R. L. Hoffman1, K. D. Simmons1, C. B. Aarons1, R. R. Kelz1 1University Of Pennsylvania,Philadelphia, PA, USA
Introduction: The ability to link cancer patient records across encounters could provide important information regarding the patterns of care associated with best practice. Using colon cancer as a model, the aim of this study was to investigate the role of physician type and order on the receipt of guideline-based therapy(GBT).
Methods: Patients aged 65-84yrs who underwent resection for AJCC stage III colon cancer were identified within the SEER-Medicare database(2005-2009). The administration of chemotherapy and/or radiation was determined using CPT codes across all encounters within 365 days of the colectomy date. Guideline adherence was assigned using stage-specific NCCN guidelines. Provider specialty(surgery, oncology, internal medicine, gastroenterology) and dates of service were identified from the first 4 claims which contained an ICD-9 diagnosis of colon cancer. Univariate analysis was performed. Forward stepwise multivariate logistic regression controlling for patient demographics and stratified by age group was performed to determine the association between physician type/order with inappropriate care.
Results:A total of 6139 stage III colon cancer patients were identified. The cohort was 56% female, 83% white, 73% <80 years of age. 69% of patients had ≥3 comorbidities. 57% received chemotherapy and 5% underwent radiation. 47% did not receive appropriate GBT(2880), 90%(2596) of whom were undertreated. A surgeon was seen within the first 4 claims following the diagnosis for 64%(3924) of cases and an oncologist in 15%(947). Patients saw multiple physicians on the same date 18%(1100) of the time. On univariate analysis, seeing a surgeon(OR 1.19; 95% CI 1.07-1.32), oncologist(OR 1.22; 95% CI 1.06-1.40) or gastroenterologist(OR 1.11; 95% CI 1.00-1.24) was associated with an increased odds of appropriate GBT, however physician order did not make a difference. On multivariate analysis, seeing a surgeon was associated with a significantly increased odds of appropriate GBT at all ages except >80 years(65-69 yrs OR 1.30, 95% CI 1.00-1.70) (70-74 yrs OR 1.35, 95% CI 1.07-1.69) (75-79 yrs OR 1.33, 95% CI 1.08-1.63) (≥80 yrs OR 1.06, 95% CI 0.85-1.33) and seeing an oncologist was significant for those age 75-79(OR 1.39, 95% CI 1.05-1.85). Other physician types were not significant. The physician of first contact was not significant except for those age 80-84yrs, where seeing an internist first was associated with an decreased odds of appropriate treatment(OR 0.60; 95% CI 0.38-0.95).
Conclusion:Rates of receipt of GBT in stage III colon cancer are low in the Medicare population, however seeing a surgeon within the first 4 physician visits has a significant impact on improving the rates of GBT in patients less than 80 years of age. Understanding the influence of provider type/order on the receipt of appropriate cancer care as a proxy for care coordination may allow a more robust understanding of where deficits occur in the patient experience.