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Integrated health care may eliminate racial disparities in colon cancer survival
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Providing fair, high-quality, evidence-based care can eliminate racial disparities in survival outcomes among patients with colon cancer, according to results of a retrospective study.
Survival rates between black patients and white patients with colon cancer have been observed for the past 2 decades. However, data suggest those disparities may be the result of treatment quality and not patient factors such as race, according to study background.
Kim F. Rhoads
Kim F. Rhoads, MD, of Stanford Cancer Institute and the department of surgery at Stanford University School of Medicine, and colleagues used the California Cancer Registry to identify patients treated for colon cancer between 2001 and 2006.
The researchers compared the rates of National Comprehensive Cancer Network (NCCN) guideline-based care, hazard rates for mortality, and racial or ethnic disparities between integrated health systems and other clinical settings.
“Our study set out to understand the influence of the location where treatment was delivered and the quality of care received on overall survival and racial disparities,” Rhoads told HemOnc Today. “By questioning the role of the health care system, we have challenged the traditional approach to cancer disparities which have focused largely on patient contributions to mortality.
“In doing so, we have identified an actionable mechanism to address colon cancer disparities—adherence to NCCN guidelines. The results of our study suggest that the ability to address cancer disparities may have more to do with the quality of care delivered than previously shown.”
The study population consisted of 33,593 patients from 348 California hospitals, of which 44 (13%) facilities were part of an integrated health system.
Overall, 19% of patients were treated in an integrated health system. From that cohort, 66% were white and 11.9% were black. Among the patients treated outside of an integrated health system, 71.4% were white and 5.6% were black.
Patients with high comorbidity scores were treated more frequently in integrated systems than other settings (9.3% vs. 7.9%).
Results showed higher rates of surgery (95% vs. 92%; P<.0001) and chemotherapy (75% vs. 54%; P<.0001) in integrated systems compared with other settings; however, there was no significant difference between the two settings in the quality of lymph node examination.
Additional analysis determined that the proportion of black patients who underwent surgery was lower than whites in both settings; however, the disparity was smaller in the integrated health systems (–2.2%) than in other settings (–5.8%).
Rhoads and colleagues observed an independent association between care in an integrated system and survival (HR=0.87; 95% CI, 0.85-0.9). In non-integrated system settings, black race was associated with a 15% increased risk for mortality (HR=1.15; 95% CI, 1.04-1.27), whereas there was no disparity among any race in the integrated health systems (P>.11).
Researchers used an adjusted model that estimated mortality in both settings to examine the potential interaction between race and location of care. That model indicated a survival advantage for blacks treated in integrated health systems (HR=0.76; 95% CI, 0.61-0.93).
“We plan to conduct future studies in other types of cancers to determine if guideline-based care is associated with the elimination of disparities,” Rhoads said. “We are also exploring ways to increase patient use of the NCCN colon cancer guidelines for advocacy and participation in shared decision making. We hope that our work will encourage third-party payers and other hospital-level policy makers to incentivize adherence to NCCN guidelines in an effort to improve colon cancer survival for all patients while simultaneously, and directly, addressing colon cancer disparities.” – by Anthony SanFilippo
Kim F. Rhoads, MD, can be reached at Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305; email: mailto:kim.rhoads@stanford.edu
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Electra Paskett, PhD
The paper by Rhoads and colleagues demonstrates the value of integrated health care systems with regard to assuring patients receive quality of care and also reducing disparities of care. Both of these strategies improved OS, leading to two suggestions: provide integrated health care and assure that all patients receive quality care. The first could be promoted by making sure patients receive appropriate care and using patient navigators to reduce loss to follow-up along the various care pathways and hand-offs. For the second, quality care should be available to all patients regardless of race, income or education, again with the use of patient navigators to identify and eliminate individual barriers to the receipt of proper and prompt care. Health care reform holds the promise to realizing these suggestions; however, health care systems must identify strategies within their individual organizations to truly realize the overall goal of delivering quality care and reducing disparities.
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