chronic conditions. As a result, treatment
of chronic conditions is an important
concern when treating lung cancer
patients.
The most prominent co-morbidities
are hypertension, other secondary
cancers, and heart disease, as seen in
Table 1.
Lung Cancer:
The impact of multiple chronic
conditions
Introduction:
Lung cancer (ICD9 162.2-162.9) is
the leading cause of cancer death for both
men and women. It is estimated that in the
year 2003, about 157,200 people will die of Table 1
lung cancer1.
Conditions
percent of lung cancer
Although considerable research has
patients affected
been devoted to the diagnosis and
treatment of lung cancer, less attention has
COPD
50.1%
been given to the impact of treating lung
Hypertension
49.0%
cancer patients with other chronic
Secondary malignancies *
39.5%
conditions and how these conditions could
Coronary atherosclerosis and other heart disease
29.1%
cause additional burden to the patient.
Other lower respiratory disease **
Most people with Lung Cancer Have 5
or More Chronic Conditions
97 percent of Medicare beneficiaries
and/or people older than 65 years of age
with lung cancer have another chronic
condition (Figure 1) and 60% of lung
cancer patients have five or more other
26.3%
Source: RIF SAF 5% Medicare files for CY 2001
*
Secondary malignancies include secondary malignant
neoplasm in the digestive organs, lymphatic system,
reproductive organs, other respiratory organs, and
other sites
**
other lower respiratory disease are post inflammatory
pulmonary fibrosis, alveolar and parieto alveolar
pneumonopathies, lung involvement in systemic
sclerosis, and other diseases of the lung and/or the
respiratory system
1
Comorbidities are defined using the Clinical
Classification System (CCS), a set of mutually
exclusive categories for ICD9 codes. Visit
http://www.ahcpr.gov/data/hcup/ccsfact.htm for a
description of CCS and the actual groupings
themselves
Figure 1
Percent of Medicare Beneficiaries with Lung Cancer
and other Chronic Conditions
4
12%
0
3
11%
1
2
3
4
5+
2
8%
1
6%
0
3%
Source: RIF SAF 5% Medicare files for CY 2001
1
Clinical studies have shown that the
presence of COPD in lung cancer
patients “is an acceptable predictor of
postoperative pulmonary
complications,”2 and these complications
5+
60%
How many people get lung cancer? American Cancer
Society, Accessed June 2003,
<http://www.cancer.org/docroot/CRI/content/CRI_2_2_
1X_How_many_people_get_lung_cancer_26.asp?siteare
a=>.
2
Behnia M., Fujisawa T., and.Sekine Y.(2002) Impact of
COPD on pulmonary complications and on long-term
survival of patients undergoing surgery for NSCLC Lung
Cancer.37(1): 95-101 Abstract [online] PubMed, NCBI
[Accessed July 1, 2003]
are associated with higher mortality
rates.3 Other studies have shown that
COPD in lung cancer patients are at
significantly higher risk for
supraventricular arrhythmias, which may
lead to a longer hospitalization.4 One
study which focused on the treatment of
lung cancer and COPD concluded that
“adequate palliative care to provide
quality survival would be the primary
goal of therapy for lung cancer patients
with COPD.”5 Another study also found
that hypertension may result in a higher
postoperative mortality.6
Number of hospitalizations increases as
number of chronic conditions increases
Lung cancer patients often have one or
more ambulatory care-sensitive conditions,
ACSCs. ACSCs are defined as conditions
for which “diagnoses for which timely and
effective outpatient care can help to reduce
the risks of hospitalization by either
preventing the onset of an illness or
condition, controlling an acute episodic
illness or condition (such as bacterial
pneumonia), or managing a chronic
disease or condition (such as asthma and
hypertension).”7 It has been observed that
“better primary care, especially
coordination of care, could reduce
avoidable hospitalization rates, especially
for individuals with multiple chronic
conditions.”8
Hospitalization for conditions (ACSCs)
that are preventable can be used to
indicate whether the patient is receiving
adequate and quality outpatient care.9 It
has been observed that as the number of
chronic conditions increase, the period of
hospitalization increases dramatically, as
seen in table 2 below.
