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Comparative Effectiveness Research on Cancer in Texas (CERCIT) is a statewide resource for outcomes and comparative effectiveness research funded by The Cancer Prevention Research Institute of Texas (CPRIT), RP101207
Project 1    |     Project 2     |     Project 3    |     Project 4

Matrix Project 1: Evaluation of Cancer Screening Practices

Despite considerable research on the underutilization of appropriate cancer screening ― focusing on patient, physician and health system factors that contribute to screening disparities ― very little similar work has been performed on overutilization of screening and inappropriate screening. Such work is important, because reductions in overutilization can free up resources to remedy underutilization of cancer screening in disadvantaged populations. Texas is an ideal state to examine both underutilization and overutilization of testing, because it is large, ethnically and economically diverse, and has dramatic contextual variations in overall per patient Medicare expenditures. For three screening modalities (PSA, mammography, and colonoscopy) we will address the following:
  1. Systematically describe the use of cancer screening in Texas.

  2. Investigate patient, provider, medical system, geographical and time factors (2001 through 2012) that predict optimal utilization (vs. over or underutilization) of cancer screening.

  3. Investigate outcomes of screening, focusing on benefits and harms associated with optimal utilization vs. overutilization or underutilization of cancer screening.
With PSA we will concentrate on overutilization by evaluating its use in men with an average life expectancy of less than 10 years based on age and comorbidity. With colonoscopy we will assess both underutilization and overutilization. Overutilization of colonoscopy will be defined as shorter than recommended intervals between screening and also by screening in populations with less than a ten year life expectancy. With mammography we will also assess both overutilization and underutilization, studying its use in women aged 40 and older stratified into cohorts of different average life expectancies.

James S. Goodwin, M.D. directs the CERCIT and also Project 1. He has directed several large multidisciplinary research programs. These include the NCI-funded Center for Population Health and Health Disparities and the NIA-funded Claude Pepper Older Americans Independence Center. In May 2010, he stepped down as PI of the Pepper Center to concentrate on development of the recently created Center for Comparative Effectiveness and Cancer Outcomes, for which he is co-director. Dr. Goodwin has been continuously funded by NIH for studies of the processes and outcomes of cancer care for 25 years. He was among the first to use Tumor Registry data and then Medicare billing data to examine how patterns in the diagnosis, treatment and outcomes of cancers vary with patient characteristics and geographic location. His 300+ articles have been cited more than 14,000 times.

Matrix Project 2: Assessing the Quality of Cancer Treatment in Texas

No data source currently exists for measuring quality of cancer treatment in Texas. Although the Texas Cancer Registry collects some treatment information, the focus is on cancer incidence, staging, and survival. As with most cancer registries, treatment data are often missing and of unknown accuracy and completeness. However, these treatment data can be supplemented and completed using other data sources. We propose to link the Texas Cancer Registry with Medicare, Medicaid, and private insurance databases to assess treatment patterns for patients in Texas. From the Medicare, Medicaid, and insurance claims records, we will be able to evaluate the use and type of surgery, chemotherapy, and radiotherapy for Texas patients with cancer. Our specific aims are:
  1. Determine the agreement of the Texas Cancer Registry and claims databases for the rates of surgery, chemotherapy, and radiotherapy use for patients in Texas with colorectal, lung, breast, prostate, and pancreatic cancer

  2. Evaluate the quality of cancer treatment in the state of Texas by studying adherence to evidence-based treatment guidelines for patients with colorectal, lung, breast, prostate, and pancreatic cancer

  3. Determine the variation in quality of cancer treatment across geographic regions of Texas and assess how variation in the availability of cancer specialists influences the quality of care
The information learned from this study will increase the completeness of the data in the Texas Cancer Registry, provide information on patterns of cancer treatment in Texas and identify potential gaps in the quality of cancer treatment in Texas. We will be able to identify areas of Texas where cancer patients are underserved due to a lack of specialists. Previous studies have shown profound variation in cancer care by geography, provider, and patient. Therefore, these data on cancer care in Texas are essential to target resources and policies to the populations and geographic areas that would benefit the most.

