paywalled: Causes of death of mutation carriers in Finnish Lynch syndrome families.

Fam Cancer. 2012 Jun 9. [Epub ahead of print]

Abstract

Lynch syndrome (LS) is an autosomal dominant cancer syndrome including increased life-long risk for colorectal (CRC) and endometrial (EC) cancer, but also for cancers of other types. The risk for CRC is up to 70-80 % and for EC up to 50-60 %. Due to screening and early diagnosing the mortality related to CRC and EC seems to be low. In spite of many studies on surveillance of mutation carriers, there is no comprehensive evaluation on causes of death in LS families. The disease history and cause of death of all the deceased, tested mutation carriers and their mutation negative relatives in the Finnish LS families (N = 179) was examined utilizing hospital records and relevant national registries. Out of 1069 mutation carriers 151 had succumbed; 97 (64 %) from cancer. Out of 1146 mutation-negative family 44 members had died; 11 (25 %) of them from cancer. In 12 (7.7 %) of the deceased mutation carriers no cancer had been diagnosed. The mean age of death from cancer was 63.2 years vs. 68.8 years from non-cancer causes. Only 7.9 % of the patients with CRC had died from CRC and 5 % of those with EC, respectively. 61 % of the cancer deaths were related to extra-colonic, extra-endometrial cancers. The cumulative overall and cancer specific death rates were significantly increased in Mut+ compared to Mut- family members. Even surveillance yields decrease in the life-long risk and mortality of the most common cancers CRC and EC in LS, almost all mutation carriers will contract with cancer, and two thirds of the deceased have died from cancer. This should be taken in account in genetic counseling. Mutation carriers should be encouraged to seek help for abnormal symptoms.

health media: Cancer Care Costs Higher in U.S. Than Europe, But Survival Longer - MedicineNet

Cancer Care Costs Higher in U.S. Than Europe, But Survival Longer - MedicineNet


MONDAY, April 9 (HealthDay News) -- The United States spends more on health care than any other country, but those high costs may be paying off in cancer survival, a new report suggests.
U.S. cancer patients often live almost two years longer than similar patients in Europe, arguing for the dollar value of care given, researchers say.
However, Dr. Otis Brawley, the chief medical officer and executive vice president at the American Cancer Society, who was not involved in the study, said that "this paper has a huge fatal flaw in it."
"When you look at survival from time of diagnosis to time of death and you have a screened population that has a lot of diagnoses, you're filling that population with people who don't need treatment and because they are over-diagnosed, they have very long survival," he added.
These researchers attribute increased survival to the treatment, when it is really over-diagnosis, Brawley said. "So they are looking at a bunch of wasted, unnecessary treatment and then saying it was money well spent," he said.
"You don't look at survival rates -- this is a classic misuse of survival rates," Brawley said. "You have to look at death rates for each disease and not survival rates. The measurement should not be expense versus survival -- it should be expense versus mortality rate."
On that scale, the United States does well for some cancers and as well as they do in most of Europe for others, he said. "Mortality rates for breast and colon cancer are close to the mortality rates in Europe, but that may include the effect of over-treatment," Brawley said.
The report was published in the April issue of Health Affairs.
For the study, Tomas Philipson, the chair in public policy at the University of Chicago, and colleagues looked at cancer care in the United States and in 10 European countries from 1983 to 1999.
The investigators found that for most cancers, U.S. patients lived longer than Europeans. Americans lived an average of 11.1 years after diagnosis, compared with 9.3 years for Europeans, they said.
When the authors translated survival data to dollars, they found those extra years were worth $598 billion, which is an average of $61,000 per cancer patient.
The value of these survival gains was highest for prostate cancer ($627 billion) and breast cancer ($173 billion), the findings indicated.
To put a monetary value on survival, the researchers used a "statistical-life concept." In many such studies, they said, estimates are based on how much income a person would exchange for a lower risk of mortality.
"Our findings bear on the larger question of whether higher U.S. health care spending is worth it, suggesting -- although not confirming -- that it is," the researchers wrote.
"Further research is required to examine the drivers of spending and their effects on outcomes, including assessing the relative contributions of treatments, screening, the skill of health care personnel and other factors in improving patient outcomes," they concluded.
On the larger issue of the costs of cancer treatment, Brawley said that "we spend money in an irrational way. We harm people by over-treating them and over-treatment costs money."
Many patients are getting treatments that cause harm, but don't really prolong life, Brawley said. It's hard for a doctor to tell a patient there is nothing that can be done.
"That is the kind of thing doctors need to be developing skills in -- it's an emotional hurdle to say 'I can't stop this,'" he said.
Many patients think that giving up is admitting defeat, and want to be treated even if the treatment will do more harm than good, Brawley said.
"We all need to take a step back and take a look at reality and ask whether the patient stands a good chance of benefiting from a particular treatment. If there aren't benefits, then we ought to, perhaps, stop," he said.
"Instead of talking about rationing care, we need to talk about the rational use of care," Brawley added.

