Publications by authors named "Nancy L Keating"

292 Publications

Higher Prices for Cancer Surgery at National Cancer Institute-Designated Cancer Centers-Are Payers Achieving Value for Their Dollars?

Authors:
Nancy L Keating

JAMA Netw Open 2021 Aug 2;4(8):e2119716. Epub 2021 Aug 2.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.19716DOI Listing
August 2021

US Trends in Opioid Access Among Patients With Poor Prognosis Cancer Near the End-of-Life.

J Clin Oncol 2021 Jul 22:JCO2100476. Epub 2021 Jul 22.

Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.

Purpose: Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer.

Methods: Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills and opioid potency (morphine milligram equivalents per day [MMED]) near the end-of-life (EOL), defined as the 30 days before death or hospice enrollment. We used administrative claims to evaluate trends in pain-related emergency department (ED) visits near EOL.

Results: Between 2007 and 2017, the proportion of decedents with poor prognosis cancers receiving ≥ 1 opioid prescription near EOL declined 15.5% (relative percent difference [RPD]), from 42.0% (95% CI, 41.4 to 42.7) to 35.5% (95% CI, 34.9 to 36.0) and the proportion receiving ≥ 1 long-acting opioid prescription declined 36.5% (RPD), from 18.1% (95% CI, 17.6 to 18.6) to 11.5% (95% CI, 11.1 to 11.9). Among decedents receiving opioids near EOL, the mean daily dose fell 24.5%, from 85.6 MMED (95% CI, 82.9 to 88.3) to 64.6 (95% CI, 62.7 to 66.6) MMED. Overall, the total amount of opioids prescribed per decedent near EOL (averaged across those who did and did not receive an opioid) fell 38.0%, from 1,075 morphine milligram equivalents per decedent (95% CI, 1,042 to 1,109) to 666 morphine milligram equivalents per decedent (95% CI, 646 to 686). Simultaneously, the proportion of patients with pain-related ED visits increased 50.8% (RPD), from 13.2% (95% CI, 12.7 to 13.6) to 19.9% (95% CI, 19.4 to 20.4). Sensitivity analyses demonstrated similar declines in opioid utilization in the 60 and 90 days before death or hospice, and suggested that trends in opioid access were not confounded by secular trends in hospice utilization.

Conclusion: Opioid use among patients dying of cancer has declined substantially from 2007 to 2017. Rising pain-related ED visits suggests that EOL cancer pain management may be worsening.
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http://dx.doi.org/10.1200/JCO.21.00476DOI Listing
July 2021

Challenges and Opportunities in Engaging Primary Care Providers in BRCA Testing: Results from the BFOR Study.

J Gen Intern Med 2021 Jun 25. Epub 2021 Jun 25.

Brigham and Women's Hospital, Boston, MA, USA.

Purpose: Engaging primary care providers (PCPs) in BRCA1/2 testing and results disclosure would increase testing access. The BRCA Founder OutReach (BFOR) study is a prospective study of BRCA1/2 founder mutation screening among individuals of Ashkenazi Jewish descent that sought to involve participants' PCPs in results disclosure. We used quantitative and qualitative methods to evaluate PCPs' perspectives, knowledge, and experience disclosing results in BFOR.

Methods: Among PCPs nominated by BFOR participants to disclose BRCA1/2 results, we assessed the proportion agreeing to disclose. To examine PCP's perspectives, knowledge, and willingness to disclose results, we surveyed 501 nominated PCPs. To examine PCPs' experiences disclosing results in BFOR, we surveyed 101 PCPs and conducted 10 semi-structured interviews.

Results: In the BFOR study overall, PCPs agreed to disclose their patient's results 40.5% of the time. Two hundred thirty-four PCPs (46.7%) responded to the initial survey. Responding PCPs were more likely to agree to disclose patients' results than non-responders (57.3% vs. 28.6%, p<0.001). Among all respondents, most felt very (19.7%) or somewhat (39.1%) qualified to share results. Among PCPs declining to disclose, insufficient knowledge was the most common reason. In multivariable logistic regression, feeling qualified was the only variable significantly associated with agreeing to disclose results (OR 6.53, 95% CI 3.31, 12.88). In post-disclosure surveys (response rate=55%), PCPs reported largely positive experiences. Interview findings suggested that although PCPs valued the study-provided educational materials, they desired better integration of results and decision support into workflows.

Conclusion: Barriers exist to incorporating BRCA1/2 testing into primary care. Most PCPs declined to disclose their patients' BFOR results, although survey respondents were motivated and had positive disclosure experiences. PCP training and integrated decision support could be beneficial.

Trial Registration: ClinicalTrials.gov (NCT03351803), November 24, 2017.
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http://dx.doi.org/10.1007/s11606-021-06970-8DOI Listing
June 2021

ACA Mandate Led To Substantial Increase In Contraceptive Use Among Women Enrolled In High-Deductible Health Plans.

Health Aff (Millwood) 2021 04;40(4):579-586

Lydia E. Pace is an assistant professor in the Division of Women's Health, Brigham and Women's Hospital, and an assistant professor of medicine at Harvard Medical School.

