Publications by authors named "Ann B Nattinger"

92 Publications

Disparities in utilization of outpatient surgical care among children.

Surgery 2021 Jun 21. Epub 2021 Jun 21.

Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. Electronic address:

Background: The purpose of this study was to quantify disparities in the utilization of outpatient pediatric surgical care and to examine the extent to which neighborhood-level socioeconomic disadvantage is associated with access to care among children.

Methods: Clinic "no-shows" were examined among children scheduled from 2017 to 2019 at seven pediatric surgery clinics associated with a tertiary care children's hospital. The association between Area Deprivation Index, a neighborhood-level measure of socioeconomic disadvantage, and other patient factors with clinic no-shows was examined using multivariable logistic regression models. Difficulties in accessing postoperative care in particular were explored in a subgroup analysis of postoperative (within 90 days) clinic visits after appendectomy or inguinal/umbilical hernia repairs.

Results: Among 10,162 patients, 16% had at least 1 no-show for a clinic appointment. Area Deprivation Index (most deprived decile adjusted odds ratio 3.17, 95% confidence interval 2.20-4.58, P < .001), Black race (adjusted odds ratio 3.30, 95% confidence interval 2.70-4.00, P < .001), and public insurance (adjusted odds ratio 2.75, 95% confidence interval 2.38-3.31, P < .001) were associated with having at least 1 no-show. Similar associations were identified among 2,399 children scheduled for postoperative clinic visits after undergoing appendectomy or inguinal/umbilical hernia repair, among whom 20% were a no-show.

Conclusion: Race, insurance type, and neighborhood-level socioeconomic disadvantage are associated with disparities in utilization of outpatient pediatric surgical care. Challenges accessing routine outpatient care among disadvantaged children may be one mechanism through which disparate outcomes result among children requiring surgical care.
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http://dx.doi.org/10.1016/j.surg.2021.05.045DOI Listing
June 2021

Mortgage Lending Bias and Breast Cancer Survival Among Older Women in the United States.

J Clin Oncol 2021 Jun 15:JCO2100112. Epub 2021 Jun 15.

Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI.

Purpose: The objective was to examine the relationship between contemporary redlining (mortgage lending bias on the basis of property location) and survival among older women with breast cancer in the United States.

Methods: A redlining index using Home Mortgage Disclosure Act data (2007-2013) was linked by census tract with a SEER-Medicare cohort of 27,516 women age 66-90 years with an initial diagnosis of stage I-IV breast cancer in 2007-2009 and follow-up through 2015. Cox proportional hazards models were used to examine the relationship between redlining and both all-cause and breast cancer-specific mortality, accounting for covariates.

Results: Overall, 34% of non-Hispanic White, 57% of Hispanic, and 79% of non-Hispanic Black individuals lived in redlined tracts. As the redlining index increased, women experienced poorer survival. This effect was strongest for women with no comorbid conditions, who comprised 54% of the sample. For redlining index values of 1 (low), 2 (moderate), and 3 (high), as compared with 0.5 (least), hazard ratios (HRs) (and 95% CIs) for all-cause mortality were HR = 1.10 (1.06 to 1.14), HR = 1.27 (1.17 to 1.38), and HR = 1.39 (1.25 to 1.55), respectively, among women with no comorbidities. A similar pattern was found for breast cancer-specific mortality.

Conclusion: Contemporary redlining is associated with poorer breast cancer survival. The impact of this bias is emphasized by the pronounced effect even among women with health insurance (Medicare) and no comorbid conditions. The magnitude of this neighborhood level effect demands an increased focus on upstream determinants of health to support comprehensive patient care. The housing sector actively reveals structural racism and economic disinvestment and is an actionable policy target to mitigate adverse upstream health determinants for the benefit of patients with cancer.
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http://dx.doi.org/10.1200/JCO.21.00112DOI Listing
June 2021

An adapted two-step floating catchment area method accounting for urban-rural differences in spatial access to pharmacies.

J Pharm Health Serv Res 2021 Mar 16;12(1):69-77. Epub 2021 Jan 16.

Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.

Objective: To adapt the two-step floating catchment area approach to account for urban-rural differences in pharmacy access in the United States.

Methods: The urban-rural two-step floating catchment area method was described mathematically. To calculate urban-rural-two-step floating catchment area measure, census tracts and pharmacies within the study area (Southeastern Wisconsin) were classified as urban, suburban or rural, and then different catchment area sizes (2, 5 and 15 miles) were applied, based on the Centers for Medicare & Medicaid Services (CMS)' criteria for Medicare Part D service access within urban, suburban and rural areas. The urban-rural-two-step floating catchment area measures were compared to traditional two-step floating catchment area measures computed using three fixed catchment area sizes (2, 5, and 15 miles) by visually examining their spatial distributions. Associations between the four pharmacy accessibility measures and selected socio-demographics are calculated using Spearman's rank-order correlation and further compared.

Key Findings: The urban-rural two-step floating catchment area measure outperforms all the fixed catchment size measures and has the strongest Spearman correlations with the selected census variables. It also reduces the number of census tracts characterized as 'no access' when compared to the original measures. The spatial distribution of urban-rural two-step floating catchment area pharmacy access exhibits a more granular variation across the study area.

Conclusions: The results support our hypothesis that spatial access to pharmacies should account for urbanicity/rurality patterns within a region.
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http://dx.doi.org/10.1093/jphsr/rmaa022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938828PMC
March 2021

Guideline-concordant treatment predicts survival: a National Cancer Database validation study of novel composite locoregional and systemic treatment scores among women with early stage breast cancer.

Breast Cancer 2021 May 4;28(3):698-709. Epub 2021 Jan 4.

Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.

Background: The aim of this large nationwide study was to validate two novel composite treatment scores that address guideline-concordant locoregional and systemic breast cancer care. We examined the relationship between these two scores and their association with survival.

Methods: Women with Stage I-III unilateral breast cancer were identified within the National Cancer Database. For each woman, a locoregional and a systemic treatment score (0, 1, 2) was assigned based on receipt of guideline-concordant care. Multivariable Cox regression models evaluated the association between the scores and survival.

Results: 623,756 women were treated at 1,221 different American College of Surgeons Commission on Cancer (CoC) facilities. Overall, 86% had a locoregional treatment score of 2 (most guideline-concordant), 75% had a systemic treatment score of 2, and 72% had both scores of 2. Median follow-up was 4.5 years. Compared to women with a locoregional treatment score of 2, those with a score of 1 or 0 had a 1.7-fold and 2.0-fold adjusted greater risk of death. Compared to women with a systemic treatment score of 2, those with a score of 1 or 0 had a 1.5-fold and 2.1-fold adjusted greater risk of death. Risk-adjusted 5-year overall survival was 91.6% when both scores were 2 compared to 73.4% when both scores were 0.

