Annual Meeting Proceedings Part 1 - American Society of Clinical ...

6118 General Poster Session (Board #11C), Mon, 1:15 PM-5:15 PM
Influence of hospital characteristics on immediate breast reconstruction
following mastectomy. Presenting Author: Catherine A. Richards, Mailman
School of Public Health, Columbia University, New York, NY
Background: Immediate breast reconstruction (IBR) following mastectomy
is underutilized in the U.S. Racial, economic and geographic factors are
associated with lower rates of IBR. Prior research has explored the
association of individual and surgeon-level factors with the use of IBR, with
little attention paid to hospital characteristics. Methods: We analyzed data
from the 2008 Nationwide Inpatient Sample (NIS), a 20% random sample
of academic, public and private U.S. hospitals. We used ICD-9 codes to
identify women diagnosed with invasive breast cancer or DCIS who
underwent mastectomy, and IBR (natural or expander/implant). If a
hospital performed at least one IBR during 2008, they were classified as
performing reconstruction. Relative risk regression was used to assess the
hospital factors associated with a hospital performing IBR. Results: Of the
3,518 hospitals that performed mastectomy in 2008 only 50.4% performed
at least one IBR. For hospitals that did not perform IBR, the average
number of mastectomies was 5, compared to 35 at hospitals that did
perform IBR (p�0.01). Among hospitals that did perform IBR, the mean
proportion of mastectomy patients that had IBR was 34% (SD�20). In a
multivariable adjusted model, urban/teaching (RR�3.47) and urban/nonteaching
(RR�2.86) hospitals were significantly more likely to perform IBR
compared to rural hospitals. Hospitals with a high proportion of privately
insured patients (RR�1.10) were significantly more likely to perform IBR
compared to hospitals with a low proportion of privately insured patients. In
contrast, hospitals with a high proportion of publically insured patients
(RR�0.24) and hospitals with a high proportion of female patients � 70
years old (RR�0.75) were significantly less likely to perform IBR. Hospital
region, hospital ownership status and the proportion of nonwhite patients
were not significantly associated with IBR. Conclusions: Almost half of all
U.S. hospitals where mastectomies are performed do not have any patients
who have undergone IBR. The likelihood a hospital will perform IBR varies
significantly by hospital characteristics.
6120 General Poster Session (Board #11E), Mon, 1:15 PM-5:15 PM
Do patient tracking, follow-up, and referral practices contribute to breast
cancer disparities in a large urban area? Presenting Author: Christine B.
Weldon, Center for Business Models in Healthcare, Chicago, IL
Background: Chicago Black women are 62% more likely to die from breast
(BC) cancer than White women. Previous data from 39 Chicago hospitals
suggested significant quality deficits in breast cancer screening and
treatment (Chicago Breast Cancer Quality Consortium, 2010). Patient
tracking, follow up and referral practices may influence quality of care for
minority women (Mojica et al, Cancer Control, 2007). Our goal is to
evaluate tracking, follow up and referral practices during screening,
diagnosis and treatment of BC at Chicago hospitals servicing Black women.
Methods: Using the framework approach of qualitative research, we
conducted interviews with providers of BC screening and care from 20
Chicago institutions with Black patients averaging 50% of patient base (15
community, 3 academic and 2 public hospitals). Informants included
surgeons, medical oncologists, radiologists, mammography technicians,
internists, nurses, administrators, and patient navigators. Interviews were
transcribed, and thematic and statistical analyses were performed (simple
frequencies and Fisher’s exact test). Results: Six of the 20 sites (30%)
follow up with patients who did not show for a scheduled mammography
visit. Five of these sites (83%, 5/6) have a low “no-show” rate (below 20%),
compared to 4 sites (29%, 4/14) with low “no-show” rates among the 14
sites without follow-up (p�0.05). Seven of the 20 sites (25%) direct
diagnosed patients to their next step in care by providing referrals and
guidance, while other 13 sites rely on a primary care physician or leave the
patient without a clear care plan. BC patients at 6 of the 7 sites directing
care (83%, 5/6) are referred to a mid- or high-volume surgeon (3� BC
surgeries / month), compared to patients from only 1 of the 13 sites not
directing care (p�0.001). Nine of the 20 sites track diagnosed BC patients
through their care. Five of them (56%, 5/9) also track survivors, compared
to none (0%, 0/11) of the 11 sites who do not track patients (p�0.008).
Conclusions: Poor tracking, follow up and referral practices for breast
cancer screening and treatment are associated with suboptimal care and
may contribute to outcome disparities for Black women in Chicago.
