The National Cancer Data Base report on patterns of childhood cancers in the United States

BACKGROUND: Patterns of and progress against childhood cancer have been reported on multi-institution, regional, national, and international bases by several sources in the past. These sources have included clinical cooperative group trials and population-based registries. In general, the population-based surveys have excluded brain tumors of either benign or uncertain behavior. The authors of this article investigated the patterns of data reported for the period 1985-1993, motivated by their interest in assessing the potential of National Cancer Data Base (NCDB) data to 1) facilitate individual institution review and 2) cover institutions that are not members of the Pediatric Oncology Group or the Children's Cancer Group, which are both national clinical cooperative groups. METHODS: Six annual calls for data, starting with a call for 1985 and 1988 cases, were issued to approximately 2100 hospitals with cancer programs (1340 programs approved by the Commission on Cancer of the American College of Surgeons and 760 other programs). The baseline data items of the NCDB included patient demography, tumor characteristics, initial treatment, and follow-up. The data for each patient were coded in the traditional manner by trained cancer registrars before being transmitted to the NCDB in standard format. RESULTS: In the most recent year for which data were reported, the NCDB included 42% of all estimated U.S. childhood cancers. The cases were reported by institutions that were members of the Pediatric Oncology Group and the Children's Cancer Group as well as nonmember institutions. The distribution of diagnostic groups reported to the NCDB was generally similar to that reported to SEER, except for lymphomas and brain cancer (the NCDB series included benign as well as malignant brain tumors). The distribution of diagnostic groups reported to the NCDB did not change over the 9-year reporting period (1985-1993). With regard to ethnicity, the most varied distribution of diagnostic groups was found among African American patients. For many types of cancer, the survival of those patients reported to the NCDB was similar to that of patients included in the SEER population-based series. These cancers included Wilms' tumor (NCDB 89% vs. SEER 88%), non-Hodgkin's lymphoma (NCDB 74% vs. SEER 70%), soft tissue sarcomas (NCDB rhabdomyosarcomas 70% and sarcomas 79% vs. SEER soft tissue sarcomas 71%), and neuroblastoma (NCDB 58% vs. SEER 57%). CONCLUSIONS: The authors concluded that the number of brain tumors of benign and uncertain behavior being diagnosed were significant enough in number that they should be included in regional and national cancer registries that report data for clinical purposes. They further concluded that for reasons of data inclusion and institutional coverage, the NCDB will be an important data base for pediatric cancers that will warrant increased use by pediatric investigators.     

Pancreatic cancer and comparison of a hospital-based tumor registry with a National Cancer Data Base

BACKGROUND: The Commission on Cancer of the American College of Surgeons has called upon institutions providing cancer care to compare practice patterns and outcomes with the National Cancer Data Base (NCDB). Using data from the Virginia Mason Tumor Registry (VMTR), we sought to compare our pancreatic cancer care patterns with those reported nationally, while critically evaluating the accuracy and usefulness of our registry. METHODS: A review of the 906 computerized patient files in the VMTR from 1973 to 1995 was performed, with more detailed data on patients from the last 5 years retrieved from 224 manual abstracts. These data were compared with the 1991 NCDB for pancreatic cancer. RESULTS: The percent of cases according to AJCC stage in the NCDB (n = 9,715) versus the VMTR (n = 149), respectively, with cases of unknown stage excluded, were stage I 22% versus 22%, stage II 9% versus 12%, stage III 17% versus 28% (P <0.05) stage IV 52% versus 38% (P <0.05). One-third of the cases in the VMTR 1991 to 1995 were of unknown stage; number of cases with unknown stage for NCDB was 26.6%. The percent of surgical procedures for the NCDB (n = 7,802) versus the VMTR (n = 224), respectively, was pancreatectomy 14% versus 11%, local excision 1% versus 0%, no cancer-directed surgery 83% versus 89% (P <0.05), unknown 2% versus 0% (P <0.05). The actuarial relative survival rates for the 1991 NCDB versus 1987 to 1995 VMTR was 3-year 18% versus 38%, and 5-year 14% versus 35%. CONCLUSIONS: In comparison with the NCDB, VMTR may have fewer stage IV pancreatic cancers, but improvement is needed in decreasing the number of patients for whom the stage is unknown, as many of these likely represent late stage disease. We have a similar resection rate and a higher survival compared with the NCDB, but a mechanism is not in place to statistically compare our survival data with those of the NCDB. Even though all accredited hospitals are required to have a tumor registry, our data were difficult to compare with those of the NCDB because of coding and reporting deficiencies and inability to statistically compare survival data. Before our practice patterns and outcomes can be compared with national standards, both the VMTR and the NCDB must have standardized data collection and better access to the data.     