The Affordable Care Act (ACA) mandated that private health plans cover contraceptives without out-of-pocket expenses for patients. Previously, long-acting reversible contraceptives (LARCs) were subject to deductibles, making them a higher-cost service for women with high-deductible health plans (HDHPs); however, the ACA mandate applied to HDHPs as well as traditional health plans. Using a national commercial claims database, we examined LARC use among continuously enrolled reproductive-age women between 2010 and 2017, comparing 9,014 women enrolled in HDHPs with 443,363 women enrolled in non-HDHPs. Using a quasi-experimental difference-in-differences analysis, we found that pre-ACA HDHP enrollees had lower LARC initiation rates than women in non-HDHPs and that rates of LARC initiation increased by 35 percent more postmandate for women in HDHPs than for women in traditional plans. These findings suggest that the ACA had a particularly important impact for women in HDHPs, who faced higher pre-ACA out-of-pocket expenses for these contraceptive methods.
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http://dx.doi.org/10.1377/hlthaff.2020.01710DOI Listing
April 2021

Evaluation of Reliability and Correlations of Quality Measures in Cancer Care.

JAMA Netw Open 2021 03 1;4(3):e212474. Epub 2021 Mar 1.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Importance: Measurement of the quality of care is important for alternative payment models in oncology, yet the ability to distinguish high-quality from low-quality care across oncology practices remains uncertain.

Objective: To assess the reliability of cancer care quality measures across oncology practices using registry and claims-based measures of process, utilization, end-of-life (EOL) care, and survival, and to assess the correlations of practice-level performance across measure and cancer types.

Design, Setting, And Participants: This cross-sectional study used the Surveillance, Epidemiology, and End Results (SEER) Program registry linked to Medicare administrative data to identify individuals with lung cancer, breast cancer, or colorectal cancer (CRC) that was newly diagnosed between January 1, 2011, and December 31, 2015, and who were treated in oncology practices with 20 or more patients. Data were analyzed from January 2018 to December 2020.

Main Outcomes And Measures: Receipt of guideline-recommended treatment and surveillance, hospitalizations or emergency department visits during 6-month chemotherapy episodes, care intensity in the last month of life, and 12-month survival were measured. Summary measures for each domain in each cohort were calculated. Practice-level rates for each measure were estimated from hierarchical linear models with practice-level random effects; practice-level reliability (reproducibility) for each measure based on the between-measure variance, within-measure variance, and distribution of patients treated in each practice; and correlations of measures across measure and cancer types.

Results: In this study of SEER registry data linked to Medicare administrative data from 49 715 patients with lung cancer treated in 502 oncology practices, 21 692 with CRC treated in 347 practices, and 52 901 with breast cancer treated in 492 practices, few practices had 20 or more patients who were eligible for most process measures during the 5-year study period. Patients were 65 years or older; approximately 50% of the patients with lung cancer and CRC and all of the patients with breast cancer were women. Most measures had limited variability across practices. Among process measures, 0 of 6 for lung cancer, 0 of 6 for CRC, and 3 of 11 for breast cancer had a practice-level reliability of 0.75 or higher for the median-sized practice. No utilization, EOL care, or survival measure had reliability across practices of 0.75 or higher. Correlations across measure types were low (r ≤ 0.20 for all) except for a correlation between the CRC process and 1-year survival summary measures (r = 0.35; P < .001). Summary process measures had limited or no correlation across lung cancer, breast cancer, and CRC (r ≤ 0.16 for all).

Conclusions And Relevance: This study found that quality measures were limited by the small numbers of Medicare patients with newly diagnosed cancer treated in oncology practices, even after pooling 5 years of data. Measures had low reliability and had limited to no correlation across measure and cancer types, suggesting the need for research to identify reliable quality measures for practice-level quality assessments.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.2474DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985722PMC
March 2021

Should Women at Lower-Than-Average Risk of Breast Cancer Undergo Less Frequent Screening?

J Natl Cancer Inst 2021 Aug;113(8):953-954

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

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http://dx.doi.org/10.1093/jnci/djaa219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328988PMC
August 2021

Individualizing Surveillance Mammography for Older Patients After Treatment for Early-Stage Breast Cancer: Multidisciplinary Expert Panel and International Society of Geriatric Oncology Consensus Statement.

JAMA Oncol 2021 Apr;7(4):609-615

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Importance: There is currently no guidance on how to approach surveillance mammography for older breast cancer survivors, particularly when life expectancy is limited.

Objective: To develop expert consensus guidelines that facilitate tailored decision-making for routine surveillance mammography for breast cancer survivors 75 years or older.

Evidence: After a literature review of the risk of ipsilateral and contralateral breast cancer events among breast cancer survivors and the harms and benefits associated with mammography, a multidisciplinary expert panel was convened to develop consensus guidelines on surveillance mammography for breast cancer survivors 75 years or older. Using an iterative consensus-based approach, input from clinician focus groups, and critical review by the International Society for Geriatric Oncology, the guidelines were refined and finalized.

