1. Defining a role for hospitals and health care systems in addressing cancer disparities
Kim F. Rhoads, MD, MS, MPH, FACS
california CANCER REGISTRARS ASSOCIATION
43rd Annual Education Conference
November 3, 2016

2. Disclosures
No commercial or financial conflicts

3. Motivation for the work: Jeannette Barnes (1935-1993)
58 years old
Presented with a locally advanced breast mass (stage IIIB)

4. Breast cancer care in a safety net hospital
No planned surgical intervention
No breast fellowship trained surgeon
No radiation therapy
?No radiation therapist
?No radiation oncologist
?No palliative care service
Given antibiotics and chemotherapy
Died during the hospitalization

5. Trends in Cancer Disparities
California Breast Cancer Trends
California Colorectal Cancer Trends
NCI website: last access 7/17/12

6. Traditional explanations for disparities in cancer survival
Patient Characteristics
Chronic disease/comorbid states
Late stage at diagnosis
Insurance Status
Lack of access to care contributes to poor outcomes
Genetic/epigenetic explanations
Minorities have more aggressive tumors

7. Expanding the explanations for cancer survival disparities
Disparities in Treatment
Lower quality treatment may drive worse outcomes
Surgical Volume & Outcomes
Use of low volume hospitals results in worse outcomes
Racial Disparities in Late Survival after Rectal Cancer
African Americans more likely to be treated for rectal cancer by low volume hospitals and fail to receive adjuvant therapy.
Morris AM, Wei Y, Birkmeyer NJ, et al. J Am Coll Surg. 2006
Race and Surgical Mortality in the United States
Black patients undergoing cancer operations in low percent black hospitals have better cancer survival.
Lucas FL, Stukel TA, Morris AM, et al. Annals of Surg 2006

8. Does Hospital Context and Quality Drive Disparities?
What is known:
Racial and ethnic disparities in cancer exist
Patient characteristics are associated with poor cancer outcomes
What is not well described:
What is the role of hospital characteristics on these disparities?
How are hospital characteristics associated with cancer outcomes and cancer disparities?

9. The IOM on hospitals serving high percentages of patients with Medicaid
“Because of Medicaid’s low reimbursement rates for doctors and hospitals, poor, disproportionately minority beneficiaries are subject to largely separate, often segregated systems of hospitals and neighborhood clinics. These systems often adopt their own norms of medical practice, shaped by tight resource constraints.”
Unequal Treatment, Confronting Racial and Ethnic Disparities in HealthCare , IOM 2002

10. Rhoads KF, Ackerson LK, Jha AK, Dudley RA. JACS 2008
Quality of Colon Cancer Outcomes in Hospitals with a High Percentage of Medicaid Patients
Rhoads KF, Ackerson LK, Jha AK, Dudley RA. JACS 2008

11. Methods
Data Sources
California Cancer Registry linked to Office of Statewide Health Planning and Development Discharge data
ICD-9CM coding of diagnosis, procedures and co-morbidities
Individual level/patient characteristics + what happens in hospitals
Added hospital financial characteristics
Defined High Medicaid hospitals based on Medicaid Utilization Rate
Analytic approach
Hierarchical modeling

12. High Medicaid Hospitals serve higher proportions of minorities and uninsured patients
Patient Characteristics
(n=18,000)
High Medicaid Hospital (%)
Non-High Medicaid Hospital (%)
Race/Ethnicity
White (non-Hispanic)
Black (non-Hispanic)
Hispanic
Asian Pacific Islander
38.6
12.5
24.9
24.0
76.5
6.2
9.9
7.4
Insurance Status
Private Insurance
Medicaid
No Insurance
Medicare
Unknown
25.5
16.6
10.7
37.9
9.3
49.2
2.5
1.4
45.1
1.8
Rhoads KF, Dudley RA. J Am Coll Surg 2008

13. High Medicaid hospitals are associated with higher colon cancer mortality
% Mortality at 30 days and 1 year for patients with colon cancer (California )
Rhoads KF, Dudley RA. J Am Coll Surg 2008

14. High Medicaid hospitals are associated with higher colon cancer mortality
% Mortality at 30 days and 1 year for patients using High Medicaid Hospitals (Colon Cancer, California )
Rhoads KF, Dudley RA. J Am Coll Surg 2008

15. Understanding disparities in cancer survival: place matters
Where you go for treatment…can influence survival
That where you go for care can directly impact what you get

16. Structural Quality Process Quality
How location of care can impact outcomes of care: Donabedian’s healthcare quality triad
Outcome Quality
Structural Quality
Process Quality
Surgical Volume
Surgical Specialists
PET/CT scanners
Rad Onc Facilities
Med/Rad Oncologists
Number of Lymph Nodes
sampled
Tumor Board Meetings
Receipt of (Neo)/Adjuvant
Preoperative Evaluation
Donabedian. Millbank Quarterly 2005