Sharon Giordano, MD, MPH directs Project 2. She is Associate Professor of Medicine, Division of Cancer Medicine, the University of Texas M.D. Anderson Cancer Center. Dr. Giordano is a board-certified medical oncologist with expertise in health services research. She is a member of international and national breast cancer guideline committee at the National Comprehensive Cancer Network, ASCO, and the International Society of Geriatric Oncology. This year, she is the Scientific Program Committee Chair for Health Services Research at ASCO. She is currently funded by the NIH to use SEER-Medicare data to study adherence to breast cancer therapy and is also a principal investigator on an American Cancer Society grant using SEER-Medicare and MarketScan data to study off-label use of chemotherapy. Her research has included studies of breast cancer patterns of care and long-term outcomes for cancer patients. She also has experience in identifying cancer treatments through administrative data claims.

Matrix Project 3: Quality of Post-Treatment Surveillance of Cancer Patients in Texas

The primary goal of surveillance following curative treatment for cancer, regardless of site, is to detect local recurrence or distant disease at a time when survival can be prolonged by interventions designed to cure or at least treat the disease more effectively than when discovered later. Evidence-based recommendations regarding surveillance can decrease variations in care, limit unnecessary care, and serve to facilitate delivery of necessary care. The availability of evidence-based recommendations varies significantly among different cancer types. Based on randomized, controlled data, the surveillance recommendations for breast and colorectal cancer are clear. In contrast, few to no evidence-based recommendations exist for post-treatment surveillance for cancers such as lung and pancreas. In national studies using both administrative data and single institution data, we and others have identified wide variation in post-treatment surveillance with respect to evidence-based recommendations. Despite clear recommendations, surveillance practices vary significantly by patient demographics, cancer type, and the type and number of physicians (primary care physicians vs. specialists) performing the surveillance. We will initially use the Texas Cancer Registry and linked Medicare, Medicaid, and private insurance claims data from 2000-2012 to address the following specific aims:
  1. Describe the patterns of surveillance testing after curative treatment for breast and colorectal cancer patients compared to available evidence-based recommendations and describe the cost of guideline adherent and non-adherent post-treatment surveillance.

  2. Describe the patterns of surveillance testing after curative treatment for non-small cell lung and pancreatic cancer patients.

  3. Describe physician visits after curative-intent cancer treatment, including the proportion of patients with regular visits to primary care physicians, surgeons, medical oncologists, and/or radiation oncologists, as well as the proportion of patients who see multiple provider types for each of the four cancers.

  4. Assess the effects of patient characteristics, provider characteristics, health care delivery factors, and time on guideline-adherent surveillance testing, overuse of testing, and underuse of testing.
Our analysis will allow us to examine the reasons for both overuse and underuse of surveillance tests and will yield important information to guide state-level decision-making and allocation of resources to optimize post-treatment cancer surveillance in Texas. We will ask questions including, but not limited to, the following: Is there significant ethnic variation in post-treatment surveillance? Does overuse of post-treatment surveillance correlate with high per capita Medicare spending in different geographic regions? How do surveillance patterns differ by physician specialty? Does care by multiple providers lead to repetitive or duplicative testing? Given the lack of evidence-based recommendations we cannot evaluate overuse or underuse of post-treatment surveillance in lung and pancreatic cancer. However, studying the patterns of post-treatment surveillance for these unstudied cancers will allow us to describe current patterns and identify potential overuse, such as repetitive testing.

Taylor Riall, MD, PhD directs Project 3. She is Associate Professor in Department of Surgery at UTMB and holds the John Sealy Distinguished Chair in Clinical Research and serves as the Director of the Center for Comparative Effectiveness and Cancer Outcomes at UTMB. She earned her PhD in the Health Services Research track of UTMB's Clinical Science Graduate Program. With Drs. Goodwin and Kuo, she has extensively used SEER, SEER-Medicare, and the Texas Hospital Inpatient Public Use Data File to examine population-based outcomes, disparities in the utilization of surgical resection and outcomes following surgical resection, the incidence of second primary cancers, and regionalization of care for patients with pancreatic cancer. She has authored over 80 papers which have been cited more than 3,000 times. She is currently funded by the NCI and the American Geriatric Society for her cancer-related health services research. Dr. Riall has clinical expertise in pancreatic, colon, and breast cancer.