interactive: First Ever Local Area Health System Scorecard Finds Significant Differences in Access, Costs, Quality, and Outcomes Within States and Among Nation's Biggest Cities

First Ever Local Area Health System Scorecard Finds Significant Differences in Access, Costs, Quality, and Outcomes Within States and Among Nation's Biggest Cities:

In the first scorecard measuring how 306 local U.S. areas are doing on key health care indicators such as insurance coverage, preventive care, and mortality rates, researchers at The Commonwealth Fund found significant differences between the best- and worst-performing localities.

open access: Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario (Canada) Hospitals, March 14, 2012 — JAMA

 Blogger's Note: universal healthcare system, this study included colorectal cancer patients, comparisons between Canadian/U.S. systems, note authors' affiliations

Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals, March 14, 2012

"Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively (and at higher cost) have lower mortality and readmissions and higher quality of care.......We studied 4 common conditions that have moderate to high incidence and mortality, that can be validly ascertained using health administrative data, and for which treatment follows relatively standard protocols. "

Design Overview

We undertook a longitudinal cohort study of patients hospitalized with selected acute clinical conditions in Ontario, Canada, and assessed the content, quality, and outcomes with respect to “exposure” to the index hospital's medical spending intensity. Medical intensity is defined as the quantity of medical care provided overall to similarly ill patients and is a marker of a hospital's propensity to treat similarly ill patients more (or less) intensively. It reflects the component of spending variation attributable to practice style rather than to differences in illness or price.

Because sicker patients use more services, higher-spending hospitals may appear to have worse outcomes, in part because patients are more severely ill. We used several techniques to remove this potential “reverse causality,” as in previous work.1,2​,3,4

 COMMENT

We found that higher hospital spending intensity was associated with better survival, lower readmission rates, and better quality of care for seriously ill, hospitalized patients in Ontario in a universal health care system with more selective access to medical technology. Higher-spending hospitals were higher-volume teaching or community hospitals with high-volume or specialist attending physicians and having specialized programs, such as regional cancer centers, and specialized services, such as on-site cardiac catheterization, cardiac surgery, and diagnostic imaging facilities. The study also points to plausible mechanisms through which higher spending may be associated with better outcomes. 

Benefits appeared early, suggesting an acute-phase hospital effect. For acute conditions, timely access to preoperative and in-hospital specialist care, skilled nursing staff, rapid response teams, cardiac high-technology services, and regional cancer centers, all found in the higher-spending systems, are related to better outcomes.^{21​,27,34​,35,36​,37,38​,39} These systems also provided consistently, but not strikingly, higher levels of evidence-based care and collaborative ambulatory care, both shown to improve care.^{22​,23,40​} Higher spending on evidence-based services delivered in the acute phase of care for severely ill hospitalized patients—by far the largest component of spending for our cohorts—is indeed likely to be beneficial. 

It would be facile to interpret this study as demonstrating that higher spending is causally related to better outcomes and that providing more money to lower-spending hospitals would necessarily improve their outcomes. Higher-spending hospitals differed in many ways, such as greater use of evidence-based care, skilled nursing and critical care staff, more intensive inpatient specialist services, and high technology, all of which are more expensive. 

