Guideline-concordant timely lung cancer care and prognosis among elderly patients in the United States: A population-based study

Objectives—Elderly carry a disproportionate burden of lung cancer in the US. Therefore, its important to ensure that these patients receive quality cancer care. Timeliness of care is an important dimension of cancer care quality but its impact on prognosis remains to be explored. This study evaluates the variations in guideline-concordant timely lung cancer care and prognosis among elderly in the US. Materials and Methods—Using the Surveillance, Epidemiology, and End Results (SEER)- Medicare database (2002-2007), we identified elderly patients with lung cancer (n = 48,850) and determined time to diagnosis and treatment. We categorized patients by receipt of timely care using guidelines from the British Thoracic Society and the RAND Corporation. Hierarchical generalized logistic model was constructed to identify variables associated with receipt of timely care. Kaplan-Meier analysis and Log Rank test was used for estimation and comparison of the three-year survival. Multivariable Cox proportional hazards model was constructed to estimate lung cancer mortality risk associated with receipt of delayed care. Results—Time to diagnosis and treatment varied significantly among the elderly. However, majority of them (77.5%) received guideline-concordant timely lung cancer care. The likelihood of receiving timely care significantly decreased with NSCLC disease, early stage diagnosis, increasing age, non-white race, higher comorbidity score, and lower income. Paradoxically, survival outcomes were significantly worse among patients receiving timely care. Adjusted lung cancer mortality risk was also significantly lower among patients receiving delayed care, relative to those receiving timely care (Hazard ratio (HR) = 0.68, 95% Confidence interval (CI)= (0.66 - 0.71); p ≤ 0.05). Conclusion—This study highlights the critical need to address disparities in receipt of guidelineconcordant timely lung cancer care among elderly. Although timely care was not associated with better prognosis in this study, any delays in diagnosis and treatment should be avoided, as it may increase the risk of disease progression and psychological stress in patients. Furthermore, given that lung cancer diagnostic and management services are covered under the Medicare program, observed delays in care among Medicare beneficiaries is also a cause for concern

Tobacco-use Cessation Counseling Service Usage

Objectives—Tobacco-use is common among elderly lung cancer patients and continued tobaccouse can impact prognosis. This study evaluates patterns of receipt of Tobacco-use Cessation Counseling (TCC) services among these patients. Methods—Using West Virginia Cancer Registry-Medicare linked database (2004–2007), we identified elderly patients with lung cancer (n = 922) and categorized them by receipt of TCC services. Hierarchical generalized logistic model was constructed and survival outcomes were analyzed by Kaplan-Meier analysis, Log-Rank test, and Cox proportional hazards modeling. Results—Majority of patients (76.7%) received TCC services. Unadjusted analysis showed favorable survival outcomes in patients who received TCC services. However, adjusted lung cancer mortality risk was no different between the groups (HR (95% CI) = 1.78 (0.87–3.64)). Conclusion—This study highlights the critical need to address disparities in receipt of TCC services among elderly. Although lung cancer preventive services are covered under the Medicare program, underutilization of these services is a concern

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

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

Guideline-concordant lung cancer care and associated health outcomes among elderly patients in the United States

Objectives—In the United States (US), the elderly carry a disproportionate burden of lung cancer. Although evidence-based guidelines for lung cancer care have been published, lack of high quality care still remains a concern among the elderly. This study comprehensively evaluates the variations in guideline-concordant lung cancer care among elderly in the US. Materials and Methods—Using the Surveillance, Epidemiology, and End Results (SEER)- Medicare database (2002–2007), we identified elderly patients (aged ≥65 years) with lung cancer (n = 42,323) and categorized them by receipt of guideline-concordant care, using evidence-based guidelines from the American College of Chest Physicians. A hierarchical generalized logistic model was constructed to identify variables associated with receipt of guideline-concordant care. Kaplan–Meier analysis and Log Rank test were used for estimation and comparison of the threeyear survival. Multivariate Cox proportional hazards model was constructed to estimate lung cancer mortality risk associated with receipt of guideline-discordant care. Results—Only less than half of all patients (44.7%) received guideline-concordant care in the study population. The likelihood of receiving guideline-concordant care significantly decreased with increasing age, non-white race, higher comorbidity score, and lower income. Three-year median survival time significantly increased (exceeded 487 days) in patients receiving guidelineconcordant care. Adjusted lung cancer mortality risk significantly increased by 91% (HR = 1.91, 95% CI: 1.82–2.00) among patients receiving guideline-discordant care. Conclusion—This study highlights the critical need to address disparities in receipt of guidelineconcordant lung cancer care among elderly. Although lung cancer diagnostic and management services are covered under the Medicare program, underutilization of these services is a concern

Microsoft Word - 04

ABSTRACT Quality by Design is the modern approach for quality of pharmaceuticals. This paper gives idea about the Pharmaceutical Quality by Design (QbD) and describes use of Quality by Design to ensure quality of Pharmaceuticals. The Quality by Design is described and some of its elements identified. Process parameters and quality attributes are identified for each unit operation. Benefits, opportunities and steps involved in Quality by Design of Pharmaceutical products are described. The aim of the pharmaceutical development is to design a quality product and its manufacturing process to consistently deliver the intended performance of the product. Quality cannot be tested into products but quality should be built in by design. It includes the Quality target product profile, critical quality attributes and key aspects of Quality by Design. It also gives comparison between product quality by end product testing and product quality by Quality by Design. The foundation of Quality by Design is ICH Guidelines. It is based on the ICH Guidelines Q8 for pharmaceutical development, Q9 for quality risk management, Q10 for pharmaceutical quality systems. It also gives application of Quality by Design in pharmaceutical development and manufacturing of pharmaceuticals