Cancer

You are currently browsing articles tagged Cancer.

California Health Care Almanac

December 23, 2011 in HC Statistics, Quality | No comments

The California Health Care Foundation (CHCF)’s Health Care Almanac provides some unique insights on trends in health care quality in California and for the United States as a whole.  Many of the national figures for the Almanac come from the CDC (BRFSS and Vital Stats) and AHRQ’s National Healthcare Quality Report.  California quality figures come from the California Department of Public Health, the Office of Statewide Health Planning and Development and the California Health Interview Survey.

Although not discussed in this post, another portion of the Health Care Almanac looks at quality by site of service.  Much of this data comes from Hospital Compare, CMS OASIS data, AHRQ’s National Healthcare Quality Report, and the Dartmouth Atlas.

Today I highlight 3 topics related to clinical quality:

  • Cesarean Deliveries
  • Infant Mortality
  • Cancer Incidence.

More detail is below.

Read the rest of this entry »

Tags: , , , , , ,

Does getting cancer incentivize individuals to switch from Medicare managed care to FFS?

November 8, 2011 in Cancer, Medicaid/Medicare, Medicare Advantage, Quality | No comments

Medicare beneficiaries have a choice: pick the standard Medicare fee-for-service (FFS) benefit or rely on managed care plans to supply their healthcare through the Medicare Advantage (MA) program.  Many Medicare beneficiaries prefer MA because it offers them lower out-of-pocket costs and provide benefits not available in the traditional FFS Medicare program. Other beneficiaries prefer the FFS benefit because MA plans typically restrict provider choice in an effort to control costs.

The quality of care in Medicare MA relative to FFS, however, has still not yet been consistently evaluated.  Because beneficiaries can switch from MA to FFS each year, if quality is low, healthy individuals may prefer MA to reap the reduced cost sharing benefits, but when they become sick they may switch to Medicare FFS.

A study by Elkin and co-authors evaluates whether or not this is the case for beneficiaries who get cancer.

Data and Methodology

“We identified Medicare managed care enrollees aged 65 years or older who were diagnosed with a first primary breast (n = 28 331), colorectal (n = 26 494), prostate (n = 29 046), or lung (n = 31 243) cancer from January 1, 1995, through December 31, 2002, in Surveillance, Epidemiology, and End Results (SEER) cancer registry records linked with Medicare enrollment files. Cancer patients were pair-matched to cancer-free enrollees by age, sex, race, and geographic location. We estimated rates of voluntary disenrollment to fee-for-service Medicare in the 2 years after each cancer patient ’ s diagnosis, adjusted for plan characteristics and Medicare managed care penetration, by use of Cox proportional hazards regression.”

Results

The authors find that MA beneficiaries with cancer are less likely to switch to FFS than a cancer-free beneficiary. The hazard ratios range from 0.78 for colorectal cancer to 0.86 for prostate cancer. The results were consistent across various age, sex, race, cancer stage and region strata.

The likely reason for this finding is that people who have a serious disease do not want to change coverage. Even if the FFS benefit offers improved access to better care, there are significant costs of switching coverage. The new FFS providers may have less knowledge of the individual beneficiary’s health condition and the change can be stressful for the beneficiary as well. A worthwhile analysis to confirm whether this is the case would be to examine whether FFS beneficiaries who contract cancer are more likely to switch to a MA plan after contracting cancer. If the transaction cost/care coordination is driving Elkin’s results, then FFS beneficiaries with cancer should also be less likely to switch to MA than cancer-free FFS beneficiaries.

It could also be the case that MA provides high quality care for the most prevalent cancers (i.e., prostate, lung, colorectal, and breast), but there is a significant improvement in quality when beneficiaries visit FFS providers when they have rarer diseases. To confirm whether or not this is the case, the authors examine whether beneficiaries with non-Hodgkin lymphoma, acute leukemia, and soft tissue sarcoma are more likely to switch to FFS. The authors found no effect of these cancer diagnoses on the likelihood of disenrollment from a managed care plan.

Read the rest of this entry »

Tags: , , , , , ,

Determining Population Size

April 26, 2011 in Econometrics | No comments

How do ecologists determine the size of a population?    One method is the mark and recapture (a.k.a. capture/recapture method).  This method relies on having two separate trials to capture (either physically or in data) members of certain population and determines the population size based on the proportion of specimens who are captured in both trials.

