John Z. Ayanian

Background: Accurate information regarding race, ethnicity, and national origins is critical for identifying disparities in the cancer burden. Objectives: To examine the use of a Spanish surname list to improve the quality of race-related information obtained from rapid case ascertainment (RCA) and to estimate the accuracy of race-related information obtained from cancer registry records collected by routine reporting. Subjects: Self-reported survey responses of 3954 participants from California enrolled in the Cancer Care Outcomes Research and Surveillance Consortium. Measures: Sensitivity, specificity, positive predictive value, and percent agreement. We used logistic regression to identify predictors of underreporting and overreporting of a race/ethnicity. Results: Use of the Spanish surname list increased the sensitivity of RCA for Latino ethnicity from 37% to 83%. Sensitivity for cancer registry records collected by routine reporting was ≥95% for whites, blacks, and Asians, and specificity was high for all groups (86%–100%). However, patterns of misclassification by race/ethnicity were found that could lead to biased cancer statistics for specific race/ethnicities. Discordance between self-reported and registry-reported race/ethnicity was more likely for women, Latinos, and Asians. Conclusions: Methods to improve race and ethnicity data, such as using Spanish surnames in RCA and instituting data collection guidelines for hospitals, are needed to ensure minorities are accurately represented in clinical and epidemiological research.

With quality-of-care bonus payments now available for Medicare Advantage health maintenance organizations (HMOs) and for accountable care organizations in traditional Medicare, the need to understand the relative quality of care delivered to Medicare enrollees has increased. We compared the quality of ambulatory care from 2003 through 2009 between beneficiaries enrolled in Medicare Advantage HMOs and those enrolled in traditional Medicare, and we assessed how the performance of various types of Medicare HMOs differed from that of traditional Medicare for these same measures. We found that beneficiaries in Medicare HMOs were consistently more likely than those in traditional Medicare to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease. We also found that Medicare HMO physicians were rated less favorably by their patients than were physicians in traditional Medicare in 2003; however, by 2009 the opposite was true. Not-for-profit, larger, and olde...

Introduction: Numerous studies across different health systems have documented that many patients with rheumatoid arthritis (RA) do not receive disease-modifying anti-rheumatic drugs (DMARDs). Relatively little is known about correlates of DMARD use and whether there are socioeconomic and demographic disparities. We examined DMARD use during 2001 to 2006 in the Medicare Current Beneficiary Survey (MCBS), a longitudinal US survey of randomly selected Medicare beneficiaries. Methods: Participants in MCBS with RA were included in the analyses, and DMARD use was based on an in-home assessment of all medications. Variables included as potential correlates of DMARD use in weighted regression models included race/ethnicity, insurance, income, education, rheumatology visit, region, age, gender, comorbidity index, and calendar year. Results: The cohort consisted of 509 MCBS participants with a diagnosis code for RA. Their median age was 70 years, 72% were female, and 24% saw a rheumatologist. Rates of DMARD use ranged from 37% among those <75 years of age to 25% of those age 75 to 84 and 4% of those age 85 and older. The multivariable adjusted predictors of DMARD use include: visit with a rheumatologist in the prior year (odds ratio, OR, 7.74, 95% CI, 5.37, 11.1) and older patient age (compared with <75 years, ages 75 to 84, OR 0.58, 95% CI 0.37, 0.92, and 85 and over, OR 0.09, 95% CI 0.02, 0.31). In those without a rheumatology visit, lower income and older age were associated with a significantly reduced probability of DMARD use; no association of DMARD use with income or age was observed for subjects seen by rheumatologists. Race and ethnicity were not significantly associated with receipt of DMARDs. Conclusions: Among individuals not seeing rheumatologists, lower income and older age were associated with a reduced probability of DMARD use.