The National Cancer Data Base report on gastric carcinoma

BACKGROUND: The National Cancer Data Base (NCDB) represents a national electronic registry system now encompassing almost 60% of incident cancers in the United States. In combination with other programs of the American College of Surgeons Commission on Cancer, the NCDB offers a working example of voluntary, accurate, and cost-effective "outcomes management" on a both a local and a national scale. METHODS: For the accession years 1985-1993, the NCDB has obtained information on demographics, patterns of care, disease stage, treatment, and outcome for a convenience sample of 57,407 gastric carcinoma cases (1.6% of total NCDB cases). In addition to describing trends, this report focuses on 5-year relative survival for a cohort of 1987-1988 cases staged according to the third edition of the American Joint Committee on Cancer's TNM classification, as well as patterns of care for a cohort of 1992-1993 cases. RESULTS: Stage-stratified 5-year relative survival for the 1987-1988 cohort was as follows: IA, 71%; IB, 56%; II, 37%; IIIA, 18%; IIIB, 11%; IV, 5%. Without noteworthy changes in stage distribution, demographics, or other factors, the proportion of patients treated by total gastrectomy is increasing slightly, but proximal gastrectomy for proximal cancers remains surprisingly popular. The proportion of cases receiving postoperative adjuvant treatment has declined slightly. Presumably because of advanced age and/or medical infirmity, a substantial proportion of U.S. patients with disease at every stage receive no treatment for cancer. CONCLUSIONS: This analysis of patterns of care has revealed unexplained variations in treatment and opportunities for improvement. Treatment of the elderly, infirm patient with gastric carcinoma appears problematic.     

A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the U.S., 1985-1995 [see commetns

BACKGROUND: The National Cancer Data Base (NCDB) represents a national electronic registry system now capturing nearly 60% of incident cancers in the U. S. In combination with other Commission on Cancer programs, the NCDB offers a working example of voluntary, accurate, cost-effective "outcomes management" on a both a local and national scale. In addition, it is of particular value in capturing clinical information concerning rare cancers, such as those of the thyroid. METHODS: For the accession years 1985-1995, NCDB captured demographic, patterns-of-care, stage, treatment, and outcome information for a convenience sample of 53,856 thyroid carcinoma cases (1% of total NCDB cases). This article focuses on overall 10-year relative survival and American Joint Committee on Cancer (AJCC) (3rd/4th edition) stage-stratified 5-year relative survival for each histologic type of thyroid carcinoma. Care patterns also are discussed. RESULTS: The 10-year overall relative survival rates for U. S. patients with papillary, follicular, Hürthle cell, medullary, and undifferentiated/anaplastic carcinoma was 93%, 85%, 76%, 75%, and 14%, respectively. For papillary and follicular neoplasms, current AJCC staging failed to discriminate between patients with Stage I and II disease at 5 years. Total thyroidectomy +/- lymph node sampling/dissection represented the dominant method of surgical treatment rendered to patients with papillary and follicular neoplasms. Approximately 38% of such patients receive adjuvant iodine-131 ablation/therapy. At 5 years, variation in surgical treatment (i.e., lobectomy vs. more extensive surgery) failed to translate into compelling differences in survival for any subgroup with papillary or follicular carcinoma, but longer follow-up is required to evaluate this. NCDB data appeared to validate the AMES prognostic system, as applied to papillary cases. Younger age appeared to influence prognosis favorably for all thyroid neoplasms, including medullary and undifferentiated/anaplastic carcinoma. NCDB data also revealed that unusual patients diagnosed with undifferentiated/anaplastic carcinoma before age of 45 years have better survival. CONCLUSIONS: The NCDB system permits analysis of care patterns and survival for large numbers of contemporaneous U. S. patients with relatively rare neoplasms, such as thyroid carcinoma. In this context, it represents an unsurpassed clinical tool for analyzing care, evaluating prognostic models, generating new hypotheses, and overcoming the volume-related drawbacks inherent in the study of such neoplasms. [See editorial on pages 2434-6, this issue.]     

