Aggressive End-of-Life Care in the Veterans Health Administration versus Fee-for-Service Medicare among Patients with Advanced Lung Cancer

Background: Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice. Methods: We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries. Results: Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare (p < 0.001). Hospice use significantly increased within both cohorts (VHA 28%-41%; SM 60%-73%, p < 0.001). Veterans receiving care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive aggressive care at end of life (adjusted odds ratio: 0.13, 95% confidence interval: 0.08-0.23, p < 0.001). Conclusions: Patients receiving lung cancer care in the VHA had a greater decline in aggressive care at end of life, perhaps due to increasing concurrent care availability.

Research on Maternal Service Area and Referral System in Hubei Province, China

Hospital service area (HSA) and Hospital referral region (HRR) are significant in organizing maternal care resources in hierarchical medical systems. This quantitative study aims to delineate HAS and HRR by using obstetrics medical record data reflecting patients' medical behavior to improve the efficiency of the utilization of medical resources. The Dartmouth method and an improved version that considers the administrative division was applied to delineate HSA and HRR by using the obstetrics medical records in Hubei Province of China in 2016. The result shows that 117 Dartmouth HSAs have a strong correlation with the county boundaries and 22 Dartmouth HRRs are highly coincident with the prefecture boundaries in Hubei. In addition, 25 improved Dartmouth HRRs within prefecture boundaries and core areas serving patients across prefecture boundaries have been identified. Based on the above results, two sets of hierarchical healthcare systems were constructed, respectively, which can provide methods and references for delineating HAS and HRR in the hierarchical medical systems in other regions of China and developing countries. The findings of this study shed light on future research and policymaking in the spatial organization of medical resources for improving the efficiency and equity in maternal care delivery.

Automated Delineation of Hospital Service Areas and Hospital Referral Regions by Modularity Optimization

OBJECTIVE

To develop an automated, data-driven, and scale-flexible method to delineate hospital service areas (HSAs) and hospital referral regions (HRRs) that are up-to-date, representative of all patients, and have the optimal localization of hospital visits.

DATA SOURCES

The 2011 state inpatient database in Florida from the Healthcare Cost and Utilization Project.

STUDY DESIGN

A network optimization method was used to redefine HSAs and HRRs by maximizing patient-to-hospital flows within each HSA/HRR while minimizing flows between them. We first constructed as many HSAs/HRRs as existing Dartmouth units in Florida, and then compared the two by various metrics. Next, we sought to derive the optimal numbers and configurations of HSAs/HRRs that best reflect the modularity of hospitalization patterns in Florida.

PRINCIPAL FINDINGS

The HSAs/HRRs by our method are favored over the Dartmouth units in balance of region size and market structure, shape, and most important, local hospitalization.

CONCLUSIONS

The new method is automated, scale-flexible, and effective in capturing the natural structure of the health care system. It has great potential for applications in delineating other health care service areas or in larger geographic regions.

The Role of Patient Factors, Cancer Characteristics, and Treatment Patterns in the Cost of Care for Medicare Beneficiaries with Breast Cancer

OBJECTIVE

To characterize Medicare expenditures on initial breast cancer care and examine variation in expenditures across hospital referral regions (HRRs).

DATA SOURCE

We identified 29,110 women with localized breast cancer diagnosed in 2005-2008 and matched controls from the Surveillance, Epidemiology, and End Results-Medicare linked database.

STUDY DESIGN

Using hierarchical generalized linear models, we estimated per patient Medicare expenditure on initial breast cancer care across HRRs and assessed the contribution of patient, cancer, and treatment factors to regional variation via incremental models.

PRINCIPAL FINDINGS

Mean Medicare expenditure for initial breast cancer care was $19,255 per patient. The average expenditures varied from $15,053 in the lowest-spending HRR quintile to $23,480 in the highest-spending HRR quintile. Patient sociodemographic, comorbidity, and tumor characteristics explained only 1.8 percent of the difference in expenditures between the lowest- and highest-spending quintiles, while use of specific treatment modalities explained 14.5 percent of the difference. Medicare spending on radiation therapy differed the most across the quintiles, with the use of intensity modulated radiation therapy increasing from 1.7 percent in the lowest-spending quintile to 11.6 percent in the highest-spending quintile.

CONCLUSIONS

Medicare expenditures on initial breast cancer care vary substantially across regions. Treatment factors are major contributors to the variation.

Technology diffusion and diagnostic testing for prostate cancer

PURPOSE

While the dissemination of robotic prostatectomy and intensity modulated radiotherapy may fuel the increased use of prostatectomy and radiotherapy, these new technologies may also have spillover effects related to diagnostic testing for prostate cancer. Therefore, we examined the association of regional technology penetration with the receipt of prostate specific antigen testing and prostate biopsy.

MATERIALS AND METHODS

In this retrospective cohort study we included 117,857 men 66 years old or older from the 5% sample of Medicare beneficiaries living in Surveillance, Epidemiology and End Results (SEER) areas from 2003 to 2007. Regional technology penetration was measured as the number of providers performing robotic prostatectomy or intensity modulated radiotherapy per population in a health care market, ie hospital referral region. We assessed the association of technology penetration with the prostate specific antigen testing rate and prostate biopsy using generalized estimating equations.

RESULTS

High technology penetration was associated with an increased rate of prostate specific antigen testing (442 vs 425/1,000 person-years, p<0.01) and a similar rate of prostate biopsy (10.1 vs 9.9/1,000 person-years, p=0.69). The impact of technology penetration on prostate specific antigen testing and prostate biopsy was much less than the effect of age, race and comorbidity, eg the prostate specific antigen testing rate per 1,000 person-years was 485 vs 373 for men with only 1 vs 3+ comorbid conditions (p<0.01).

CONCLUSIONS

Increased technology penetration is associated with a slightly higher rate of prostate specific antigen testing and no change in the prostate biopsy rate. Collectively, our findings temper concerns that adopting new technology accelerates diagnostic testing for prostate cancer.