The quality of treatment for cancer-associated complications, those complications directly attributable to the cancer itself or that result from chemotherapy and/or radiation, have received little attention. This is particularly problematic as cancer-associated complications are associated with significant morbidity, are often accompanied by pain and discomfort, and require the expenditure of substantial healthcare resources for treatment. The management of cancer-associated complications is compounded by the availability of a myriad of treatment options, many of which are unproven and associated with significant cost. Little is known about the factors that influence allocation of care for thes complications and what factors influence outcome. The health care a patient receives and its associated outcomes are influenced by the interplay of a number of patient, physician, and hospital factors. For acute inpatient medical conditions the characteristics of the hospital in which a patient is treated play a crucial role. There is growing recognition that there is widespread between-hospital variation in how care is allocated and that these differences in practice patterns explain a large portion of treatment variability. Uninsured and minority patients are particularly vulnerable to these hospital level disparities as these patients are disproportionately more likely to receive care at facilities with limited clinical and financial resources that may adversely affect quality. In this proposal we will determine the quality of treatment for hospitalized patients admitted with a primary diagnosis of: febrile neutropenia, hypercalcemia of malignancy, esophagitis, and acute cancer-associated pain. For each cancer-associated complication we will determine patterns of treatment, the factors that underlie treatment decisions, and the effect of prompt initiation of guideline-based therapy on outcomes. For each condition we will first examine the utilization of guideline-based and non-indicated treatments. We will then comprehensively examine the influence of patient, physician, and hospital characteristics as well as between- hospital variations on the allocation of guideline-based care. We hypothesize that there is substantial variation in treatment between hospitals that is unexplained by traditional measures. Finally, we will perform novel causal inference and mediation analyses to determine the direct and indirect effects operating through a mediator of prompt guideline-based treatment on outcomes (length of stay, readmission, cost, non-routine discharge and mortality) for each complication. In addition to including a number of novel statistical methodologies, this proposal will utilize a unique database ideally suited to the study of these complications. The data from these studies will lead to immediately actionable results that can be used to guide the implementation pragmatic hospital-based interventions to improve the quality of care for patients with cancer-associated complications.

Public Health Relevance

To date, the complications that result either directly from cancer or from its treatment have received almost no attention. Our findings will provide important data on the management of these complications to patients, providers, and payers that are immediately actionable and can guide the development of targeted hospital-based interventions to improve the quality of care for patients with cancer-associated complications.

Agency
National Institute of Health (NIH)
Institute
National Cancer Institute (NCI)
Type
Research Project (R01)
Project #
1R01CA169121-01A1
Application #
8457724
Study Section
Health Services Organization and Delivery Study Section (HSOD)
Program Officer
Castro, Kathleen M
Project Start
2013-01-01
Project End
2017-12-31
Budget Start
2013-01-01
Budget End
2013-12-31
Support Year
1
Fiscal Year
2013
Total Cost
$332,000
Indirect Cost
$124,500
Name
Columbia University (N.Y.)
Department
Obstetrics & Gynecology
Type
Schools of Medicine
DUNS #
621889815
City
New York
State
NY
Country
United States
Zip Code
10032
George, Erin M; Tergas, Ana I; Ananth, Cande V et al. (2014) Safety and tolerance of radical hysterectomy for cervical cancer in the elderly. Gynecol Oncol 134:36-41
Wright, Jason D; Ananth, Cande V; Tsui, Jennifer et al. (2014) Comparative effectiveness of upfront treatment strategies in elderly women with ovarian cancer. Cancer 120:1246-54
Wright, Jason D; Kostolias, Alessandra; Ananth, Cande V et al. (2014) Comparative effectiveness of robotically assisted compared with laparoscopic adnexal surgery for benign gynecologic disease. Obstet Gynecol 124:886-96
Wright, Jason D; Ananth, Cande V; Tergas, Ana I et al. (2014) An economic analysis of robotically assisted hysterectomy. Obstet Gynecol 123:1038-48
Hershman, Dawn L; Neugut, Alfred I; Shim, Jin Joo et al. (2014) Erythropoiesis-stimulating agent use after changes in medicare reimbursement policies. J Oncol Pract 10:264-9
Wright, Jason D; Tergas, Ana I; Burke, William M et al. (2014) Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA 312:1253-5
Hershman, Dawn L; Wright, Jason D; Lim, Emerson et al. (2013) Contraindicated use of bevacizumab and toxicity in elderly patients with cancer. J Clin Oncol 31:3592-9
Wright, Jason D; Ananth, Cande V; Ojalvo, Laureen et al. (2013) Failure to rescue after major gynecologic surgery. Am J Obstet Gynecol 209:420.e1-8
Wright, Jason D; Herzog, Thomas J; Tsui, Jennifer et al. (2013) Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol 122:233-41
Galic, Vijaya; Schiavone, Maria B; Herzog, Thomas J et al. (2013) Prognostic significance of mucinous differentiation of endometrioid adenocarcinoma of the endometrium. Cancer Invest 31:500-4

Showing the most recent 10 out of 12 publications