The National Cancer Data Base report on non-Hodgkin's lymphoma

BACKGROUND: The National Cancer Data Base (NCDB) has reported on many malignancies occurring in men and women in the U. S. from >1400 contributing hospitals. The current report on non-Hodgkin's lymphoma (NHL) is a companion to an upcoming Patient Care Evaluation study of this relatively common and serious cancer. METHODS: This report is comprised of all NHL cases submitted to the NCDB divided into two diagnostic-year groups: 1985-1988 and 1990-1993. Variables routinely collected by hospital cancer registries have been analyzed to report on patterns of diagnosis and treatment. RESULTS: High grade NHL cases were more likely to be Stage IV (40.8%) than were low or intermediate grade cases (34.8% and 32.5%, respectively). Patients with NHL arising from lymph node sites tended to present with more advanced disease (55.8% with Stages III and IV disease), whereas patients with NHL arising from extranodal sites and non-lymph node nodal sites presented at an earlier stage (64.7% and 74.0%, respectively, with Stage I or Stage II disease). Approximately 67% of all patients underwent chemotherapy, whereas only 25% underwent surgery or radiation. By histology, 5-year survival was 68.8% for low grade disease, 51.9% for intermediate grade disease, and 45.8% for high grade disease; by stage, survival rates ranged from 73.5% for Stage I to 42.9% for Stage IV disease. CONCLUSIONS: To the authors' knowledge, the 91,306 cases in this study represent the largest contemporary sample of NHL patients. The material reported here may serve as a reference with which to compare local patterns with national data. The Working Formulation's ability to stratify patients' survival rates confirms its utility for NHL. Stage according to the American Joint Committee on Cancer also was accurate in predicting survival.     

The National Cancer Data Base report on completeness of American Joint Committee on Cancer staging in United States cancer facilities. The American College of Surgeons Commission on Cancer and the American Cancer Society

BACKGROUND: American Joint Committee on Cancer (AJCC) staging is increasingly accepted as a prognostic standard for cancer management. The Commission on Cancer requires approved cancer programs to use AJCC staging for all cancers. Previous studies document increasing use of AJCC staging by hospitals with cancer programs. This review examines programmatic and clinical factors affecting AJCC staging completeness. METHODS: The data are registry records submitted to the National Cancer Data Base (NCDB) for cases diagnosed during 1993 or, for comparison, 1988. RESULTS: The mean facility staging rate was 87% in 1993, up from 65% in 1988. Approximately 64% of facilities staged greater than 90% of their stageable cases; 3% staged less than 5%. Even facilities with "complete" staging implementation were unable to stage substantial portions of some sites. Accessibility of tumor and overall prognosis affected the choice between pathologic and clinical staging. Staging completeness and the mix of pathologic and clinical staging also differed by state of the reporting facility. CONCLUSIONS: AJCC staging use is high among common tumors for which treatment is dependent upon stage of disease. However, if accurate staging is not expected to affect the treatment or outcome of the case or the overall outcome is poor, staging is less frequently recorded.     

The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. The American College of Surgeons Commission on Cancer and the American Cancer Society

BACKGROUND: This study reviews the case-mix characteristics, management, and outcomes of melanoma cases occuring in the U.S. within the last decade. METHODS: Analyses of the National Cancer Data Base (NCDB) were performed on cases diagnosed between 1985 through 1994. A total of 84,836 cases comprised of cutaneous and noncutaneous melanomas were evaluated. RESULTS: The percentages of melanomas that were cutaneous, ocular, mucosal, and unknown primaries were 91.2%, 5.2%, 1.3%, and 2.2%, respectively. For cutaneous melanomas, the proportion of patients presenting with American Joint Committee on Cancer Stages 0, I, II, III, and IV were 14.9%, 47.7%, 23.1%, 8.9%, and 5.3%, respectively. Factors associated with decreased survival included more advanced stage at diagnosis, nodular or acral lentiginous histology, increased age, male gender, nonwhite race, and lower income. Multivariate analysis identified stage, histology, gender, age, and income as independent prognostic factors. For ocular melanomas, 85.0% were uveal, 4.8% were conjunctival, and 10.2% occurred at other sites. During the study period, there was a large increase in the proportion of ocular melanoma patients treated with radiation therapy alone. For mucosal melanomas, the distribution of head and neck, female genital tract, anal/rectal, and urinary tract sites was 55.4%, 18.0%, 23.8%, and 2.8%, respectively. Patients with lymph node involvement had a poor prognosis. For unknown primary melanomas, the distribution of metastases as localized to a region or multiple sites at presentation was 43.0% and 57.0%, respectively. Surgical treatment of patients with unknown primary site of the melanoma resulted in better survival compared with no treatment. CONCLUSIONS: Treatment of early stage cutaneous melanoma resulted in excellent patient outcomes. In addition to conventional prognostic factors, socioeconomic factors were found to be associated with survival.     

