Adjuvantt Chemotherapy
Adj
Ch
th
in
i
Colon Cancer:
Differences by System of
Care and Stage
Elizabeth Tarlov, RN, PhD
Center for Management of Complex Chronic Care and
VA Information Resource Center
Hines VA Hospital, Hines, IL
Academy Health Annual Research Meeting
June 29, 2009
Collaborators
Todd A. Lee, PharmD, PhD1,2,3
Ramon Durazo-Arvizu
Durazo Arvizu, PhD4
Qiuying Zhang, MS1
Thomas Weichle, MS1
Ruth Perrin, MA1,2
Charles L. Bennett, MD, PhD, MPP1,5,6
Denise M. Hynes, PhD, MPH, RN1,2,3 *
1Center
for Management of Complex Chronic Care, Hines VA Hospital,
Hines, IL; 2VA Information Resource Center, Hines VA Hospital, Hines, IL;
3University
y of Illinois at Chicago,
g , Chicago,
g , IL;; 4Loyola
y
Universityy Chicago,
g ,
Chicago, IL; 5Jesse Brown VA Medical Center, Chicago, IL; 6Northwestern
University, Chicago, IL
* Principal Investigator, VA HSR&D IIR 03-196, “Quality and Costs of Colon Cancer
Care in VA and Medicare”. Dr. Hynes is also supported through an HSR&D
Research Career Scientist Award.
2
New York Times/CBS News Poll on Health
J
June
12
12-16,
16 2009
 When y
you think about the p
problems with the U.S.
health care system, how serious a problem is doctors
ordering medical tests and treatments their patients
don'tt really need?
don
Somewhat or Very Serious Problem: 73%
 When you think about the problems with the U.S.
health care system,
system how serious a problem is people
NOT getting medical tests and treatments they need.
Somewhat or Very Serious Problem: 87%
3
Adjuvant
j
Chemotherapy
py for Colon Cancer
S
Stage
age III

40% reduction in risk
of recurrence

Standard of care
since 1990: routine
use

 Stage
g II

Little-to-no convincing
evidence of survival
benefit

Adjuvant
j
chemotherapy only in
context of clinical trial

Rates of use 27%
Rates of use 55-65%
4
Chemotherapy
py for Stage
g II Colon Cancer
 Uncertainty regarding most efficacious
therapy
py
 Medicare: Reimbursement structure provides
incentives to treat
 VA: Treatment has no bearing on income
5
Objectives
A
Ascertain
t i

whether VA/Non-VA system of care is
associated with likelihood of chemotherapy
receipt, and

whether that relationship differs depending
on the certainty of the treatment value
6
Hypotheses
Compared to their VA counterparts,
•
Stage II colon cancer patients treated
outside the VA will be more likely to
receive chemotherapy
•
Stage III colon
St
l cancer patients
ti t treated
t t d
outside the VA will be equally likely to
receive chemotherapy
chemotherapy.
7
Methods
 Retrospective cohort study
 Population

Elderly colon cancer patients

Dually eligible for VA and Medicare-covered
care

Veterans known to the VA
8
Study
y Sample
p
 Cases identified through 8 NCI SEER cancer
registries
California, Georgia, Hawaii, Iowa, Louisiana,
Metropolitan Detroit, New Jersey, Western
Washington
 Diagnosis July 1, 1999 - Dec 31, 2001
 Stage II or III at diagnosis
 Post-colectomy
P t l t
 Survived > 30 days beyond colectomy
9
Exclusions
No or incomplete health care utilization
information
•
•
•
•
•
Autopsy- or death-certificate-only cases
Medicare HMO enrollment
Non-Medicare primary payer
Part B Medicare coverage only
Other, unknown reasons
10
Data Sources
 NCI SEER and VA Cancer Registries
 VA inpatient and outpatient utilization data

Medical SAS Datasets

Fee Basis Files

Pharmacy Benefits Management
 Medicare administrative and claims data

Inpatient and Outpatient SAF

Carrier
11
Operational
p
Definitions
 Chemotherapy
py receipt
p
 Diagnosis, procedure, other administrative
codes indicating chemotherapy service
 First claim date within 6 months following
surgery
 System of care
 System in which surgery was done
12
Analysis
y
 Cox Proportional Hazards Regression

Outcome: Receipt of one or more
chemotherapy services

Propensity score approach to control for
likelihood of using the VA
13
Results
 Sample Characteristics (n=1000)

Mean age at diagnosis 76

94% male*

14% African American*

20% VA care*
care

42% received at least one chemotherapy
service (Stage II 27%; Stage III 62%)
_______________________
* In bivariate analysis, associated with chemotherapy receipt, p< 0.05
14
Table 1.
Sample Characteristics by System of Care
VA
(N=204)
%
Non-VA
(N=796)
%
II
III
62.7
37 3
37.3
58.0
42 0
42.0
66 – 75 yrs
>=76 yrs
54.4
45.6
42.5
57.5
Race/ethnicity† African American
24 0
24.0
11 3
11.3
HS Education†
(Mean %)
61.8
67.3
0
1
>=2
45.1
26.5
28.4
36.7
28.9
34.4
Stage at Diagnosis
Age at Diagnosis†
Charlson Index Score
* Statistically significant differences across groups, p<0.05
†
Statistically significant differences across groups, p<0.01
15
Table 2
Estimated Relative ‘Risk’
Risk of Receiving Adjuvant Chemotherapy
Adjusted Incidence Rate Ratiosa
(95% Confidence Limits)
P
Stage at Diagnosis
III
VA
o
Non-VA
Ref
1.11 (0
(0.79–1.55)
9 55)
0.54
0
5
VA
Non-VA
Ref
2.46 (1.51–4.01)
0.00
II
a
Incidence rate ratios obtained from a Cox Proportional Hazards model
adjusted for propensity score predicting VA/Non-VA care, categorized as
quintiles. Statistical tests were two-sided.
16
Summary
y
 Stage III
Equally likely to have adjuvant chemotherapy,
regardless of system of care
care.
 Stage II
When care received outside VA, 2½ times
more likely to get adjuvant chemotherapy
17
Discussion
 Large difference in treatment received only
when the benefit of treatment was
unproved/uncertain
 Patients receiving care in setting where
physician reimbursement is tied to number and
type of services were more likely to get the
treatment of uncertain benefit.
18
Implications
 Costs:

