1. Patterns of Care in Breast Cancer: On Care Coordination in Underserved Populations and the Use of Health Claims Data. Patterns of Care in Breast Cancer: On Care Coordination in Underserved Populations and the Use of Health Claims Data. Roger Anderson, Ph.D. Professor Health Services Research Core Penn State Cancer Institute Penn State Hershey Medical College Research Roundtable Appalachia Community Cancer Network September 28, 2007 Hershey, PA

2. Research team PSU:Fabian Camacho, M.S. Gary Chase, Ph.D. WFU:Wenke Hwang, Ph.D. Kristie Long-Foley, Ph.D. Duke:Gretchen Kimmick, M.D. CCR:Karen Knight NCHS:Tim Whitmire, Ph.D. PSU:Fabian Camacho, M.S. Gary Chase, Ph.D. WFU:Wenke Hwang, Ph.D. Kristie Long-Foley, Ph.D. Duke:Gretchen Kimmick, M.D. CCR:Karen Knight NCHS:Tim Whitmire, Ph.D.

3. North Eastern North Carolina Counties Source, North Carolina Cancer Registry, 2005,; SEER, National Cancer Institute, 2005 Age adjusted Breast Cancer Death rate per 100,000

4. Objectives Describe assembly of linked-Medicaid- North Carolina cancer registry data. Describe assembly of linked-Medicaid- North Carolina cancer registry data. Describe the use of this dataset to identify unmet needs in cancer prevention and control Describe the use of this dataset to identify unmet needs in cancer prevention and control Discuss applicability to ACCN Discuss applicability to ACCN Discuss health services research implications Discuss health services research implications

5. Medicaid and Rural Health Medicaid is an important source of health insurance coverage for both rural residents and rural providers. Rural residents are more likely to live in poverty than urban residents, and are less likely to have employer sponsored health insurance coverage. Rural residents are more likely to be covered by Medicaid than are urban residents.

6. Percent Residents with Medicaid Coverage During the Past Year in Urban and Rural Counties. CPS, 2004-2005 StateRuralUrban Kentucky17.412.1 Maryland16.88.6 New York 17.418.3 Ohio11.212.3 Pennsylvania12.011.3 Virginia11.56.9 West Virginia 18.211.3

7. North Carolina Project NC Tumor Registry + Incident cases Incident cases Clinical data Clinical data 1 st course of Tx (FORDS) 1 st course of Tx (FORDS) Hospital Registrars Hospital Registrars Other facilities Other facilities Merged data Merged data CDC proficiency testing CDC proficiency testing NC Medicaid Claims All medical services* (ICD-9/10, CPT) All medical services* (ICD-9/10, CPT) Pharmacy (NDC) Pharmacy (NDC) [monthly eligibility] [monthly eligibility] [no clinical data] [no clinical data] * Variable by state

8. Database 1998-99 Medicaid Claims for North Carolina. N=1,401 female breast cancer (single primary, all stages, 20% all cases) N=1,401 female breast cancer (single primary, all stages, 20% all cases) Caveats of Medicaid claims: Caveats of Medicaid claims: Managed care organizations omittedManaged care organizations omitted Dual eligibility - MedicareDual eligibility - Medicare Continuous enrollment - pre-and-post diagnosis.Continuous enrollment - pre-and-post diagnosis. Bundling of claims (date/services)Bundling of claims (date/services) Completeness of claims (unbilled services?)Completeness of claims (unbilled services?)

9. Data Sources Caveats of Hospital Registry data: Caveats of Hospital Registry data: First course of treatment may be defined as 4-months post diagnosis.First course of treatment may be defined as 4-months post diagnosis. Treatment in physician offices may go unreported.Treatment in physician offices may go unreported. Out-of state services often missingOut-of state services often missing May exclude VHA casesMay exclude VHA cases Comorbidity – added in 2003Comorbidity – added in 2003 Non-registry (mid-size) hospitals lower quality dataNon-registry (mid-size) hospitals lower quality data

10. Data Sources Caveats of Medicaid data: Caveats of Medicaid data: 9- 12 months of continuous eligibility is generally needed. 9- 12 months of continuous eligibility is generally needed. Medicare files m,ay be needed for dually insured.Medicare files m,ay be needed for dually insured. Policies on covered services may vary by state.Policies on covered services may vary by state.

11. Methods Test Population (1998-99 cases): 1,401 cases single primary breast cancer in NC registry years 1998 - 1999. Test Population (1998-99 cases): 1,401 cases single primary breast cancer in NC registry years 1998 - 1999. Test sample: 845 (60%) cases enrolled in Medicaid 1 month prior and 12 months post registry date of diagnosis Test sample: 845 (60%) cases enrolled in Medicaid 1 month prior and 12 months post registry date of diagnosis Approach: Approach: 1) Assume registry data is accurate if treatment is listed as provided (not missing or indeterminate).1) Assume registry data is accurate if treatment is listed as provided (not missing or indeterminate). 2) Else, replace data with Medicaid claims (if discordant).2) Else, replace data with Medicaid claims (if discordant). 3) Validate by performing record review on sample of cases.3) Validate by performing record review on sample of cases.

