A new report based on 2011 data takes an in-depth look at salaries and benefits for a variety of positions in assisted living communities across the country. The report found an overall increase in salaries for senior living professionals, with some positions seeing a greater increase than others.

The study surveyed over 1,700 for-profit and not-for profit assisted living communities, which provided salary and benefit data on almost 65,000 employees. The report summarizes data on 19 management positions and 27 nursing, dietary, and clerical positions as well as 18 fringe benefits.

 All management professions and most other assisted living professions saw a salary bump in 2011. Chief financial officers saw the highest increase out of all management positions. CFOs received a salary of 122,226 dollars, a 3.9 percent increase over 2010. Marketing directors also saw a large increase in compensation. Although marketing directors only saw a salary increase of 2.05 percent, their average bonus was 9,354 dollars or 20 percent of their annual salary. 2010’s average bonus was only 14.64 percent of that year’s average salary.

The data also revealed an average salary increase of 3.3 percent, to 141,847 dollars, for CEOs and an average salary increase of 2 percent, to 65,251 dollars, for directors of nursing.

To purchase the report: 2011-2012 Assisted Living Salary & Benefits Report, visit the Hospital & Healthcare Compensation Service’s website.

As part of its ongoing series of webinars on hot topics in the bioethics field, Creighton University will host a complimentary webinar titled “No Place for Dying: Hospitals and the Ideology of Rescue.” The webinar will be presented by Helen Stanton Chapple, PhD, RN, MA, CT, a Creighton faculty member who teaches in the online Master of Science in Health Care Ethics program. Chapple is also a past president of the Association for Death Education and Counseling (ADEC) and current chair of the ADEC Credentialing Council.

Chapple will discuss the idea that many end-of-life dilemmas in the United States are a result of conflicts in American ideology rather than a question of ethics. In addition, the proliferation of advanced technology, the respect for choice, and the need to provide equal opportunity for death avoidance has led to a “rescue first, ask questions later” mentality. Yet often there comes a point where clinicians must work to limit suffering and prepare for death. In her research on treatment for the dying, Chapple discovered that clinicians turned to a “ritual of intensification” that allowed seriously ill patients to be moved from “rescuable” to “non-rescuable” status. This process helped medical professionals to navigate potential conflicts and guilt.

“The ritual preserves belief in the project of medicine,” said Chapple. “Clinicians use ritual to separate the living from the dying, and ultimately the dying from ourselves.”

Date, time, and registration information for the webinar are as follows:

TITLE: “No Place for Dying: Hospitals and the Ideology of Rescue.”

DATE: Monday, February 27, 2012

TIME: 6:30 PM CST

Click here to register

The webinar series is designed to inform medical professionals and others who deal with ethical issues in health care about trends and ideas in the field, as well as to promote Creighton’s Master of Science in Health Care Ethics program. Offered in the convenient online format, the online program pulls from such diverse areas as history, culture, philosophy, politics, economics, and law to explore the meaning, history, context, and implications of bioethics. With courses in Health Policy, the Law and Health Care Ethics, Social & Cultural Contexts of Health Care, Theories of Justice, and Public Heath Ethics, students build their awareness and understanding of the meaning, impact, and practical applications of ethics in the real world. Offered through Creighton’s Center for Health Policy and Ethics (CHPE), the program is built upon the University’s core Catholic and Jesuit values of conscience, compassion, and concern for poor and marginalized groups and individuals.

To learn more about upcoming events at Creighton, go to the Upcoming Events page. To learn more about the webinar series, contact Allison Anderson at the phone number or email provided.

About Creighton University

Creighton University, a Catholic, Jesuit institution located in Omaha, Neb., enrolls more than 4,200 undergraduate and 3,500 professional school and graduate students. Nationally recognized for providing a balanced educational experience, the University offers a rigorous academic agenda with a broad range of disciplines, providing undergraduate, graduate and professional degree programs that emphasize educating the whole person: academically, socially and spiritually. Creighton has been a top-ranked Midwestern university in the college edition of US News & World Report magazine for more than 20 years. For more information, visit our website at http://www.creighton.edu.

Yale School of Medicine researchers have found that the likelihood of becoming disabled with age increases with the following factors: having a chronic condition or cognitive impairment; low physical activity; slower gross motor coordination; having poor lower-extremity function; and being hospitalized. Women are also more likely than men to become disabled in their later years.