Conclusions: In this large national study of CoC facilities, two composite scores capturing guideline-concordant breast cancer care had independent and combined robust effects on survival. These clinically constructed novel scores are promising tools for health services research and quality-of-care studies.
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http://dx.doi.org/10.1007/s12282-020-01206-9DOI Listing
May 2021

Can Regionalization of Care Reduce Socioeconomic Disparities in Breast Cancer Survival?

Med Care 2021 01;59(1):77-81

Department of Medicine.

Background: Breast cancer patients of low socioeconomic status (SES) have worse survival than more affluent women and are also more likely to undergo surgery in low-volume facilities. Since breast cancer patients treated in high-volume facilities have better survival, regionalizing the care of low SES patients toward high-volume facilities might reduce SES disparities in survival.

Objective: We leverage a natural experiment in New York state to examine whether a policy precluding payment for breast cancer surgery for New York Medicaid beneficiaries undergoing surgery in low-volume facilities led to reduced SES disparities in mortality.

Research Design: A multivariable difference-in-differences regression analysis compared mortality of low SES (dual enrollees, Medicare-Medicaid) breast cancer patients to that of wealthier patients exempt from the policy (Medicare only) for time periods before and after the policy implementation.

Subjects: A total of 14,183 Medicare beneficiaries with breast cancer in 2006-2008 or 2014-2015.

Measures: All-cause mortality at 3 years after diagnosis and Medicaid status, determined by Medicare administrative data.

Results: Both low SES and Medicare-only patients had better 3-year survival after the policy implementation. However, the decline in mortality was larger in magnitude among the low SES women than others, resulting in a 53% smaller SES survival disparity after the policy after adjustment for age, race, and comorbid illness.

Conclusion: Regionalization of early breast cancer care away from low-volume centers may improve outcomes and reduce SES disparities in survival.
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http://dx.doi.org/10.1097/MLR.0000000000001456DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737859PMC
January 2021

Racial Disparities in Incidence and Outcomes Among Patients With COVID-19.

JAMA Netw Open 2020 09 1;3(9):e2021892. Epub 2020 Sep 1.

Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee.

Importance: Initial public health data show that Black race may be a risk factor for worse outcomes of coronavirus disease 2019 (COVID-19).

Objective: To characterize the association of race with incidence and outcomes of COVID-19, while controlling for age, sex, socioeconomic status, and comorbidities.

Design, Setting, And Participants: This cross-sectional study included 2595 consecutive adults tested for COVID-19 from March 12 to March 31, 2020, at Froedtert Health and Medical College of Wisconsin (Milwaukee), the largest academic system in Wisconsin, with 879 inpatient beds (of which 128 are intensive care unit beds).

Exposures: Race (Black vs White, Native Hawaiian or Pacific Islander, Native American or Alaska Native, Asian, or unknown).

Main Outcomes And Measures: Main outcomes included COVID-19 positivity, hospitalization, intensive care unit admission, mechanical ventilation, and death. Additional independent variables measured and tested included socioeconomic status, sex, and comorbidities. Reverse transcription polymerase chain reaction assay was used to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Results: A total of 2595 patients were included. The mean (SD) age was 53.8 (17.5) years, 978 (37.7%) were men, and 785 (30.2%) were African American patients. Of the 369 patients (14.2%) who tested positive for COVID-19, 170 (46.1%) were men, 148 (40.1%) were aged 60 years or older, and 218 (59.1%) were African American individuals. Positive tests were associated with Black race (odds ratio [OR], 5.37; 95% CI, 3.94-7.29; P = .001), male sex (OR, 1.55; 95% CI, 1.21-2.00; P = .001), and age 60 years or older (OR, 2.04; 95% CI, 1.53-2.73; P = .001). Zip code of residence explained 79% of the overall variance in COVID-19 positivity in the cohort (ρ = 0.79; 95% CI, 0.58-0.91). Adjusting for zip code of residence, Black race (OR, 1.85; 95% CI, 1.00-3.65; P = .04) and poverty (OR, 3.84; 95% CI, 1.20-12.30; P = .02) were associated with hospitalization. Poverty (OR, 3.58; 95% CI, 1.08-11.80; P = .04) but not Black race (OR, 1.52; 95% CI, 0.75-3.07; P = .24) was associated with intensive care unit admission. Overall, 20 (17.2%) deaths associated with COVID-19 were reported. Shortness of breath at presentation (OR, 10.67; 95% CI, 1.52-25.54; P = .02), higher body mass index (OR per unit of body mass index, 1.19; 95% CI, 1.05-1.35; P = .006), and age 60 years or older (OR, 22.79; 95% CI, 3.38-53.81; P = .001) were associated with an increased likelihood of death.

Conclusions And Relevance: In this cross-sectional study of adults tested for COVID-19 in a large midwestern academic health system, COVID-19 positivity was associated with Black race. Among patients with COVID-19, both race and poverty were associated with higher risk of hospitalization, but only poverty was associated with higher risk of intensive care unit admission. These findings can be helpful in targeting mitigation strategies for racial disparities in the incidence and outcomes of COVID-19.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.21892DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519420PMC
September 2020

Qualitative Assessment of Unmet Information Management Needs of Informal Cancer Caregivers: Four Themes to Inform Oncology Practice.

JCO Clin Cancer Inform 2020 06;4:521-528

Medical College of Wisconsin, Milwaukee, WI.

Purpose: Family and friends often provide informal care for patients with cancer, coordinating care and supporting patients at home. Stress, depression, and burnout are increasingly recognized among these informal caregivers. Although past research has described a range of needs, including the need for information, details about unmet informational needs for caregivers have not been fully described. We sought to assess unmet information management needs for informal caregivers in the digital era.

Methods: This was a qualitative research study with semistructured interviews and focus groups of nonprofessional caregivers for patients with cancer, facilitated using a discussion guide. Eligible caregivers supported patients in the community who were in treatment (chemotherapy or radiotherapy) or completed treatment within 3 years. Participants were recruited using informational flyers at an academic cancer center and in the local community of metropolitan Milwaukee, Wisconsin. Sessions were transcribed verbatim and analyzed inductively to identify themes.

Results: Thirteen caregivers participated, the majority between 41 and 60 years of age: seven of 13, 53.8%, were predominantly women; 10 of 13 (76.9%) were educated, 10 of 13 (76.9%) had graduated from college; and of modest means, six of 13 (46.2%) had household incomes < $35,000. Four themes emerged: (1) the information overload paradox, where caregivers felt overloaded by information yet had unmet informational needs; (2) navigating volatility as a caregiver, with changing or unknown expectations; (3) caregivers as information brokers, which placed new burdens on caregivers to seek, share, and protect information; and (4) care for the caregiver, including unmet information needs related to self-care.