Table 2
Number of Chronic
Conditions in
Addition to lung cancer
Hospitalizations for
ACSC Admissions
per 1000
Patients over age 65
0
1
2
3
4
5+
15.6
45.2
68.2
104.7
161.8
383.8
Source: RIF SAF 5% Medicare files for CY 2001
3
Francisco Algar et al. (2003) Predicting pulmonary
complications after pneumonectomy for lung cancer
European Journal of Cardio-Thoracic Surgery 23(2):
201-208 Abstract [online] PubMed, NCBI [Accessed
July 1, 2003]
4
Yasuo Sekine et al. (2001) COPD May Increase the
Incidence of Refractory Supraventricular Arrhythmias
Following Pulmonary Resection for Non-small Cell
Lung Cancer Chest. 120(6): 1783-90 Abstract [online]
PubMed, NCBI [Accessed July 1, 2003]
5
K. Kurishima et al. (2001) Lung cancer patients with
chronic obstructive pulmonary disease Oncol Rep. 8(1):
63-5 Abstract [online] PubMed, NCBI [Accessed July 1,
2003]
6
Drukin E., Zarkh SA., and Paikin MD., (1981) Surgical
treatment of lung cancer in patients with concurrent
cardiovascular system diseases Voprosy Onkologii27(2):
74-8 Abstract [online] PubMed, NCBI [Accessed July 1,
2003]
7
Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE,
Newman L. Impact of socioeconomic status on hospital
use in New York City Heath Affairs(Millwood).
1993:12: p.163-166
8
Anderson G, Starfield B, and Wolff J.(2002)
Prevalence, Expenditures, and Complications of
Multiple Chronic Conditions in the Elderly Arch Intern.
Med. 162(20): 2269-76 Abstract [online] PubMed,
NCBI [Accessed July 1, 2003]
9
Millman M. Access to Health Care in America
Washington, DC: National Academy Press; 1993
Health Care spending increases with
more chronic conditions
People with chronic conditions in
addition to lung cancer have higher health
care expenses. Figure 2 shows all
Medicare spending by number of chronic
conditions. Medicare beneficiaries with
lung cancer and five or more additional
chronic conditions have almost fourteen
times higher expenditures per beneficiary
compared to beneficiaries with only lung
cancer.
Utilization increases with more chronic
conditions
People with multiple chronic
conditions in addition to lung cancer utilize
more healthcare resources. As Figure 3
shows, lung cancer patients with other
chronic conditions visit the doctor more
often. As Figure 4 shows, patients with 5 or
more chronic conditions see an average of
20 unique physicians during the year. It
may be easier for physicians to
communicate with each other if a single
physician is in charge of the patient.
Figure 4
Number of Chronic Conditions in addition to Lung Cancer
Average Number of Unique Physicians
5+
19.7
4
12.6
3
10.4
2
8.6
1
6.8
none
4.3
0.0
5.0
10.0
15.0
20.0
Source: RIF SAF 5% Medicare files for CY 2001
Conclusion:
Treatment has become increasingly
difficult when lung cancer patients have
other chronic conditions. Research
suggests that patients have better
outcomes at lower cost when care is
coordinated10. Care coordination becomes
essential to improvements in care for
patients with lung cancer.
10
Anderson G, Starfield B, and Wolff J. Prevalence,
Expenditures, and Complications of Multiple Chronic
Conditions in the Elderly Arch Intern. Med. Vol. 162,
Nov. 2002, p. 2275
25.0
About Partnership for Solutions
Partnership for Solutions, led by
Johns Hopkins University and The Robert
Wood Johnson Foundation, is an initiative
to improve the care and quality of life for
the estimated 125 million Americans with
chronic health conditions. The Partnership
is engaged in three major activities:
conducting original research and
identifying existing research that clarifies
the nature of the problem; communicating
these research findings to policymakers,
business leaders, health professionals,
advocates, and others; and working with
public and private programs to identify
promising solutions to the problems faced
by people with chronic conditions.