use of large databases for cancer prevention and control research gregory s. cooper, md case western...
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Use of Large Databases for Cancer Prevention and Control
ResearchGregory S. Cooper, MD
Case Western Reserve University
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Goals
• Introduction to large database research
• Colon cancer screening
• Screening for Barrett’s esophagus
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Existing Cancer Data Sources
• Screening– Telephone surveys (BRFSS)– Single health plan/institution
• Incidence/Treatment– Population-based registries (state, region)– Health plan/institution
• Follow Up– Health plan/institution
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Limitations of Existing Data
• Generalizability
• Screening– Recall biases– Oversample higher SES
• No national-level registry
• Cancer patients– No pre- or post-treatment data
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Advantages of Claims Data
• Nationally Representative– Community practice– Different treatment locations– Efficacy vs. effectiveness
• Large Sample Sizes
• Little Incremental Research Costs
• Turnaround Time Typically Low
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Disadvantages
• Not Designed for Research– Nonstandardized definitions– No data on severity
• Coding Inaccuracies– Systematic– Random
• Missing Patients (VA, Age Cutoff, HMO, Outpatient)
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Sources of Claims Data
• Federal Government– Medicare– VA
• State Level– Medicaid– Hospital discharges
• Private Insurers
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Types of Medicare Files
• Part A 100% of patients (hospitalizations, skilled nursing short stay)
• Part B > 95% of patients (extra premium, outpatient treatment, physician services)
• All contain demographics, diagnosis (ICD-9) and procedure codes (ICD-9 hospital, CPT-4 outpatient services)
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Diagnosis Codes - Example
• Enterostomy Malfunction
• Intestinal Adhesion with Obstruction
• Depressive Disorder
• Surgical Complication GI Tract
• Postoperative Infection
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Procedure Codes - Example
• Pericolostomy Hernia Repair• Peritoneal Adhesiolysis• Culture-Peritoneum• Culture and Sensitivity-Lower Resp Tract• Pulmonary Artery Wedge Monitor• Insert Endotracheal Tube• Mechanical Respiratory Assistance• Small Bowel Series
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Example - Narrative
• Patient with history of bowel resection admitted for surgical repair of malfunctioning enterostomy. On HD#1, underwent repair of pericolostomy hernia & lysis of adhesions. Developed postop infection & became acutely unstable. On HD#7, required PA monitoring, endotracheal intubation & mech ventilation.
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Basic Methodology
Exclude H M O , patien ts < 65Incom plete c la im s
L inkage w ith O ther D ata
C ohort o f Interest ? Exclude P revious D iagnosis(P reva lent cases)
Se lect D iagnosis or P rocedure
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Appropriate Conditions to Study
• Common diagnoses
• Seen in Medicare age population
• Result in hospitalization or encounter
• Coded frequently– Impact on reimbursement
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Potential Linkages
• Socioeconomic Measures– Census data (proxy)
• Tumor Registry– SEER-Medicare
• Physician and Provider– AMA Master File, AHA
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SEER-Medicare Database
• Collaborative effort with NCI and CMS– patients 65 years linked by unique identifiers
• SEER population-based registries (states and metro areas)– Covers ~ 25% of US population
• All Medicare files– inpatient and outpatient records
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500
1000
1500
2000
2500
1965 1970 1975 1980
0.25
0.5
0.75
1
1.25
1.5
storksbabies
pairs
of b
rood
ing
stor
ks
mil l
ions
of
new
born
bab
ies
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Colon Cancer Screening
What is current status of colon cancer screening?
What interventions protect against cancer development?