Conclusion: This study identified several informational challenges affecting caregivers. Caregivers have dynamic and evolving informational needs, and strategies that support caregivers through just-in-time information availability or dedicated caregiver check-ins may provide relief within the stress of caregiving.
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http://dx.doi.org/10.1200/CCI.19.00159DOI Listing
June 2020

Association Between Environmental Factors and Toxigenic Clostridioides difficile Carriage at Hospital Admission.

JAMA Netw Open 2020 01 3;3(1):e1919132. Epub 2020 Jan 3.

Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee.

Importance: Clostridioides difficile infection is the most frequent health care-associated infection in the United States. However, exposure to this organism might occur outside the health care setting.

Objective: To examine whether exposure to environmental factors, such as livestock farms, is associated with a higher probability of being colonized with C difficile at hospital admission.

Design, Setting, And Participants: This retrospective cohort study was conducted from May 1, 2017, to June 30, 2018, at a teaching-affiliated hospital in Milwaukee, Wisconsin. All consecutive patients underwent C difficile screening using a nucleic acid amplification test at hospital admission. Data analyses were performed from July 2018 to October 2019.

Exposures: The distances from patient residence to the nearest livestock farms, meat processing plants, raw materials services, and sewage facilities were measured in addition to risk factors previously evaluated in other studies.

Main Outcomes And Measures: The main outcome was a positive result on C difficile screening tests performed within 72 hours of hospital admission.

Results: A total of 3043 patients admitted to the hospital were included in the final analysis. Of those, 1564 (51.4%) were women and 2074 (68.9%) were white, with a mean (SD) age of 62.0 (15.9) years; 978 patients (32.1%) were admitted to hematology-oncology units. At first admission, 318 patients (10.4%) were detected through testing as C difficile carriers. Multivariable logistic regression analyses were performed on a stratified sample of patients based on hematology-oncology admission status. These analyses indicated that although patients admitted to hematology-oncology units were 35% more likely to be colonized with C difficile, no significant association existed between their sociodemographic and economic characteristics or health care and environmental exposures and the likelihood of a positive C difficile test result. In contrast, among patients admitted to non-hematology-oncology units, comorbidities increased the likelihood for colonization by more than 4 times; women had 60% greater colonization than men, and a history of recent hospitalization (ie, within the preceding 6 months) increased the likelihood of colonization by 70%. Residential proximity to livestock farms were all significantly associated with a higher likelihood of a positive C difficile test result. Residential proximity to livestock farms more than doubled the probability of C difficile colonization in patients admitted to non-hematology-oncology units.

Conclusions And Relevance: A shorter distance between residence and livestock farms was associated with C difficile colonization. Knowledge of the epidemiology of C difficile in the community surrounding the hospital is important, as it has potential implications for the incidence of hospital-onset C difficile infection.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.19132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991319PMC
January 2020

Factors associated with chronic opioid use after cervical spine surgery for degenerative conditions.

J Neurosurg Spine 2019 Oct 11:1-8. Epub 2019 Oct 11.

5Minneapolis VA Health Care System, and University of Minnesota Medical School, Minneapolis, Minnesota.

Objective: Opioids are commonly prescribed after surgery for painful spinal conditions, yet little is known about postoperative opioid use. The relationship between chronic opioid use and patient-reported outcomes and satisfaction with surgery is also unclear. The purpose of this study was to evaluate factors associated with opioid use 1 year after elective cervical spine surgery for degenerative conditions causing radiculopathy and myelopathy. The authors hypothesized that patients with preoperative opioid use would be more likely to report postoperative opioid use at 1 year, and that postoperative opioid use would be associated with patient-reported outcomes and dissatisfaction with surgery.

Methods: The authors performed a retrospective study of a prospective cohort of adult patients who underwent elective cervical spine surgery for degenerative changes causing radiculopathy or myelopathy. Patients were prospectively and consecutively enrolled from a single academic center after the decision for surgery had been made. Postoperative in-hospital pain management was conducted using a standardized protocol. The primary outcome was any opioid use 1 year after surgery. Secondary outcomes were the Neck Disability Index (NDI); 36-Item Short-Form Health Survey (SF-36) physical function (PF), bodily pain (BP), and mental component summary (MCS) scores; the modified Japanese Orthopaedic Association (mJOA) score among myelopathy patients; and patient expectations surveys. Patients with and without preoperative opioid use were compared using the chi-square and Student t-tests, and multiple logistic regression was used to study the associations between patient and surgical characteristics and postoperative opioid use 1 year after surgery.

Results: Two hundred eleven patients were prospectively and consecutively enrolled, of whom 39 were lost to follow-up for the primary outcome; 43.6% reported preoperative opioid use. Preoperative NDI and SF-36 PF and BP scores were significantly worse in the preoperative opioid cohort. More than 94% of both cohorts rated expectations of pain relief as extremely or somewhat important. At 1 year after surgery, 50.7% of the preoperative-opioid-use cohort reported ongoing opioid use, and 17.5% of patients in the no-preoperative-opioid-use cohort reported ongoing opioid use. Despite this, both cohorts reported similar improvements in NDI as well as SF-36 PF, BP, and MCS scores. More than 70% of both cohorts also reported being extremely or somewhat satisfied with pain relief after surgery. Predictors of 1-year opioid use included preoperative opioid use, duration of symptoms for more than 9 months before surgery, tobacco use, and higher comorbidity index.

Conclusions: One year after elective cervical spine surgery, patients with preoperative opioid use were significantly more likely to report ongoing opioid use. However, patients in both groups reported similar improvements in patient-reported outcomes and satisfaction with pain relief. Interventions targeted at decreasing opioid use may need to focus on patient factors such as preoperative opioid use or duration of symptoms before surgery.
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http://dx.doi.org/10.3171/2019.7.SPINE19563DOI Listing
October 2019

Prevalence and scope of advanced practice provider oncology care among Medicare beneficiaries with breast cancer.

Breast Cancer Res Treat 2020 Jan 21;179(1):57-65. Epub 2019 Sep 21.

Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.

Purpose: Advanced practice providers (APPs) have increasingly become members of the oncology care team. Little is known about the scope of care that APPs are performing nationally. We determined the prevalence and extent of APP practice and examined associations between APP care and scope of practice regulations, phase of cancer care, and patient characteristics.

Methods: We performed an observational study among women identified from Medicare claims as having had incident breast cancer in 2008 with claims through 2012. Outpatient APP care included at least one APP independently billing for cancer visits/services. APP scope of practice was classified as independent, reduced, or restricted. A logistic regression model with patient-level random effects was estimated to determine the probability of receiving APP care at any point during active treatment or surveillance.