Superior survival of young women with malignant melanoma

BACKGROUND: The Commission on Cancer data from the National Cancer Data Base (NCDB) relating to patients with malignant melanoma are used to examine patterns of long-term survival by patient gender and age, stage of disease, disease morphology, and anatomic subsite. METHODS: Five calls for data have yielded more than 3,700,000 cases of cancer for the years 1985 through 1993, including 23,341 cases of malignant melanoma between 1985 and 1989, from hospital cancer registries across the US, representing slightly less than a quarter of all melanoma cases diagnosed in the US between 1985 and 1989. RESULTS: Three statements can be made from this data: (1) There is little difference in the frequency of malignant melanoma between men and women with respect to stage of disease or morphology. However, differences between the genders do appear with respect to the anatomic subsite of melanotic tumors. (2) Overall, young women (45 years of age and under) enjoy superior survival rates when compared with older women (55 years of age and older) and men of any age. (3) The survival advantage held by young women is particularly pronounced among patients diagnosed with advanced stage disease. CONCLUSIONS: These data suggest that factors present in younger women may be critical in the superior survival rates seen among premenopausal women and might be hormonal in nature.     

Quality indicators using hospital discharge data: state and national applications

BACKGROUND: Demand for information about the quality of health care has escalated. Yet many organizations lack well-specified quality measures, statistical expertise, or the requisite data to produce such information. The Healthcare Cost and Utilization Project Quality Indicators (HCUP QIs) represent one approach to measuring health care quality using readily available data on hospital inpatients. METHODS: The HCUP QIs, developed in 1994, address clinical performance rather than other dimensions of quality such as satisfaction or efficiency. The 33 indicators produce rates that represent measures of outcomes (mortality and complications), utilization, and access. In lieu of complex multivariate techniques, two methods were used: (1) restrictions in defining patient subgroups to isolate homogeneous at-risk populations and (2) standardization when populations are diverse. Stratified analyses are recommended when patient or hospital factors are believed to influence the outcome. A simple method for making statistical comparisons to national rates was developed. The HCUP QI software, available in both mainframe and microcomputer applications, have enabled organizations to use their own data to produce comparative statistics and examine trends over time. Results summarized at the individual hospital or aggregate level are being used to stimulate continuous quality improvement initiatives. CONCLUSIONS: The HCUP QIs offer a low-cost alternative for organizations that have access to administrative data. Current users include hospital associations, state health departments, statewide data organizations, and individual hospitals. Although the HCUP QIs are intended to serve as indicators, not definitive measures, of quality, they were designed to highlight quality concerns and to target areas for more intensive study.     

Breast carcinoma survival analysis for African American and white women in an equal-access health care system

