Jennifer Malin - Academia.edu (original) (raw)

Papers by Jennifer Malin

Research paper thumbnail of Cancer Patients' Roles in Treatment Decisions: Do Characteristics of the Decision Influence Roles?

Journal of Clinical Oncology, 2010

Patients with more active roles in decisions are more satisfied and may have better health outcom... more Patients with more active roles in decisions are more satisfied and may have better health outcomes. Younger and better educated patients have more active roles in decisions, but whether patients' roles in decisions differ by characteristics of the decision itself is unknown.

Research paper thumbnail of Palliative Radiation Therapy Practice in Patients With Metastatic Non-Small-Cell Lung Cancer: A Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study

Journal of Clinical Oncology

PURPOSERandomized data suggest that single-fraction or short-course palliative radiation therapy ... more PURPOSERandomized data suggest that single-fraction or short-course palliative radiation therapy (RT) is sufficient in the majority of patients with metastatic cancer. We investigated population-based patterns in the use of palliative RT among patients with metastatic non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS From patients diagnosed with lung cancer from 2003 to 2005 at a participating geographic or organizational site and who consented to the Cancer Care Outcomes Research and Surveillance Consortium study, we identified patients with metastatic NSCLC who had complete medical records abstractions. Patient characteristics and clinical factors associated with receipt of palliative RT and RT intensity (total dose and number of treatments) were evaluated with multivariable regression.ResultsOf 1,574 patients with metastatic NSCLC, 780 (50%) received at least one course of RT, and 21% and 12% received RT to the chest and bone, respectively. Use of palliative RT was associa...

Research paper thumbnail of Palliative Radiation Therapy (RT) Practice In Metastatic Non-small Cell Lung Cancer (NSCLC) Patients

Fuel and Energy Abstracts

Research paper thumbnail of Did Changes in Drug Reimbursement After the Medicare Modernization Act Affect Chemotherapy Prescribing?

Journal of Clinical Oncology, 2014

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) decreased fee-fo... more The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) decreased fee-for-service (FFS) payments for outpatient chemotherapy. We assessed how this policy affected chemotherapy in FFS settings versus in integrated health networks (IHNs). We examined 5,831 chemotherapy regimens for 3,613 patients from 2003 to 2006 with colorectal cancer (CRC) or lung cancers in the Cancer Care Outcomes Research Surveillance Consortium. Patients were from four geographically defined regions, seven large health maintenance organizations, and 15 Veterans Affairs Medical Centers. The outcome of interest was receipt of chemotherapy that included at least one drug for which reimbursement declined after the MMA. The odds of receiving an MMA-affected drug were lower in the post-MMA era: the odds ratio (OR) was 0.73 (95% CI, 0.59 to 0.89). Important differences across cancers were detected: for CRC, the OR was 0.65 (95% CI, 0.46 to 0.92); for non-small-cell lung cancer (NSCLC), the OR was 1.60 (95% CI, 1.09 to 2.35); and for small-cell lung cancer, the OR was 0.63 (95% CI, 0.34 to 1.16). After the MMA, FFS patients were less likely to receive MMA-affected drugs: OR, 0.73 (95% CI, 0.59 to 0.89). No pre- versus post-MMA difference in the use of MMA-affected drugs was detected among IHN patients: OR, 1.01 (95% CI, 0.66 to 1.56). Patients with CRC were less likely to receive an MMA-affected drug in both FFS and IHN settings in the post- versus pre-MMA era, whereas patients with NSCLC were the opposite: OR, 1.60 (95% CI, 1.09 to 2.35) for FFS and 6.33 (95% CI, 2.09 to 19.11) for IHNs post- versus pre-MMA. Changes in reimbursement after the passage of MMA appear to have had less of an impact on prescribing patterns in FFS settings than the introduction of new drugs and clinical evidence as well as other factors driving adoption of new practice patterns.

Research paper thumbnail of Uptake and Costs of Hypofractionated vs Conventional Whole Breast Irradiation After Breast Conserving Surgery in the United States, 2008–2013

JAMA, 2014

IMPORTANCE Based on randomized evidence, expert guidelines in 2011 endorsed shorter, hypofraction... more IMPORTANCE Based on randomized evidence, expert guidelines in 2011 endorsed shorter, hypofractionated whole breast irradiation (WBI) for selected patients with early-stage breast cancer and permitted hypofractionated WBI for other patients.