Medicare Modernization Act reduced but did
not eliminate financial incentives.

New chemotherapy agents much more
expensive
 Quality: More or better?

Quality competes with financial incentives

Clinical guidelines won’t solve this problem

Solutions are urgently needed
19
Recommended Reading
Atul Gawande, “The Cost Conundrum”
New Yorker
Yorker, June 1
1, 2009
20
Thank you
21
Bonus Slides
22
Medicare System
y
Influences
on Provider Behavior
 Provider reimbursement tied to number and type
of services
 Medicare coverage for chemotherapy

Physicians purchase drugs, Medicare reimburses at
95% of AWP (until recently)

Discounts widelyy available

Inadequate reimbursement for costs of chemotherapy
administration and other services.
23
COLON CANCER STUDY COHORT
VIReC Finder File
8 SEER Program Registries
Veterans known to the VA who were at
least 66 years old and dually eligible to
use the VHA and the Medicare program
between 1999 and 2001
sent to
California
Iowa
Georgia
Louisiana
New Jersey
Hawaii
Western Washington
Metropolitan Detroit
3,482,654
match procedure
Match Yield
Veterans with stage I-IV colon cancer diagnosed between
July 1, 1999 and Dec. 31, 2001 and age 66 or older at the
time of diagnosis
3 000
3,000
EXCLUSIONS
Incomplete or Absent Utilization Information
At some point during the study period*:
 Not enrolled or not eligible for VA care (238)
 Medicare HMO enrollment (790)
 Non-Medicare primary payer (private insurance) (52)
 Medicare Part B coverage only (15)
No healthcare utilization records during study period, reason unknown (59)
No utilization records during 6
6-month
month period surrounding diagnosis date
date,
reason unknown (19)
Autopsy Only Diagnosis (4)
1,038
Colon Cancer Study Analytic Cohort
1,962
* Study period: 6 months before to 3 years after colon cancer diagnosis
24
O
Operational
ti
l Definition:
D fi iti
System
S t
off Care
C
 System
S t
in
i which
hi h surgery was d
done
 Final determination of stage and formulation of
treatment plan occurs at/shortly after surgery
 “Switching” uncommon
 Dual use for colon cancer care <8% in first 6
months after diagnosis
25
Likelihood of Receiving Adjuvant Chemotherapy
Adjusted Incidence Rate
Ratiosa
(95% Confidence Limits)
Age at Diagnosis
66 – 75
76 – 85
86 and
d older
ld
Race
Non-African American
African American
Charlson Index Score
0
1
2 or 3
4 or higher
Marital Status
Not Married
Married
Stage at Diagnosis
III
VA Surgical Venue
Non-VA Surgical Venue
II
VA Surgical Venue
Non VA Surgical Venue
Non-VA
Pb
6.72 (3.16–14.26)
3.23 (1.53–6.79)
R f
Ref
0.00
0.00
1.52 (1.27–1.80)
Ref
0.00
2.68 (1.82–3.94)
2.65 (1.74–4.03)
1.52 (1.02–2.26)
Ref
0.00
0.00
0.04
Ref
1.43 (1.11–1.83)
0.01
Ref
1.31 (1.04–1.66)
0.02
Ref
2 35 (1.12–4.93)
2.35
(1 12 4 93)
0 02
0.02
a
Incidence rate ratios obtained from a Cox Proportional Hazards model, also adjusted
for year of diagnosis, family income, and geographic region.
b
All statistical tests were two-sided.
26
Discussion
 Alternative Explanations

VA and non-VA patient preferences differ

VA patients are more likely than non-VA
non VA
patients to experience complications of
surgery
27
Discussion
 Our findings are consistent with those of
Si i h ett al.
Sirovich,
l (2008)
(2008), H
Health
lth Aff
Affairs.
i

High- compared to low-spending regions:
When clinical judgment is discretionary,
physicians in high-spending regions
recommend more services than those in low
lowspending regions.

Practice differences disappear in situations
where there is a clear clinical guideline.
28
References
1. Gill S,, Loprinzi
p
CL,, Sargent
g
DJ,, et al. Pooled Analysis
y
of
Fluorouracil-Based Adjuvant Therapy for Stage II and III
Colon Cancer: Who Benefits and by How Much?
Journal of Clinical Oncology
Oncology. 2004;22(10):1797-1806.
2004;22(10):1797 1806
2. Schrag D, Rifas-Shiman S, Saltz L, Bach PB, Begg CB.
Adjuvant chemotherapy use for Medicare beneficiaries
with stage II colon cancer. J Clin Oncol.
2002;20(19):3999-4005.
29