Findings: The literature review established a low risk for ipsilateral and contralateral breast cancer events in most older breast cancer survivors and summarized the benefits and harms associated with mammography. Draft mammography guidelines were iteratively evaluated by the expert panel and clinician focus groups, emphasizing a patient's risk for in-breast cancer events, age, life expectancy, and personal preferences. The final consensus guidelines recommend discontinuation of routine mammography for all breast cancer survivors when life expectancy is less than 5 years, including those with a history of high-risk cancers; consideration to discontinue mammography when life expectancy is 5 to 10 years; and continuation of mammography when life expectancy is more than 10 years. Individualized, shared decision-making is encouraged to optimally tailor recommendations after weighing the benefits and harms associated with surveillance mammography and patient preferences. The panel also recommends ongoing clinical breast examinations and diagnostic mammography to evaluate clinical findings and symptoms, with reassurance for patients that these practices will continue.

Conclusions And Relevance: It is anticipated that these expert guidelines will enhance clinical practice by providing a framework for individualized discussions, facilitating shared decision-making regarding surveillance mammography for breast cancer survivors 75 years or older.
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http://dx.doi.org/10.1001/jamaoncol.2020.7582DOI Listing
April 2021

Assessment of Racial Disparities in Primary Care Physician Specialty Referrals.

JAMA Netw Open 2021 01 4;4(1):e2029238. Epub 2021 Jan 4.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Importance: Disparities in quality of care according to patient race and socioeconomic status persist in the US. Differential referral patterns to specialist physicians might be associated with observed disparities.

Objective: To examine whether differences exist between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians (PCPs) and physicians in the 6 specialties to which patients were most frequently referred.

Design, Setting, And Participants: This cross-sectional observational study of Black and White Medicare beneficiaries used claims data from 2009 to 2010 on 100% of traditional Medicare beneficiaries who were seen by PCPs and selected high-volume specialists in 12 health care markets with at least 10% of the population being Black. Statistical analyses were conducted from December 20, 2017, to September 30, 2020.

Exposures: Differences in patterns of patient sharing among Black and White patients.

Main Outcomes And Measures: Primary care physician and specialist degree (the number of other PCPs or specialists to whom each physician is connected) and strength (the number of shared patients per connection, overall, for Black patients and White patients and after equalizing the numbers of Black and White patients per PCP), as well as distance between PCP and patient and specialist zip code centroids.

Results: The 12 selected markets ranged in size from Manhattan, New York (187 054 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 9794 total physicians), to Tallahassee, Florida (44 644 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% (Huntsville, Alabama) to 46.8% (Chicago, Illinois). The mean PCP-specialist degree (number of specialists with whom a PCP shares patients) was lower for Black patients than for White patients. For instance, the mean PCP-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. After sampling White patients to equalize the numbers of patients seen, the degree differences narrowed but were still not equivalent in many markets (eg, for all specialties in Baton Rouge, Louisiana: 4.5 for Black patients vs 5.7 for White patients). Specialist networks among White patients were much larger than those constructed based just on Black patients (eg, for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per PCP (123 for Black patients vs 211 for White patients). The overall test for differences in referral patterns was statistically significant for all 6 specialties examined in 7 of the 12 markets and in 5 specialties for another 3.

Conclusions And Relevance: This study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries. This is an observational study, and thus some differences might have resulted from patient-initiated visits to specialists.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.29238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835717PMC
January 2021

Authorized Generics and Their Evolving Role in Prescription Drug Pricing and Access.

JAMA Intern Med 2021 Apr;181(4):423-424

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2020.8450DOI Listing
April 2021

Broken Promises - How Medicare Part D Has Failed to Deliver Savings to Older Adults.

N Engl J Med 2020 Dec 5;383(24):2299-2301. Epub 2020 Dec 5.

From the Department of Health Policy, Vanderbilt University School of Medicine, and the Vanderbilt-Ingram Comprehensive Cancer Center, Nashville (S.B.D.); the University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill (B.M.); and the Department of Health Care Policy, Harvard Medical School (N.L.K., H.A.H.), and the Division of General Internal Medicine, Brigham and Women's Hospital (N.L.K.) - both in Boston.

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http://dx.doi.org/10.1056/NEJMp2027580DOI Listing
December 2020

How Do Claims-Based Measures of End-of-Life Care Compare to Family Ratings of Care Quality?

J Am Geriatr Soc 2021 Apr 9;69(4):900-907. Epub 2020 Nov 9.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.

Objectives: Assess whether frequently-used claims-based end-of-life (EOL) measures are associated with higher ratings of care quality.

Design: Retrospective cohort study.

Setting/participants: Deceased fee-for-service Medicare beneficiaries with cancer who underwent chemotherapy during July 2016 to January 2017 and died within 12 months and their caregiver respondents to an after-death survey (n = 2,559).

Measurements: We examined claims-based measures of EOL care: chemotherapy 14 days or more before death; inpatient admissions, intensive care unit (ICU) use, and emergency department (ED) visits 30 days or more before death; hospice election and the timing of election before death. Primary outcomes are family ratings of "excellent" care in the last month of life and reports that hospice care began "at the right time." Associations were assessed with logistic regression, adjusted by patient characteristics.