BACKGROUND: This retrospective review of breast carcinoma cases in the Department of Defense (DoD) Central Tumor Registry evaluated differences in survival patterns between African American and white women treated in U.S. military health care facilities. The study examined the effects of age, stage of cancer, tumor size, grade, lymph node involvement, waiting time between diagnosis and first treatment, marital status, military dependent status, alcohol usage, tobacco usage, and family history of cancer. METHODS: Researchers reviewed the tumor registry records of 6577 women (5879 whites and 698 African Americans) diagnosed with breast carcinoma. The patients, ages 19-97 years, were diagnosed between 1975 and 1994. A hazard ratio (relative risk of mortality) model compared African American and white patients, adjusting for various combinations of covariates; impact of independent variables on the risk of death; prognostic factors significantly associated with survival; disease free and overall survival times; effects of ethnicity, stage, and age on survival; and trends in stage at diagnosis. A P value (2-sided) of less than 0.05 was considered statistically significant. RESULTS: After adjustment for age, the risk of death was 1.45 (95% confidence interval [CI], 1.20-1.76) times greater for African American women than for white women. Adjustment for stage reduced the risk to 1.41 (95% CI, 1.16-1.70); further adjustment for demographic variables and most clinical variables had no effect. Still, African American women treated in the military health care facilities had a better survival rate than African American women represented in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. In our study, the 5-year risk of death, from any cause, was 1.37 for African American women with breast carcinoma; in other words, the mortality rate for African American women was 24.77% compared with 18.08% for white women. In the latest SEER data, the 5-year relative risk of death for African American women compared with white women is 1.86. The mortality rate in SEER is 34.2% for African American women and 18.4% for white women. The survival rate for white DoD beneficiaries is comparable to that for white women in SEER. CONCLUSIONS: These observations suggest that ready access to medical facilities and the full complement of treatment options that are standard for all DoD patients improve survival rates for African American women. However, a significant unexplained difference in survival still exists between African American and white military beneficiaries.     

Cancer surveillance in the U.S.: can we have a national system?

Cancer-related services are consuming ever-increasing health resources; along with this trend, health care costs are rising. As health care planners, researchers, and policymakers formulate strategies to meet this challenge, they are looking to cancer registries and the health information system built around them as collectors of the most extensive information regarding cancer treatment in the U.S. Currently, there are multiple programs collecting and reporting data regarding cancer incidence, morbidity, mortality, and survival. This report profiles cancer surveillance efforts in the U.S. and describes the National Coordinating Council for Cancer Surveillance, which was organized in 1995 to facilitate a collaborative approach among the organizations involved.     

Population-based analysis of treatment of pancreatic cancer and Whipple resection: Department of Defense hospitals, 1989-1994

BACKGROUND: The influence of hospital experience and referral patterns on the operative mortality rate of pancreaticoduodenectomy was studied in a worldwide hospital system. METHODS: We analyzed computerized data on pancreatic cancer patients from U.S. Department of Defense (DOD) hospitals from 1989 to 1994. RESULTS: Six hundred ninety-eight patients had pancreatic cancer, and 130 Whipple operations (105 for pancreatic and 25 for other cancers) were performed with an 8.5% 30-day operative mortality rate. Although most resections were done in teaching hospitals performing more than 1 Whipple procedure per year, their results were not superior to smaller, lower volume nonteaching hospitals. Patients transported for resection were younger than patients undergoing resection at their local DOD hospital but had similar outcomes. The operative mortality rate was higher after unusual resections and with increasing age; the tumor stage had no effect. Unresected patients undergoing combined radiation and chemotherapy had the longest survival times. Radiation therapy was associated with significantly longer survival times in patients without distant metastases, but chemotherapy was associated with a longer survival time when metastases were present. CONCLUSIONS: This mortality rate 8.5% for Whipple resections matches that from other large populations. Equivalent results were obtained in DOD teaching hospitals and smaller, community-type institutions. Because the DOD medical system minimizes financial and logistic barriers to transfer, the even distribution of DOD pancreatectomy mortality suggests that these barriers may favorably influence single institutional outcomes.     

The National Cancer Data Base report on race, age, and region variations in prostate cancer treatment

BACKGROUND: Patterns of care for prostate cancer patients in the United States have changed as early detection has improved. The National Cancer Data Base of the American College of Surgeons Commission on Cancer provides information about the treatment of patients in all age, race, and regional groups from institutions that represent cancer care at the community level as well as in medical centers. METHODS: Data on 251,416 prostate cancer patients diagnosed between 1992 and 1994 were studied. Patient and disease characteristics, including age, race, the geographic region from which a case was reported, American Joint Committee on Cancer stage, and tumor grade were related to the primary pattern of treatment. Stage-standardized comparisons were made among different age groups, race groups, and regional groups. RESULTS: Stage and tumor grade varied little across age, race, and regional classifications. African American patients were more likely than white patients to have Stage IV prostate cancer at the time of diagnosis. Men older than 75 years had greater proportions than younger men of both the earliest and the most advanced stages of cancer. Overall, 24.6% of patients received no cancer-directed therapy, 11.6% were treated with hormones or endocrine surgery, 28.6% received radiation therapy, 28.3% underwent radical prostatectomy, and 6.9% were treated by other modalities or combinations of modalities. Treatment patterns varied markedly by age. The selection of radical prostatectomy relative to no treatment and radiation therapy varied by race and region. CONCLUSIONS: The results of this study showed that prostate cancer treatment varies by patient age, race, and geographic region. The reasons for some of these variations are not well understood and deserve further investigation.     