Research paper thumbnail of PCN23 Primary Prophylaxis Against Febrile Neutropenia With Pegfilgrastim is Cost-Effective Compared With Filgrastim in Non-Hodgkin's Lymphoma Patients Receiving CHOP-21 in Italy

Research paper thumbnail of PCN7 Primary Prophylaxis Against Febrile Neutropenia With Pegfilgrastim is Cost-Effective Compared With Filgrastim in Non-Hodgkin's Lymphoma Patients Receiving CHOP-21 in Spain

Research paper thumbnail of Measuring health-related quality of life and neutropenia-specific concerns among older adults undergoing chemotherapy: validation of the Functional Assessment of Cancer Therapy–Neutropenia (FACT-N)

Supportive Care in Cancer, 2008

Objective The present study established the psychometric properties of the Functional Assessment ... more Objective The present study established the psychometric properties of the Functional Assessment of Cancer Therapy-Neutropenia (FACT-N), a self-report instrument to assess neutropenia-specific concerns and health-related quality of life (HRQL), in a sample of adults 65 years of age and older. Materials and methods Participants were undergoing chemotherapy for lung, breast, or ovarian cancer or non-Hodgkin's lymphoma (n=852) and were randomly assigned to receive pegfilgrastim beginning with cycle 1 (primary prophylaxis) or pegfilgrastim subsequent to cycle 1 at their clinicians' discretion (usual care). Participants completed a self-report assessment on day 1 of each cycle (up to six cycles) and at the expected nadir of the white blood cell count of each cycle. Using factor analysis, three subscales were identified in the 19-item FACT-N subscale: Malaise, Worry, and Flu-like symptoms. Results and discussions The FACT-N and each of the subscales were sensitive to the presence of neutropenia although did not correlate with the absolute neutrophil count (ANC). While ANC is a marker of the impact of chemotherapy on the myeloid precursors of the bone marrow and is correlated with risk of febrile neutropenia, however the constellation of symptoms and patient experience vary throughout the period of neutropenia as the ANC first declines and then recovers. The 19-item neutropenia subscale can be used alone; however, evidence supporting reliability and validity was most robust for aggregate scores from the FACT-N and the Trial Outcome Index-Neutropenia (TOI-N).

Research paper thumbnail of 82 Specification and Validation of Prostate Cancer Quality of Care E-Measures in the Veterans Health Administration

The Journal of Urology, 2013

CONCLUSIONS: In obese men, RARP is independently associated with a lower blood transfusion rate, ... more CONCLUSIONS: In obese men, RARP is independently associated with a lower blood transfusion rate, decreased LOS, and higher charges compared to ORP. The rate of immediate postoperative complications was lower for obese men undergoing RARP, but this finding was not statistically significant on multivariate analysis.

Research paper thumbnail of Use of Colony-Stimulating Factors With Chemotherapy: Opportunities for Cost Savings and Improved Outcomes

JNCI Journal of the National Cancer Institute, 2011

Myeloid colony-stimulating factors (CSFs) decrease the risk of febrile neutropenia (FN) from high... more Myeloid colony-stimulating factors (CSFs) decrease the risk of febrile neutropenia (FN) from high-risk chemotherapy regimens administered to patients at 20% or greater risk of FN, but little is known about their use in clinical practice. We evaluated CSF use in a multiregional population-based cohort of lung and colorectal cancer patients (N = 1849). Only 17% (95% confidence interval [CI] = 8% to 26%) patients treated with high-risk chemotherapy regimens received CSFs, compared with 18% (95% CI = 16% to 20%) and 10% (95% CI = 8% to 12%) of patients treated with intermediate-(10%-20% risk of FN) and low-risk (<10% risk of FN) chemotherapy regimens, respectively. Using a generalized estimating equation model, we found that enrollment in a health maintenance organization (HMO) was strongly associated with a lower adjusted odds of discretionary CSF use, compared with non-HMO patients (odds ratio = 0.44, 95% CI = 0.32 to 0.60, P < .001). All statistical tests were two-sided. Overall, 96% (95% CI = 93% to 98%) of CSFs were administered in scenarios where CSF therapy is not recommended by evidence-based guidelines. This finding suggests that policies to decrease CSF use in patients at lower or intermediate risk of FN may yield substantial cost savings without compromising patient outcomes.