To place the study in context, the United States has a 3- to 4-times higher per capita supply of specialized technology, such as computed tomography and magnetic resonance imaging scanners, but a similar supply of acute care beds and nurses.⁴¹ Ontario 2001 population rates of cardiac testing and revascularization lagged behind corresponding 1992 US rates and paralleled the supply of cardiologists and catheterization facilities.^{42​,43,44​} It is therefore possible that Canadian hospitals, with fewer specialized resources, selective access to medical technology, and global budgets, are using these resources more efficiently, especially during the inpatient episode for care-sensitive conditions.^45,46​ Canada's health care expenditures per capita are about 57% of those in the United States.⁴⁷ At this spending level, there might still be a positive association between spending and outcomes. For example, the same-day PCI rate for patients with AMI in low-intensity hospitals in 2008 was 3.5%, leaving room for improvement. This pattern is consistent with studies in the United States showing a positive association between spending and outcomes among low-intensity hospitals or regions but no association at average or higher intensity levels.^5​,6

Strengths of the study include the population-based, longitudinal cohort design; the consistency of findings across cardiac, cancer, medical, and surgical patients; the examination of plausible clinical mechanisms whereby higher intensity may be associated with better outcomes; and the examination of readmissions. The “look-back” (EOL-EI) and “look-forward” (AC-EI) measures of spending intensity were highly correlated and produced similar findings, as in US studies.²

 ^​

Several limitations should be considered. Because the design precludes strong inferences about causation, we cannot know which components of care may have led to better outcomes. In observational studies, comparisons of exposure groups may be biased because of unobserved selection bias.¹³ It is unlikely that the findings are the result of unmeasured case mix, because patients in higher-spending hospitals had similar or higher illness severity at admission, which would, if anything, bias toward finding worse outcomes. We cannot rule out the possibility that higher-intensity hospitals coded more aggressively, but there is less incentive to do so in a system with global hospital budgets. Although admission severity would be determined more accurately using clinical detail from medical charts, previous work has shown high concordance between risk-adjusted hospital outcomes using chart and administrative data.^48​,49 Canadian data distinguish between comorbidities present at admission and complications, leading to improved admission severity coding. The EOL-EI has been critiqued for the purpose of estimating hospital efficiency^50​,51 but is used here simply to distinguish high- and low-intensity hospitals, as in other US studies.^{1​,2,3​,4} The findings may not generalize to chronic conditions, for which avoiding exacerbations of disease that lead to hospitalization through coordinated ambulatory care is key. The findings also may not generalize to jurisdictions in which hospital resources are more abundant and are used in cost-effective as well as cost-ineffective ways, leading to inefficiency.^45​,46

This study shows that in Ontario, a province with global hospital budgets and fewer specialized health care resources than the United States, outcomes following an acute hospitalization are positively associated with higher hospital spending intensity. Higher spending intensity, in turn, is associated with greater use of specialists, better patient care, and more use of advanced procedures. These results suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services. 

pdf file: 

http://jama.ama-assn.org/content/307/10/1037.full.pdf

US Deaths Resulting From Inpatient Surgery Decline

 "January 18, 2012 — The number of surgical procedures performed in the United States increased between 1996 and 2006, whereas inpatient postsurgical deaths within 30 days of admission dropped significantly, according to a national, population-level analysis published  (abstract) in the February issue of Surgery....."

".....In 2006, more patients had sepsis or pneumonia than in 1996, and the absolute number of deaths resulting from complications increased. However, the failure-to-rescue rate declined during the study period for both groups (sepsis, from 18.69% to 14.03%; pneumonia, from 8.54% to 7.34%). Meanwhile, the number of deaths resulting from deep venous thrombosis or pulmonary embolism, upper gastrointestinal bleeding, and shock declined during the study period.
Overall, the number of patients with 1 to 5 complications increased, but the failure-to-rescue rate for patients with an identified complication decreased from 12.10% to 9.84% (P < .001)
"The decline in the number of deaths may have occurred through reduced mortality of individual procedures, reductions in the volume of high-risk procedures, and the rescue of patients who had a complication," the authors write.
They estimate that 51,000 fewer people died in 2006 than would have with the 1996 mortality rate. However, they also note that some portion of the decline in mortality "may represent the effect of premature discharge as opposed to an actual improvement in survival." Data were not linked across admissions, and a patient discharged postoperatively who was later readmitted with a complication and died would not be counted as a death in this study."

Cervical, Uterine Corpus, and Ovarian Cancer Mortality in Greece During 1980 to 2005: A Trend Analysis

"The increasing trend of uterine corpus and ovarian cancer mortality in older women suggests that development of well-organized tertiary centers for the implementation of modern therapeutic modalities is urgently needed."