Disparities in Lung Cancer Care and Outcomes among Elderly in a Medically Underserved State Population-A Cancer Registry-Linked Database Study

Abstract

Despite availability of guidelines for lung cancer care, variations in lung cancer care among the elderly exist across the nation and are a cause for concern in rural and medically underserved areas. Therefore, the purpose of this study was to evaluate the patterns of lung cancer care and associated health outcomes among elderly residing in a rural and medically underserved area. The authors identified 1924 elderly lung cancer patients from the West Virginia Cancer Registry-Medicare linked database (2002-2007) and categorized them by receipt of guideline-concordant (appropriate and timely) care using guidelines from the American College of Chest Physicians, British Thoracic Society, and the RAND Corporation. Hierarchical generalized logistic models were constructed to identify variables associated with receipt of guideline-concordant care. Kaplan-Meier analysis and log-rank test were used to compare 3-year survival outcomes. Multivariate Cox proportional hazards models were constructed to estimate lung cancer mortality risk associated with nonreceipt of guideline-concordant care. Although guideline-concordant appropriate care was received by fewer than half of all patients (46.5%), of those receiving care, 78.7% received it in a timely manner. Delays in diagnosis and treatment varied significantly. Survival outcomes significantly improved with appropriate care (799 vs. 366 days; P≤0.05), but did not improve with timely care. This study highlights the critical need to address disparities in receipt of guideline-concordant lung cancer care among the elderly residing in rural and medically underserved areas. Although lung cancer diagnostic and management services are covered under the Medicare program, underutilization of these services is a concern. (Population Health Management 2016;19:109-119).

FIG. 1.

Algorithm adapted from American College of Chest Physicians (ACCP) evidence-based guidelines for diagnosis and management of lung cancer published in January 2003, and used to determine receipt of guideline-concordant appropriate lung cancer care.

FIG. 2.

Delays in diagnosis and treatment among continuously enrolled Medicare Fee-for-service beneficiaries with incident lung cancer diagnosis in West Virginia, 2003 through 2006. CXR, chest X-ray; ICD-9, International Classification of Diseases, Ninth Revision; IQR, interquartile range. The number of beneficiaries included in the calculation of median delay varied by type of delay, as not all beneficiaries experienced the event of interest necessary to calculate the delay. Source: West Virginia Cancer Registry–Medicare linked data files, 2002–2007.