Research paper thumbnail of Re: Personalized Medicine and Cancer Supportive Care: Appropriate Use of Colony-Stimulating Factor Support of Chemotherapy

JNCI Journal of the National Cancer Institute, 2011

Research paper thumbnail of Providing Cancer Care: Individual or Team Sport?

Journal of General Internal Medicine, 2012

Research paper thumbnail of Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study

Journal of Clinical Oncology, 2012

National guidelines recommend that discussions about end-of-life (EOL) care planning happen early... more National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death.

Research paper thumbnail of Expectations About the Effectiveness of Radiation Therapy Among Patients With Incurable Lung Cancer

Journal of Clinical Oncology, 2013

Although radiation therapy (RT) can palliate symptoms and may prolong life, it is not curative fo... more Although radiation therapy (RT) can palliate symptoms and may prolong life, it is not curative for patients with metastatic lung cancer. We investigated patient expectations about the goals of RT for incurable lung cancers. The Cancer Care Outcomes Research and Surveillance Consortium enrolled a population- and health system-based cohort of patients diagnosed with lung cancer from 2003 to 2005. We identified patients with stage wet IIIB or IV lung cancer who received RT and answered questions on their expectations about RT. We assessed patient expectations about the goals of RT and identified factors associated with inaccurate beliefs about cure. In all, 384 patients completed surveys on their expectations about RT. Seventy-eight percent of patients believed that RT was very or somewhat likely to help them live longer, and 67% believed that RT was very or somewhat likely to help them with problems related to their cancer. However, 64% did not understand that RT was not at all likely to cure them. Older patients and nonwhites were more likely to have inaccurate beliefs, and patients whose surveys were completed by surrogates were less likely to have inaccurate beliefs. Ninety-two percent of patients with inaccurate beliefs about cure from RT also had inaccurate beliefs about chemotherapy. Although patients receiving RT for incurable lung cancer believe it will help them, most do not understand that it is not at all likely to cure their disease. This indicates a need to improve communication regarding the goals and limitations of palliative RT.

Research paper thumbnail of Medical Oncologists' Perceptions of Financial Incentives in Cancer Care

Journal of Clinical Oncology, 2013

The cost of cancer care continues to increase at an unprecedented rate. Concerns have been raised... more The cost of cancer care continues to increase at an unprecedented rate. Concerns have been raised about financial incentives associated with the chemotherapy concession in oncology practices and their impact on treatment recommendations.

Research paper thumbnail of The Value of Specialty Oncology Drugs

Health Services Research, 2010

Objective. To estimate patients' elasticity of demand, willingness to pay, and consumer surplus f... more Objective. To estimate patients' elasticity of demand, willingness to pay, and consumer surplus for five high-cost specialty medications treating metastatic disease or hematologic malignancies. Data Source/Study Setting. Claims data from 71 private health plans from 1997 to 2005. Study Design. This is a revealed preference analysis of the demand for specialty drugs among cancer patients. We exploit differences in plan generosity to examine how utilization of specialty oncology drugs varies with patient out-of-pocket costs. Data Collection/Extraction Methods. We extracted key variables from administrative health insurance claims records. Principal Findings. A 25 percent reduction in out-of-pocket costs leads to a 5 percent increase in the probability that a patient initiates specialty cancer drug therapy. Among patients who initiate, a 25 percent reduction in out-of-pocket costs reduces the number of treatments (claims) by 1-3 percent, depending on the drug. On average, the value of these drugs to patients who use them is about four times the total cost paid by the patient and his or her insurer, although this ratio may be lower for oral specialty therapies. Conclusions. The decision to initiate therapy with specialty oncology drugs is responsive to price, but not highly so. Among patients who initiate therapy, the amount of treatment is equally responsive. The drugs we examine are highly valued by patients in excess of their total costs, although oral agents warrant further scrutiny as copayments increase.

