Factors Contributing To Geographic Variation In End-Of-Life Expenditures For Cancer Patients

Health care spending in the months before death varies across geographic areas but is not associated with outcomes. Using data from the prospective multiregional Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, we assessed the extent to which such variation is explained by differences in patients' sociodemographic factors, clinical factors, and beliefs; physicians' beliefs; and the availability of services. Among 1,132 patients ages sixty-five and older who were diagnosed with lung or colorectal cancer in 2003-05, had advanced-stage cancer, died before 2013, and were enrolled in fee-for-service Medicare, mean expenditures in the last month of life were $13,663. Physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared to those in lower-spending areas. Higher-spending areas also had more physicians and fewer primary care providers and hospices in proportion to their total population than lower-spending areas did. Availability of services and physicians' beliefs, but not patients' beliefs, were important in explaining geographic variations in end-of-life spending. Enhanced training to better equip physicians to care for patients at the end of life and strategic resource allocation may have potential for decreasing unwarranted variation in care

Understanding Breast Cancer Knowledge and Barriers to Treatment Adherence: A Qualitative Study Among Breast Cancer Survivors

Abstract Disparities in breast cancer treatment receipt are common and multifactorial. Data are limited on how knowledge about one's breast cancer and understanding treatment rationales may impact treatment completion. In this qualitative analysis, we explored barriers to care with a focus on knowledge. We conducted 18 in-depth interviews with women from diverse socioeconomic backgrounds who were treated at Dana-Farber Cancer Institute (n = 12; Boston, MA) and Columbia University Medical Center (n = 6; New York, NY) and had undergone neo/adjuvant breast cancer treatment within the prior 3 years. Interviews focused on treatments received, adherence, barriers experienced, and questions related to breast cancer knowledge and treatment rationales. We analyzed transcribed interview recordings in N'Vivo using a two-stage coding process that allowed for both preconfigured and emergent themes. Answers for breast cancer knowledge were confirmed using medical records. In our analysis, over one-third of women reported incomplete therapy, including never initiating treatment, stopping treatment prematurely, or missing/delaying treatments due to logistical reasons (childcare, transportation) or patient preferences. Others reported treatment modifications because of provider recommendations. Nearly all women were able to accurately describe the rationale for recommended treatments. Among 17 women for whom medical records were available, women correctly reported 18–71% of their tumor characteristics; incorrect reporting was not consistently associated with treatment incompletion. In conclusion, logistical issues and patient preferences were the main reasons for incomplete therapy in our study. Understanding of treatment rationale was high, but breast cancer knowledge was variable. Further assessment of how knowledge may impact cancer care is warranted

Evaluation of Breast Cancer Knowledge Among Health Promoters in Mexico Before and After Focused Training

OBJECTIVE. Breast cancer is a leading cause of morbidity and mortality in Mexico. We assessed the effectiveness of a train-the-trainer program in two Mexican states in improving knowledge among professional and nonprofessional community health workers. MATERIALS AND METHODS. We worked with local organizations to develop and implement a train-the-trainer program to improve breast cancer knowledge among community health workers, including professional health promoters (PHPs) who were trained and then trained nonprofessional community health promoters (CHPs). We surveyed participants before and after training that included in-person and online classes and again approximately 3 months later. We used paired t tests and chi-square tests to compare survey responses at the different times. We also used logistic regression to assess whether promoter characteristics were associated with greater improvements in breast cancer knowledge after training. RESULTS. Overall, 169 PHPs (mean age, 36 years) completed training and provided a 10-hour training course to 2,651 CHPs, who also completed the pre- and post-training survey. For both PHPs and CHPs, post-training surveys demonstrated increases in an understanding of breast cancer as a problem; an understanding of screening, treatment, and insurance coverage issues; and knowledge of breast cancer risk factors, symptoms, and what constitutes a family history of breast cancer (all p < .05). These improvements were maintained 3 to 6 months after training. CONCLUSION. Train-the-trainer programs hold promise for leveraging community health workers, who far outnumber other health professionals in many low- and middle-income countries, to engage in health promotion activities for cancer and other noncommunicable diseases