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  • Population Sciences

    Deciphering Disparities in Diagnosis and Treatment

    Investigators are leading a variety of studies to uncover the sources and extent of disparities and to identify ways of eliminating them.

    Understanding Cancer Care Differences among Insured Populations

    Deborah Schrag, MD, MPH, is leading a project that focuses on the quality of cancer care provided to patients insured by state Medicaid programs. Researchers are examining whether such patients receive care that is timely and similar to that provided to patients with private insurance. They are also investigating whether treatment outcomes for Medicaid patients are worse than for those who are privately insured.

    Schrag's team is analyzing data on thousands of patients insured by Medicaid, Medicare, or both when they were diagnosed with cancer. The researchers are scrutinizing the data to determine if poor and elderly people – covered by Medicaid and Medicare, respectively – tend to be diagnosed with more advanced cancers than people with private insurance. Since early detection and diagnosis can be critical to successful cancer therapy, the study may give insights into why treatment often produces less favorable results among these groups. By examining whether racial or ethnic differences persist among patients with similar public insurance, the research will also help specify the root cause of such disparities.

    The researchers have linked cancer registry information to Medicaid, Medicare, and hospital admission data in two states. "Joining Medicare and Medicaid claims with tumor registry records offers an inexpensive, timely way to monitor the caliber of cancer care delivery," Schrag remarks. "Discrepancies in care will help us identify areas where interventions can equalize services for all patients."

    Another project, the Gear Up for Health Study, tested a new approach to weight loss and smoking reduction among long-haul truck drivers. The study examined whether providing telephone counseling to drivers could help them lose weight and decrease tobacco use. "The rate of tobacco use among truck drivers is 40 percent, about double the national average," says Glorian Sorensen, PhD, MPH, who led the study in collaboration with the International Brotherhood of Teamsters. "Drivers are also more likely than the average American to be overweight."

    Because a trucker's working environment – long hours of little physical activity, boredom, deadline pressure – may contribute to health problems, the intervention was geared specifically to those conditions. "It was clear that a generic weight loss and smoking cessation program was unlikely to be effective." Sorensen says, "so the messages delivered by the telephone counselors were designed to reflect the reality of the drivers' work setting." The researchers found that the intervention had a significant impact on smoking cessation among the drivers, but wasn't effective in weight reduction. The results show that phone counseling can be effective for tackling some of the job-related health problems experienced by truckers, but that other approaches may be necessary to deal with other issues.

    The Road to Better Treatment Decisions

    Schrag and Sorensen's projects are part of a larger trend in population sciences that extends beyond documenting the prevalence of inequities to defining the causes of inequities and ways to overcome them.

    As a recent study shows, the "apparent" reason for a health care disparity isn't always the right one. The question to be answered was why elderly patients with colorectal cancer are much less likely to receive adjuvant chemotherapy than are their younger counterparts. To Weeks, the reason seemed obvious: "These patients never get a chance to talk with their oncologists, because surgeons think they're too old and don't refer them."

    In fact, the study showed that virtually all patients, regardless of age, had the opportunity to consult with an oncologist, though some chose not to do so. By correlating data from thousands of medical records, Weeks and fellow researchers found that in two-thirds of the instances in which patients did not receive chemotherapy, oncologists had deemed the treatment unnecessary. The doctor's decision was influenced, in part, by uncertainty over the effects of chemotherapy in older patients.

    This study was undertaken by the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium, which was formed to identify flaws in the cancer care system and identify ways of correcting them. The results point to the need for clinical trials that focus on the effects of chemotherapy in older patients. Such studies, plus education for oncologists on the risk-benefit ratio of therapy, may lead to better, more consistent treatment decisions.

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