Background The research goals of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium are to determine how characteristics and beliefs of patients, providers, and health care organizations influence the treatments and outcomes of individuals with newly diagnosed lung and colorectal cancers. As CanCORS results will inform national policy, it is important to know how they generalize to the United States population with these cancers. Research Design This study assessed the representativeness of the CanCORS cohort of 10,547 patients with lung cancer (LC) or colorectal cancer (CRC) enrolled between 2003 and 2005. We compared characteristics (sex, race, age, and disease stage) with the Surveillance, Epidemiology, and End Results (SEER) population of 234,464 patients with new onset of these cancers during the CanCORS recruitment period. Results The CanCORS sample is well matched to the SEER Program for both cancers. In CanCORS, 41% LC/47% CRC were female versus 47% LC/49% CRC in SEER. African American, Hispanic, and Asian cases differed by no more than 5 percentage points between CanCORS and SEER. The SEER population is slightly older, with the percentage of patients older than 75 years 33.1% LC/37.3% CRC in SEER versus 26.9% LC/29.4% in CanCORS, and also has a slightly higher proportion of early stage patients. We also found that the CanCORS cohort was representative within specific SEER regions that map closely to CanCORS sites. Conclusions This study demonstrates that the CanCORS Consortium was successful in enrolling a demographically representative sample within the CanCORS regions.

Background: The patient-centered medical home (PCMH) model has gained support, but the impact of this model on the quality and equity of care merits further evaluation. Objective: To determine if PCMHs are associated with improved quality and equity in pediatric primary care. Research Design: Using the 2007/2008 National Survey of Children’s Health, a nationally representative survey of parents/guardians of children (age, 0–17 y), we evaluated the association of PCMHs with 10 quality-of-care measures using multivariable regression models, adjusting for demographic and socioeconomic covariates. For quality indicators that were significantly associated with medical homes, we determined if this association differed by race/ethnicity. Results: Compared with children without medical homes, those with medical homes had significantly better adjusted rates for 6 of 10 quality measures (all P≤0.02), such as obtaining a developmental history [adjusted rates % (SE): 41.7 (1.3) vs. 52.0 (1.1), PP=0.83]. Conclusions: Our results underscore the benefits of the medical home model for children while highlighting areas for improvement, such as narrowing disparities. Our findings also emphasize the key role of patient experience measures in the evaluation of medical homes.

BACKGROUND Despite a growing need for primary care physicians in the United States, the proportion of medical school graduates pursuing primary care careers has declined over the past decade. OBJECTIVE To assess the association of medical school research funding with graduates matching in family medicine residencies and practicing primary care. DESIGN Observational study of United States medical schools. PARTICIPANTS One hundred twenty-one allopathic medical schools. MAIN MEASURES The primary outcomes included the proportion of each school’s graduates from 1999 to 2001 who were primary care physicians in 2008, and the proportion of each school’s graduates who entered family medicine residencies during 2007 through 2009. The 25 medical schools with the highest levels of research funding from the National Institutes of Health in 2010 were designated as “research-intensive.” KEY RESULTS Among research-intensive medical schools, the 16 private medical schools produced significantly fewer practicing primary care physicians (median 24.1 % vs. 33.4 %, p < 0.001) and fewer recent graduates matching in family medicine residencies (median 2.4 % vs. 6.2 %, p < 0.001) than the other 30 private schools. In contrast, the nine research-intensive public medical schools produced comparable proportions of graduates pursuing primary care careers (median 36.1 % vs. 36.3 %, p = 0.87) and matching in family medicine residencies (median 7.4 % vs. 10.0 %, p = 0.37) relative to the other 66 public medical schools. CONCLUSIONS To meet the health care needs of the US population, research-intensive private medical schools should play a more active role in promoting primary care careers for their students and graduates.

The federal system of the United States gives states substantial latitude and authority to regulate their economic affairs. With health care having grown from 13.8% of the national economy in 2000 to 17.9% in 2010, state governments have developed a major stake in ensuring that relentless growth in health care spending is controlled more effectively. In Massachusetts, for example, the costs of Medicaid for low-income residents and private health insurance for state employees account for approximately 40% of the state budget. Rising insurance premiums are also dampening wages in the private sector. A recently enacted Massachusetts law that seeks to control health care spending may therefore provide useful policy lessons for other states and the federal government.