Research paper thumbnail of American Society of Clinical Oncology clinical practice guideline update on the use of pharmacologic interventions including tamoxifen, raloxifene, and aromatase inhibition for breast cancer risk reduction

Gynecologic Oncology, 2009

Research paper thumbnail of Quality of prostate cancer care among rural men in the Veterans Health Administration

Cancer, 2013

Patient travel distances, coupled with variation in facility-level resources, create barriers for... more Patient travel distances, coupled with variation in facility-level resources, create barriers for prostate cancer care in the Veterans Health Administration integrated delivery system. For these reasons, the authors investigated the degree to which these barriers impact the quality of prostate cancer care. The Veterans Affairs Central Cancer Registry was used to identify all men who were diagnosed with prostate cancer in 2008. Patient residence was characterized using Rural Urban Commuting Area codes. The authors then examined whether rural residence, compared with urban residence, was associated with less access to cancer-related resources and worse quality of care for 5 prostate cancer quality measures. Approximately 25% of the 11,368 patients who were diagnosed with prostate cancer in 2008 lived in either a rural area or a large town. Rural patients tended to be white (62% urban vs 86% rural) and married (47% urban vs 63% rural), and they tended to have slightly higher incomes (all P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.01) but similar tumor grade (P=.23) and stage (P=.12) compared with urban patients. Rural patients were significantly less likely to be treated at facilities with comprehensive cancer resources, although they received a similar or better quality of care for 4 of the 5 prostate cancer quality measures. The time to prostate cancer treatment was similar (rural patients vs urban patients, 96.6 days vs 105.7 days). Rural patients with prostate cancer had less access to comprehensive oncology resources, although they received a similar quality of care, compared with their urban counterparts in the Veterans Health Administration integrated delivery system. A better understanding of the degree to which facility factors contribute to the quality of cancer care may assist other organizations involved in rural health care delivery.

Research paper thumbnail of Using Cost-Effectiveness Analysis to Define a Breast Cancer Benefits Package for the Uninsured

Breast Cancer Research and Treatment, 2002

Objectives. In 1999, California was considering legislation to fund breast cancer treatment for i... more Objectives. In 1999, California was considering legislation to fund breast cancer treatment for its uninsured. We sought to define the most cost-effective breast cancer benefits package in order to inform this debate.

Research paper thumbnail of Adherence to adjuvant hormone therapy in low-income women with breast cancer: the role of provider–patient communication

Breast Cancer Research and Treatment, 2013

To assess the impact of patient-provider communication on adherence to tamoxifen (TAM) and aromat... more To assess the impact of patient-provider communication on adherence to tamoxifen (TAM) and aromatase inhibitors (AIs) 36 months after breast cancer (BC) diagnosis in a low-income population of women. California statewide surveys were conducted among 921 low-income women with BC at 6, 18, and 36 months after BC diagnosis. A subset of 303 women with stage I-III BC who initiated hormone treatment after diagnosis was identified. Bivariate and multivariate logistic regression analyses were performed, and adjusted adherence rates were calculated. The main outcome measure was self-reported hormone use at 36 months after BC diagnosis and the chief independent variables were patient-centered communication after diagnosis by patient report as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; self-efficacy in patient-physician interactions (PEPPI). Overall adherence to TAM/AI was relatively high (88 %). Adjusted rates of adherence were 59 and 94 % for patients with the lowest versus highest scores on the CAHPS communication scale (AOR = 1.22, P = 0.006) and 72 versus 91 % for patients with the lowest and highest rating of PEPPI (AOR = 1.04, P = 0.04). Having at least one comorbid condition also increased the odds of adherence to hormonal therapy (AOR = 3.14, P = 0.03). Having no health insurance and experiencing side-effects from hormone treatment were barriers for adherence (AOR = 0.12, P = 0.001; AOR = 0.26, P = 0.003, respectively). Patient-centered communication and perceived self-efficacy in patient-physician interaction were significantly associated with patient adherence to ongoing TAM/AI therapy among low-income women with BC. Interventions on patient-provider communication may provide opportunities to improve patient outcomes in this vulnerable population.

Research paper thumbnail of Cancer Patients' Roles in Treatment Decisions: Do Characteristics of the Decision Influence Roles?

