Project Title

Building CER Capacity: Aligning CRN, CMS, and State Resources to Map Cancer Care – Research on the effectiveness of advanced cancer treatments (REACT)

Shortened Title

Research on the effectiveness of advanced cancer treatments (REACT)

Publication Date

5-23-2013

Abstract

Through a partnership between investigators in the Cancer Research Network (CRN) and Dana-Farber/Harvard Cancer Center, the goal of this American Recovery and Reinvestment Act of 2009 and NCI sponsored Grand Opportunity grant titled “Building CER Capacity: Aligning CRN, CMS, and State Resources to Map Cancer Care – Research on the effectiveness of advanced cancer treatments (REACT),” was to develop a resource to support high quality cancer comparative effectiveness research (CER) by addressing two key knowledge gaps -- treatment of advanced disease, and population-based research on patterns and outcomes of cancer care for patients who are not represented in SEER-Medicare. While capitalizing on pre-existing infrastructure, we focused our activities to selectively enhance and create a sustainable resource to support CER studies in patients with advanced cancer by addressing the following aims:

Aim 1. Build broad capacity by assembling national data sets (CRN, SEER-Medicare, Medicaid, and NCCN) to support studies of patterns of care and outcomes among patients with advanced cancer and developing, validating, and implementing strategies to enhance the accuracy of key data elements;

Aim 2. In one region (California) augment the patient level data from the national sources in Aim 1 with regional data on supply to build a comprehensive cancer “map” of the region;

Aim 3. Test capacity and understand limitations of the data systems assembled in Specific Aims 1 and 2 by conducting 5 “use case” analyses that describe patterns of care for select decisions in advanced cancer that span the major treatment modalities, have significant clinical or economic ramifications, and are likely influenced by patient, provider, and/or health system factors; and

Aim 4. Launch comparative effectiveness analyses that capitalize on the resources developed and tested in Aims 1-3 by (a) conducting analyses to fully determine the CE of two interventions for advanced cancer, (b) designing and vetting a CE trial appropriate for the CRN, and (c) partnering with NCI to convene a national stakeholders meeting where project data will be presented and strategies for future CER research in cancer discussed.

Our project recruited both MD and PhD investigators (senior and junior) and trainees from Dana –Farber Cancer Institute (DFCI), Harvard University, and the CRN to utilize the infrastructure we developed, and to conduct studies of patterns of care and CER analyses related to the treatment of advanced disease. Our strategy to assemble multiple national datasets from sources that include registry-linked Medicaid data, tumor registry data, CRN based electronic medical record (EMR) and claims data, SEER-Medicare linked data, and data from the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium project, allowed us make substantial progress in developing and testing the infrastructure to support CER of advanced cancer. We have used this infrastructure to conduct several focused analyses, frequently juxtaposing the data sources to enable meaningful comparisons and also allowing us to identify variations in the patterns and predictors of treatment and outcomes. In addition, we conducted several CER analyses associated chemotherapy and radiotherapy.

EHR/EMR System or Vendor

EpicCare®

Healthcare Settings

Primary care or ambulatory clinics, Inpatient facilities, Emergency departments, Specialty clinics, Academic medical centers

Data Types

Electronic Health/Medical Records (EHR or EMR), Diagnostic data, Pharmacy databases, Claims, Patient Registries, Data Collected for Independent, Research Studies (e.g. clinical trial, longitudinal outcomes study)

Geographic scope type

National

Locations of Focus

We used EHR/EHR and other administrative data from four of the 9 integrated HMOs that are members of the Cancer Research Network (CRN): Kaiser Permanente Northern California (KPNC), KP Colorado (KPCO), KP Northwest (KPNW); and Group Health (GH). This four plans cover more than 5 million individuals. In addition, we also used data from the SEER-Medicare data link which contained information on 105,000 incident cancer cases diagnosed in 2005 and longitudinal claims data characterizing care are available for the approximately 80% of Medicare beneficiaries enrolled in fee-for-service plans. Cancer Registry and Medicaid enrollment data from the states of California and New York were included in several of the analyses along with primary data that was collected at 21 cancer centers across the US who participate in the National Comprehensive Cancer Network (NCCN).