Health Services Research
411s
6119 General Poster Session (Board #11D), Mon, 1:15 PM-5:15 PM
Why do cancer patients die in the emergency department (ED)? Analysis of
283 deaths in North Carolina EDs in 2008. Presenting Author: Ashley
Nicole Leak, UNC Gillings School of Global Public Health, Department of
Health Policy and Management, Chapel Hill, NC
Background: Emergency departments (ED) in the US are utilized by cancer
patients for symptom management, treatment side effects, oncologic
emergencies, and/or end of life care. EDs have become a place where acute
care needs are addressed and there are discussions about end of life care.
The purpose of this study was to describe characteristics of cancer patients
who died in the ED, highlighting lung cancer patients and their ED visit
characteristics. Methods: A secondary data analysis of ED visit data fromthe
North Carolina Disease Event Tracking and Epidemiologic Collection Tool
(NC DETECT), a population database of 110 of the 112 EDs in NC in 2008.
This was a descriptive, retrospective analysis providing descriptive statistics
of patient demographics including: sex, age at death, insurance,
cancer type, and visit categories (hour, day, month). Free text chief
complaints, as recorded by the health care provider, were cleaned and
categorized. Results: There were37,760 ED visits by 27,644 patients
associated with cancer; 283 (1%) of these visits resulted in death in the
ED. The most common chief complaints of those who died were respiratory
distress (17.3%), neurological changes (13.4%), and pain (5.7%). Of all
cancer deaths, 63% were male with a mean age of 66 (SD 14.2). Over a
third (N� 104, 36.7%) of cancer ED visits resulting in death had a code for
lung cancer listed. Medicare was the insurance provided for almost half
(47.3%) of these patients. Majority of deaths occurred on a patient’s first
ED visit (70.9%). Although a third (34.7%) of deaths occurred during
weekends, over a third (37.5%) occurred during weekday clinic hours.
Conclusions: Even though deaths in the ED were infrequent, this study
provides insight into reasons patients visit the ED. Some patients were
enrolled in Hospice and/or had a DNR documented. This study can inform
future research associated with precipitating factors leading up to the ED
visit (e.g. worsening shortness of breath, location of care prior to ED visit).
This study illustrates the importance of research on discussion of end of life
care needs (advanced directives, code status, use of Hospice services) with
cancer patients and their family before they reach the final stage of their
disease.
6121 General Poster Session (Board #11F), Mon, 1:15 PM-5:15 PM
Competing event risk stratification may improve the design and efficiency
of clinical trials: Secondary analysis of SWOG 8794. Presenting Author:
Brent Shane Rose, Harvard University, Boston, MA
Background: Efficiency of clinical trials may be improved by stratifying
according to competing event risk. We aimed to test whether effect and
sample size estimates would be altered when adjusting for competing event
risk, using data from the SWOG 8794 trial of adjuvant radiation therapy
(RT) for high-risk post-operative prostate cancer. Methods: The primary
outcome was metastasis-free survival (MFS), defined as time to first
occurrence of metastasis or death from any cause (i.e., competing mortality
(CM)). We developed separate risk scores for time to metastasis and CM
using backward stepwise competing risks regression. Risk factors for
metastasis were PSA, Gleason score, and seminal vesicle invasion, and for
CM were age, performance status, and Charlson comorbidity index.
Treatment effects were estimated using Cox models adjusted for risk
scores. We identified an enriched subgroup of 75 patients at high risk of
metastasis and low risk of CM, based on risk score cutoffs. Sample size
estimates assumed type I and II error of 0.10 and 0.20, and accrual and
follow-up times of 6 and 6 years. Results: The mean CM risk score was
significantly lower in the RT vs. control arm (p�0.001). The effect of RT on
MFS (HR 0.70; 95% CI, 0.53-0.92; p�0.010) was attenuated when
controlling for metastasis and CM risk (HR 0.76; 95% CI, 0.58-1.00;
p�0.049). The hazard for CM was reduced by RT (HR 0.82; 95% CI,
0.59-1.14; p�0.24), but this effect was attenuated when controlling for
CM risk (HR 0.94; 95% CI, 0.67-1.31; p�0.71). In contrast, there was no
difference in the adjusted and unadjusted HRs for metastasis (0.50; 95%
CI, 0.31-0.81; p�0.005 and 0.49; 95% CI, 0.30-0.81; p�0.005).
Compared to the whole cohort, the enriched subgroup had the same
baseline 10-year incidence of MFS (40%; 95% CI 22-57%), but a higher
incidence of metastasis (30% (95% CI, 15-47%) vs. 20% (95% CI,
15-26%)). A randomized trial in an enriched population could have
achieved 80% power with 44% less patients (313 vs. 709 patients,
respectively), due to the differing event composition. Conclusions: Stratification
based on competing event risk may improve the design and
efficiency of clinical trials. These findings should be externally validated.
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