Results: Among 42,550 women, 6583 (15%) received APP care, of whom 83% had APP care during the surveillance phase and 41% during the treatment phase. Among women who received APP care during a given year of surveillance, the overall proportion of APP-billed clinic visits increased with each additional year of surveillance (36% in Year 1 to 61% in Year 4). Logistic regression model results indicate that women were more likely to receive APP care if they were younger, black, healthier, had higher income status, or lived in a rural county or state with independent APP scope of practice.

Conclusions: This study provides important clinical and policy-relevant findings regarding national practice patterns of APP oncology care. Among Medicare beneficiaries with incident breast cancer, 15% received outpatient oncology care that included APPs who were billing; most of this care was during the surveillance phase. Future studies are needed to define the degree of APP oncology practice and training that maximizes patient access and satisfaction while optimizing the efficiency and quality of cancer care.
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http://dx.doi.org/10.1007/s10549-019-05447-xDOI Listing
January 2020

The association of pharmacy fill synchronization with breast cancer endocrine therapy adherence.

Cancer 2019 11 2;125(22):3960-3965. Epub 2019 Aug 2.

Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: One-third to one-half of patients prescribed adjuvant endocrine therapy are nonadherent during the recommended 5-year endocrine therapy course. This study investigated whether poor pharmacy synchronization of medication fills (requiring refills on different days) acts as a barrier to adherence.

Methods: A cohort of older women with stage 0 to III endocrine receptor-positive breast cancer in 2011 was identified from the Surveillance, Epidemiology, and End Result-Medicare claims-linked cancer registry. Women with endocrine therapy and at least 1 other medication fill were identified, and the 3-month synchronization of their fills was calculated as 1 minus the quotient of the number of pharmacy visits and the number of filled medications. Regression models were used to examine the association between synchronization (in quartiles adjusted for the number of medications) and adherence to endocrine therapy (defined as a medication possession ratio ≥80%) over the subsequent year.

Results: During the 3 months after the first endocrine therapy prescription, the study cohort of 3212 women had a mean of 8.6 pharmacy visits (standard deviation, 4.7) with a mean synchronization of 0.3 (standard deviation, 0.2). Those in the third (odds ratio, 1.29; 95% confidence interval, 1.04-1.59) and fourth (most) medication number-adjusted synchronization quartiles (odds ratio, 1.49; 95% confidence interval, 1.19-1.86) were more likely to be adherent than those in the least. Multivariate model predictions showed that the proportion of patients who were adherent over 1 year varied from 68.9% in the least synchronized quartile to 76.6% in the most synchronized one.

Conclusions: Prescription refill synchronization is strongly associated with adherence to endocrine therapy. Efforts to improve adherence should address this.
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http://dx.doi.org/10.1002/cncr.32433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946341PMC
November 2019

Housing discrimination and racial cancer disparities among the 100 largest US metropolitan areas.

Cancer 2019 11 9;125(21):3818-3827. Epub 2019 Jul 9.

Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: Cancer contributes substantially to the life expectancy gap between US blacks and whites, and racial cancer disparities remain stubborn to eradicate. Disparities vary geographically, suggesting that they are not inevitable.

Methods: The authors examined the relationship between housing discrimination and the size of cancer disparities across large US metropolitan statistical areas (MSAs). MSA-level cancer disparities were measured using data from the US Centers for Disease Control and Prevention. Mortgage discrimination for each MSA was estimated using the Home Mortgage Disclosure Act database, and MSA racial segregation was determined using US Census data. Patterns of housing discrimination and cancer disparities were mapped, and the associations between these place-based factors and cancer disparities across MSAs were measured.

Results: Black-to-white cancer mortality disparities (rate ratios) varied geographically, ranging from 1.50 to 0.86; 88% of mortality ratios were >1, indicating higher mortality for blacks. In areas with greater mortgage discrimination, the gap between black and white cancer mortality rates was larger (correlation coefficient [r] = 0.32; P = .001). This relationship persisted in sex-specific analyses (males, r = 0.37; P < .001; females, r = 0.23; P = .02) and in models controlling for confounders. In contrast, segregation was inconsistently associated with disparities. Adjusting for incidence disparities attenuated, but did not eliminate, the correlation between mortgage discrimination and mortality disparities (r = 0.22-0.24), suggesting that cancer incidence and survival each account for part of the mortality disparity.

Conclusions: Mortgage discrimination is associated with larger black-to-white cancer mortality disparities. Some areas are exceptions to this trend. Examination of these exceptions and of policies related to housing discrimination may offer novel strategies for explaining and eliminating cancer disparities.
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http://dx.doi.org/10.1002/cncr.32358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788939PMC
November 2019

Variation Among Primary Care Physicians in 30-Day Readmissions.

Ann Intern Med 2019 06 21;170(11):749-755. Epub 2019 May 21.

Collaborative for Healthcare Delivery Science, Medical College of Wisconsin, Milwaukee, Wisconsin (S.S., A.B.N.).

Background: Whether readmission rates vary by primary care physician (PCP) is unknown, although federal policy holds PCPs accountable for reducing readmissions.

Objective: To determine whether 30-day readmission rates vary by PCP.

Design: Retrospective cohort study using marginal models and multilevel logistic regression with 100% of data on Texas Medicare claims from 2008 to 2015.

Setting: Texas.

Participants: Patients discharged alive between 1 January 2008 and 30 November 2015 who had a PCP in the prior year and whose PCP had at least 50 admissions in the study period.

Measurements: Readmission within 30 days of discharge. Follow-up visits with a PCP within 7 days of discharge were also measured.

Results: Between 2012 and 2015, the mean risk-standardized rate of 30-day readmissions was 12.9%. Of 4230 PCPs, 1 had a readmission rate that was significantly higher than the mean and none had a significantly lower rate. The 10th and 90th percentiles of PCP readmission rates were 12.4% and 13.4%, respectively, each only 0.5 percentage point different from the mean. The 99th percentile of PCP readmission rates was 14.0%, 1.1 percentage points higher than the mean. Detecting a 1.1-percentage point difference from the mean adjusted readmission rate would require more than 3500 admissions per PCP per year.

Limitations: Only fee-for-service Medicare patients in a single state were included. The authors could not account for confounders not included in Medicare databases or classify readmissions as avoidable.

Conclusion: Variation in readmission rates among PCPs is very low. Programs holding PCPs accountable for readmissions may prove ineffective.

Primary Funding Source: National Institutes of Health.
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http://dx.doi.org/10.7326/M18-2526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743324PMC
June 2019

Temporal trends and regional variation in the utilization of low-value breast cancer care: has the Choosing Wisely campaign made a difference?

Breast Cancer Res Treat 2019 Jul 10;176(1):205-215. Epub 2019 Apr 10.

Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.

Purpose: Since 2012, about 80 specialty societies have released Choosing Wisely (CW) recommendations aimed at reducing the use of low-value, unproven, or ineffective medical services. The extent to which these recommendations have influenced the behavior of physicians and patients remains largely unknown.