Results: Family rated EOL care as excellent less often, if within 30 days before death the cancer patient had inpatient admissions (1 hospitalization = 41.5% vs 51.5% none, adjusted difference -10.1 percentage points), ICU use (38.6% for any ICU use vs 47.4% none; adjusted difference -8.8 percentage points), ED visits (41.0% 1 visit vs 51.6% no visits; adjusted difference -10.6 percentage points), or elected hospice within 7 days before death. Among hospice enrollees, family more often reported that hospice began at the right time if it started at least 7 days before death (hospice 1-2 days before death 60.2% vs hospice 7-13 days 74.9%; adjusted difference +14.7 percentage points).

Conclusions: Claims-based measures of EOL care for cancer patients that reflect avoidance of hospital-based care and earlier hospice enrollment are associated with higher ratings of care quality by bereaved family members.
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http://dx.doi.org/10.1111/jgs.16905DOI Listing
April 2021

Medicaid Expansion and Mortality Among Patients With Breast, Lung, and Colorectal Cancer.

JAMA Netw Open 2020 11 2;3(11):e2024366. Epub 2020 Nov 2.

Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: Medicaid expansion under the Patient Protection and Affordable Care Act may be associated with increased screening and may improve access to earlier treatment for cancer, but its association with mortality for patients with cancer is uncertain.

Objective: To determine whether Medicaid expansion is associated with improved mortality among patients with cancer.

Design, Setting, And Participants: This is a quasi-experimental, difference-in-difference (DID), cross-sectional, population-based study. Patients in the National Cancer Database with breast, lung, or colorectal cancer newly diagnosed from January 1, 2012, to December 31, 2015, were included. Data analysis was performed from January to May 2020.

Exposure: Living in a state where Medicaid was expanded vs a nonexpansion state.

Main Outcomes And Measures: The main outcome was mortality rate according to whether the patient lived in a state where Medicaid was expanded.

Results: A total of 523 802 patients (385 739 women [73.6%]; mean [SD] age, 54.8 [6.5] years) had a new diagnosis of invasive breast (273 272 patients [52.2%]), colorectal (111 720 patients [21.3%]), or lung (138 810 patients [26.5%]) cancer; 289 330 patients (55.2%) lived in Medicaid expansion states, and 234 472 patients (44.8%) lived in nonexpansion states. After Medicaid expansion, mortality significantly decreased in expansion states (hazard ratio [HR], 0.98; 95% CI, 0.97-0.99; P = .008) but not in nonexpansion states (HR, 1.01; 95% CI, 0.99-1.02; P = .43), resulting in a significant DID (HR, 1.03; 95% CI, 1.01-1.05; P = .01). This difference was seen primarily in patients with nonmetastatic cancer (stages I-III). After adjusting for cancer stage, the mortality improvement in expansion states from the periods before and after expansion was no longer evident (HR, 1.00; 95% CI, 0.98-1.02; P = .94), nor was the difference between expansion vs nonexpansion states (DID HR, 1.00; 95% CI, 0.98-1.02; P = .84).

Conclusions And Relevance: Among patients with newly diagnosed breast, colorectal, and lung cancer, Medicaid expansion was associated with a decreased hazard of mortality in the postexpansion period, which was mediated by earlier stage of diagnosis.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.24366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645694PMC
November 2020

The impact of sampling patients on measuring physician patient-sharing networks using Medicare data.

Health Serv Res 2020 Oct 14. Epub 2020 Oct 14.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To investigate the impact of sampling patients on descriptive characteristics of physician patient-sharing networks.

Data Sources: Medicare claims data from 10 hospital referral regions (HRRs) in the United States in 2010.

Study Design: We form a sampling frame consisting of the full cohort of patients (Medicare enrollees) with claims in the 2010 calendar year from the selected HRRs. For each sampling fraction, we form samples of patients from which a physician ("patient-sharing") network is constructed in which an edge between two physicians depicts that at least one patient in the sample encountered both of those physicians. The network is summarized using 18 network measures. For each network measure and sampling fraction, we compare the values determined from the sample and the full cohort of patients. Finally, we assess the sampling fraction that is needed to measure each network measure to specified levels of accuracy.

Data Collection/extraction Methods: We utilized administrative claims from the traditional (fee-for-service) Medicare.

Principal Findings: We found that measures of physician degree (the number of ties to other physicians) in the network and physician centrality (importance or prominence in the network) are learned quickly in the sense that a small sampling fraction suffices to accurately compute the measure. At the network level, network density (the proportion of possible edges that are present) was learned quickly while measures based on more complex configurations (subnetworks involving multiple actors) are learned relatively slowly with relative rates of learning depending on network size (the number of nodes).

Conclusions: The sampling fraction applied to Medicare patients has a highly heterogeneous effect across different network measures on the extent to which sample-based network measures resemble those evaluated using the full cohort. Even random sampling of patients may yield physician networks that distort descriptive features of the network based on the full cohort, potentially resulting in biased results.
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http://dx.doi.org/10.1111/1475-6773.13568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968944PMC
October 2020

Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process.

