MarketWatch: Is spending more always wasteful? The appropriateness of care and outcomes among colorectal cancer patients

Health Affairs

Volumn 27, Issue 1, 2008, Pages 159-168

  Landrum, Mary Beth ^a   Meara, Ellen R ^a   Chandra, Amitabh ^b   Guadagnoli, Edward ^a   Keating, Nancy L ^a  

^a HARVARD MEDICAL SCHOOL   (United States)

^b HARVARD UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANTINEOPLASTIC AGENT;

AGED; ARTICLE; CANCER ADJUVANT THERAPY; CANCER MORTALITY; CANCER PATIENT; CANCER SURGERY; CAUSE OF DEATH; COLONOSCOPY; COLORECTAL CANCER; COMORBIDITY; CONTROLLED STUDY; DISEASE SEVERITY; FEMALE; HEALTH CARE COST; HEALTH CARE UTILIZATION; HEALTH SERVICE; HUMAN; LOGISTIC REGRESSION ANALYSIS; MAJOR CLINICAL STUDY; MALE; MEDICARE; PATIENT CARE; PROBABILITY; CANCER REGISTRY; CLUSTER ANALYSIS; COLORECTAL TUMOR; COST BENEFIT ANALYSIS; COST OF ILLNESS; ECONOMICS; MORTALITY; STATISTICS; SURVIVAL; TREATMENT OUTCOME; UNITED STATES; UTILIZATION REVIEW;

AGED; AGED, 80 AND OVER; COLORECTAL NEOPLASMS; COST OF ILLNESS; COST-BENEFIT ANALYSIS; FEMALE; HEALTH CARE COSTS; HEALTH EXPENDITURES; HUMANS; MALE; MEDICARE; OUTCOME AND PROCESS ASSESSMENT (HEALTH CARE); SEER PROGRAM; SMALL-AREA ANALYSIS; SURVIVAL ANALYSIS; UNITED STATES;

EID: 38849155203     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.27.1.159     Document Type: Article

References (47)

