted costs decreased with increasing age. Unadjusted costs for the youngest group (60-64) were £15,895, double the cost for those aged 90+. People dying of haematological cancers had the highest hospital-based costs (mean £24,772) followed by those with ovarian cancer (mean £17,556). The largest single contributor to hospital-based costs in the last year of life was unscheduled admissions. Conclusions: People in Scotland in their last year of life with cancer use substantial hospital-based care. Unscheduled admission rates are high, particularly in the last month of life when the value of acute intervention may be uncertain. Further research is needed to examine triggers for hospitalisation and to assess the value of hospital-based care to people living with advanced cancer.

Creation of the first national linked colorectal cancer dataset in Scotland: prospects for future research and a reflection on lessons learned

INTRODUCTION

Current understanding of cancer patients, their treatment pathways and outcomes relies mainly on information from clinical trials and prospective research studies representing a selected sub-set of the patient population. Whole-population analysis is necessary if we are to assess the true impact of new interventions or policy in a real-world setting. Accurate measurement of geographic variation in healthcare use and outcomes also relies on population-level data. Routine access to such data offers efficiency in research resource allocation and a basis for policy that addresses inequalities in care provision.

OBJECTIVE

Acknowledging these benefits, the objective of this project was to create a population level dataset in Scotland of patients with a diagnosis of colorectal cancer (CRC).

METHODS

This paper describes the process of creating a novel, national dataset in Scotland.

RESULTS

In total, thirty two separate healthcare administrative datasets have been linked to provide a comprehensive resource to investigate the management pathways and outcomes for patients with CRC in Scotland, as well as the costs of providing CRC treatment. This is the first time that chemotherapy prescribing and national audit datasets have been linked with the Scottish Cancer Registry on a national scale.

CONCLUSIONS

We describe how the acquired dataset can be used as a research resource and reflect on the data access challenges relating to its creation. Lessons learned from this process and the policy implications for future studies using administrative cancer data are highlighted.

Healthcare use and costs in the last year of life: a national population data linkage study

BACKGROUND

People who are nearing the end of life are high users of healthcare. The cost to providers is high and the value of care is uncertain.

OBJECTIVES

To describe the pattern, trajectory and drivers of secondary care use and cost by people in Scotland in their last year of life.

METHODS

Retrospective whole-population secondary care administrative data linkage study of Scottish decedents of 60 years and over between 2012 and 2017 (N=274 048).

RESULTS

Secondary care use was high in the last year of life with a sharp rise in inpatient admissions in the last 3 months. The mean cost was £10 000. Cause of death was associated with differing patterns of healthcare use: dying of cancer was preceded by the greatest number of hospital admissions and dementia the least. Greater age was associated with lower admission rates and cost. There was higher resource use in the urban areas. No difference was observed by deprivation.

CONCLUSIONS

Hospitalisation near the end of life was least frequent for older people and those living rurally, although length of stay for both groups, when they were admitted, was longer. Research is required to understand if variation in hospitalisation is due to variation in the quantity or quality of end-of-life care available, varying community support, patient preferences or an inevitable consequence of disease-specific needs.

Utilisation of Personal Care Services in Scotland: the Influence of Unpaid Carers

Scotland is unique in its collection of routine data for all individuals in receipt of social care services. This care encompasses home and personal care services, down to telecare and meals services. As the Scottish population continues to age and local authorities stretch shrinking budgets over an increasing number of people, there is a pressing need to understand how older people use these services to ensure they are delivered in an efficient and effective way. The availability of administrative data in Scotland provides an opportunity to explore how it might be used in a research setting to enhance this understanding. One area of interest concerns the relationship between unpaid care and formal care services. In particular, how unpaid carers might influence older peoples use of formal care services. Whether this influence is positive or negative will have important implications for the costs of care provision. The existing evidence on the impact of unpaid care on social care utilisation is extremely mixed. Scotland provides an interesting context in which to study this relationship because unlike many other jurisdictions, personal care in Scotland is provided free to all individuals aged 65+ who are assessed as needing it. This may affect the incentives faced by unpaid carers, leading to different conclusions about the relationship between unpaid and paid care, compared to previous literature. This paper uses Scotland's unique administrative Social Care Survey (SCS) for the years 2014-2016 to investigate how the presence of an unpaid carer influences personal care use by those aged 65+ in Scotland. The results suggest that unpaid care complements personal care services. Complementarity between unpaid and paid care may imply that incentivising unpaid care could increase personal care costs, and at the same time it points to the potential for unmet need of those who do not have an unpaid carer. The paper highlights some of the limitations of the administrative SCS but also demonstrates how it can be used in an effective way to enhance our understanding in an important, policy relevant area.