Journal of the National Cancer Institute Advance Access originally published online on December 25, 2007
JNCI Journal of the National Cancer Institute 2008 100(1):21-31; doi:10.1093/jnci/djm271
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© The Author 2007. Published by Oxford University Press.
ARTICLES |
Absence of Cancer Diagnosis and Treatment in Elderly Medicaid-Insured Nursing Home Residents
Affiliations of authors: Department of Health Administration (CJB, JPC, CL) and Massey Cancer Center (CJB), Virginia Commonwealth University, Richmond, VA
Correspondence to: Cathy J. Bradley, PhD, Department of Health Administration and Massey Cancer Center, Virginia Commonwealth University, Grant House, 1008 Clay Street, PO Box 980203, Richmond, VA 23298-0203 (e-mail: cjbradley{at}vcu.edu).
Background: Little is known about the effect cancer has on the lives of nursing home patients and the quality of care, including palliative care, delivered to them.
Methods: Using a statewide population-based dataset assembled from the Michigan Tumor Registry and Medicare records, we identified 1907 elderly Medicaid-insured nursing home residents who were diagnosed with cancer between 1997 and 2000. Logistic regression models were used to estimate odds ratios (ORs) and relative risks (RRs) according to age, race, sex, income, comorbidity, and cancer site for late or unstaged cancer at diagnosis, death within 3 months of diagnosis, receipt of hospice care, and—for patients diagnosed with early-stage breast, colorectal, lung, or prostate cancer—the likelihood of cancer-directed surgery. All statistical tests were two-sided.
Results: Nursing home residents diagnosed with cancer had a preponderance of late or unstaged disease (62%), high mortality within 3 months of diagnosis (48%), and low hospice use if they had distant-stage cancer (28%). Only 22% received cancer-directed surgery, 61% of which was confined to breast cancer patients, and only 6% of patients received chemotherapy and/or radiation. Older age was positively associated with late or unstaged cancer and with death within 3 months of diagnosis. Patients aged 71–75 years were more likely to have cancer-directed surgery than patients aged 86 years and older (OR = 2.83, 95% confidence interval [CI] = 1.26 to 6.32; RR = 1.37, 95% CI = 1.08 to 1.75). African American patients were less likely to receive surgery (OR = 0.51, 95% CI = 0.26 to 0.99; RR = 0.80, 95% CI = 0.62 to 1.03) than white patients. Other demographic characteristics and comorbid conditions had little predictive value with regard to cancer treatment or hospice use in nursing home patients.
Conclusions: Very few cancer services are provided to Medicaid-insured nursing home patients, despite the fact that many of these patients likely experienced cancer-related symptoms and marked physical decline before diagnosis and death. A middle ground between what would be considered guideline treatment practices and the apparent absence of diagnosis and treatment is needed.
| CONTEXT AND CAVEATS Prior knowledge The extent and quality of cancer care provided to nursing home patients have not been carefully assessed. Study design Regression models based on federal (Medicaid and Medicare) and state (Michigan Tumor Registry) databases were used to analyze the frequency of cancer-related medical care among nursing home residents according to age, race, and other variables. Contribution The study provides quantitative information needed to assess the extent of cancer care delivered to nursing home residents. Implications A preponderance of late or unstaged disease, high mortality within a few months of cancer diagnosis, and low rates of hospice use and cancer treatment warrant the attention of the medical community. Limitations Information on patient or family preferences for treatment was not available and the study was restricted to Michigan Medicaid patients and thus not representative of the entire nursing home population.
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The authors take full responsibility for the study design, data collection, analysis and interpretation of the data, the decision to submit the manuscript for publication, and the writing of the manuscript.
Manuscript received May 31, 2007; revised October 11, 2007; accepted November 16, 2007.
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J Natl Cancer Inst 2008 100: 4-5.
J Natl Cancer Inst 2008 100: 1.