Surgical treatment of lung cancer: Predicting postoperative morbidity in the elderly population Rueth, Natasha M., MD, MS; Parsons, Helen M., MPH; Habermann, Elizabeth B., PhD, MPH ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
06/2012, Letnik:
143, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Objectives Surgical resection is standard treatment for early-stage non–small cell lung cancer; however, perception of postoperative risk may influence the decision to proceed for elderly patients. ...With population data, we analyzed postoperative complications and morbidity predictors for older patients undergoing lobectomy for stage I non–small cell lung cancer. Methods The Surveillance Epidemiology and End-Results–Medicare linked database (2000–2005) identified patients (ages 66–80 years) undergoing lobectomy for stage I non–small cell lung cancer. We comprehensively evaluated in-hospital postoperative complications (pulmonary, cardiac, infectious, noncardiopulmonary) with International Classification of Diseases, Ninth Revision , diagnosis codes. Logistic regression models were constructed to identify patient, tumor, and treatment characteristics associated with complications. Results In all, 4171 patients were included, 2329 of whom had 4097 in-hospital postoperative complications (55.8%). Pulmonary complications were most common (n = 1598; 38.3%) followed by cardiac (n = 1020; 24.5%). Complications were significantly associated with age at least 75 years, male sex, higher comorbidity index, larger tumors, and treatment at nonteaching hospitals ( P < .05). Patients with complications had a longer median stay (8 days) than patients without (6 days; P < .001). The 30-day mortality was 4.2%. Conclusions Population-based analysis demonstrated that perioperative complications after lobectomy for stage I non–small cell lung cancer in older patients exceeded 50% and were associated with specific patient, tumor, and treatment characteristics. Better understanding of the impact of these risk factors may facilitate surgical decision making and encourage implementation of more effective perioperative care guidelines for older surgical patients.
Abstract Purpose Pancreatitis—an inflammation of pancreas—is a severe and costly disease. Although many risk factors for pancreatitis are known, many pancreatitis cases, especially in elderly women, ...are of unknown etiology. Methods Risk factors for acute pancreatitis (AP) and chronic pancreatitis (CP) were assessed in a prospective cohort ( n = 36,436 women, aged ≥ 65 years). Exposures were self-reported at baseline. Pancreatitis was ascertained by linkage to Medicare claims (1986–2004) categorized by a physician as follows: “AP”, one AP episode ( n = 511) or “CP”, 2+ AP or 1+ CP episodes ( n = 149). Results Multivariable odds ratios (ORs) and 95% confidence intervals for AP and CP were calculated using multinomial logistic regression. Alcohol use was not associated with AP or CP. Heavy smoking (40+ vs. 0 pack-years) was associated with a twofold increased OR for CP. For body mass index greater than or equal to 30 versus less than 25 kg/m2 , the ORs were 1.35 (1.07–1.70) for AP ( P trend = .009) and 0.59 (0.37–0.94) for CP ( P trend = .01). ORs for AP and CP were increased for hormone replacement therapy use, heart disease, and hypertension. There were positive significant associations between protein and total fat intake for CP and AP. Conclusions We identified factors associated with AP and CP that may be specific to older women.
Background Little is known about the role of diet in the development of venous thromboembolism (VTE). We explored the prospective relation of dietary patterns, food groups, and nutrients to incident ...VTE in older women. Methods In 1986, Iowa women aged 55 to 69 years completed a mailed survey, including a 127-item food frequency questionnaire. These data were linked to Medicare data from 1986 to 2004, and International Classification of Diseases discharge codes were used to identify hospitalized VTE cases. Cox regression analyses evaluated relations of 2 principal components–derived dietary patterns, 11 food groups, and 6 nutrients to VTE, adjusted for age, education, smoking status, physical activity, and energy intake. Results Over 19 years of follow-up, 1,950 of the 37,393 women developed VTE. Women consuming alcohol daily were at 26% (95% CI 11%-38%) lower risk of VTE as compared to nonconsumers. All alcoholic beverages types were in the direction of lower risk; however, only beer and liquor were statistically significant. After basic adjustments, coffee was inversely related to VTE, and diet soda and fish positively related. However, these associations were confounded and became nonsignificant after adjustment for body mass index and diabetes. No associations were observed with consumption of ‘Western‘ or ‘Prudent‘ dietary patterns, fruit, vegetables, dairy, meat, refined grains, whole grains, regular soda, vitamins E, vitamin B6 , vitamin B12 , folate, ω -3 fatty acids, or saturated fat. Conclusions In this cohort of older women, greater intake of alcohol was associated with a lower risk of incident VTE. No other independent associations were seen between diet and VTE.