Journal of Clinical Oncology, 2010

Patients with more active roles in decisions are more satisfied and may have better health outcom... more Patients with more active roles in decisions are more satisfied and may have better health outcomes. Younger and better educated patients have more active roles in decisions, but whether patients' roles in decisions differ by characteristics of the decision itself is unknown.

Research paper thumbnail of Palliative Radiation Therapy Practice in Patients With Metastatic Non-Small-Cell Lung Cancer: A Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) Study

Journal of Clinical Oncology

PURPOSERandomized data suggest that single-fraction or short-course palliative radiation therapy ... more PURPOSERandomized data suggest that single-fraction or short-course palliative radiation therapy (RT) is sufficient in the majority of patients with metastatic cancer. We investigated population-based patterns in the use of palliative RT among patients with metastatic non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS From patients diagnosed with lung cancer from 2003 to 2005 at a participating geographic or organizational site and who consented to the Cancer Care Outcomes Research and Surveillance Consortium study, we identified patients with metastatic NSCLC who had complete medical records abstractions. Patient characteristics and clinical factors associated with receipt of palliative RT and RT intensity (total dose and number of treatments) were evaluated with multivariable regression.ResultsOf 1,574 patients with metastatic NSCLC, 780 (50%) received at least one course of RT, and 21% and 12% received RT to the chest and bone, respectively. Use of palliative RT was associa...

Research paper thumbnail of Palliative Radiation Therapy (RT) Practice In Metastatic Non-small Cell Lung Cancer (NSCLC) Patients

Fuel and Energy Abstracts

Research paper thumbnail of Did Changes in Drug Reimbursement After the Medicare Modernization Act Affect Chemotherapy Prescribing?

Journal of Clinical Oncology, 2014

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) decreased fee-fo... more The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) decreased fee-for-service (FFS) payments for outpatient chemotherapy. We assessed how this policy affected chemotherapy in FFS settings versus in integrated health networks (IHNs). We examined 5,831 chemotherapy regimens for 3,613 patients from 2003 to 2006 with colorectal cancer (CRC) or lung cancers in the Cancer Care Outcomes Research Surveillance Consortium. Patients were from four geographically defined regions, seven large health maintenance organizations, and 15 Veterans Affairs Medical Centers. The outcome of interest was receipt of chemotherapy that included at least one drug for which reimbursement declined after the MMA. The odds of receiving an MMA-affected drug were lower in the post-MMA era: the odds ratio (OR) was 0.73 (95% CI, 0.59 to 0.89). Important differences across cancers were detected: for CRC, the OR was 0.65 (95% CI, 0.46 to 0.92); for non-small-cell lung cancer (NSCLC), the OR was 1.60 (95% CI, 1.09 to 2.35); and for small-cell lung cancer, the OR was 0.63 (95% CI, 0.34 to 1.16). After the MMA, FFS patients were less likely to receive MMA-affected drugs: OR, 0.73 (95% CI, 0.59 to 0.89). No pre- versus post-MMA difference in the use of MMA-affected drugs was detected among IHN patients: OR, 1.01 (95% CI, 0.66 to 1.56). Patients with CRC were less likely to receive an MMA-affected drug in both FFS and IHN settings in the post- versus pre-MMA era, whereas patients with NSCLC were the opposite: OR, 1.60 (95% CI, 1.09 to 2.35) for FFS and 6.33 (95% CI, 2.09 to 19.11) for IHNs post- versus pre-MMA. Changes in reimbursement after the passage of MMA appear to have had less of an impact on prescribing patterns in FFS settings than the introduction of new drugs and clinical evidence as well as other factors driving adoption of new practice patterns.

Research paper thumbnail of Uptake and Costs of Hypofractionated vs Conventional Whole Breast Irradiation After Breast Conserving Surgery in the United States, 2008–2013

JAMA, 2014

IMPORTANCE Based on randomized evidence, expert guidelines in 2011 endorsed shorter, hypofraction... more IMPORTANCE Based on randomized evidence, expert guidelines in 2011 endorsed shorter, hypofractionated whole breast irradiation (WBI) for selected patients with early-stage breast cancer and permitted hypofractionated WBI for other patients.