The key assumption for the capture/recapture method is that the probability of capturing any given specimen is independent for each trial.  If one was doing a capture/recapture study and one could more easily capture fat and old birds, then the likelihood of catching the same bird in the second trial would increase.  This would inflate the value of m, and thus the approximation of the population would be too low.

One application of the capture/recapture method is McClish et al. (1997)‘s examination of the size of the elderly cancer population in Virgina.  The authors estimate  the likelihood cancer patients appear in both the Virgina Cancer Registry (VCR) and the Medicare claims files (MEDPAR) for Virginia resident 65 and older.

“Capture-recapture techniques were used to estimate the actual cancer population size, based on the concordance and discordance of the data sources. If VCR identifies M cases and MEDPAR identifies n cases, m of which are common to both sources, then the estimated number of cases in the entire population of cases at reporting hospitals will be N = [(M + 1) X (n + 1 )/(m + 1)] – 1. With this estimate of the population, the sensitivity of each source alone, as well as those of the combined sources, was estimated.”

The variance of the total population is simply:

  • var(N) = [(M+1)(n+1)(M-m)(n-m)]/[m+1)(m+1)(m+2)]

Read the rest of this entry »

Tags: , ,

Calculating zero inflation when drug costs rose from $100 to $36,000

August 23, 2009 in Pharmaceuticals | No comments

A paper by  Claudio Lucarelli and Sean Nicholson  (2009) examines the skyrocketing cost of colorectal cancer treatment.  In 1993, the price of treating these patients with chemotherapy was only $100.  By 2005, this price had skyrocketed to $36,000.  Is this what is wrong with our health care system?

The authors claim that the answer is no.  Although prices increased, so did quality.  Thus, the price per unit of quality has stayed fairly constant over time.  In the author’s words:

“Using discrete choice methods to estimate demand, we construct a price index for colorectal cancer drugs for each quarter between 1993 and 2005 that takes into consideration the quality (i.e., the efficacy and side effects in randomized clinical trials) of each drug on the market and the value that oncologists place on drug quality.  A naive price index, which makes no adjustments for the changing attributes of drugs on the market, greatly overstates the true price increase.  By contrast, a hedonic price index and two quality-adjusted price indices show that prices have actually remained fairly constant over this 13-year period, with slight increases or decreases depending on a model’s assumptions.”

Tags: , , , ,

Cuban Exports: Sugar, Cigars…and Cancer drugs?

March 26, 2009 in Health Care in Developing Nations, International Health Care Systems, Pharmaceuticals | 3 comments

Cuba is well known for its high quality cigars and sugar production, but is less well-known for its production of high quality pharmaceuticals.  According to MSNBC, “With more than 7,000 scientists dedicated to researching new drugs, Cuba has one of the most sophisticated biotech industries in the developing world. Last year the country earned $350 million from exporting 180 different medicines.”  After Ronald Regean reinstated the Cuban trade embargo in 1982, Cuba had to rely on its own biotech industry to produce drugs, since it could not import them directly from the U.S.  Thus spawned the Cuban biotech industry.

The latest news out of Havana claims that Cuba researchers have a new discovery.  According to news reports from Havana, a Cuban Research Institute has just patented a promising lung cancer drug.  The drug is called CimaVax EGF and in clinical trials it has been shown to increase life expectancy in lung cancer patients by 4-5 months.  Researchers claim that those who use CimaVax EGF “…breathe easier, experience less fatigue, less pain and increased appetite. It is administered in conjunction with conventional treatments of chemo and radiotherapy.”

When you think of Cuba, images of  Fidel Castro and Cohiba may come to mind.  But soon, you may have to think of Cuba as the home of live-saving lung cancer drugs.

Tags: , ,

Are we winning the war on cancer?

January 9, 2009 in HC Statistics | 3 comments

Since the early 1980s, age-adjusted cancer mortality rates have been falling over time. Is this due to better screening, better treatment, or healthier behavioral factors? Is this progress cost-effective? Are we really winning the war on cancer?

A paper by Culter (2008) tries to answer this question. First it is important to note that there are two types of cancer. Localized tumors are located only in the originating tissue and metastatic tumors have spread to other parts of the body. “Localized cancer isn’t fatal; metastatic cancer is both lethal and incurable—even with recent treatment advances.”