Background Among surgically treated patients with colon cancer, lower long-term mortality has been demonstrated in those with 12 or more lymph nodes evaluated. We examined whether patients receiving ...adequate lymph node evaluation were also more likely to receive comprehensive postsurgical care, leading to lower mortality. Study Design We used the 1992 to 2007 Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify surgically treated American Joint Committee on Cancer (AJCC) stage III colon cancer patients. We used chi-square analyses and logistic regression to evaluate the association between adequate (≥12) lymph node evaluation and receipt of postsurgical care (adjuvant chemotherapy, surveillance colonoscopy, CT scans, and CEA testing) and Cox proportional hazards regression to evaluate 10-year all-cause mortality, adjusting for postsurgical care. Results Among 17,906 surgically treated stage III colon cancer patients, adequate (≥12) lymph node evaluation was not associated with receiving comprehensive postsurgical care after adjustment for patient and tumor characteristics (p > 0.05 for all). Initially, adequate lymph node evaluation was associated with lower all-cause mortality (hazard ratio HR 0.88; 95% CI 0.85 to 0.91), but among 3-year survivors, the impact of adequate lymph node evaluation on lower mortality was diminished (HR 0.94; 95% CI 0.88 to 1.01). However, receiving comprehensive postsurgical care was associated with continued lower mortality in 3-year survivors. Conclusions Adequate lymph node evaluation for colon cancer was associated with lower mortality among all patients. However, among 3-year survivors, the association between lymph node evaluation and lower hazard of death was no longer significant, while postsurgical care remained strongly associated with lower long-term mortality, indicating that postsurgical care may partially explain the relationship between lymph node evaluation and mortality.
Abstract Purpose Health insurance facilitates financial access to health services, including prenatal and preconception care. This study characterized changes in health insurance coverage among ...reproductive-age women in the United States from 2000 to 2009. Methods Data from female respondents (ages 18–49) to the National Health Interview Surveys, 2000 to 2009 ( n = 207,968), including those pregnant when surveyed ( n = 3,204), were used in a repeated cross-sectional design. Changes over time were estimated using longitudinal regression models. Main Findings Of the reproductive-age women in this study, 25% were uninsured at some point in the prior year. Ten percent of pregnant women reported currently being uninsured, and 27% and 58% reported Medicaid coverage or private health insurance, respectively. Among women who were not pregnant, 19% were currently uninsured, 8% had Medicaid, and 68% had private coverage. From 2000 to 2009, an increasing percentage of reproductive-age women reported having gone without health insurance in the past year. Controlling for sociodemographic and health variables, the chances that a reproductive-age woman had been uninsured increased by approximately 1.5% annually ( p < .001), and did not differ between pregnant women and those who were not pregnant. The odds that an insured pregnant woman had Medicaid coverage increased 7% per year over the study period ( p < .001), whereas the odds of private coverage decreased. Conclusion Reproductive-age women are increasingly at risk of being uninsured, which raises concerns about access to prenatal and preconception care. Among pregnant women, access to private health insurance has decreased, and state Medicaid programs have covered a growing percentage of women. Health reform will likely impact future trends.
Objectives: To examine whether there are urban‐rural differences in use of the Medicare hospice benefit before death and whether those differences suggest that there is a problem with access to ...hospice care for rural Medicare beneficiaries.
Design: Observational study using 100% of Medicare enrollment, hospice, and hospital claims data.
Setting: Inpatient hospitals and hospices.
Participants: Persons aged 65 and older in the Medicare program who died in 1999.
Measurements: Rates of hospice use before death and in‐hospital death rates were calculated.
Results: In 1999, there were 1.76 million deaths of Medicare beneficiaries aged 65 and older. Hospice services were used by 365,700 of these beneficiaries. Rates of hospice care before death were negatively associated with degree of rurality. The lowest rate of hospice use, 15.2% of deaths, was seen in rural areas not adjacent to an urban area. The highest rate of use, 22.2% of deaths, was seen in urban areas. Rural areas adjacent to urban areas had an intermediate level of hospice use (17.0% of deaths). Hospices based in rural areas had a smaller number of elderly patients each year than hospices based in urban areas (P<.001) and were more likely to have very low volumes (average daily census of three patients or less).
