Ensuring Quality Cancer Care (1999) / Chapter Skim
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5 Health Care Delivery and Quality of Cancer Care
5 Health Care Delivery and Quality of Cancer Care
Pages 116-143
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From page 116... ...
Whereas Chapter 4 was confined to a review of the literature on breast and prostate cancer, this summary focuses on the way attributes of the health care system affect quality more generally and thus includes studies of other cancers. Many studies, for example, address the relationship between professional or institutional experience, as measured by the number of operations performed, and outcomes for individuals with cancers for which high-risk surgery is indicated (e.g., pancreatic cancer)
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From page 117... ...
Ohen cancer patients are identified retrospectively, through cancer registry data or hospital discharge records, and outcomes are compared across different health care settings or processes of care. Alternatively, individuals with cancer in different settings may be identified shortly after diagnosis and followed prospectively with systematic measurement tools designed to assess different outcomes (e.g., quality-of-life measures)
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From page 118... ...
In a study by Greenberg and colleagues of patients with non-small-cell lung cancer, the significantly better mortality observed at university cancer centers than at community hospitals disappeared when functional status, instead of stage, was used to adjust the analysis. The patients diagnosed in academic cancer centers underwent more staging procedures (e.g., bone and liver scans)
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From page 119... ...
. A study of 28-day mortality rates for very low birth weight infants reported no difference associated with the number of such infants treated in the neonatal intensive care unit (Horbar et al., 1997)
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From page 120... ...
The effect of individual surgeon volume was not addressed. A limitation of this study is its reliance on hospital discharge data, which do not capture postdischarge events.
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From page 121... ...
chose five procedures that involve preoperative judgment, diagnostic accuracy, meticulous surgical technique, and demanding postoperative care: ~ . Pneumonectomy (removal of part or all of the Jung)
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From page 122... ...
: · Esophagectomy 62% · Pancreatectomy 53% · Hepatic resection 60% · Pelvic exenteration 36% · Pneumonectomy 35% TABLE 5.4 30-Day Mortality (percent) for High-Risk Cancer Surgery Among Medicare Beneficiaries, by Hospital Volume, ~98~!
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From page 123... ...
(1998) assessed the effect of hospital volume on inhospital mortality for both palliative and curative surgical procedures for 1,236 patients with pancreatic cancer hospitalized in Maryland from 1990 to 1995.
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From page 124... ...
(1995) used hospital discharge abstracts to identify 1,972 patients having pancreatic resection in New York State between 1984 and 1991.
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From page 125... ...
These analyses controlled for differences across facilities in patient age' race, year of surgery' surgeon specialty' and hospital teaching status. TABLE 5.S Radical Prostatectomy Outcomes Among Medicare Beneficiaries, by Hospital Volume, 1991-1994 Odds Ratio Compared to High-Volume Hospitals 30-Day Readmission Surgical Hospital Volume Mortality Rate Complication Low 1.53 1.25 1.30 Medium-low 1.44 1.13 1.16 Medium-high 1.41 1.08 1.08 High 1.00 1.00 1.00 SOURCE: Lu-Yao and Yao, 1998.
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From page 126... ...
Breast Cancer Surgery Roohan and colleagues report on the effect of hospital volume of breast cancer surgical cases on the five-year survival of 47,890 women (white and black) treated for breast cancer in New York from 1984 to 1989, identified through hospital discharge data and linked to the New York State cancer registry (Roohan et al., 19981.
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From page 127... ...
In particular, differences in staging procedures and case mix associated with hospital volume could bias results in favor of nlgner-volume hospitals te.g., referral centers tend to have a more favorable case mix)
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From page 128... ...
For breast cancer, where there were a number of methodologically sound studies, a pooled estimate of the effect of specialization showed that specialized cancer care was associated with an 18 percent reduction in five-year mortality. In general, Grilli judged the evidence far from conclusive because of major methodological flaws and speculated that publication bias favoring specialized centers may have accounted for observed trends.
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From page 129... ...
(1994) retrospectively compared survival of 133 patients with metastatic testicular cancer participating in a clinical trial at a large cancer center in New York (Memorial SIoan-Kettering Cancer Center)
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From page 130... ...
They studied 193 patients with metastatic testicular cancer treated at 14 Swedish or Norwegian centers between 1981 and ~ 986 who entered a clinical trial. if all care had been given at the lead institution, which treated 46 percent of cases, the chance of dying after controlling for known prognostic factors would have ~ ~ - ~ ~ - r -- ~been reduced by 28 percent.
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From page 131... ...
A limitation of this study is the lack of details about postoperative management, specifically chemotherapy, especially platinum-based regimens. The assumption was made that the primary surgeon was also in charge of the patient's postoperative care, including chemotherapy and referral to a medical oncologist, and that the ultimate survival outcome depended on the total management by the primary surgeon.
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From page 132... ...
compared the survival experience of women with breast cancer diagnosed between 198O and 1988 in western Scotland, according to whether or not their provider was a "specialist." Surgeons were characterized as specialists if they were involved in a dedicated breast clinic, organized and facilitated clinical trials, and kept separate records of patients limited to breast cancer. Such specialists provided about 25 percent of the care to the 3,786 cases.
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From page 133... ...
Specialty providers such as those in teaching hospitals differ from community-based providers in their use of staging procedures, which could contribute to a stage migration bias that favors specialists. MANAGED CARE VERSUS FEE-FOR-SERVICE CARE There is a great deal of interest in the way patients with chronic illnesses such as cancer fare within managed care organizations (see definition and discussion of managed care in Chapter 2)
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From page 134... ...
. Women enrolled in HMOs in both areas were more likely than those covered by FFS plans to have received breast conserving surgery (BCS)
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From page 135... ...
~ ~. TABLE 5.13 Outcome and Process Odds Ratios for HMO versus FFS Care for Elderly Women with Breast Cancer (in situ' Stages ~ and Il)
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From page 136... ...
Patients treated at an HMO facility had a 63 percent increased risk of dying, compared with the reference group treated in small hospitals, when age, tumor size, number of positive lymph nodes, and type of treatment (e.g., breast conserving surgery with radiation versus no radiation) were controlled for.
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From page 137... ...
There is very limited evidence on the way structures and technical processes of care affect cancer care outcomes, and the strength of available evidence is weakened by methodological shortcomings of the research. Only a handful of studies were available for this review on the effects of managed care or on the effects of the volume and specialization of facilities or physicians on cancer care quality.
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From page 138... ...
Few studies compared cancer care under managed care with fee-for-service care, and studies are usually limited to group- or staff-model HMOs that have a relatively small share of the total managed care enrollment. The limited body of evidence suggests that processes and outcomes of care in these managed care settings are equal to or better than those in fee-for-service settings.
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From page 139... ...
1998. Impact of hospital volume on operative mortality for major cancer surgery.
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From page 140... ...
1997. Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants.
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From page 141... ...
1995. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy.
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From page 142... ...
1998. Importance of hospital volume in the overall management of pancreatic cancer.
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From page 143... ...
1991. Use of Medicare claims data to evaluate outcomes in elderly patients undergoing lung resection for lung cancer.
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