Falling Cancer Mortality Rates

Raw cancer mortality statistics mask the significant benefits of cancer treatment and screening.  Since the reduction in the number of deaths from cardiovascular disease has fallen since 1970, the concurrent decline of cancer deaths is even more impressive since individual who will not die of heart disease are more at risk now of dying of cancer.  Of the decline in cancer-related mortality, 78% of this decline is due to decrease mortality in 4 types of cancer: lung cancer, colorectal cancer, breast cancer, and prostate cancer.   The risk factors for each of these disease can be found in Table 1.

Explanations for the reduction in cancer mortality can be found in Table 2.  Of the reduction in cancer mortality 78% comes from improved mortality from lung, colorectal, breast, and prostate cancers.  Of this reduction, 71% is due to healthier behaviors and better screening; only 29% is due to improved treatments.

Cost Effectiveness

One question that remains was whether or not this reduction in mortality was worth the cost.  Many people will say that life is priceless and we can not measure the value of a year of life…but economists believe they can.  “The analysis of screening is complicated, because the cost-effectiveness of screening depends on how frequently it is performed: if screening is either too frequent or too infrequent, it will have high costs relative to benefits.”  Further, decreasing mortality, but ignoring side effects may not be rational.  “Treatment of prostate cancer, for example, may lead to greater survival, but it frequently leads to reduced quality of life—impotence and incontinence are common side effects. For cancers where treatment is not very effective or where cancer would often not be a cause of death, treatment may even reduce quality-adjusted life expectancy.”

Table 3 shows Cutler’s evaluation of the cost effectiveness of various cancer screening tests.  Breast cancer and colorectal cancer screening are highly cost effective.  On the other hand, lung cancer screening is not seen to be cost effective since the knowledge of the existence of lung cancer rarely alters the treatment.  Prostate cancer screening does improve longevity, but the cost effectiveness depends on how one values the potential side effects of impotence and incontinence.

Compared to screening or behavior changes, cancer therapies are much less cost effective (Table 4).  The author notes that “Spending on cancer is generally U-shaped with time from diagnosis. Costs are high immediately after diagnosis, decline as the cancer goes into remission (if it does), and then increase substantially at the end of life.”

More Cost Effectiveness

The cost of treatment is growing over time.  One example of this the price of cancer drugs (see Table 5).  In the U.S., drugs only have to meet a safety and a minimum efficacy requirement.  In the UK, NICE ensures that drugs are cost effective as well.  In fact, NICE does not cover Avastin or Erbitux because they are not deemed to be cost effective.  Another issue related to drug cost-effectiveness is that “Many of the new, expensive drugs are tested first in metastatic settings because that is where clinical trials are easiest to conduct. Only later are tests done in non-metastatic cases. It is possible—even likely—that the effectiveness of new medications will be greater in non-metastatic settings.”

Tags:

Americans have the best cancer survival rates

July 22, 2008 in International Health Care Systems, Medical Studies | Permalink

On Friday I reported that the U.S. scored poorly on the Commonwealth Fund’s National Scorecard. Those in favor of universal health care are probably rejoicing. “The U.S. system is dysfunctional beyond repair and we need universal health care!”

Yesterday, the Economist reported on an article in The Lancet Oncology journal which found that the U.S. has the best five year survival probabilities for breast and prostate cancer. Score one for those against universal health care. “The American free market is always the best!”

How can this be? How can we reconcile these two results?

The Lancet Oncology article controls also for other covariates which are related to survival probabilities, but do not relate to the quality of health care. For instance, if Americans get cancer later in life than people from other countries this is taken into account since people who are older are more likely to die of almost all causes, including cancer. Further, if traffic mortalities or the homicide rate are higher in the U.S. than in other countries, this will likely decrease the probability a cancer patient survival for 5 years, but is unrelated to the quality of medical care. If Americans are more likely to be obese, this also will decrease their survival probabilities, but should not be an indictment against the health care system. For these reasons, the 5 year cancer survival probabilities are adjusted to take into account the age and death rates in the general population. After these effects are taken into account, the U.S. scores very well in terms of cancer survival.

Of course cancer survival is only one of a myriad of ways of measuring the quality of the American health care system. Further, the U.S. spends the most money on healthcare (in total and per capita) compared to any other country. While the U.S. may (or may not) be the best, it is certainly the most expensive.

Tags: ,