Methods: Using MarketScan Commercial Claims and Medicare Supplemental and Coordination of Benefits databases, we identified annual cohorts of women with incident, early-stage breast cancer and estimated the prevalence of four initial treatment and six surveillance metrics deemed as low-value breast cancer care by CW. Multivariable logistic regressions were subsequently used to estimate temporal trends and regional variation in the use of these metrics, with a special focus on the year of CW's publication.

Results: There were 122,341 women identified as undergoing treatment for incident breast cancer between 2010 and 2014. Two of the four low-value initial treatment metrics and four of the six low-value surveillance metrics declined significantly over time. The temporal trend of declining use, however, preceded the release of CW's guidelines. Declines ranged from 11.0% for follow-up mammography to 40.6% for receipt of surgical biopsy without an attempted needle biopsy. There were marked regional differences in use of low-value breast cancer care for all metrics, much of which persisted after publication of CW.

Conclusions: With two notable exceptions, use of low-value breast cancer care has declined steadily since 2010. The declines, however, were not accelerated by the publication of CW recommendations.
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http://dx.doi.org/10.1007/s10549-019-05213-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6687306PMC
July 2019

Oncologists' Views Regarding the Role of Electronic Health Records in Care Coordination.

JCO Clin Cancer Inform 2018 12;2:1-12

Onur Asan, Ann B. Nattinger, Jeanne T. Tyszka, and Tina W. F. Yen, Medical College of Wisconsin, Milwaukee, WI; and Ayse P. Gurses, Johns Hopkins University, Baltimore, MD.

Background: Electronic health records (EHRs) play a significant role in complex health care processes, especially in information transfer with patients and care coordination among providers. EHRs may also generate unintended consequences, introducing new patient safety risks. To date, little investigation has been performed in oncology settings, despite the need for quality provider-patient communication and information transfer during oncology visits. In this qualitative study, we focused on oncology providers' perceptions of EHRs for supporting communication with patients and coordination of care with other providers.

Methods: We conducted semistructured interviews with oncologists from an urban academic medical center to learn their perceptions of the use of EHRs before, during, and after clinic visits with patients. Our interview guide was developed on the basis of the work system model. We coded transcripts using inductive content analysis.

Results: Data analysis yielded four main themes regarding oncologists' practices in using the EHR and perceptions about EHRs: (1) EHR use for care coordination (eg, timeliness of receiving information, SmartSet documentation); (2) EHR use in the clinic visit (eg, educating patients, using as a reinforcement tool); (3) safety hazards in care coordination associated with EHRs (eg, incomplete documentation, error propagating, no filtering mechanism to capture errors); and (4) suggestions for improvements (eg, improved SmartSet functionalities, simplification of user interface).

Conclusion: Current EHRs do not adequately support teamwork of oncology providers, which could lead to potential hazards in the care of patients with cancer. Redesigning EHR features that are tailored to support oncology care and addressing the concerns regarding information overload, improved organization of flagging abnormal results, and documentation-related workload are needed to minimize potential safety hazards.
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http://dx.doi.org/10.1200/CCI.17.00118DOI Listing
December 2018

Work Schedules of Hospitalists and Continuity of Care During Hospital Stays of Texas Medicare Patients: an Observational Study.

J Gen Intern Med 2019 04;34(4):489-491

Department of Medicine and the Center for Medical Outcomes, Medical College of Wisconsin, Milwaukee, USA.

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http://dx.doi.org/10.1007/s11606-018-4777-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6446002PMC
April 2019

Are aromatase inhibitors associated with higher myocardial infarction risk in breast cancer patients? A Medicare population-based study.

Clin Cardiol 2019 Jan 7;42(1):93-100. Epub 2018 Dec 7.

Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: Theoretically, the estrogen deprivation induced by aromatase inhibitors (AIs) might cause ischemic heart disease, but empiric studies have shown mixed results. We aimed to compare AIs and tamoxifen with regard to cardiovascular events among older breast cancer patients outside of clinical trials. We hypothesized that AIs increase the risk of myocardial infarction.

Methods: We identified women age ≥67 years diagnosed with breast cancer from June 30, 2006 to June 1, 2008 in the surveillance, epidemiology, and end results (SEER)-Medicare database, treated with either tamoxifen or an AI, and followed through December 31, 2012. To compare myocardial infarction (MI) risk for the treatment groups of AIs vs tamoxifen, we developed and assigned stabilized probability of treatment weights and used the Fine and Gray model for time to MI with death not related to MI as a competing risk.

Results: Of the cohort of 5648 women, 4690 were treated with AIs and 958 with tamoxifen; a total of 251 patients developed MI, and 22 patients died of MI during the study period while 476 died of other causes. The hazard for MI was not significantly different between AI vs tamoxifen groups (HR = 1.01, 95% CI 0.72-1.42), after adjusting for the following known MI risk factors at the start of adjuvant therapy: diabetes, ischemic heart disease, congestive heart failure, MI, and peripheral vascular disease.

Conclusions: In this SEER-Medicare-based population study, there were no significant differences in the risk of MI between AI and tamoxifen users after adjustment for known risk factors.
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http://dx.doi.org/10.1002/clc.23114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6344290PMC
January 2019

Investigating the Association Between Advanced Practice Providers and Chemotherapy-Related Adverse Events in Women With Breast Cancer: A Nested Case-Control Study.

J Oncol Pract 2018 Oct 10:JOP1800277. Epub 2018 Oct 10.

Medical College of Wisconsin, Milwaukee, WI.

Purpose:: The effect of advanced practice provider (APP) involvement in oncology care on cancer-specific outcomes is unknown. We examined the association between team-based APP-physician care during chemotherapy and chemotherapy-related adverse events (AEs) among women with breast cancer.

Methods:: We performed separate nested case-control analyses in two national cohorts of women who received chemotherapy for incident breast cancer. Cohorts were identified from Medicare (≥ 65 years of age) and MarketScan (18 to 64 years of age) data. Cases experienced a chemotherapy-related AE (emergency room visit and/or hospitalization). Controls were matched 1:1 on the basis of each patient's age, comorbidities, census region, state's APP scope of practice regulations, and observation period from chemotherapy initiation to first AE. APP exposure (any outpatient claim billed by an APP during the observation period) was assessed for each matched pair member.

Results:: Among the 1,948 cases in the Medicare cohort, 225 (12%) had APP exposure before the first chemotherapy-related AE, compared with 213 controls (11%; P = .54). Among the 725 cases in the MarketScan cohort, 52 (7%) had APP exposure compared with 65 controls (9%; P = .21). In the matched case-control analysis, there was no association between outpatient APP exposure during chemotherapy and AEs in either cohort (Medicare: OR, 1.06 [95% CI, 0.87 to 1.30]; MarketScan: OR, 0.76 [95% CI, 0.50 to 1.14]).