A novel immunophilin ligand: distinct branching effects on dopaminergic neurons in culture and neurotrophic actions after oral administration in an animal model of Parkinson''s disease

This study was undertaken to update and revise the estimate of the economic impact of obesity in the United States. A prevalence-based approach to the cost of illness was used to estimate the economic costs in 1995 dollars attributable to obesity for type 2 diabetes mellitus, coronary heart disease (CHD), hypertension, gallbladder disease, breast, endometrial and colon cancer, and osteoarthritis. Additionally and independently, excess physician visits, work-lost days, restricted activity, and bed-days attributable to obesity were analyzed cross-sectionally using the 1988 and 1994 National Health Interview Survey (NHIS). Direct (personal health care, hospital care, physician services, allied health services, and medications) and indirect costs (lost output as a result of a reduction or cessation of productivity due to morbidity or mortality) are from published reports and inflated to 1995 dollars using the medical component of the consumer price index (CPI) for direct cost and the all-items CPI for indirect cost. Population-attributable risk percents (PAR%) are estimated from large prospective studies. Excess work-lost days, restricted activity, bed-days, and physician visits are estimated from 88,262 U.S. citizens who participated in the 1988 NHIS and 80,261 who participated in the 1994 NHIS. Sample weights have been incorporated into the NHIS analyses, making these data generalizable to the U.S. population. The total cost attributable to obesity amounted to $99.2 billion dollars in 1995. Approximately $51.64 billion of those dollars were direct medical costs. Using the 1994 NHIS data, cost of lost productivity attributed to obesity (BMI> or =30) was $3.9 billion and reflected 39.2 million days of lost work. In addition, 239 million restricted-activity days, 89.5 million bed-days, and 62.6 million physician visits were attributable to obesity in 1994. Compared with 1988 NHIS data, in 1994 the number of restricted-activity days (36%), bed-days (28%), and work-lost days (50%) increased substantially. The number of physician visits attributed to obesity increased 88% from 1988 to 1994. The economic and personal health costs of overweight and obesity are enormous and compromise the health of the United States. The direct costs associated with obesity represent 5.7% of our National Health Expenditure in the United States.     

Organizational stages and processes of change for continuous quality improvement in health care.

This article provides an overview of the transtheoretical model of change (TTM, or stage model) and how it can guide the development of stage-matched interventions to increase physicians' readiness for continuous quality improvement (CQI) in health care. In addition, this article describes the development and initial validation of two TTM measures—stages and processes of change—designed to assess the extent to which hospitals are engaging in activities that can facilitate individual providers' movement through the stages of change for CQI. 299 Ss participated in the study. A majority (57%) of informants reported that their organizations were in the maintenance stage for CQI. Organizational-level processes of change differed significantly across the stages: Hospitals in the precontemplation stage tended to use the processes least, and hospitals in the maintenance stage tended to use them most. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study

BACKGROUND: Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis. METHODS: The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance. RESULTS: Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven. CONCLUSION: A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.     