Population Network Size

See above

Major Partners

- CRN - Dana Farber Cancer Institute - NCCN

CER/PCOR Study Priority Populations

Low-income groups, Women, The elderly, Individuals who need chronic care, Individuals who need end-of-life care, Cancer

Treatment Comparators

  • Coumadin versus low molecular weight heparin (LMWH) for secondary prophylaxis of thromboembolic disease
  • Use and choice of first line chemotherapy for lung lung cancer,
  • Use and choice of home versus inpatient hospice programs,
  • Whole brain radiotherapy alone vs. stereotactic radiosurgery vs. intensity modulated radiotherapy vs. surgical resection for cancer related brain metastases
  • The utilization and frequency of high cost imaging (CT, MRI, and PET) among patients with metastatic lung, colorectal, breast, or prostate cancer

Outcome(s) of Interest

  • VTE
  • overall survival
  • toxicities
  • inpatient admissions
  • cost

Suggested Reading

1. Hassett MP, Ritzwoller DP, Taback N, Carroll N, Cronin AM, Ting GV, Schrag D, Warren JL, Hornbrook MC, Weeks JC, Validating Billing/Encounter Codes as Indicators of Lung, Colorectal, Breast, and Prostate Cancer Recurrence using Two Large Contemporary Cohorts, Med Care. 2012 Dec 6. [Epub ahead of print] PMID: 23222531 2. Zhu J, Sharma DB, Gray SW, Chen AB, Weeks JC, Schrag D. Carboplatin and paclitaxel with vs without bevacizumab in older patients with advanced non-small cell lung cancer. JAMA 2012; 307(15):1593-1601 PMCID: PMC3418968 3. Zhu J, Sharma DB, Gray SW, Chen AB, Weeks JC, Schrag D. Comparative Effectiveness of Three Platinumdoublet Chemotherapy Regimens in Elderly Patients with Advanced Non-Small-Cell Lung Cancer. Cancer. 2013 Apr 5. doi: 10.1002/cncr.28022. [Epub ahead of print] PMID: 23564469 4. Hu Y, Kwok AC, Jiang W, Taback N, Loggers ET, Ting GV, Lipsitz SR, Weeks JC, Greenberg CC. High-cost imaging in elderly patients with stage IV cancer. J Natl Cancer Inst. 2012 Aug 8;104(15):1164-72. doi: 10.1093/jnci/djs286. Epub 2012 Jul 31. PMC ID# in process 5. Halasz LM, Weeks JC, Neville BA, Taback N, Punglia RS Use of stereotactic radiosurgery for treatment of brain metastases in the United States. Int J Radiat Oncol Biol Phys. 2013 Feb 1;85(2):e109-16. doi: 10.1016/j.ijrobp.2012.08.007. Epub 2012 Oct 9. PMID: 23058058 6. Ritzwoller DP, Carroll N, Delate T, O’Keeffe-Rossetti M, Fishman PA, Loggers ET, Aiello Bowles EJ, Elston-Lafata J, Hornbrook MC. Validation of Electronic Data on Chemotherapy and Hormone Therapy Use in HMOs. Med Care. 2012 Apr 23. [Epub ahead of print]PMID: 22531648 PMCID: PMC3406224 7. Hornbrook MC, Fishman PA, Ritzwoller DP, Elston-Lafata J, O'Keeffe-Rosetti MC, Salloum RG. When does an episode of care for cancer begin? Medical care. 2013;51(4):324-9. Epub 2012/12/12. 6. Ritzwoller DP, Carroll NM, Delate T, Hornbrook MC, Kushi L, Aiello Bowles EJ, et al. Patterns and predictors of first-line chemotherapy use among adults with advanced non-small cell lung cancer in the cancer research network. Lung cancer (Amsterdam, Netherlands). 2012;78(3):245-52. Epub 2012/10/02. 7. Delate T, Witt DM, Ritzwoller D, Weeks JC, Kushi L, Hornbrook MC, Aiello Bowles EJ, Schrag D. Outpatient use of low molecular weight heparin monotherapy for first-line treatment of venous thromboembolism in advanced cancer. The Oncologist.2012;17(3):419-27. Epub 2012 Feb 14. PMCID: PMC3316928 8. Lowry SJ, Loggers ET, Bowles EJA, Wagner EH. Evidence gaps in advanced cancer care: community-based clinicians’ perspectives and priorities for comparative effectiveness research. Joint publication in both the Journal of Oncology Practice, 2012 May; 8(3 Suppl):28s-33s., and Am J Manag Care, 2012 May; 18(5 Spec No 2):SP77-83. PMCID: PMC3348591 10. Kwan ML, Haque R, Lee VS, Joanie Chung WL, Avila CC, Clancy HA, et al. Validation of AJCC TNM staging for breast tumors diagnosed before 2004 in cancer registries. Cancer causes & control : CCC. 2012;23(9):1587-91. Epub 2012/07/17.

Acknowledgement of Funders

NCI Grant No. RC2 CA148185, Building CER Capacity: Aligning CRN, CMS, and State Resources to Map Cancer Care, Co-PIs: Jane C. Weeks, MD and Debra P. Ritzwoller, PhD

Additional Information

Advanced cancer is an ideal topic for comparative effectiveness research because the existing evidence base is less well-developed than for early disease, and the potential impact of CER therefore greater. Our hope is that primary beneficiaries of this work will be cancer patients, since a better understanding of the most effective strategies of care could lead to meaningful improvements in the length and quality of their lives.

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