Conclusion:: Our results suggest that team-based APP-physician care that includes an APP who is billing independently, at least for certain patients receiving chemotherapy, may be a viable strategy to safely leverage the scarce oncology workforce to increase access and delivery of cancer care.
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http://dx.doi.org/10.1200/JOP.18.00277DOI Listing
October 2018

The relationship between patient and tumor characteristics, patterns of breast cancer care, and 5-year survival among elderly women with incident breast cancer.

Breast Cancer Res Treat 2018 Sep 5;171(2):477-488. Epub 2018 Jun 5.

Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA.

Purpose: To examine the relationship between patient and tumor characteristics, patterns of breast cancer care, and 5-year survival among a population-based cohort of elderly women with incident breast cancer, with a special focus on identifying sources of socioeconomic (SES) disparities in outcomes.

Methods: We identified women with newly diagnosed breast cancer in 2006-2009 from the Surveillance and Epidemiology End Result study linked with Medicare claims. A Classification and Regression Tree (CART) model was applied to 13 individual indicators of neoadjuvant and adjuvant breast cancer treatment, tumor characteristics, and patient sociodemographic variables to identify patterns with the greatest discriminant value in predicting 5-year survival. We subsequently examined the extent to which these patterns varied by the patient's SES.

Results: Survival probabilities associated with the 18 unique CART-identified patterns ranged from 22 to 87%. The number of positive axillary nodes was the best single discriminator between high and lower survival outcomes. The most common discriminant factor among patterns with poor (< 25%) survival was the absence of radiation treatment, followed by the presence of comorbidities, tumor size > 2 cm, and no breast surgery. Relative to high SES women, poor women were nearly four times (12.3% vs. 3.2%, p < 0.001) as likely to be classified in the pattern associated with worse survival, and less likely (31.7% vs. 52.9%, p = 0.04) to receive the pattern associated with the greatest survival.

Conclusions: Greater adoption of effective patterns of care could improve survival of elderly women with incident breast cancer overall, and reduce SES disparities therein.
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http://dx.doi.org/10.1007/s10549-018-4837-4DOI Listing
September 2018

Association of Hospitalist Years of Experience With Mortality in the Hospitalized Medicare Population.

JAMA Intern Med 2018 02;178(2):196-203

Department of Medicine, Medical College of Wisconsin, Milwaukee.

Importance: Substantial numbers of hospitalists are fresh graduates of residency training programs. Current data about the effect of hospitalist years of experience on patient outcomes are lacking.

Objective: To describe the association of hospitalist years of experience with 30-day mortality and hospital mortality of their patients.

Design, Setting, And Participants: We used a 5% sample of national Medicare data of patient and hospital characteristics to build a multilevel logistic regression model to predict mortality as a function of years of experience of the hospitalists. We created 2 cohorts. The first was a cross-sectional cohort of 21 612 hospitalists working between July 1, 2013, and June 30, 2014, with a 5-year look-back period to assess their years of prior experience as a hospitalist, and the second was a longitudinal cohort of 3860 hospitalists in their first year of practice between July 1, 2008, and June 30, 2011, who continued practicing hospital medicine for at least 4 years.

Main Outcomes And Measures: Thirty-day postadmission mortality adjusted for patient and hospital characteristics in a 3-level logistic regression model. Hospital mortality was a secondary outcome.

Results: Among 21 612 hospitalists caring for Medicare inpatients from July 1, 2013, to June 30, 2014, 5445 (25%) had 1 year of experience or less, while 11 596 (54%) had 4 years of experience or more. We then identified 3860 physicians in their first year as hospitalists who continued to practice as hospitalists for 4 years. There was a significant association between hospitalist experience and mortality. Observed 30-day mortality was 10.50% for patients of first-year hospitalists vs 9.97% for patients of hospitalists in their second year. The mortality odds for patients of second-year hospitalists were 0.90 (95% CI, 0.84-0.96) compared with patients of first-year hospitalists. Observed hospital mortality was 3.33% for patients cared for by first-year hospitalists vs 2.96% for second-year hospitalists. (odds ratio, 0.84; 95% CI, 0.75-0.95). For both 30-day and hospital mortality, there was little change in odds of mortality between the second year and subsequent years of experience.

Conclusions And Relevance: Patients cared for by hospitalists in their first year of practice experience higher mortality. Early-career hospitalists may require additional support to ensure optimal outcomes for their patients.
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http://dx.doi.org/10.1001/jamainternmed.2017.7049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801052PMC
February 2018

Geographic Variation of Adjuvant Breast Cancer Therapy Initiation in the United States: Lessons From Medicare Part D.

J Natl Compr Canc Netw 2017 12;15(12):1509-1517

From the Department of Medicine and Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin.

Drug utilization under Medicare Part D varies significantly by geographic region. This study examined the extent to which geographic variation in Part D plan characteristics contributes to the variation in choice of initial endocrine therapy agent among women with incident breast cancer. Two-stage multivariate regression analyses were applied to the 16,541 women identified from Medicare claims as having incident breast cancer in 2006-2007. The first stage determined the effect of state of residence on the probability of having an aromatase inhibitor (AI), as opposed to tamoxifen, as initial endocrine therapy. The second stage provided estimates of the impact of state-specific Part D plan characteristics on variation in choice of initial therapy. There was substantial residual geographic variation in the likelihood of using an AI as initial endocrine therapy, despite controlling for socioeconomic status, breast cancer treatment, and other factors. Regression-adjusted probabilities of starting an AI ranged from 57.3% in Wyoming to 92.6% in the District of Columbia. Results from the second stage revealed that variation in characteristics of Part D plans across states explained approximately one-third (30%) of the state-level variability in endocrine therapy. A higher number of plans with cost-sharing above the mean, greater spread in deductibles, and a greater spread in monthly drug premiums were associated with lower adjusted state probabilities of initiating an AI. In contrast, a higher number of drug plans with monthly premiums above the state mean and higher mean cost-sharing (in dollars) were both positively associated with likelihood of starting on an AI. Study findings suggest that variation in benefit design of Part D plans accounts for an important share of the large and persisting variability in use of AIs-the preferred oral therapy for breast cancer.
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http://dx.doi.org/10.6004/jnccn.2017.7021DOI Listing
December 2017

Prevalence and Consequences of Axillary Lymph Node Dissection in the Era of Sentinel Lymph Node Biopsy for Breast Cancer.

Med Care 2018 01;56(1):78-84

Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI.

Background: Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity.

Objective: Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND.

Research Design/subjects: Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009.

Measures: Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated.

Results: Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases.

Conclusions: In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.
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http://dx.doi.org/10.1097/MLR.0000000000000832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725235PMC
January 2018

Socioeconomic status and breast cancer treatment.

