Showing papers by "David K. Blough published in 2012"

Risk Factors for Financial Hardship in Patients Receiving Adjuvant Chemotherapy for Colon Cancer: A Population-Based Exploratory Analysis

Abstract: Purpose Characteristics that predispose patients to financial hardship during cancer treatment are poorly understood. We therefore conducted a population-based exploratory analysis of potential factors associated with financial hardship and treatment nonadherence during and following adjuvant chemotherapy for colon cancer. Patients and Methods Patients diagnosed with stage III colon cancer between 2008 and 2010 were identified from a population-based cancer registry representing 13 counties in Washington state. Patients were asked to complete a comprehensive survey on treatment-related costs. Patients were considered to have experienced financial hardship if they accrued debt, sold or refinanced their home, borrowed money from friends or family, or experienced a 20% or greater decline in their annual income as a result of treatment-related expenses. Logistic regression analysis was used to investigate factors associated with financial hardship and treatment nonadherence. Results A total of 284 responses w...

Is Distance to Provider a Barrier to Care for Medicaid Patients With Breast, Colorectal, or Lung Cancer?

Abstract: Low-income populations bear a relatively high burden of travel to primary care providers (PCP) because they often reside in remote, rural areas and have limited means of transportation.1,2 In addition, American Indians/Alaska Natives (AI/ANs), many of whom live on remote reservations, have been shown to be a particularly vulnerable group with respect to late diagnosis and are of special interest here.3–7 The burden of travel from a patient’s residence to his or her health care provider can be an important issue influencing access to preventive and treatment services for cancer. Adverse outcomes associated with greater distance and/or greater travel time to provider may include delay in treatment and discontinuity in follow-up care.8 Cancer patients may be at particular risk, because delays in initiating treatment may result in more advanced and difficult-to-treat disease or in increased risk of relapse after treatment. Longer distances to treatment facilities have been associated with decreased likelihood of receiving treatment for breast cancer,9–11 undergoing breast-conserving surgery, and with greater likelihood of later stage of diagnosis for melanoma and colorectal cancer (CRC).12–15 Most studies that have found associations between distance to provider and cancer diagnosis or treatment have measured distance by using either straight-line distance or driving distance based on Geographic Information System (GIS) software.9–15 The results of one study were based on distances derived from patient surveys.16 Because travel distances do not necessarily correlate with travel time, we used software tools to test the hypothesis that for Medicaid populations, including AI/ANs and other vulnerable groups, longer travel times to PCPs were associated with (1) later stage at cancer diagnosis, (2) less frequent receipt of recommended surgery for initial cancer treatment, and (3) for those who received recommended surgery, greater number of days between the date of cancer diagnosis and the date of surgery. We further explored whether driving time or driving distance better predicted access to care. We hypothesized that driving time would be more important than driving distance.

An Inducible Cytochrome P450 3A4-Dependent Vitamin D Catabolic Pathway

Abstract: Vitamin D3 is critical for the regulation of calcium and phosphate homeostasis. In some individuals, mineral homeostasis can be disrupted by long-term therapy with certain antiepileptic drugs and the antimicrobial agent rifampin, resulting in drug-induced osteomalacia, which is attributed to vitamin D deficiency. We now report a novel CYP3A4-dependent pathway, the 4-hydroxylation of 25-hydroxyvitamin D3 (25OHD3), the induction of which may contribute to drug-induced vitamin D deficiency. The metabolism of 25OHD3 was fully characterized in vitro. CYP3A4 was the predominant source of 25OHD3 hydroxylation by human liver microsomes, with the formation of 4β,25-dihydroxyvitamin D3 [4β,25(OH)2D3] dominating (Vmax/Km = 0.85 ml · min−1 · nmol enzyme−1). 4β,25(OH)2D3 was found in human plasma at concentrations comparable to that of 1α,25-dihydroxyvitamin D3, and its formation rate in a panel of human liver microsomes was strongly correlated with CYP3A4 content and midazolam hydroxylation activity. Formation of 4β,25(OH)2D3 in primary human hepatocytes was induced by rifampin and inhibited by CYP3A4-specific inhibitors. Short-term treatment of healthy volunteers (n = 6) with rifampin selectively induced CYP3A4-dependent 4β,25(OH)2D3, but not CYP24A1-dependent 24R,25-dihydroxyvitamin D3 formation, and altered systemic mineral homeostasis. Our results suggest that CYP3A4-dependent 25OHD3 metabolism may play an important role in the regulation of vitamin D3 in vivo and in the etiology of drug-induced osteomalacia.

AUDIT-C Alcohol Screening Results and Postoperative Inpatient Health Care Use.