12. Accuracy of Radiation data in BCS sample BCS sample Sensitivity Specificity Sensitivity Specificity Registry 84% 100% Registry 84% 100% Claims 95% 93% Claims 95% 93% Combined 97% 98%

13. Table 3. Adjusted Odds of Registry Codes for Radiation and Chemotherapy when Medicaid Claims are Present Sample N Caucasian vs Other # with radiation claims: 279 0.89 (0.48, 1.66) # with chemotherapy claims: 236 0.57 (0.31, 1.05) Dually Eligible No vs Yes 0.72 (0.37,1.40) 2.33 (1.24, 4.41) N/A vs 5 + cm 1.10 (0.36,3.31) 0.62 (0.17,2.35) 0-1 cm vs 5+ cm 2.39 (0.67, 8.54) 0.27 (0.05,1.65) 1-2 cm vs 5+ cm 1.71 (0.60, 4.84) 0.65 (0.18,2.27) 2-5 cm vs 5+ cm 2-5 cm vs 5+ cm 0.74 (0.29,1.94) 0.35 (0.12,1.09) Lymph Nodes Removed 1.15 (0.58,2.25) 0.94 (0.45,1.95) Class of Case 1 or 2 present 4 5.27 (0.54,51.14) 7.74 (1.22,49.09) 0.11 (0.037, 0.35) 0.43 (0.18,1.05) Registry Facility 7.77 (2.80,21.58) 4.31 (2.08,8.94) Days to first claims since dx (Rad column, Chem column) 0.989 (0.985,0.993) 0.994 (0.988, 0.998) Tumor Size CCR Agreement on Radiation CCR Agreement on Chemotherapy

14. Examples of Application to Answer Patterns of Care And Outcomes Research Questions And Outcomes Research Questions

15. Table 1. Correlates of Under Use of Radiation Treatment with BCS in North Carolina Medicaid TotalRadiationNo Radiationp N= 344 N=242 (70.4%) N=102 (30.0%) Age group at time of diagnosis 65+ years159 (46.2%)58.4941.51<.0001 <65 years185 (53.8%)80.5419.46 Race/ethnicity White175 (50.9%)69.7130.290.7931 Other169 (49.1%)71.0128.99 Charlson Comorbidity Score (Excluding Cancer dx) 0166 (48.26%)75.9024.100.0931 152 (15.12%)65.3834.62 2126 (36.63%)65.0834.92 Patient County of Residence Non-metropolitan county116 (33.7%)64.6635.340.0991 Metropolitan county228 (66.3%)73.2526.75 County Medicaid Density High (> 50 percentile)167 (48.55)68.2631.740.4107 Low177 (51.45)72.3227.68 Assisted Living 1 Yes80 (23.3%) 52.5047.500.0001 No264 (76.7%) 75.7624.24 Hospital Size 2 Large / Medium302 (72.52%) 72.5227.480.0182 Small 42 (12.21%) 54.7645.24 Surgery Hospital Volume 3 High/Medium (> 5000 patients discharges) 301 (87.50%) 72.4327.570.0257 Low43 (12.50%) 55.8144.19 Breast cancer patient volume (Medicaid) 4 Higher >50%312 (90.70%) 72.4427.560.0081 Lower 50%32 (9.30%) 50.00 1. Based on presence of any paid claims from nursing home (location of service=T), home healthcare services (Q) or skilled nursing facility (cos = 35,36). 2. Tertile distribution of number of beds reported by American Hospital Directory. 3. Based on patient discharges reported by American Hospital Directory 4. Median split of all breast cancer cases with Medicaid enrollment. Correlates of Under Use of Radiation Treatment with BCS in North Carolina Medicaid

16. Table 3. Interaction Graph showing unadjusted proportions of Radiation Treatment in BCS patients by Metropolitan Status and Hospital Size

17. Kaplan-Meier Survival Curves of All-Cause Mortality by Radiotherapy Treatment 0.00 0.25 0.50 0.75 1.00 05001000150020002500 Days since diagnosis No Radiation Radiation

18. Cormorbidity among Women with Breast Cancer in NC Medicaid N= 1,401 55 % had at least one other comorbid condition defined in Charlson comorbidity index 55 % had at least one other comorbid condition defined in Charlson comorbidity index Among those with comorbidity, > 50% had multiple conditions. Among those with comorbidity, > 50% had multiple conditions. The top three comorbid conditions were: The top three comorbid conditions were: Diabetes (26%) Diabetes (26%) Congestive heart failure (18%), Congestive heart failure (18%), Chronic pulmonary disease (11%). Chronic pulmonary disease (11%).

19. North Carolina Medicaid enrollees with a diagnosis of diabetes with and without breast cancer: Medication Possession Ratio: diabetes medicines/ insulin products 12 month days supply mean days (SD) ____________________________________________________ Women without cancer 300 (19) With breast cancer 205 (95)

20. Hormone Medication Persistence. NC Medicaid Breast Cancer Monali Bhosle OSU Cumulative nonpersistence rate based on number with + ER status who started therapy. No significant association between race and medication persistence adjusting for a type of index therapy and other confounders (hazard ratio (SE) [95%CI]: 1.13 (0.30) [0.68-1.89].

21. Current Multi-Site Study CDC Patterns of Care Study (Breast and CDC Patterns of Care Study (Breast and Prostate CA) Prostate CA) 7 States + PSU Registry data + CMS Centralized data processing (5 sites). Pooled data analysis Model Model NCCN guideline concordant care Health system and patient characteristics Care coordination

22. Proposal Develop set of cancer prevention and control outcomes consistent with CDC pattern of care studies. Develop set of cancer prevention and control outcomes consistent with CDC pattern of care studies. Seek funding to link 7 ACCN States Registry data to Medicaid/Medicare. Seek funding to link 7 ACCN States Registry data to Medicaid/Medicare. PSCI Health Services Research Core serve as Data and Support Center to provide: PSCI Health Services Research Core serve as Data and Support Center to provide: IRB templates Data acquisition and linkage Archive Analysis support