Matrix Project 4: Quality of Supportive Cancer Care in Texas

High quality cancer care is a priority for the nation owing to cancer’s high prevalence and mortality. Over the last three decades, many treatments and care strategies have shown promise for improving cancer outcomes and quality of care. Most efforts to measure and improve the quality of cancer care have focused on the entire US. We propose to link cancer-specific information from the Texas Cancer Registry (TCR) to Medicare, Medicaid and private insurance claims, creating a unique resource for quality measurement for Texas. We will use these data to assess the quality of supportive cancer care of Texans and to target knowledge translation activities to populations that will benefit.
Our goal is to conduct actionable, policy-relevant quality of cancer care research about Texas to inform our integrated knowledge translation plan. To accomplish this goal we will identify gaps in quality in which we can intervene to improve quality. Interventions could be directly targeted at providers or patients (providing feedback on adherence and outcomes for the state or regions, predefined order sets, electronic guidelines, or patient guides), or through policy (identifying gaps in insurance coverage of supportive care). A secondary goal is to develop methods and experience with the new data sets that can be generalized to future studies of the comparative effectiveness and quality of cancer care.
We focus on 5 indicators of quality supportive care across the cancer care continuum: emesis prevention and infection prevention during initial cancer treatment, surveillance of bone health and cardiac health during and after treatment, and appropriate delivery of hospice/palliative care at the end of life.
  1. Describe the quality of supportive cancer care among Texas residents and changes in quality of care over time (2001-2012). Quality of care will be measured as adherence to national guidelines for emesis and infection prevention, surveillance for bone and cardiac health, and delivery of end of life care.

  2. Describe variation in guideline adherence related to patient or provider demographic factors, provider specialty and experience, practice environment, and geographic region of Texas.

  3. Compare the clinical outcomes (effectiveness) and average cost of care of patients with guideline adherent and non-adherent care overall and changes over time.
Linda Elting, DrPH co-directs the CERCIT and directs Project 4. She is Professor and Chief, Section of Health Services Research, The University of Texas M.D. Anderson Cancer Center, and an epidemiologist and health services researcher. With over 2 decades of experience in research on delivery of care and outcomes of supportive cancer care she is ideally suited to study the quality of such care. She has published more than 100 papers on the treatment, outcomes and costs of infections, thrombocytopenia, mucositis, nausea and vomiting, osteonecrosis, lymphedema, and deep venous thrombosis in cancer patients. Dr. Elting has also published on determinants of in-hospital death among patients with cancer. She has served on national and international panels to develop guidelines (including one specifying quality indicators for this study) for prevention and management of thrombocytopenia, febrile neutropenia, and mucositis. Dr. Elting has led many studies using medical claims data (including Medicare) and cancer registry data, including the first published report on the costs of hospitalization for supportive cancer care in Texas. She has extensive experience in leading multi-institutional and multi-national research projects and has served as Principal Investigator or Core Director on grants funded by the Komen Foundation, American Cancer Society, and the NIH.

Project Participants include the following:

UTMB MD Anderson Cancer Center
Dr. Catherine Cooksley
Dr. Tony DiNuzzo
Dr. Karl Eschbach
Dr. Jean Freeman
Dr. Yong-Fang Kuo
Dr. Meredith Masel
Dr. Kenneth Ottenbacher
Dr. Alai Tan
Dr. Kristin Sheffield
Dr. Dong Zhang
Dr. Eduardo Bruera
Dr. Joe Ensor
Dr. Ya-Chen Tina Shih
Dr. Benjamin Smith
Dr. Maria Suarez-Almazor
Mr. John Venier
Dr. Ying Xu
Dr. Leonard Zwelling

University of Texas School of Public Health Rice University
Dr. Xianglin Du Dr. Vivian Ho

Baylor College of Medicine Texas Cancer Registry
Dr. David Berger Dr. Melanie Williams