Abstract: Background Alcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission. Study Design This cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group. Results Adjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 [95% CI, 5.0−6.7] vs 5.0 [95% CI, 4.7−5.3] days), more ICU days (4.5 [95% CI, 3.2−5.8] vs 2.8 [95% CI, 2.6−3.1] days), and increased probability of return to the operating room (10% [95% CI, 6−13%] vs 5% [95% CI, 4−6%]) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group. Conclusions AUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.

Association between alcohol screening results and hospitalizations for trauma in Veterans Affairs outpatients.

Abstract: Background: Alcohol consumption is a risk factor for traumatic injury, but it is unknown whether responses to alcohol screening questionnaires administered routinely in primary care are associated with subsequent hospitalization for traumatic injury. Objective: We evaluated the association between alcohol screening scores and the risk for subsequent hospitalizations for trauma among Veterans Affairs (VA) general medicine patients. Method: This study included VA outpatients (n = 32,623) at seven sites who returned mailed surveys (1997–1999). Alcohol Use Disorders Identification Test Consumption (AUDIT-C) scores grouped patients into six drinking categories representing nondrinkers, screen-negative drinkers, and drinkers who screened positive for mild, moderate, severe, and very severe alcohol misuse (scores 0, 1–3, 4–5, 6–7, 8–9, 10–12, respectively). VA administrative and Medicare data identified primary discharge diagnoses for trauma. Cox proportional hazard models were used to estimate the risk of traum...

Predicting costs of care in heart failure patients

Abstract: Identifying heart failure patients most likely to suffer poor outcomes is an essential part of delivering interventions to those most likely to benefit. We sought a comprehensive account of heart failure events and their cumulative economic burden by examining patient characteristics that predict increased cost or poor outcomes. We collected electronic medical data from members of a large HMO who had a heart failure diagnosis and an echocardiogram from 1999–2004, and followed them for one year. We examined the role of demographics, clinical and laboratory findings, comorbid disease and whether the heart failure was incident, as well as mortality. We used regression methods appropriate for censored cost data. Of the 4,696 patients, 8% were incident. Several diseases were associated with significantly higher and economically relevant cost changes, including atrial fibrillation (15% higher), coronary artery disease (14% higher), chronic lung disease (29% higher), depression (36% higher), diabetes (38% higher) and hyperlipidemia (21% higher). Some factors were associated with costs in a counterintuitive fashion (i.e. lower costs in the presence of the factor) including age, ejection fraction and anemia. But anemia and ejection fraction were also associated with a higher death rate. Close control of factors that are independently associated with higher cost or poor outcomes may be important for disease management. Analysis of costs in a disease like heart failure that has a high death rate underscores the need for economic methods to consider how mortality should best be considered in costing studies.

Complementary and alternative medicine use among newly diagnosed prostate cancer patients.

Abstract: We surveyed prostate cancer patients about complementary and alternative medicine (CAM) use and evaluated patient factors that correlated with CAM use 6 months following diagnosis. The Prostate CAncer Therapy Selection study was a prospective, observational multi-site study of men’s treatment decision-making process after a diagnosis of local stage prostate cancer. Recruitment occurred in community urology practices in Washington State, hospital-based urology clinics affiliated with the University of Southern California, and Kaiser Permanente in Northern California. Eligible study participants included men over age 21 diagnosed with local stage prostate cancer between May 1, 2005 and December 31, 2006. Fifty-two percent of survey respondents (379) reported using one or more types of CAM. Of the patients, 51% used one CAM method, 26% used two methods, and 23% used three or more methods. The most commonly reported category was mind–body therapies (65%). Only 43% of patients discussed their CAM use with a health professional; of those, 20% informed their primary care physician and 30% told the doctor managing their prostate cancer care. Less than half thought the CAM they used was “very helpful”, but a majority thought it was somewhat helpful for their condition. Further research is needed to characterize the goals prostate cancer patients have for CAM, whether the treatments met those goals, and how this translates into the perceived helpfulness of these therapies. The implications of patients not discussing CAM use with health professionals at the time of prostate cancer treatment need further studies.

Measures of adherence to oral hypoglycemic agents at the primary care clinic level: the role of risk adjustment.

Abstract: Background:Prior research found that in the Veterans Affairs health care system (VA), the proportion of patients adherent to oral hypoglycemic agents varies from 50% to 80% across primary care clinics. This study examined whether variation in patient and facility characteristics determined those dif

Colony-Stimulating Factor Use and Impact on Febrile Neutropenia Among Patients with Newly Diagnosed Breast, Colorectal, or Non–Small Cell Lung Cancer Who Were Receiving Chemotherapy