17. Rhoads KF, Ngo JV, Welton ML, Dudley RA. JHCPU, 2013
Do hospitals serving a high percentage of Medicaid patients perform poorly on evidence-based care for colon cancer ?
Rhoads KF, Ngo JV, Welton ML, Dudley RA. JHCPU, 2013

18. Defining evidence based care for colon cancer (NCCN guidelines)
2. At least 12 Lymph node should be examined after resection to determine disease stage.
Stage III
Stage I-II – 0 positive lymph nodes
Stage III – Any positive lymph nodes
1. Resections for colon cancer follow oncologic principles.
Stage I-II – No chemotherapy
Stage III – Chemotherapy
3. Disease stage determines therapy
Available at nccn.org

19. High Medicaid hospitals lag behind others for uptake and rate of 12 LN examination
0.0000
0.1000
0.2000
0.3000
0.4000
0.5000
0.6000
0.7000
0.8000
Proportion of Patients
HMH40
Teach
HVH
Trends in Receipt of adequate LN examination * * *
Consensus panel recommendation
Colon Cancer, California, ; from Rhoads et al. JHCPU 2013

20. Patients treated in HMH settings received chemotherapy for stage III disease at lower rates
0.5000
0.5500
0.6000
0.6500
0.7000
0.7500
0.8000
0.8500
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Proportion of Patients
Trends in Receipt of Appropriate Chemo
(Stage III | Colon Cancer)
HMH40
Teach
HVH
(Colon Cancer, California, ; from Rhoads et al. JHCPU 2013

21. Understanding disparities in cancer survival: place matters
Where you go for treatment determines the quality of care you get… and can influence survival

22. Structural Quality Process Quality
How location of care can impact outcomes of care: Donabedian’s healthcare quality triad
Outcome Quality
Structural Quality
Process Quality
Surgical Volume
Surgical Specialists
PET/CT scanners
Rad Onc Facilities
Med/Rad Oncologists
Number of Lymph Nodes
sampled
Tumor Board Meetings
Receipt of (Neo)/Adjuvant
Preoperative Evaluation
Donabedian. Millbank Quarterly 2005

23. Disparities in cancer mortality vary by tumor type
5-year survival rate
Absolute difference
Black
White
Prostate
97.5%
99.9%
2.4%
Pancreas
4.6%
4.7%
0.1%
Liver
6.5%
9.1%
2.6%
Lung
12.2%
15.2% 3%
Esophagus
10.5%
16.8%
6.3%
Colorectal
55.5%
65.6%
10.1%
Breast
76.6%
89.8%
13.2%
Bladder
64.8%
83.2%
18.4%
Head & Neck
40.5%
62.1%
21.6%
Uterine
61.8%
86.4%
24.6%
Morris and Rhoads JACS 2010.
Source: last accessed 7/08

24. How do integrated systems address disparities in colon cancer?
Rhoads KF, Patel MI, Ma Y, and Schmidt L. JCO, March 2015

25. Methods Data Source Predictor Variables Outcomes Analytic Approach
CCR + OSHPD + California hospital financial data ( )
Predictor Variables
Hospital characteristics—fully integrated (Berkeley Forum definition) versus all other health care settings
Outcomes
Delivery of evidence based care (NCCN guidelines)
5- year survival
Racial/ethnic disparities
Analytic Approach
Propensity Score Matching
with clinical, demographic AND social characteristics

26. Rates of NCCN guideline compliance were higher
Rates of NCCN guideline compliance were higher* in Integrated versus other settings
* There was no different between settings for 12 LN examination; rates ranged from 43.3% to 49.1%
Rhoads KF, Patel MI, Ma Y, and Schmidt L. JCO, March 2015

27. Propensity score matched survival shows integrated settings associated with survival advantage
Rhoads KF, Patel MI, JCO, March 2015

28. IHS are associated with smaller gaps in racial/ethnic survival
California, Colon Cancer, ; from: Rhoads KF, Patel MI, JCO, March 2015

29. Mortality disparities in integrated versus other settings; quality of care makes the difference
 Baseline Model
Integrated System
HR (95%CI) P
All Other Systems
Race/ethnicity
White
1.0 (referent)
Black
0.96 ( ) NS
1.15 ( )
<0.001
Hispanic
0.92 ( )
0.90 ( )
0.009
API
0.83 ( )
0.79 ( )
Baseline + Evidence Based Care
0.79 ( )
0.02
1.09 ( )
0.86 ( )
0.09
0.87 ( )
0.001
Asian
0.79 ( )
0.05
0.73 ( )
Models adjusted for age; gender; Charlson comorbidity score; stage of disease. Abbreviations: HR-hazard ratio; 95% CI-95% confidence interval; API-Asian/Pacific Islander
Interaction terms crossing race * location of care no qualitative difference (not shown)