JCO Glob Oncol 2020 09;6:1446-1454

Brigham and Women's Hospital, Boston, MA.

Purpose: The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings.

Methods: To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda.

Results: Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda.

Conclusion: A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.
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http://dx.doi.org/10.1200/GO.20.00186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529520PMC
September 2020

Patient and proxy reports regarding the experience of treatment decision-making in cancer care.

Psychooncology 2020 11 27;29(11):1943-1950. Epub 2020 Sep 27.

Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: Shared decision-making, including the elicitation of patient preferences regarding treatment decisions, is considered part of high-quality cancer care. However, patients may not be able to self-report due to illness, and therefore proxy reports may be used. We sought to determine the difference between proxy and patient reports about patient decisions and preferences among patients who received or were scheduled for chemotherapy using data from a large, population-based survey of patients with incident lung or colorectal cancer.

Methods: Of 3573 patients who received or were scheduled for chemotherapy, 3108 self-reported and 465 had proxies reporting on their behalf about preferred and actual decision roles regarding this treatment. Preferred and actual decision roles were assessed using the Control Preferences Scale, and categorized as shared, patient-controlled, or doctor-controlled. Multivariable logistic regression models were used to assess the association between patient and proxy responses and whether preferences were met. The models adjusted for sociodemographic and clinical variables and patient/proxy-reported health status.

Results: Sixty-three percent of all respondents reported actual roles in decisions that matched their preferred roles (role attainment). Proxies and patients were similarly likely to report role attainment (65% vs 63%). In adjusted analyses, proxies were more likely report role attainment (OR = 1.27, 95%CI = 1.02-1.59), but this difference was smaller if health variables were excluded from the model (OR = 1.14, 95%CI = 0.92-1.41).

Conclusion: Most patients' preferences for treatment participation were met. Surveys from proxies appear to yield small differences on the reports of attainment of preferred treatment decision-making roles in cancer care vs surveys from patients.
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http://dx.doi.org/10.1002/pon.5528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722082PMC
November 2020

Comparison of up-front cash cards and checks as incentives for participation in a clinician survey: a study within a trial.

BMC Med Res Methodol 2020 08 17;20(1):210. Epub 2020 Aug 17.

Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.

Background: Evidence is needed regarding effective incentive strategies to increase clinician survey response rates. Cash cards are increasingly used as survey incentives; they are appealing because of their convenience and because in some cases their value can be reclaimed by investigators if not used. However, their effectiveness in clinician surveys is not known. In this study within the BRCA Founder OutReach (BFOR) study, a clinical trial of population-based BRCA1/2 mutation screening, we compared the use of upfront cash cards requiring email activation versus checks as clinician survey incentives.

Methods: Participants receiving BRCA1/2 testing in the BFOR study could elect to receive their results from their primary care provider (PCP, named by the patient) or from a geneticist associated with the study. In order to understand PCPs' knowledge, attitudes, experiences and willingness to disclose results we mailed paper surveys to the first 501 primary care providers (PCPs) in New York, Boston, Los Angeles and Philadelphia who were nominated by study participants to disclose their BRCA1/2 mutation results obtained through the study. We used alternating assignment stratified by city to assign the first 303 clinicians to receive a $50 up-front incentive as a cash card (N = 155) or check (N = 148). The cash card required PCPs to send an activation email in order to be used. We compared response rates by incentive type, adjusting for PCP characteristics and study site.

Results: In unadjusted analyses, PCPs who received checks were more likely to respond to the survey than those who received cash cards (54.1% versus 41.9%, p = 0.046); this remained true when we adjusted for provider characteristics (OR for checks 1.61, 95% CI 1.01, 2.59). No other clinician characteristics had a statistically significant association with response rates in adjusted analyses. When we included an interaction term for incentive type and city, the favorable impact of checks on response rates was evident only in Los Angeles and Philadelphia.

Conclusions: An up-front cash card incentive requiring email activation may be less effective in eliciting clinician responses than up-front checks. However, the benefit of checks for clinician response rates may depend on clinicians' geographic location.

Trial Registration: ClinicalTrials.gov ( NCT03351803 ), November 24, 2017.
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http://dx.doi.org/10.1186/s12874-020-01086-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430023PMC
August 2020

Oncologists' perceptions of the usefulness of cancer survivorship care plan components.

Support Care Cancer 2021 Feb 14;29(2):945-954. Epub 2020 Jun 14.

Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.

Purpose: The Institute of Medicine recommends that cancer patients receive survivorship care plans (SCP) summarizing information important to the individual's long-term care. The various components of SCPs have varying levels of evidence supporting their impact. We surveyed medical oncologists to better understand how they perceived the relative value of different SCP components.

Methods: Medical oncologists caring for patients in diverse US practice settings were surveyed (357 respondents; participation rate 52.9%) about their perceptions of the usefulness of various components of SCPs to both patients and primary care physicians (PCPs).