Based on 12 years of data, the findings are published in the Jan.17 issue of Annals of Internal Medicine by a research team led by Thomas Gill, M.D., the Humana Foundation Professor of Geriatric Medicine and professor of medicine, epidemiology, and public health at Yale School of Medicine.

With age, many people can no longer walk short distances or drive a car, and those with long-term loss of mobility have difficulty regaining independence.

“Losing the ability to walk independently not only leads to a poorer overall quality of life, but prolonged disability leads to higher rates of illness, death, depression and social isolation,” said Gill, who followed a group of 641 people aged 70 or older who could walk a quarter mile unassisted or who were active drivers at the start of the study. All participants could perform essential activities of daily living, such as bathing and dressing.

Gill and his team assessed the participants for changes in potential disability risk factors every 18 months between 1998 and 2008. They also assessed the participants’ mobility each month. Those who said they needed help from another person to walk a quarter mile were considered to be walking disabled. Those who said that they had not driven a car during the past month were considered driving disabled.

On a monthly basis, the research team also assessed the participants’ exposure to potential causes of disability, including illnesses or injuries leading to hospitalization and restricted activity, which increased the likelihood of long-term disability by 6-fold.

The team found that multiple risk factors, together with subsequent illness and injury leading to hospitalization and restricted activity, are associated with an increased likelihood of developing long-term walking and driving disability. The team considered a disability to be long term if it persisted for at least six months.

“We’ve learned that targeted strategies are needed to prevent disability among older people living independently in the community,” said Gill.

When looking back on 2011, senior housing industry professionals agree that the billions of dollars worth of real estate investment trust (REIT) activity played an integral role in shaping today’s market. But some say that going forward into 2012, healthcare reform will be a key influence in the industry, and others point out the changing roles of assisted living, independent living, and skilled nursing, as providers see acuity rise across the spectrum of care.

Here’s a rundown of notable developments and what they might mean heading into the new year:

Market Consolidation: The Year of the REIT

Real estate investment trusts (REITs) continued their power play from the second half of 2010 well into 2011, with M&A activity reaching a fever pitch in the second quarter, featuring deals such as Ventas REIT’s $7.4 billion acquisition of Nationwide Health Properties and $3.1 billion acquisition of Atria Assisted Living’s real estate; HCP REIT’s $6.1 billion sale-leaseback of more than 300 HCR Manorcare properties; and Health Care REIT’s $2.4 billion sale-leaseback of Genesis Healthcare.

“The biggest surprise was how big of an M&A year 2011 turned out to be,” says Nick Gesue, senior vice president of operations and underwriting at Lancaster Pollard, a healthcare, senior housing, and affordable housing financier headquartered in Columbus, Ohio.

Apart from REITs, some investment brokers say there’s also been strong and steady demand for one, two, or three-property portfolios.

“We’ve seen a very large appetite for these types of properties,” said Grant Kief, president of Senior Living Investment Brokerage, Inc., based in Glen Ellyn, Ill. “I see a continued stream of facilities coming for sale at aggressive pricing; it’s a very active market right now. I don’t see it slowing down.”

Rising Acuity and Expanding Services

Providers have seen rising acuity across the continuum of care, from independent living, to assisted living, to skilled nursing, and it’s forced them to expand their services to keep up with the trend.

“With independent living, it’s morphed more into assisted living than ever before. It’s a pretty unusual and quickening trend,” says Aaron D’Costa, chief business development officer of Des Plaines, Ill.-based Pathway Senior Living.

A lot of this points back to troubled economic conditions, with seniors wanting to go into the least costly setting where they can then choose to get “unbundled” assisted living services through third parties such as home health care companies, D’Costa says.

The trend is further impacted by operators seeking to pad margins eroded by lower occupancy; operators are now more willing to provide services and retain residents longer than before in order to maintain occupancy rates.

With one provider referring to some skilled nursing facilities as functioning like “mini hospitals,” the rising acuity trend is clear across the spectrum of senior care, including assisted living.

“Assisted living has evolved from an environment that was more residential than medical,” says D’Costa. “It forces the conversation about having assisted living being in the continuum of the medical field, and this will continue into 2012.”

Changing Roles & Demographics in Senior Living Communities

Higher acuity levels are also shifting the demographics of those who move into different types of facilities.