Breast Cancer Res Treat 2018 01 7;167(1):1-8. Epub 2017 Sep 7.

Department of Medicine and Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Suite H3100, Milwaukee, WI, 53226, USA.

Purpose: Evidence suggests substantial disparities in breast cancer survival by socioeconomic status (SES). We examine the extent to which receipt of newer, less invasive, or more effective treatments-a plausible source of disparities in survival-varies by SES among elderly women with early-stage breast cancer.

Methods: Multivariate regression analyses applied to 11,368 women (age 66-90 years) identified from SEER-Medicare as having invasive breast cancer diagnosed in 2006-2009. Socioeconomic status was defined based on Medicaid enrollment and level of poverty of the census tract of residence. All analyses controlled for demographic, clinical health status, spatial, and healthcare system characteristics.

Results: Poor and near-poor women were less likely than high SES women to receive sentinel lymph node biopsy and radiation after breast-conserving surgery (BCS). Poor women were also less likely than near-poor or high SES women to receive any axillary surgery and adjuvant chemotherapy. There were no significant differences in use of aromatase inhibitors (AI) between poor and high SES women. However, near-poor women who initiated hormonal therapy were more likely to rely exclusively on tamoxifen, and less likely to use the more expensive but more effective AI when compared to both poor and high SES women.

Conclusions: Our results indicate that SES disparities in the receipt of treatments for incident breast cancer are both pervasive and substantial. These disparities remained despite women's geographic area of residence and extent of disease, suggesting important gaps in access to effective breast cancer care.
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http://dx.doi.org/10.1007/s10549-017-4490-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5790605PMC
January 2018

Socioeconomic Disparities in Mortality Among Women With Incident Breast Cancer Before and After Implementation of Medicare Part D.

Med Care 2017 05;55(5):463-469

*Department of Medicine, Medical College of Wisconsin †Center for Patient Care and Outcomes Research, Medical College of Wisconsin ‡Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI.

Background: Breast cancer patients exhibit survival disparities based on socioeconomic status (SES). Disparities may be attributable to access to expensive oral endocrine agents.

Objectives: Define recent socioeconomic disparities in breast cancer survival and determine whether these improved after implementation of the Medicare Part D program.

Design: Difference-in-difference natural experiment of women diagnosed and treated before or after implementation of Medicare Part D.

Subjects: Female Medicare beneficiaries with early-stage breast cancer: 54,772 diagnosed in 2001 and 46,371 in 2007.

Measures: SES was based on Medicaid enrollment and zip code per capita income, all-cause mortality from Medicare, and cause of death from National Death Index.

Results: Among women diagnosed pre-Part D, 40.5% of poor beneficiaries had died within 5 years compared with 20.3% of high-income women (P<0.0001). Post-Part D, 33.6% of poor women and 18.4% of high-income women died by 5 years. After adjustment for potential confounders, improvement in all-cause mortality post-Part D was greater for poorer women compared with more affluent women (P=0.002). However, absolute improvement in breast cancer-specific mortality was 1.8%, 1.2%, and 0.8% (P=0.88 for difference in improvement by SES), respectively for poor, near-poor, and high-income women, whereas analogous improvement in mortality from other causes was 5.1%, 3.8%, and 0.9% (P=0.067 for difference in improvement by SES).

Conclusions: Large survival disparities by SES exist among breast cancer patients. The Part D program successfully ameliorated SES disparities in all-cause mortality. However, improvement was concentrated in causes of death other than breast cancer, suggesting remaining gaps in care.
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http://dx.doi.org/10.1097/MLR.0000000000000685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5391268PMC
May 2017

Medicare D Subsidies and Racial Disparities in Persistence and Adherence With Hormonal Therapy.

J Clin Oncol 2016 12 24;34(36):4398-4404. Epub 2016 Oct 24.

Alana Biggers, University of Illinois-Chicago, Chicago, IL; and Yushu Shi, John Charlson, Elizabeth C. Smith, Alicia J. Smallwood, Ann B. Nattinger, Purushottam W. Laud, and Joan M. Neuner, Medical College of Wisconsin, Milwaukee, WI.

Purpose To investigate the role of out-of-pocket cost supports through the Medicare Part D Low-Income Subsidy on disparities in breast cancer hormonal therapy persistence and adherence by race or ethnicity. Methods A nationwide cohort of women age ≥ 65 years with a breast cancer operation between 2006 and 2007 and at least one prescription filled for oral breast cancer hormonal therapy was identified from all Medicare D enrollees. The association of race or ethnicity with nonpersistence (90 consecutive days with no claims for a hormonal therapy prescription) and nonadherence (medication possession rate < 80%) was examined. Survival analyses were used to account for potential differences in age, comorbidity, or intensity of other treatments. Results Among the 25,111 women in the study sample, 77% of the Hispanic and 70% of the black women received a subsidy compared with 21% of the white women. By 2 years, 69% of black and 70% of Hispanic patients were persistent compared with 61% of white patients. In adjusted analyses, patients in all three unsubsidized race or ethnicity groups had greater discontinuation than subsidized groups (white patients: hazard ratio [HR], 1.83; 95% CI, 1.70 to 1.95; black patients: HR, 2.09; 95% CI, 1.73 to 2.51; Hispanic patients: HR, 3.00; 95% CI, 2.37 to 3.89). Racial or ethnic persistence disparities that were present for unsubsidized patients were not present or reversed among subsidized patients. All three subsidized race or ethnicity groups also had higher adherence than all three unsubsidized groups, although with the smallest difference occurring in black women. Conclusion Receipt of a prescription subsidy was associated with substantially improved persistence to breast cancer hormonal therapy among white, black, and Hispanic women and lack of racial or ethnic disparities in persistence. Given high subsidy enrollment among black and Hispanic women, policies targeted at low-income patients have the potential to also substantially reduce racial and ethnic disparities.
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http://dx.doi.org/10.1200/JCO.2016.67.3350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5455308PMC
December 2016

Effect of hospital volume on processes of breast cancer care: A National Cancer Data Base study.

Cancer 2017 05 8;123(6):957-966. Epub 2016 Nov 8.

Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin.

Background: The purpose of this study was to examine variations in delivery of several breast cancer processes of care that are correlated with lower mortality and disease recurrence, and to determine the extent to which hospital volume explains this variation.

Methods: Women who were diagnosed with stage I-III unilateral breast cancer between 2007 and 2011 were identified within the National Cancer Data Base. Multiple logistic regression models were developed to determine whether hospital volume was independently associated with each of 10 individual process of care measures addressing diagnosis and treatment, and 2 composite measures assessing appropriateness of systemic treatment (chemotherapy and hormonal therapy) and locoregional treatment (margin status and radiation therapy).

