1. Using SEER-Medicare Data to Enhance Registry Data to Assess Quality of Care Joan Warren Applied Research Program National Cancer Institute NAACCR June 6, 2007

2. What are the SEER - Medicare data? The SEER-Medicare data are the result of the linkage of two large population-based sources of data: cancer registry data from NCI’s sponsored cancer registries (SEER program) and Medicare claims from CMS The SEER registries collect detailed clinical, demographic and cause of death information for persons with cancer Medicare data are longitudinal, with claims for all covered fee-for-service health care from the time of eligibility to death There are currently over 1.8 million cases in the data

3. Why link the SEER-Medicare Data? The linked data can be used for a number of analyses that span the course of cancer control activities Diagnosis/ Tx  Survivorship  Second Occurrence  Terminal Care Patterns of care Peri-operative complications Volume outcomes studies Extent of staging Comorbidities Late effects of treatment Post-diagnostic surveillance Treatment of prevalent cancers Survival Rates of second primaries Relationship of second events to initial treatment and ongoing surveillance Use of hospice services Patterns of care during the last year of life Quality of care, h ealth disparities, and cost of treatment

4. Persons included in the SEER-Medicare Data 100% of patients in the SEER data who are found to be Medicare eligible 5% random sample of persons residing in the SEER areas who have not been diagnosed with cancer These people can be used to create comparison groups as well as to create estimates of diagnostic testing and treatment practices in the entire population Medicare files available for the non-cancer cases are the same as for the cancer cases

5. What is included in the SEER-Medicare Data SEER Data including Incidence, site, stage, initial tx, demographics and vital status Medicare claims for: Short stay hospitals Physician and lab services Hospital outpatient claims Home health and hospice bills

6. Other variables available in the SEER-Medicare data 1990 and 2000 Census data at the census tract and zip code level for ecological SES measures Health Care Service Area from Area Resource File Hospital and physician characteristics- ex. bedsize, hospital ownership, physician specialty

7. Years of SEER-Medicare Data Available SEER data are available for the entire time a registry has participated in the SEER program; some registries go back to 1973 Medicare claims are available from 1991-2005, except for hospital data that are available back to 1986 Cases reported through 2002 Update of the linkage is underway. It will include cases through 2005 with Medicare claims through 2006.

8. Limitations of the SEER-Medicare Data Observational data- pts are not randomly assigned to treatment Non-covered services excluded: prescription drugs, long- term care, free screenings Reasons for tests are not known; this raises challenges w/measuring screening Results of tests not available Does not include claims for care provided to persons in HMOs (about 22% in SEER areas) Under 65 population includes only the disabled/ESRD

9. Using the SEER-Medicare Data to Assess Quality of Cancer Care The SEER-Medicare data are a good resource to measure quality of cancer care: Data are longitudinal Can look at claims prior to diagnosis to adjust for pre- existing conditions Cross most components of the health care system Challenges of using these data to assess quality of care Secondary data do not capture factors that may influence treatment choices; especially an issue in the elderly There are a limited number of treatments for which there is consensus regarding treatment

10. Examples of Quality of Care Studies Using SEER-Medicare Data Investigators have used SEER-Medicare data to: Assess if patients received routinely provided care- Surgery Adjuvant therapy (RT/Chemo) Post-diagnostic surveillance Examine health system factors related to outcomes Hospital and physician characteristics Volume outcomes

11. Are All Medicare Beneficiaries with Early-Stage Non-Small Cell Lung Cancer Receiving Potentially Curative Surgery? Black persons with early stage non-small cell lung cancer have poorer survival than do comparable white persons Early-stage non-small cell lung cancer is potentially curable by surgical resection Investigators used SEER-Medicare data to estimate the rates of surgical treatment between blacks and whites and to determine if disparities in survival could be explained by differences in use of surgery

12. Survival of Medicare beneficiaries aged 65+ with Stage I/II non-small cell lung cancer, by treatment and race, 1985-1993

13. CONCLUSIONS The lower survival rate among black patients with early-stage, non-small-cell lung cancer, as compared with white patients, is largely explained by the lower rate of surgical treatment among blacks.

14. Use of Adjuvant Chemotherapy for Medicare Beneficiaries with Stage III Colon Cancer Use of adjuvant chemotherapy following a diagnosis of Stage III colon cancer has been guideline treatment for many years There are concerns that some patients are not receiving adjuvant treatment because of their age or race Investigators have used the SEER-Medicare data to assess use of adjuvant chemo in Medicare beneficiaries with Stage III colon cancer

15. Schrag et al, JNCI 2001 Receipt of Adjuvant Chemotherapy for Medicare Beneficiaries with Stage III Colon Cancer by Age Group

16. Referral to Medical Oncologist and Receipt of Chemotherapy Among Those Who Saw an Oncologist Among Medicare Beneficiaries with Stage III Colon Cancer Baldwin LM, et al. JNCI Aug 2005. Saw a Medical Oncologist Received Chemotherapy Percent

17. Assessment of Post-diagnostic Surveillance SEER-Medicare data have been used to evaluate whether patients are receiving the recommended surveillance following a cancer diagnosis: Persons with superficial bladder cancer who have not undergone total cystectomy should undergo bladder surveillance with cystoscopy every 3-6 months Men with prostate cancer who opt for expectant management should have a PSA test every 6 months

18. Surveillance among Medicare Eligible Patients with Superficial Bladder Cancer over a 30-month interval following diagnosis, by Age Group Source: Schrag D et al. J Natl Cancer Inst. 2003 Apr 16.

19. Receipt of PSA Testing 7-24 Months Following a Diagnosis of Prostate Cancer for Men Choosing Expectant Management Shavers, et al., Medical Care 2004

20. Conclusions Bladder surveillance: Only 40% of the cohort received the recommended surveillance PSA tests: African Americans and Hispanics were significantly less likely to receive a PSA test. Black men are more likely to be treated with expectant management.

21. Does Provider Specialty or Provider Volume Impact on Patient Outcomes? Earlier studies have suggested that provider specialty and/or volume may improve patient outcomes Investigators used the SEER-Medicare data to compare outcomes for women following surgery for ovarian cancer Two studies were done: Does the specialty of the physician performing the surgeon impact on overall survival ? Is there a volume-outcome effect?

22. Adjusted Cox proportional hazards model for death from any cause for Medicare women with ovarian cancer Adjusted Hazards Ratio General Surgeon Gynecologic oncologist 1.00 0.85* General gynecologist 0.86* * P < 0.05 Earle CC et al. JNCI Feb 1 2006

23. Percent of Patients with Stage III/IV Ovarian Cancer Surviving 48 Months After Surgery by Hospital and Surgeon Volume Schrag D. et al. J Natl Cancer Inst. 2006 Feb 1.

24. Conclusions About Ovarian Cancer Treatment These data show that the volume of procedures is not a significant factor in patient survival It appears that physician training is associated with improved outcomes

25. Final Thoughts About Using SEER-Medicare Data to Assess Quality of Care Secondary data sources such as SEER-Medicare can be a powerful source of information because of their size and breadth However, these types of data do not offer definitive information about quality- why was treatment not given, what other factors influenced outcomes These data should be used to determine where more in-depth research should be focused.

26. More Details on the SEER-Medicare data SEER-Medicare WEB site http://appliedresearch.cancer.gov/seermedicare http://appliedresearch.cancer.gov/seermedicare