1. J.E. Wennberg and M.M. Cooper, The Dartmouth Atlas of Health Care 1999 (Chicago: American Hospital Publishing, 1999).
2. W.P. Welch et al., "Geographic Variation in Expenditures for Physicians' Services in the United States," New England Journal of Medicine 328, no. 9 (1993): 621-627;
3. J.S. Skinner, E.S. Fisher and J.E. Wennberg, "The Efficiency of Medicare," in Analyses in the Economics of Aging, ed. D.A. Wise (Chicago: University of Chicago Press, 2005), 129-157;
4. and K. Baicker and A. Chandra, "The Productivity of Physician Specialization: Evidence from the Medicare Program," American Economic Review 94, no. 2 (2004): 357-361.
5. K. Baicker and A. Chandra, "Medicare Spending, the Physician Workforce, and Beneficiaries' Quality of Care," Health Affairs (2004): w184-w197 (published online 7 April 2004; 10.1377/hlthaff.w4.184);
6. E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 273-287;
7. and "Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-298.
8. J.E. Wennberg, E.S. Fisher, and J.S. Skinner, "Geography and the Debate over Medicare Reform," Health Affairs 21 (2002): w96-w114 (published online 13 February 2002; 10.1377/hlthaff.w2.96).
9. A. Jemal et al., "Cancer Statistics, 2007," Cancer Journal for Clinicians 57, no. 1 (2007): 43-66;
10. N.L. Keating et al., "Do Increases in the Market Share of Managed Care Influence Quality of Cancer Care in the Fee-for-Service Sector?" Journal of the National Cancer Institute 97, no. 4 (2005): 257-264;
11. D. Schrag et al., "Age and Adjuvant Chemotherapy Use after Surgery for Stage III Colon Cancer," Journal of the National Cancer Institute 93, no. 11 (2001): 850-857;
12. and D. Schrag et al., "Who Gets Adjuvant Treatment for Stage II and III Rectal Cancer? Insight from Surveillance, Epidemiology, and End Results - Medicare," Journal of Clinical Oncology 19, no. 17 (2001): 3712-3718.
13. A.L. Potosky et al., "Potential for Cancer Related Health Services Research Using a Linked Medicare-Tumor Registry Database," Medical Care 31, no. 8 (1993): 732-748.
14. For more details regarding the inclusion and exclusion criteria for our analytic cohort, see Exhibit A1 in the online appendix at http://content. healthaffairs.org/cgi/content/full/27/1/159/DC1.
15. Previous studies have used an end-of-life spending index that included spending for both inpatient care and physician services, whereas we used a publicly available measure that accounts for inpatient spending only. However, hospital care represents the largest and most variable category of spending. C. Smith et al., "National Health Spending in 2004: Recent Slowdown Led by Prescription Drug Spending," Health Affairs 25, no. 1 (2006): 186-196;
16. and Fisher et al., "The Implications of Regional Variations, Part 1."
17. Fisher et al., "The Implications of Regional Variations, Part 1."
18. Ibid.; Fisher et al., "The Implications of Regional Variations, Part 2"; and Skinner et al., "The Efficiency of Medicare."
19. See, for example, "NIH Consensus Conference: Adjuvant Therapy for Patients with Colon and Rectal Cancer," Journal of the American Medical Association 264, no. 11 (1990): 1444-1450;
20. C.E. Desch et al., "Recommended Colorectal Cancer Surveillance Guidelines by the American Society of Clinical Oncology," Journal of Clinical Oncolcology 17, no. 4 (1999): 1312;
21. and M.J. Edelman, F.J. Meyers, and D. Siegel, "The Utility of Follow-up Testing after Curative Cancer Therapy: A Critical Review and Economic Analysis," Journal of General Internal Medicine 12, no. 5 (1997): 318-331. For details on the level of evidence supporting each measure and on the eligibility criteria and coding specifications, see Exhibit A2 in the online appendix, as in Note 7.
22. Cause of death was available through 31 December 2000. To maximize inclusion of a majority of our cohort, we analyzed three-year mortality, restricting mortality analyses to patients diagnosed before 31 December 1997.
23. C.N. Klabunde et al., "Development of a Comorbidity Index Using Physician Claims Data," Journal of Clinical Epidemiology 53, no. 12 (2000): 1258-1267.
24. Cut points for the quintiles of EOL-IEI were set so that each quintile would have approximately equal numbers of study participants.
25. In sensitivity analyses,we repeated test of trends using quintile of EOL-IEI instead of actual inpatient spending. Our results were not changed.
26. Formore socioeconomic and clinical characteristics according to EOL-IEI quintile, see Exhibit A3 in the online appendix, as in Note 7.
27. We found that older and sicker patients underwent chemotherapy in high EOL-IEI areas in most cases when we examined these trends in stage-specific cohorts.
28. For stage-specific results, see Exhibit A4 in the online appendix, as in Note 7.
29. Baicker and Chandra, "Medicare Spending"; Fisher et al., "The Implications of Regional Variations, Part 1 and Part 2"; and Skinner et al., "The Efficiency of Medicare."
30. Fisher et al., "The Implications of Regional Variations, Part 1"; and J.E. Wennberg et al., "Use of Hospitals, Physician Visits, and Hospice Care during Last Six Months of Life among Cohorts Loyal to Highly Respected Hospitals in the United States," British Medical Journal 328, no. 7440 (2004): 607.
31. M.R. Chassin et al., "Does Inappropriate Use Explain Geographic Variations in the Use of Health Care Services? A Study of Three Procedures," Journal of the American Medical Association 258, no. 18 (1987): 2533-2537;
32. E. Guadagnoli et al., "Impact of Underuse, Overuse, and Discretionary Use on Geographic Variation in the Use of Coronary Angiography after Acute Myocardial Infarction," Medical Care 39, no. 5 (2001): 446-458;
33. and L.L. Leape et al., "Does Inappropriate Use Explain Small-Area Variation in the Use of Health Care Services?" Journal of the American Medical Association 263, no. 5 (1990): 669-672.
34. "NIH Consensus Conference"; D.J. Sargent et al., "A Pooled Analysis of Adjuvant Chemotherapy for Resected Colon Cancer in Elderly Patients," New England Journal of Medicine 345, no. 15 (2001): 1091-1097;
35. and J.A. Meyerhardt and R.J. Mayer, "Systemic Therapy for Colorectal Cancer," New England Journal of Medicine 352, no. 5 (2005): 476-487.
36. Meyerhardt and Mayer, "Systemic Therapy for Colorectal Cancer"; and "NCCN Colon Cancer Clinical Practice Guidelines in Oncology," Journal of the National Comprehensive Cancer Network 1, no. 1 (2003): 54-63.
37. The validity of cause-of-death information from state death certificates has been questioned. See P. Bach et al., "Patient Demographic and Socio-economic Characteristics in the SEER-Medicare Database: Applications and Limitations," Medical Care 40, no. 8 Supp. (2002): IV-19-IV-25.
38. For details on number of excluded patients across spending quintiles, see Exhibit A1 in the online appendix, as in Note 7.
39. J.L. Warren et al., "Overview of the SEER-Medicare Data: Content, Research Applications, and Generalizability to the United States Elderly Population," Medical Care 40, no. 8 Supp. (2002): IV-3-IV-18;
40. and A.B. Nattinger, T.L. McAuliffe, and M.M. Schapira, "Generalizability of the Surveillance, Epidemiology, and End Results Registry Population: Factors Relevant to Epidemiologic and Health Care Research," Journal of Clinical Epidemiology 50, no. 8 (1997): 939-945.
41. For example, the range between the 5th and 95th percentiles in EOL-IEI is $4,600 across all 307 HRRs compared to $4,900 across the 43 HRRs within the SEER regions.
42. Wennberg et al., "Geography and the Debate."
43. J.S. Hacker, "Health Care for America: A Proposal for Guaranteed, Affordable Health Care for All Americans Building on Medicare and Employment-Based Insurance," Briefing Paper no. 180 (Washington: Economic Policy Institute, 2007);
44. and S. Woolhandler et al., "Proposal of the Physicians' Working Group for Single-Payer National Health Insurance," Journal of the American Medical Association 290, no. 6 (2003): 798-805.
45. U.E. Reinhardt, P.S. Hussey, and G.F. Anderson, "U.S. Health Care Spending in an International Context," Health Affairs 23, no. 3 (2004): 10-25;
46. and C. Schoen et al., "U.S. Health System Performance: A National Scorecard," Health Affairs 25, no. 6 (2006): w457-w475 (published online 20 September 2006; 10.1377/hlthaff.25.w457).
47. D.M. Cutler, Your Money or Your Life: Strong Medicine for America's Health Care System (Oxford: Oxford University Press, 2004).