Results: Oncologists perceived treatment summaries as "very useful" for PCPs but were less likely to perceive them as "very useful" for patients (55% vs. 40%, p < 0.001). Information about the psychological effects of cancer (41% vs. 29%; p < 0.001) and healthy behaviors (67% vs. 41%; p < 0.001) were considered more useful to patients than to PCPs. From 3 to 20% of oncologists believed that any given component of the SCP was not useful to either PCPs or patients. Oncologists who perceived SCPs to be more useful tended to be female or to practice in settings with a fully implemented electronic health record.

Conclusions: Oncologists do not perceive all components of SCPs to be equally useful to both patients and PCPs. To be successfully implemented, the SCP should be efficiently tailored to the unique needs and knowledge of patients and their PCPs. A minority of oncologists appear to be late adopters, suggesting that some resistance to the adoption of SCPs remains.
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http://dx.doi.org/10.1007/s00520-020-05531-9DOI Listing
February 2021

Medicare Part D and Insulin Affordability - The Devil Is in the Details.

N Engl J Med 2020 May 1;382(20):1878-1880. Epub 2020 Apr 1.

From the Department of Health Policy, Vanderbilt University School of Medicine, Nashville (S.B.D., L.M.K.); and the Department of Health Care Policy, Harvard Medical School (H.A.H., N.L.K), and Brigham and Women's Hospital (N.L.K.) - both in Boston.

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http://dx.doi.org/10.1056/NEJMp2001649DOI Listing
May 2020

Deep Natural Language Processing Identifies Variation in Care Preference Documentation.

J Pain Symptom Manage 2020 06 9;59(6):1186-1194.e3. Epub 2020 Jan 9.

Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, USA.

Context: Documentation of care preferences within 48 hours of admission to an intensive care unit (ICU) is a National Quality Forum-endorsed quality metric for older adults. Care preferences are poorly captured by administrative data.

Objectives: Using deep natural language processing, our aim was to determine the rate of care preference documentation in free-text notes and to assess associated patient factors.

Methods: Retrospective review of notes by clinicians using a deep natural language processing to identify care preference documentation, including goals-of-care and treatment limitations, within 48 hours of ICU admission within five ICUs (medical, cardiac, surgery, trauma surgery, and cardiac surgery) for adults 75 years and older. Covariates included demographics, ICU type, sequential organ failure assessment score, and need for mechanical ventilation.

Results: Deep natural language processing reviewed 11,575 clinician notes for 1350 ICU admissions. Median patient age was 84.0 years (interquartile range 78.0-88.4). Overall, 64.7% had documentation of care preferences. Patients with documentation were older (85 vs. 83 years; P < 0.001) and more often female (53.8% vs. 43.4%; P < 0.001). In adjusted analysis, rates of care preference documentation were higher for older patients, females, nonelective admissions, and admissions to the medical vs. the cardiac or surgical ICUs (all P ≤ 0.01).

Conclusion: Care preference documentation within 48 hours was absent in more than one-third of ICU admissions among patients aged 75 years and older and was more likely to occur in medical vs. cardiac or surgical ICUs.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.12.374DOI Listing
June 2020

Medicaid Expansion Slowed Rates Of Health Decline For Low-Income Adults In Southern States.

Health Aff (Millwood) 2020 01;39(1):67-76

J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School.

Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans. We analyzed longitudinal survey and vital status data from the twelve-state Southern Community Cohort Study (SCCS) for 15,356 nonelderly adult participants with low incomes, 86 percent of whom were enrolled at community health centers. In difference-in-differences analyses, we compared changes in self-reported health between participants in four expansion and eight nonexpansion states before (2008-13) and after (2015-17) Medicaid expansion. We found that a higher proportion of SCCS participants in expansion states reported increases in Medicaid coverage (a differential change of 7.6 percentage points), a lower proportion experienced a health status decline (-1.8 percentage points), and a higher proportion maintained their baseline health status (1.4 percentage points). The magnitude of estimated reductions in health declines would meaningfully affect a nonexpansion state's health ranking in our sample if that state elected to expand Medicaid. Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits-even for those with established access to safety-net care.
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http://dx.doi.org/10.1377/hlthaff.2019.00929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169046PMC
January 2020

Association of Physician Peer Influence With Subsequent Physician Adoption and Use of Bevacizumab.

JAMA Netw Open 2020 01 3;3(1):e1918586. Epub 2020 Jan 3.

Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.

Importance: Understanding adoption of new cancer therapies may help identify opportunities to increase use for high-value indications.

Objective: To determine whether use of bevacizumab in 2005 to 2006 by oncologists' peers was associated with greater bevacizumab use among oncologists in 2007 to 2010.

Design, Setting, And Participants: This cohort study of physicians and their patients took place in 51 randomly selected hospital referral regions in the United States. Participants were 44 012 fee-for-service Medicare beneficiaries aged 65 years or older with cancers of the colorectum, lung, breast, kidney, brain, or ovary treated by 3261 oncologists in 2005 to 2010 and assigned to one of 252 communities. Data were analyzed in 2017 to 2018.

