Impact of breast cancer treatment guidelines on surgeon practice patterns: results of a hospital-based intervention.

BACKGROUND: Despite evidence regarding the effectiveness of post-surgical treatments for early-stage breast cancer, older women are less likely to receive appropriate therapy. We evaluated the impact of surgeon-specific "performance reports" on adherence to treatment guidelines among older women with breast cancer. METHODS: We obtained diagnostic and treatment data from hospital tumor registries supplemented with self-reported adjuvant therapy information on 1099 patients with stage I or II breast cancer diagnosed between November 1, 1992, and January 31, 1997, at 6 Rhode Island hospitals. We compared rates of appropriate treatment receipt before and after distribution of performance reports. Hierarchical analysis was used to account for the nesting of patients within surgeons. Separate analyses of mastectomy and breast-conserving surgery were performed. RESULTS: Age was negatively associated with post-surgical treatment, with patients who had breast-conserving surgery and who were older than 80 years significantly less likely to undergo radiation therapy (adjusted odds ratio = 0.08 [0.04, 0.14]) or appropriate adjuvant therapies (adjusted odds ratio = 0.14 [0.08, 0.22]) or both relative to 70- to 79-year-old patients. This effect did not improve post-intervention. While there was much variability in compliance with guidelines, surgeons' characteristics did not explain this variation. CONCLUSIONS: In Rhode Island, advanced age continues to be associated with less than adequate breast cancer therapy. Providing surgeons with "feedback" on the appropriateness of adjuvant treatment for older patients was insufficient to alter established practices. Using guideline compliance data as standard "quality indicators" of physician practice may be required.

The treatment decision-making process: age differences in a sample of women recently diagnosed with nonrecurrent, early-stage breast cancer.

This research utilizes retrospective, self-report data collected from a nonprobability sample of women recently diagnosed with nonrecurrent, early-stage breast cancer to better understand how the treatment decision-making process varies with patient age. Three important areas--context, decision-making style, and influencing factors--are examined using bivariate and multivariate analyses. Findings indicate that although patients recalled similar contextual attributes, they reported attitudes, behavior, and considerations that differed by age. Older women were less likely than their younger counterparts to have desired participation in therapy selection, sought out medical information, or considered the possibility of recurrence when making treatment decisions.

Effect of the Medicare Catastrophic Coverage Act on payer source changes among nursing home residents.

The Medicare Catastrophic Coverage Act (MCCA) of 1989 was designed to expand Medicare's post-acute care benefits, reduce copayments, and raise the asset limit for Medicaid eligibility. This analysis uses a semi-Markov transition model to estimate the effect of the MCCA on changes to Medicare coverage and the spend-down rate among 5,551 new nursing home admissions followed for an average of 2.5 years. We found that Medicare use increased in 1989 and the risk of transiting from Medicare to self-pay decreased compared to 1988. Spend-down from self-pay to Medicaid was 60% more likely in 1990. The MCCA clearly increased access to Medicare coverage of nursing home care among individuals previously paying privately.

Longitudinal patterns of medical service use and costs among people with AIDS.

OBJECTIVE: This study examines the effect of race, HIV transmission group, and decedent status on the use and cost of inpatient and outpatient care among people with AIDS. DATA SOURCES: Data come from 914 people with AIDS who were receiving services in nine cities across the United States in 1990-1991 and who indicated that a hospital clinic was their usual source of care. Review of hospital medical and billing records provided data on use and costs of medical services over an 18-month period. Vital status was determined from hospital records and death certificates. STUDY DESIGN: Data from each respondent were aggregated into three-month intervals, beginning with the last quarter of data and working backward. Regression analyses using random-effect models and generalized estimating equations were conducted to assess temporal patterns of inpatient and outpatient use and costs. PRINCIPAL FINDINGS: Inpatient utilization and costs were higher for decedents than for nondecedents. However, differences between decedents and nondecedents varied as a function of race. Nonwhites had more inpatient use and higher costs than whites, but lower outpatient use, and these differences were greater among decedents. Inpatient nights and costs rose sharply in the six months prior to death. Outpatient use and costs did not display as strong a temporal trend. CONCLUSIONS: Much of the cost of treating HIV infection is concentrated in the period immediately preceding death. The intensity of service use in the terminal period should be considered when developing estimates of annual costs of care and when designing programs to provide community-based treatment.

An examination of the relationship of reimbursement and organizational structure to the use of hospice volunteers.

This article examines the use of volunteers in hospice based on a national study of hospice programs. The data collected as part of the study make it possible to address several questions related to the prevalence and role of volunteers. Does the prevalence of volunteers decrease with the availability of reimbursement for hospice services? Is reimbursement related to a shift in the types of activities performed by volunteers? Is the level of volunteer involvement and the mix of volunteer activities related to type of hospice organization? Although it was hypothesized that volunteer activities would shift to non-patient-related tasks with the availability of reimbursement, this was not found to be the case. The availability of Medicare reimbursement for hospice services was not related to a decrease in the ratio of volunteers to paid staff. Freestanding hospices utilized volunteers to a greater degree than institution-affiliated hospices.