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Physician Specialty and Endoscopic Procedures
• 5% sample of Medicare claims, 1993
• Procedures examined– Colonoscopy– EGD– Sigmoidoscopy
• Medicare and AMA designated specialties
Meyer, J Gen Intern Med 2000
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Colonoscopy by Specialty
GIGenSurgColSurgGIMFP/GP
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Flexible Sigmoidoscopy Use
GIGenSurgColSurgGIMFP/GP
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Procedure Characteristics
• Specialists more likely to perform therapeutics, cancer or bleeding indications
• Generalists more likely in underserved counties
• Most colonoscopies and EGD’s by PCP’s in counties with at least one GI
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Hospital Type and Patient Outcomes
• SEER-Medicare database 1984-93• Major surgery: Whipple, esophagectomy,
pneumonectomy, liver resection (colorectal), pelvic exenteration
• Hospitals classified by total number of procedures
• Adjusted for age, stage and comorbidityBegg, JAMA 1998
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Hospital Volume and Mortality
0
2
4
6
8
10
12
14
16
18
30 Day Mortality
Whip Esoph Pneum Liver Pelvic
1--56--1011+
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Current Status of Screening
• Use largely determined by telephone surveys
• Differences among population subgroups
• Impact of 1998 legislation– Colonoscopy in “high risk” every 2 years (fam
hx, hx polyp or cancer, IBD) – Yearly FOBT, sigmoidoscopy every 4 years,
screening barium enema as substitute
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Cohort
• 1997-1999 Medicare Physician/Supplier and Outpatient files
• Claims for FOBT, flex sig, BE, colonoscopy
• Two comparison procedures (UGI and EGD)
• Approximately 25 million beneficiaries/year
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Annual Procedure Use
0
2000
4000
6000
8000
10000
12000
14000
16000
per 100,000
FOBT FS Colon BE EGD UGI
199719981999
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P r o c e d u r e U s e b y Q u a r te r - M a le s
05 0 0
1 0 0 01 5 0 02 0 0 02 5 0 03 0 0 03 5 0 04 0 0 0
Q u a r t e r
Vol
/100
,000 F O B T
F SC YB E
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Procedure Use in MenThree Year Average
0
2
4
6
8
10
12
14
16
18
FOBT Sig Colon BE EGD UGI
Ann
ual % Cau
AfAm
59%
61%
14%
18%
10%16%
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Procedure Use in WomenThree Year Average
0
5
10
15
20
25
FOBT Sig Colon BE EGD UGI
Ann
ual % Cau
AfAm
47%
33%0%
15%18% 16%
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Racial Differences in Indications for FOBT
0
2
4
6
8
10
12
14
16
M W M W
Ann
uali
zed
%
CauAfAm21% 13%
81%67%
DIAGNOSTIC SCREENING
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Racial Differences in Indication for Colonoscopy
0
0.5
1
1.5
2
2.5
3
3.5
4
M W M W M W
Ann
uali
zed
%
CauAfAm
DIAG SURV SCREEN
20% 17%
117%
63%
30%
9%
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Summary
• Use of screening procedures lower than targets
• Little impact of reimbursement changes
• Use of colonoscopy increased despite reimbursement issues
• Racial disparities persist
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Barrett’s Screening
Does endoscopic screening improve outcome?
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Prior EGD for Esophageal Adenocarcinoma
• Screening for and Surveillance of Barrett’s Esophagus Recommended
• Goal to Detect Presymptomatic High Grade Dysplasia and Adenocarcinoma
• Actual Use and Potential Impact of Screening Not Well Defined
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Cohort
• SEER-Medicare Database
• Patients with Adenocarcinoma of the Esophagus (n=777) or Cardia (n=856)
• Diagnosed 1993-6
• Age 70
• Non-HMO enrollees
• Staged
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Measures
• EGD Prior to Diagnosis– > 6 months– > 1 year
• Prior Diagnosis of Barrett’s Esophagus
• Stage at Diagnosis
• Survival - unadjusted, adjusted
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Rate of Barrett’s Diagnosis & Prior EGD
7.5
14.713
1.3
8.66.8
0
2
4
6
8
10
12
14
16
% Patients
Esophagus Cardia
BE 6 mosEGD 6 mosEGD 1 yr
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Staging Comparisons: 1 Year EGD & Esophageal Cancer
1.4
12.2
34.1
50
30.7
21.6
33.9
16.2
05
101520253035404550
% of Patients
In Situ Local Regional Distant
p<0.001
No EGDEGD
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Staging Comparisons: 1 Year EGD & Cardia Adenocarcinoma
1.3 0
26
48.9
35.1
28.9
37.6
22.2
05
101520253035404550
% of Patients
In Situ Local Regional Distant
p<0.01
No EGDEGD
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Outcomes of Patients With and Without Prior EGD
• Median Survival Time– Cardia: 8 months EGD vs. 6 months others– Esophagus: 7 months EGD vs. 5 months others
• Adjusted Survival– Cardia: Hazard Ratio 0.87 (0.63-1.20)– Esophagus: Hazard Ratio 0.73 (0.57-0.93)
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Conclusions
• EGD Performed > 1 Year Prior to Diagnosis of Esophageal or Cardia Adenocarcinoma Associated with Earlier Stage at Diagnosis and Improved Survival
• Most Patients at Risk Appear Undiagnosed
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Summary - 1
• Claims data provide a unique opportunity to study:– Epidemiological measures– Patterns of care/practice patterns– Treatment/outcome differences – Provider performance
• Data are linkable with registry, population demographics, provider characteristics
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Summary - 2
• Complexity of files– inpatient alone simplest but also most limited– outpatient and pharmacy data complex
• Limitations of data– adequate severity adjustment – incident vs. prevalent cases– miscoding (random vs. systematic)