30. Conclusion: improving quality of care & cancer care equity can address cancer disparities
California’s largest integrated system has higher adherence to evidence based care guidelines than other systems in the state
Propensity score matched comparisons showed lower mortality after care within an integrated system
There were smaller disparity gaps in treatment in the integrated system and no detectable racial differences in survival
Most importantly, adjusting survival models for delivery of evidence based care eliminated survival disparities in all other settings
Similar findings in Acute Myeloid Leukemia
Patel MI & Rhoads KF, CEBP March 2015

31. Why is the role of hospitals and health care systems so important in addressing cancer disparities?

32. Structural Quality Process Quality
How location of care can impact outcomes of care: Donabedian’s healthcare quality triad
Outcome Quality
Structural Quality
Process Quality
Surgical Volume
Surgical Specialists
PET/CT scanners
Rad Onc Facilities
Med/Rad Oncologists
Number of Lymph Nodes
sampled
Tumor Board Meetings
Receipt of (Neo)/Adjuvant
Preoperative Evaluation
Donabedian. Millbank Quarterly 2005

33. Minorities under utilize facilities that deliver high quality cancer care
Huang lC, Ma Y, NgO JV, Rhoads KF. Cancer 2014
Huang lC, Ma Y, NgO JV, Rhoads KF. dis col and rectum 2015

34. Higher proportions of minorities in California live close to an NCI center
Percentage of each racial group living nearby (within 5 miles of) an NCI hospital (Colorectal Cancer , California (N=79,231))
10% % % %
Huang LC, Rhoads KF. Cancer 2014

35. Insurance status does not explain minority under-utilization of NCI settings
Baseline Model
Odds ratio
P-value
Insurance Model
Race
White (ref)
1.0
Black
0.83
0.008
0.81
<0.001
Hispanic
0.72
0.70
API
1.40
1.39
Insurance
Private (ref)
Medicaid
1.85
Medicare
2.10
No insurance
0.86
0.311
Missing data
1.93
Huang LC, Rhoads KF. Cancer 2014

36. Neighborhood demographics are more important predictor of NCI use than travel distance
Lower odds of utilization Higher odds of utilization
Huang LC, Rhoads KF. Cancer 2014

37. Where do we go from here? Implications for increasing equity and quality in cancer care

38. A conceptual framework for understanding disparities in cancer survival

39. California Cancer Registry Data: Current State
CCR data is collected and curated under California state law whose language focuses on reporting of cancer incidence (epidemiology); and detection of geographic high incident areas
There is no language (currently) in the law to support the use of data for quality reporting or quality improvement

40. Leveraging the CCR to measure & improve quality of care and outcomes
Section of the Health and Safety Code recommended amendments:
c) The director shall analyze data collected under the program to assess , measure and publicly report on the quality of cancer care in the state. In assessing and measuring the quality of cancer care, the director shall define and identify oncology providers. In publicly reporting the quality of cancer care in the state, the director shall identify oncology providers but not any cancer patients….
Section of the Health and Safety Code recommended amendments:
a) “The director shall also identify and include in the statewide system cancer care quality measures for use in public reporting.
Fighting cancer with data: Enabling the California cancer registry to Measure and Improve care.
California Health Care Foundation, November 2014 (Available online at:

41. Registry data can play a critical role in helping hospitals & healthcare systems address disparities
Patient Level: Increasing patient access to cancer care quality information
Use data to identify high and low performing health systems and hospitals
Hospital level: Monitoring hospital performance
Use the data to identify high and low performing hospital (by name or characteristics)
Designing and deploying large scale interventions to improve quality (at the hospital level)
Health Care System level: Inform CMS reimbursement policy for Oncology Care Model sites
NCCN guidelines define high quality care for OCM
Use registry data to document compliance with guidelines (over time)
Use long term data to rationally risk adjust reimbursement policies (Pay for Performance programs), to avoid unintended consequences of financial penalties in low resource settings
Acknowledge the importance of the data we have available in California and begin to talk about the important ways in which we can leverage it to improve the quality of care for everyone AND address disparities, because it is a matter of quality.
The CCR has strength at multiple levels in terms of addressing these issues:

42. Where are we trying to go: Equality versus Equity
AS WE MOVE toward equity we need to look at systems that have found ways to steer behavior through control over the environment—what’s available to provide care, “what’s in the fridge” because it provides less opportunity to disadvantage the already disadvantaged
Everyone gets the same
resources
Everyone gets the resources they need

43. IN CLOSING…

44. Defining a role for hospitals and health care systems in addressing cancer disparities
Thank You for what you do!