Research paper thumbnail of PCN23 Primary Prophylaxis Against Febrile Neutropenia With Pegfilgrastim is Cost-Effective Compared With Filgrastim in Non-Hodgkin's Lymphoma Patients Receiving CHOP-21 in Italy

Research paper thumbnail of PCN7 Primary Prophylaxis Against Febrile Neutropenia With Pegfilgrastim is Cost-Effective Compared With Filgrastim in Non-Hodgkin's Lymphoma Patients Receiving CHOP-21 in Spain

Research paper thumbnail of Measuring health-related quality of life and neutropenia-specific concerns among older adults undergoing chemotherapy: validation of the Functional Assessment of Cancer Therapy–Neutropenia (FACT-N)

Supportive Care in Cancer, 2008

Objective The present study established the psychometric properties of the Functional Assessment ... more Objective The present study established the psychometric properties of the Functional Assessment of Cancer Therapy-Neutropenia (FACT-N), a self-report instrument to assess neutropenia-specific concerns and health-related quality of life (HRQL), in a sample of adults 65 years of age and older. Materials and methods Participants were undergoing chemotherapy for lung, breast, or ovarian cancer or non-Hodgkin's lymphoma (n=852) and were randomly assigned to receive pegfilgrastim beginning with cycle 1 (primary prophylaxis) or pegfilgrastim subsequent to cycle 1 at their clinicians' discretion (usual care). Participants completed a self-report assessment on day 1 of each cycle (up to six cycles) and at the expected nadir of the white blood cell count of each cycle. Using factor analysis, three subscales were identified in the 19-item FACT-N subscale: Malaise, Worry, and Flu-like symptoms. Results and discussions The FACT-N and each of the subscales were sensitive to the presence of neutropenia although did not correlate with the absolute neutrophil count (ANC). While ANC is a marker of the impact of chemotherapy on the myeloid precursors of the bone marrow and is correlated with risk of febrile neutropenia, however the constellation of symptoms and patient experience vary throughout the period of neutropenia as the ANC first declines and then recovers. The 19-item neutropenia subscale can be used alone; however, evidence supporting reliability and validity was most robust for aggregate scores from the FACT-N and the Trial Outcome Index-Neutropenia (TOI-N).

Research paper thumbnail of 82 Specification and Validation of Prostate Cancer Quality of Care E-Measures in the Veterans Health Administration

The Journal of Urology, 2013

CONCLUSIONS: In obese men, RARP is independently associated with a lower blood transfusion rate, ... more CONCLUSIONS: In obese men, RARP is independently associated with a lower blood transfusion rate, decreased LOS, and higher charges compared to ORP. The rate of immediate postoperative complications was lower for obese men undergoing RARP, but this finding was not statistically significant on multivariate analysis.

Research paper thumbnail of Use of Colony-Stimulating Factors With Chemotherapy: Opportunities for Cost Savings and Improved Outcomes

JNCI Journal of the National Cancer Institute, 2011

Myeloid colony-stimulating factors (CSFs) decrease the risk of febrile neutropenia (FN) from high... more Myeloid colony-stimulating factors (CSFs) decrease the risk of febrile neutropenia (FN) from high-risk chemotherapy regimens administered to patients at 20% or greater risk of FN, but little is known about their use in clinical practice. We evaluated CSF use in a multiregional population-based cohort of lung and colorectal cancer patients (N = 1849). Only 17% (95% confidence interval [CI] = 8% to 26%) patients treated with high-risk chemotherapy regimens received CSFs, compared with 18% (95% CI = 16% to 20%) and 10% (95% CI = 8% to 12%) of patients treated with intermediate-(10%-20% risk of FN) and low-risk (<10% risk of FN) chemotherapy regimens, respectively. Using a generalized estimating equation model, we found that enrollment in a health maintenance organization (HMO) was strongly associated with a lower adjusted odds of discretionary CSF use, compared with non-HMO patients (odds ratio = 0.44, 95% CI = 0.32 to 0.60, P < .001). All statistical tests were two-sided. Overall, 96% (95% CI = 93% to 98%) of CSFs were administered in scenarios where CSF therapy is not recommended by evidence-based guidelines. This finding suggests that policies to decrease CSF use in patients at lower or intermediate risk of FN may yield substantial cost savings without compromising patient outcomes.