Results: Among 573,571 women treated at 1755 different hospitals, 38%, 51%, and 10% were treated at high-, medium-, and low-volume hospitals, respectively. On multivariate analysis controlling for patient sociodemographic characteristics, treatment year and geographic location, hospital volume was a significant predictor for cancer diagnosis by initial biopsy (medium volume: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.05-1.25; high volume: OR = 1.30, 95% CI = 1.14-1.49), negative surgical margins (medium volume: OR = 1.15, 95% CI = 1.06-1.24; high volume: OR = 1.28, 95% CI = 1.13-1.44), and appropriate locoregional treatment (medium volume: OR = 1.12, 95% CI = 1.07-1.17; high volume: OR = 1.16, 95% CI = 1.09-1.24).

Conclusions: Diagnosis of breast cancer before initial surgery, negative surgical margins and appropriate use of radiation therapy may partially explain the volume-survival relationship. Dissemination of these processes of care to a broader group of hospitals could potentially improve the overall quality of care and outcomes of breast cancer survivors. Cancer 2017;123:957-66. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30413DOI Listing
May 2017

A statewide controlled trial intervention to reduce use of unproven or ineffective breast cancer care.

Contemp Clin Trials 2016 09 10;50:150-6. Epub 2016 Aug 10.

Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, United States.

Background: Challenged by public opinion, peers and the Congressional Budget Office, medical specialty societies have begun to develop "Top Five" lists of expensive procedures that do not provide meaningful benefit to at least some categories of patients for whom they are commonly ordered. The extent to which these lists have influenced the behavior of physicians or patients, however, remains unknown.

Methods: We partner with a statewide consortium of health systems to examine the effectiveness of two interventions: (i) "basic" public reporting and (ii) an "enhanced" intervention, augmenting public reporting with a smart phone-based application that gives providers just-in-time information, decision-making tools, and personalized patient education materials to support reductions in the use of eight breast cancer interventions targeted by Choosing Wisely® or oncology society guidelines. Our aims are: (1) to examine whether basic public reporting reduces use of targeted breast cancer practices among a contemporary cohort of patients with incident breast cancer in the intervention state relative to usual care in comparison states; (2) to examine the effectiveness of the enhanced intervention relative to the basic intervention; and (3) to simulate cost savings forthcoming from nationwide implementation of both interventions.

Discussion: The results will provide rigorous evidence regarding the effectiveness of a unique all-payer, all-age public reporting system for influencing provider behavior that may be easily exportable to other states, and potentially also to large healthcare systems. Findings will be further relevant to the ACO environment, which is expected to provide financial disincentives for ineffective or unproven care.

Trial Registration: ClinicalTrials.gov number pending.
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http://dx.doi.org/10.1016/j.cct.2016.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5565266PMC
September 2016

The interplay between hospital and surgeon factors and the use of sentinel lymph node biopsy for breast cancer.

Medicine (Baltimore) 2016 Aug;95(31):e4392

Department of Surgery, Division of Surgical Oncology Division of Biostatistics Department of Medicine Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA.

Background: Several surgeon characteristics are associated with the use of sentinel lymph node biopsy (SLNB) for breast cancer. No studies have systematically examined the relative contribution of both surgeon and hospital factors on receipt of SLNB.

Objective: To evaluate the relationship between surgeon and hospital characteristics, including a novel claims-based classification of hospital commitment to cancer care (HC), and receipt of SLNB for breast cancer, a marker of quality care.

Data Sources/study Design: Observational prospective survey study was performed in a population-based cohort of Medicare beneficiaries who underwent incident invasive breast cancer surgery, linked to Medicare claims, state tumor registries, American Hospital Association Annual Survey Database, and American Medical Association Physician Masterfile. Multiple logistic regression models determined surgeon and hospital characteristics that were predictors of SLNB.

Results: Of the 1703 women treated at 471 different hospitals by 947 different surgeons, 65% underwent an initial SLNB. Eleven percent of hospitals were high-volume and 58% had a high commitment to cancer care. In separate adjusted models, both high HC (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.12-2.10) and high hospital volume (HV, OR 1.90, 95% CI 1.28-2.79) were associated with SLNB. Adding surgeon factors to a model including both HV and HC minimally modified the effect of high HC (OR 1.34, 95% CI 0.95-1.88) but significantly weakened the effect of high HV (OR 1.25, 95% CI 0.82-1.90). Surgeon characteristics (higher volume and percentage of breast cancer cases) remained strong independent predictors of SLNB, even when controlling for various hospital characteristics.

Conclusions: Hospital factors are associated with receipt of SLNB but surgeon factors have a stronger association. Since regionalization of breast cancer care in the U.S. is unlikely to occur, efforts to improve the surgical care and outcomes of breast cancer patients must focus on optimizing patient access to SLNB by ensuring hospitals have the necessary resources and training to perform SLNB, staffing hospitals with surgeons who specialize/focus in breast cancer and referring patients who do not have access to SLNB to an experienced center.
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http://dx.doi.org/10.1097/MD.0000000000004392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4979807PMC
August 2016

Time Spent Outdoors, Depressive Symptoms, and Variation by Race and Ethnicity.

Am J Prev Med 2016 09 16;51(3):281-90. Epub 2016 Jun 16.

Department of Medicine and Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin.

Introduction: Numerous studies have explored neighborhood environmental correlates of mental illnesses, presuming that the time individuals spend in their environment can confer benefit or harm based on environmental characteristics. However, few population-based studies have directly examined the relationship between time spent outdoors and mental health, and little work has been done to explore how experiences differ by race and ethnicity. Though some have proposed "doses of outdoor time" to improve health, the absence of information about the benefits conferred by particular "doses," and expected baseline levels of outdoor time, are needed to inform the development of recommendations and interventions.

Methods: This study examined the relationship between time spent outdoors and depression among a population-based sample of American adults, characterized current levels of time spent outdoors by race and ethnicity, and examined how the relationship between time spent outdoors and depression varies by race and ethnicity. Descriptive statistics and survey regression models were used to examine data from the National Health and Nutrition Examination Survey for 2009-2012.

Results: Findings provide evidence that time spent outdoors is associated with fewer depressive symptoms, but this benefit may not be equally distributed by race and ethnicity. Descriptive analyses also reveal differences in time spent outdoors among different racial and ethnic groups.

Conclusions: Study findings support the notion that increasing time spent outdoors may result in mental health benefits. However, this study questions whether that benefit is experienced equally among different groups, particularly given differences in occupational experiences and environmental characteristics of neighborhoods.
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http://dx.doi.org/10.1016/j.amepre.2016.05.004DOI Listing
September 2016

Breast Cancer Screening and Prevention.

Ann Intern Med 2016 Jun;164(11):ITC81-ITC96

This issue provides a clinical overview of breast cancer screening and prevention, focusing on risk assessment, screening, prevention, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.
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http://dx.doi.org/10.7326/AITC201606070DOI Listing
June 2016
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