Conclusion: The consistently lower use of Medicare hospice services before death and smaller sizes of rural hospices suggest that the combination of Medicare hospice payment policies and hospice volumes are problematic for rural hospices. Adjusting Medicare payment policies might be a critical step to assure availability of hospice services forterminally ill beneficiaries regardless of where they live.
Objective The purpose of the study was to determine whether women who survived uterine cancer received 4 recommended preventive services (mammography, colorectal cancer screening, influenza ...immunization, and bone density testing) at the same rates as women with no history of cancer. Study Design We used the Surveillance, Epidemiology, and End Results–Medicare database to compare the rates among survivors aged 67 years or older with a matched group of women with no history of cancer. Results Survivors were significantly more likely to have a mammogram (adjusted odds ratio OR, 1.40; 95% confidence interval CI, 1.30-1.50) or a colorectal cancer screening examination (adjusted OR, 1.11; 95% CI, 1.05-1.18). Influenza immunization and bone density testing rates were similar. The 28% of survivors seen by an obstetrician-gynecologist or gynecologic oncologist had the highest rates of use. Conclusion Efforts need to be made to increase the use of services by all women to achieve the target rates established by Healthy People 2010.
Abstract Background Breast reconstruction after mastectomy offers clinical, cosmetic, and psychological benefits compared with mastectomy alone. Although reconstruction rates have increased, ...racial/ethnic disparities in breast reconstruction persist. Insurance coverage facilitates access to care, but few studies have examined whether health insurance ameliorates disparities. Methods We used the Nationwide Inpatient Sample for 2002 through 2006 to examine the relationships between health insurance coverage, race/ethnicity, and breast reconstruction rates among women who underwent mastectomy for breast cancer. We examined reconstruction rates as a function of the interaction of race and the primary payer (self-pay, private health insurance, government) while controlling for patient comorbidity, and we used generalized estimating equations to account for clustering and hospital characteristics. Findings Minority women had lower breast reconstruction rates than White women (adjusted odds ratio AOR, 0.57 for African American; AOR, 0.70 for Hispanic; AOR, 0.45 for Asian; p < .001). Uninsured women (AOR, 0.33) and those with public coverage were less likely to undergo reconstruction (AOR, 0.35; p < .001) than privately insured women. Racial/ethnic disparities were less prominent within insurance types. Minority women, whether privately or publicly insured, had lower odds of undergoing reconstruction than White women. Among those without insurance, reconstruction rates did not differ by race/ethnicity. Conclusions Insurance facilitates access to care, but does not eliminate racial/ethnic disparities in reconstruction rates. Our findings—which reveal persistent health care disparities not explained by patient health status—should prompt efforts to promote both access to and use of beneficial covered services for women with breast cancer.
Cervical cancer treatment is associated with a risk of urinary adverse events (UAEs) such as ureteral stricture and vesicovaginal fistula. We sought to measure the long-term UAE risk after surgery ...and radiation therapy (RT), with confounding controlled through propensity-weighted models.
From the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we identified women ≥66 years old with nonmetastatic cervical cancer treated with simple surgery (SS), radical hysterectomy (RH), external beam RT plus brachytherapy (EBRT+BT), or RT+surgery. We matched them to noncancer controls 1:3. Differences in demographic and cancer characteristics were balanced by propensity weighting. Grade 3 to 4 UAEs were identified by diagnosis codes plus treatment codes. Cumulative incidence was measured using Kaplan-Meier methods. The hazard associated with different cancer treatments was compared using Cox models.
UAEs occurred in 272 of 1808 cases (17%) and 222 of 5424 (4%) controls; most (62%) were ureteral strictures. The raw cumulative incidence of UAEs was highest in advanced cancers. UAEs occurred in 31% of patients after EBRT+BT, 25% of patients after RT+surgery, and 15% of patients after RH; however, after propensity weighting, the incidence was similar. In adjusted Cox models (reference = controls), the UAE risk was highest after RT+surgery (hazard ratio HR, 5.07; 95% confidence interval CI, 2.32-11.07), followed by EBRT+BT (HR, 3.33; 95% CI, 1.45-7.65), RH (HR, 3.65; 95% CI, 1.41-9.46) and SS (HR, 0.99; 95% CI, 0.32-3.01). The higher risk after RT+surgery versus EBRT+BT was statistically significant, whereas, EBRT+BT and RH were not significantly different from each other.
UAEs are common after cervical cancer treatment, particularly in patients with advanced cancers. UAEs are more common after RT, but these women tend to have the advanced cancers. After propensity weighting, the risk after RT was similar to that after surgery.
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