Abstract: Study Objective To determine the impact of primary prophylactic colony-stimulating factor (CSF) use on febrile neutropenia in a large patient population receiving contemporary chemotherapy regimens to treat breast cancer, colorectal cancer, or non–small cell lung cancer (NSCLC). Design Retrospective claims analysis. Data Sources The Surveillance, Epidemiology, and End Results (SEER)-Puget Sound cancer registry and insurance claims records. Patients A total of 2728 patients aged 25 years or older who received a diagnosis of breast cancer (998 patients), colorectal cancer (688 patients), or NSCLC (1042 patients) between January 1, 2002, and December 31, 2005, and received chemotherapy. Measurements and Main Results Initial chemotherapy regimen, CSF use (filgrastim or pegfilgrastim), and febrile neutropenia events were evaluated after the first chemotherapy administration. Subsequently, febrile neutropenia rates in patients receiving primary prophylactic CSF were compared with febrile neutropenia rates in patients receiving CSF in settings other than primary prophylaxis or not at all. The impact of primary prophylactic CSF could not be assessed for patients with colorectal cancer or NSCLC because only 1 and 18 febrile neutropenia events, respectively, occurred in those receiving primary prophylactic CSF. Of the 998 patients with breast cancer, 72 (7.2%) experienced febrile neutropenia, 28 of whom received primary prophylactic CSF. In the patients with breast cancer, we observed that primary prophylactic CSF use was associated with reduced febrile neutropenia rates; however, the analysis may have been confounded by unmeasured factors associated with febrile neutropenia. Conclusion The impact of primary prophylactic CSFs on febrile neutropenia rates could not be demonstrated. Given the substantive cost of CSFs to pharmacy budgets, there are numerous opportunities for pharmacists to optimize CSF use. Research studies are needed to evaluate if guideline-directed prescribing of primary prophylactic CSFs can improve clinical outcomes.

Patterns of blood product use among patients with myelodysplastic syndrome.

Abstract: Background and Objectives Most patients with myelodysplastic syndrome (MDS) require blood product support to manage the severe anaemias, which frequently accompany MDS. Our objective was to show the feasibility of linking the Surveillance, Epidemiology and End Results (SEER) database with records from Puget Sound Blood Center (PSBC) to characterize blood product use over time in successive cohorts of patients with MDS. Materials and Methods We identified patients with MDS in the SEER registry. The cohort was then linked to PSBC records to discern blood product use. Results Included in the analysis were 783 patients with MDS entered in the SEER database from 2001 to 2007 for whom data were also available in the PSBC database. Among patients with MDS who received transfusions, 97% received packed red blood cells; 52% received platelets. The proportion of patients with MDS receiving blood products declined from 2001 to 2007. Conclusion These data show a recent decline in blood product use for patients with MDS. Future studies are needed to further evaluate the reasons for this finding, specifically exploring the impact of newer medications on blood product use in patients with MDS.

A comparison of approaches for association studies of polymorphisms and colorectal cancer risk.

Abstract: Aim Meta-analyses have been used to evaluate associations between polymorphisms and colorectal cancer risk, but the quality of individual studies used to inform them may vary substantially. Our aim was to apply well-established quality-control criteria to individual association studies and then compare the results of meta-analyses that included or excluded studies that did not meet these criteria. Method We used meta-analyses of studies reporting a relationship between polymorphisms and colorectal cancer published between 1996 and 2008. Polymorphism–cancer associations were derived in separate meta-analyses including only those meeting the quality-control criteria. Results Relative ORs varied substantially between the open and restricted group meta-analyses for all variants except MTHFR 677 CT. However, the associations were modest and the direction of relative risk did not change after applying criteria. Publication bias was detected for all associations, except the restricted set of studies for GSTP1 GG. Conclusion We observed variation in calculated relative risk and changes in tests for publication bias that were dependent on the inclusion criteria used for association studies of polymorphisms and colorectal cancer. Standardizing study inclusion criteria may reduce the variation in findings for meta-analyses of gene-association studies of common diseases such as colorectal cancer.

Health insurer policies toward risk-stratified colorectal cancer screening: a survey of health plan medical directors.

Abstract: OBJECTIVES We sought to determine whether health insurance coverage of colorectal cancer (CRC) screening varied based on risk. BACKGROUND Population-wide screening guidelines for cancer often incorporate risk information, with modified screening recommendations for those at higher risk due to family history or other factors. METHODS In a nationwide Internet- and mail-based survey of health insurance plan medical directors, respondents were asked about their organization's policies towards coverage of CRC screening for persons at average and higher risk of CRC. Additional questions asked about whether the insurer had a definition of increased risk, and coverage of genetic testing for familial CRC syndromes. RESULTS Survey invitations were sent to 1158 medical directors; 133 (11%) completed the survey. All plans covered screening for average and high-risk persons. The onset of screening was earlier and intervals were more frequent for higher risk compared to average risk persons, with most respondents stating coverage was determined by "physician discretion." While 75% had a definition of high risk, only 55% covered genetic testing. CONCLUSIONS Most insurers offer enhanced coverage of CRC screening, most commonly following the discretion of the physician. Whether this coverage results in earlier, more frequent, or more complete screening of higher risk persons remains uncertain.