Research paper thumbnail of Re: Personalized Medicine and Cancer Supportive Care: Appropriate Use of Colony-Stimulating Factor Support of Chemotherapy

JNCI Journal of the National Cancer Institute, 2011

Research paper thumbnail of Providing Cancer Care: Individual or Team Sport?

Journal of General Internal Medicine, 2012

Research paper thumbnail of Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study

Journal of Clinical Oncology, 2012

National guidelines recommend that discussions about end-of-life (EOL) care planning happen early... more National guidelines recommend that discussions about end-of-life (EOL) care planning happen early for patients with incurable cancer. We do not know whether earlier EOL discussions lead to less aggressive care near death. We sought to evaluate the extent to which EOL discussion characteristics, such as timing, involved providers, and location, are associated with the aggressiveness of care received near death.

Research paper thumbnail of Expectations About the Effectiveness of Radiation Therapy Among Patients With Incurable Lung Cancer

Journal of Clinical Oncology, 2013

Although radiation therapy (RT) can palliate symptoms and may prolong life, it is not curative fo... more Although radiation therapy (RT) can palliate symptoms and may prolong life, it is not curative for patients with metastatic lung cancer. We investigated patient expectations about the goals of RT for incurable lung cancers. The Cancer Care Outcomes Research and Surveillance Consortium enrolled a population- and health system-based cohort of patients diagnosed with lung cancer from 2003 to 2005. We identified patients with stage wet IIIB or IV lung cancer who received RT and answered questions on their expectations about RT. We assessed patient expectations about the goals of RT and identified factors associated with inaccurate beliefs about cure. In all, 384 patients completed surveys on their expectations about RT. Seventy-eight percent of patients believed that RT was very or somewhat likely to help them live longer, and 67% believed that RT was very or somewhat likely to help them with problems related to their cancer. However, 64% did not understand that RT was not at all likely to cure them. Older patients and nonwhites were more likely to have inaccurate beliefs, and patients whose surveys were completed by surrogates were less likely to have inaccurate beliefs. Ninety-two percent of patients with inaccurate beliefs about cure from RT also had inaccurate beliefs about chemotherapy. Although patients receiving RT for incurable lung cancer believe it will help them, most do not understand that it is not at all likely to cure their disease. This indicates a need to improve communication regarding the goals and limitations of palliative RT.

Research paper thumbnail of Medical Oncologists' Perceptions of Financial Incentives in Cancer Care

Journal of Clinical Oncology, 2013

The cost of cancer care continues to increase at an unprecedented rate. Concerns have been raised... more The cost of cancer care continues to increase at an unprecedented rate. Concerns have been raised about financial incentives associated with the chemotherapy concession in oncology practices and their impact on treatment recommendations.

Research paper thumbnail of The Value of Specialty Oncology Drugs

Health Services Research, 2010

Objective. To estimate patients' elasticity of demand, willingness to pay, and consumer surplus f... more Objective. To estimate patients' elasticity of demand, willingness to pay, and consumer surplus for five high-cost specialty medications treating metastatic disease or hematologic malignancies. Data Source/Study Setting. Claims data from 71 private health plans from 1997 to 2005. Study Design. This is a revealed preference analysis of the demand for specialty drugs among cancer patients. We exploit differences in plan generosity to examine how utilization of specialty oncology drugs varies with patient out-of-pocket costs. Data Collection/Extraction Methods. We extracted key variables from administrative health insurance claims records. Principal Findings. A 25 percent reduction in out-of-pocket costs leads to a 5 percent increase in the probability that a patient initiates specialty cancer drug therapy. Among patients who initiate, a 25 percent reduction in out-of-pocket costs reduces the number of treatments (claims) by 1-3 percent, depending on the drug. On average, the value of these drugs to patients who use them is about four times the total cost paid by the patient and his or her insurer, although this ratio may be lower for oral specialty therapies. Conclusions. The decision to initiate therapy with specialty oncology drugs is responsive to price, but not highly so. Among patients who initiate therapy, the amount of treatment is equally responsive. The drugs we examine are highly valued by patients in excess of their total costs, although oral agents warrant further scrutiny as copayments increase.