Exposures: Among patients treated with chemotherapy during 2007 to 2010 by an oncologist who had not treated patients with bevacizumab in 2005 to 2006, models assessed the association of bevacizumab use with rates of bevacizumab use in their physician's community of connected physicians in 2005 to 2006. Models adjusted for patient and physician characteristics and physician, practice, and community random effects.

Main Outcomes And Measures: Receipt of bevacizumab.

Results: A total of 34 750 patients (14 126 [40.6%] aged ≥75 years; 21 321 [61.4%] female) with cancers of the colorectum, lung, breast, kidney, brain, and ovary were treated with chemotherapy in 2005 to 2006 in the 51 hospital referral regions. Among 9262 patients treated in 2007 to 2010 by 829 physicians whose patients did not use bevacizumab in 2005 to 2006, 3654 (39.5%) were aged 75 years or older and 6227 (67.2%) were female. The rate of bevacizumab use relative to other chemotherapy in 2007 to 2010 by tertile of use (bevacizumab for <4.4%, 4.4%-6.2%, and >6.2% of all patients receiving chemotherapy) among their physician's peers in 2005 to 2006 was 10.0%, 9.5%, and 13.6%, respectively. After adjustment, use of bevacizumab in 2007 to 2010 was greater among physicians in communities with the highest rates of bevacizumab use in 2005 to 2006 compared with those whose peers were in the lowest tertile of bevacizumab use in 2005 to 2006 (adjusted odds ratio, 1.64; 95% CI, 1.20-2.25).

Conclusions And Relevance: This study found that an increase in oncologists' adoption and use of bevacizumab in the years after its approval was associated with their peer physicians being earlier adopters. As organizations seek to provide better care at lower costs, interventions that leverage physician ties may help to promote adoption of high-value use of new cancer treatments and deimplementation of low-value therapies.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.18586DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991243PMC
January 2020

Oral Oncology Parity Laws, Medication Use, and Out-of-Pocket Spending for Patients With Blood Cancers.

J Natl Cancer Inst 2020 10;112(10):1055-1062

Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.

Background: In this study, we sought to estimate the association between oral oncology parity law adoption and anticancer medication use for patients with chronic myeloid leukemia or multiple myeloma.

Methods: This was an observational study of administrative claims from 2008 to 2017. Among individuals initiating tyrosine kinase inhibitors (TKIs) for chronic myeloid leukemia or immunomodulatory drugs for multiple myeloma, we compared out-of-pocket spending, adherence, and discontinuation before and after parity among individuals in fully insured plans (subject to parity) vs self-funded plans (exempt from parity) using propensity-score weighted difference-in-differences regression models.

Results: Among patients initiating TKIs (N = 2082) or immunomodulatory drugs (N = 3326) there were no statistically significant differences in adherence or discontinuation associated with parity. The proportion of patients with initial out-of-pocket payments of $0 increased in fully insured plans after parity from 5.7% to 46.1% for TKIs and from 10.9% to 48.8% for immunomodulatory drugs. Relative to changes in self-funded plans, those in fully insured plans were 4.27 (95% CI = 2.20 to 8.27) times as likely to pay nothing for TKIs and 1.96 (95% CI = 1.40 to 2.73) times as likely to pay nothing for immunomodulatory drugs after parity. Similarly, the proportion paying more than $100 decreased from 30.3% to 24.7% for TKIs and 30.6% to 27.5% for immunomodulatory drugs in fully insured plans after parity. Relative to changes in self-funded plans, those in fully insured plans were 0.74 (95% CI = 0.54 to 1.01) times as likely to pay more than $100 for TKIs and 0.85 (95% CI = 0.68 to 1.06) times as likely to pay more than $100 for immunomodulatory drugs after parity.

Conclusions: Among patients initiating TKIs or immunomodulatory drugs, parity was not associated with better adherence or less discontinuation of therapy but yielded decreased patient out-of-pocket payments for some patients.
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http://dx.doi.org/10.1093/jnci/djz243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566334PMC
October 2020

Oncology Practices and Clinicians Participating in the Oncology Care Model.

JCO Oncol Pract 2020 02 27;16(2):99-100. Epub 2019 Dec 27.

Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, Boston, MA; and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; Amanda Tripp, PhD, The Lewin Group, Falls Church, VA; Shalini Jhatakia, MA, The Lewin Group, Falls Church, VA; Andrea Hassol, MSPH; Abt Associates, Cambridge, MA; and Carol Simon, PhD, The Lewin Group, Falls Church, VA.

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http://dx.doi.org/10.1200/JOP.19.00617DOI Listing
February 2020

Insurance Networks and Access to Affordable Cancer Care.

J Clin Oncol 2020 02 5;38(4):310-315. Epub 2019 Dec 5.

Dana-Farber Cancer Institute, Boston, MA.

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http://dx.doi.org/10.1200/JCO.19.01484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6994255PMC
February 2020

Cluster Randomized Trial to Facilitate Breast Cancer Early Diagnosis in a Rural District of Rwanda.

J Glob Oncol 2019 11;5:1-13

Ministry of Health, Kigali, Rwanda.