Relationship between physician and hospital coronary angioplasty volume and outcome in elderly patients

BACKGROUND: With the expectation that physicians who perform larger numbers of coronary angioplasty procedures will have better outcomes, the American College of Cardiology/ American Heart Association guidelines recommend minimum physician volumes of 75 procedures per year. However, there is little empirical data to support this recommendation. METHODS AND RESULTS: We examined in-hospital bypass surgery and death after angioplasty according to 1992 physician and hospital Medicare procedure volume. In 1992, 6115 physicians performed angioplasty on 97,478 Medicare patients at 984 hospitals. The median numbers of procedures performed per physician and per hospital were 13 (interquartile range, 5 to 25) and 98 (interquartile range, 40 to 181), respectively. With the assumption that Medicare patients composed one half to one third of all patients undergoing angioplasty, these median values are consistent with an overall physician volume of 26 to 39 cases per year and an overall hospital volume of 196 to 294 cases per year. After adjusting for age, sex, race, acute myocardial infarction, and comorbidity, low-volume physicians were associated with higher rates of bypass surgery (P < .001) and low-volume hospitals were associated with higher rates of bypass surgery and death (P < .001). Improving outcomes were seen up to threshold values of 75 Medicare cases per physician and 200 Medicare cases per hospital. CONCLUSIONS: More than 50% of physicians and 25% of hospitals performing coronary angioplasty in 1992 were unlikely to have met the minimum volume guidelines first published in 1988, and these patients had worse outcomes. While more recent data are required to determine whether the same relationships persist after the introduction of newer technologies, this study suggests that adherence to minimum volume standards by physicians and hospitals will lead to better outcomes for elderly patients undergoing coronary angioplasty.     

Suppression of sustained ventricular tachyarrhythmias: a comparison of d,l-sotalol with no antiarrhythmic drug treatment

CONTEXT: Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth. OBJECTIVE: To evaluate dissemination strategies aimed at increasing appropriate use of this therapy. DESIGN AND SETTING: Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13). SUBJECTS: Obstetricians and their preterm delivery cases at participating hospitals. INTERVENTION: Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback. MAIN OUTCOME MEASURE: Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122). RESULTS: Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways. CONCLUSION: An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.     

Prostate cancer in American Indians, New Mexico, 1969 to 1994

PURPOSE: Prostate cancer is the most frequently diagnosed cancer as well as the leading cause of cancer death among American Indian men. MATERIALS AND METHODS: To describe further the occurrence of prostate cancer among American Indian men, we examined population based incidence, treatment, survival and mortality data for American Indians in New Mexico during the 25-year period 1969 to 1994. RESULTS: Although American Indian men have a lower risk of prostate cancer than nonHispanic white men, the incidence and mortality rates are rising for American Indians, and mortality rates are now equal to those for nonHispanic white men. During the 25-year period age adjusted incidence rates for American Indians increased from 42.2/100,000 (95% confidence interval 27.1 to 57.3) to 64.6/100,000 (95% confidence interval 46.2 to 83.0). The burden of prostate cancer among American Indian men compared with nonHispanic white men was reflected in disproportionately high mortality rates in relation to incidence rates. The mortality rates were high because American Indian cases were more advanced at diagnosis, 23.3% of prostate cancers were diagnosed after distant spread had occurred compared with 11.6% for nonHispanic white men and the 5-year relative survival rate was poorer (57.1% compared with 77.6% for nonHispanic white men). CONCLUSIONS: Effective and culturally sensitive cancer control efforts for prostate cancer in American Indian communities are urgently needed.     

Focal epithelial hyperplasia: Heck disease

BACKGROUND: The increasing numbers of cancer patients, the high costs of terminal care, and the development of palliative care services have led to a growing interest in patterns of terminal cancer care. These patterns are relevant to the formulation and evaluation of health services policy. AIMS: To investigate trends in the place of death of South Australian cancer patients between 1981 and 1990, and to examine associations of socio-demographic and clinical variables with the place of death. METHODS: Data relating to 2715 deaths attributed to cancer in 1990 were extracted from the Central Cancer Registry. To assess trends, these data were directly standardised to the age-sex distribution of cancer deaths in 1981 and 1985 which were investigated in a previous study. Unconditional logistic regression was used to investigate predictors of place of death. RESULTS: The proportion of deaths which occurred in major metropolitan public hospitals decreased from 40% in 1981 to 28% in 1990. Conversely, the proportion which occurred in hospice units increased from 5% to 20% over the same period. There was a decline in the proportion of deaths which occurred in private hospitals, but there was no significant change in the proportion which occurred in country hospitals or nursing homes. The proportion of deaths at home remained around 14%. Associated with place of death were age, sex, type of malignancy, survival time from diagnosis to death, Aboriginality, and area of residence. Further research to assess the clinical appropriateness of terminal care patterns is suggested.