Research paper thumbnail of American Society of Clinical Oncology clinical practice guideline update on the use of pharmacologic interventions including tamoxifen, raloxifene, and aromatase inhibition for breast cancer risk reduction

Gynecologic Oncology, 2009

Research paper thumbnail of Quality of prostate cancer care among rural men in the Veterans Health Administration

Cancer, 2013

Patient travel distances, coupled with variation in facility-level resources, create barriers for... more Patient travel distances, coupled with variation in facility-level resources, create barriers for prostate cancer care in the Veterans Health Administration integrated delivery system. For these reasons, the authors investigated the degree to which these barriers impact the quality of prostate cancer care. The Veterans Affairs Central Cancer Registry was used to identify all men who were diagnosed with prostate cancer in 2008. Patient residence was characterized using Rural Urban Commuting Area codes. The authors then examined whether rural residence, compared with urban residence, was associated with less access to cancer-related resources and worse quality of care for 5 prostate cancer quality measures. Approximately 25% of the 11,368 patients who were diagnosed with prostate cancer in 2008 lived in either a rural area or a large town. Rural patients tended to be white (62% urban vs 86% rural) and married (47% urban vs 63% rural), and they tended to have slightly higher incomes (all P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;.01) but similar tumor grade (P=.23) and stage (P=.12) compared with urban patients. Rural patients were significantly less likely to be treated at facilities with comprehensive cancer resources, although they received a similar or better quality of care for 4 of the 5 prostate cancer quality measures. The time to prostate cancer treatment was similar (rural patients vs urban patients, 96.6 days vs 105.7 days). Rural patients with prostate cancer had less access to comprehensive oncology resources, although they received a similar quality of care, compared with their urban counterparts in the Veterans Health Administration integrated delivery system. A better understanding of the degree to which facility factors contribute to the quality of cancer care may assist other organizations involved in rural health care delivery.

Research paper thumbnail of Using Cost-Effectiveness Analysis to Define a Breast Cancer Benefits Package for the Uninsured

Breast Cancer Research and Treatment, 2002

Objectives. In 1999, California was considering legislation to fund breast cancer treatment for i... more Objectives. In 1999, California was considering legislation to fund breast cancer treatment for its uninsured. We sought to define the most cost-effective breast cancer benefits package in order to inform this debate.

Research paper thumbnail of Adherence to adjuvant hormone therapy in low-income women with breast cancer: the role of provider–patient communication

Breast Cancer Research and Treatment, 2013

To assess the impact of patient-provider communication on adherence to tamoxifen (TAM) and aromat... more To assess the impact of patient-provider communication on adherence to tamoxifen (TAM) and aromatase inhibitors (AIs) 36 months after breast cancer (BC) diagnosis in a low-income population of women. California statewide surveys were conducted among 921 low-income women with BC at 6, 18, and 36 months after BC diagnosis. A subset of 303 women with stage I-III BC who initiated hormone treatment after diagnosis was identified. Bivariate and multivariate logistic regression analyses were performed, and adjusted adherence rates were calculated. The main outcome measure was self-reported hormone use at 36 months after BC diagnosis and the chief independent variables were patient-centered communication after diagnosis by patient report as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) and patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; self-efficacy in patient-physician interactions (PEPPI). Overall adherence to TAM/AI was relatively high (88 %). Adjusted rates of adherence were 59 and 94 % for patients with the lowest versus highest scores on the CAHPS communication scale (AOR = 1.22, P = 0.006) and 72 versus 91 % for patients with the lowest and highest rating of PEPPI (AOR = 1.04, P = 0.04). Having at least one comorbid condition also increased the odds of adherence to hormonal therapy (AOR = 3.14, P = 0.03). Having no health insurance and experiencing side-effects from hormone treatment were barriers for adherence (AOR = 0.12, P = 0.001; AOR = 0.26, P = 0.003, respectively). Patient-centered communication and perceived self-efficacy in patient-physician interaction were significantly associated with patient adherence to ongoing TAM/AI therapy among low-income women with BC. Interventions on patient-provider communication may provide opportunities to improve patient outcomes in this vulnerable population.