Purpose: Feasible and effective strategies are needed to facilitate earlier diagnosis of breast cancer in low-income countries. The goal of this study was to examine the impact of health worker breast health training on health care utilization, patient diagnoses, and cancer stage in a rural Rwandan district.

Methods: We conducted a cluster randomized trial of a training intervention at 12 of the 19 health centers (HCs) in Burera District, Rwanda, in 2 phases. We evaluated the trainings' impact on the volume of patient visits for breast concerns using difference-in-difference models. We used generalized estimating equations to evaluate incidence of HC and hospital visits for breast concerns, biopsies, benign breast diagnoses, breast cancer, and early-stage disease in catchment areas served by intervention versus control HCs.

Results: From April 2015 to April 2017, 1,484 patients visited intervention HCs, and 308 visited control HCs for breast concerns. The intervention led to an increase of 4.7 visits/month for phase 1 HCs ( = .001) and 7.9 visits/month for phase 2 HCs ( = .007) compared with control HCs. The population served by intervention HCs had more hospital visits (115.1 20.5/100,000 person-years, < .001) and biopsies (36.6 8.9/100,000 person-years, < .001) and higher breast cancer incidence (6.9 3.3/100,000 person-years; = .28). The incidence of early-stage breast cancer was 3.3 per 100,000 in intervention areas and 0.7 per 100,000 in control areas ( = .048).

Conclusion: In this cluster randomized trial in rural Rwanda, the training of health workers and establishment of regular breast clinics were associated with increased numbers of patients who presented with breast concerns at health facilities, more breast biopsies, and a higher incidence of benign breast diagnoses and early-stage breast cancers.
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http://dx.doi.org/10.1200/JGO.19.00209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882507PMC
November 2019

Multimodality cancer care and implications for episode-based payments in cancer.

Am J Manag Care 2019 11;25(11):537-538

Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115. Email:

Most patients receiving multimodality cancer care receive care from different practices. Therefore, episode-based payments in oncology must hold multiple providers accountable for costs and quality.
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November 2019

Nephrologists' emotional burden regarding decision-making about dialysis initiation in older adults: a qualitative study.

BMC Nephrol 2019 10 24;20(1):385. Epub 2019 Oct 24.

Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.

Background: Conservative management, an approach to treating end-stage kidney disease without dialysis, while generally associated with shorter life expectancy than treatment with dialysis, is associated with fewer hospitalizations, better functional status and, potentially, better quality of life. Conservative management is a well-established treatment approach in a number of Western countries, including the United Kingdom (U.K.). In contrast, despite clinical practice guidelines in the United States (U.S.) recommending that nephrologists discuss all treatment options, including conservative management, with stage 4 and 5 chronic kidney disease patients, studies suggest that this rarely occurs. Therefore, we explored U.S. nephrologists' approaches to decision-making about dialysis and perspectives on conservative management among older adults.

Methods: We conducted a qualitative research study. We interviewed 20 nephrologists - 15 from academic centers and 5 from community practices - utilizing a semi-structured interview guide containing open-ended questions. Interview transcripts were analyzed using grounded thematic analysis in which codes were generated inductively and iteratively modified, and themes were identified. Transcripts were coded independently by two investigators, and interviews were conducted until thematic saturation.

Results: Twenty nephrologists (85% white, 75% male, mean age 50) participated in interviews. We found that decision-making about dialysis initiation in older adults can create emotional burden for nephrologists. We identified four themes that reflected factors that contribute to this emotional burden including nephrologists' perspectives that: 1) uncertainty exists about how a patient will do on dialysis, 2) the alternative to dialysis is death, 3) confronting death is difficult, and 4) patients do not regret initiating dialysis. Three themes revealed different decision-making strategies that nephrologists use to reduce this emotional burden: 1) convincing patients to "just do it" (i.e. dialysis), 2) shifting the decision-making responsibility to patients, and 3) utilizing time-limited trials of dialysis.

Conclusions: A decision not to start dialysis and instead pursue conservative management can be emotionally burdensome for nephrologists for a number of reasons including clinical uncertainty about prognosis on dialysis and discomfort with death. Nephrologists' attempts to reduce this burden may be reflected in different decision-making styles - paternalistic, informed, and shared decision-making. Shared decision-making may relieve some of the emotional burden while preserving patient-centered care.
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http://dx.doi.org/10.1186/s12882-019-1565-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814056PMC
October 2019

Proposals to Redesign Medicare Part D - Easing the Burden of Rising Drug Prices.

N Engl J Med 2019 Oct 4;381(15):1401-1404. Epub 2019 Sep 4.

From the Department of Health Policy, Vanderbilt University School of Medicine, Nashville (S.B.D.); and the Department of Health Care Policy, Harvard Medical School, Boston (N.L.K., H.A.H.).

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http://dx.doi.org/10.1056/NEJMp1908688DOI Listing
October 2019

Medications to Reduce Breast Cancer Risk: Promise and Limitations.

JAMA 2019 09;322(9):821-823

Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jama.2019.9689DOI Listing
September 2019
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