With the average age for an independent living resident now in the mid-80s, and assisted living in the late 80s, the senior housing scene is changing. Younger seniors in their mid-70s to 80s who may have gone to an independent living community in the past are now choosing to either put off entering senior housing, or to instead go to “active adult” communities, says Margaret Wylde, president and CEO of ProMatura, a market research company based in Oxford, Miss. and London, UK.

Independent living, in particular, is undergoing a substantial transition as its residents begin to look more and more like those formerly found in assisted living.

Going forward into 2012, many companies will have an increased awareness of marketing and sales, says Wylde, and some communities will start transitioning toward a more natural, less programmed product offering, although it’s a long-term process.

“We are seeing active adult communities rattling the cage quite a bit,” she says. “A lot depends on the economy, but we’re seeing more of that product emerge.”

Medicare & Medicaid Funding’s Impact on the Industry

In 2011, the health care industry was rocked by adjustments to government entitlement programs, most noticeably the 11.1% reduction in Medicare reimbursement rates to skilled nursing facilities, which went into effect Oct. 1. The impact of these cuts and general reductions to state Medicaid funding will continue to play out.

“Medicaid and Medicare changes will have the biggest impact in 2011 going into 2012,” D’Costa told SHN.

With about 70% of nursing home residents relying on Medicaid to pay for their care, according to data from the American Health Care Association (AHCA), most Medicaid directors are feeling the pinch as the federal debt crisis places a heavier emphasis on state budgets.

The Medicare cuts to reimbursement rates only directly impacted nursing homes, but it’s affecting acuity levels in assisted living and independent living as well, says D’Costa, as people may not be able to afford skilled nursing, and slots for Medicaid residents dwindle.

The cuts have also forced skilled nursing operators to trim down already slim margins and maintain investor confidence. And although Medicaid is exempt from the sequestration triggered by the “Supercomittee’s” failure to reach a deficit agreement, Medicare is not, and faces a further 2% cut.

Written by Alyssa Gerace

St. Joseph’s is the only hospital in Tampa to test the device under an FDA investigational trial. The minimally invasive catheter system is the first and only of its kind in the United States, and is already being used throughout Europe.

“For years, we have used catheter-assisted thrombolysis to drastically change the outcomes for stroke patients at St. Joseph’s Hospital and the Trevo™ provides a significant leap in the retrieval of blood clots,” says Berlet, who serves as the Medical Director of St. Joseph’s Hospital’s Comprehensive Stroke Center.

Recently, Dr. Stambo used the new technology to save the life of a 69-year-old man who was sent to St. Joseph’s ER with a National Institute of Health Stroke Score of 14 of 42, a severe stroke.

“I never had a headache and I never thought I could have lost my life in that moment,” says Charles Melious. “Luckily, my wife noticed something was wrong and called 911.”

Paramedics rushed Charles to St. Joseph’s Comprehensive Stroke Center where he was greeted by its Stroke Team and whisked away to the emergency room’s CT scanner. Dr. Stambo removed a large basilar artery clot with just one pass of the Trevo. Melious could have been severely disabled by the stroke with minimal chance of recovery, but instead was discharged from the hospital after only three days with no disability.

“Today my life is back to normal. It’s like the stroke never happened, like it was a dream,” Melious adds.

Acute ischemic stroke is caused by an abnormal blood clot, called a thrombosis, that blocks blood flow and can potentially be life threatening. The key to treating acute ischemic stroke is to activate thrombolysis, or clot retrieval, as quickly as possible.

The Trevo™ is a hybrid of current clot-retrieval systems that are used in catheter-guided thrombolysis. Catheter-guided thrombolysis is the most definitive way to treat stroke and reverse the neurological effect, but it should be done as soon as possible to obtain optimal benefits. It is recommended that patients reach a hospital within three hours of symptom onset to be considered for intravenous thrombolysis.

St. Joseph’s Hospital is designated by the Florida Agency for Health Care Administration as a Comprehensive Stroke Center, which certifies that St. Joseph’s Hospital is nationally recognized to deliver the highest quality care to stroke patients. This distinction recognizes that St. Joseph’s has the resources to provide the best treatments for stroke, offering patients a better chance of recovery with minimal disability.

This year St. Joseph’s Hospital received the American Heart Association/American Stroke Association’s Get With The Guidelines®-Stroke Gold Plus Quality Achievement Award. The award recognizes St. Joseph’s Hospital’s commitment and success in implementing excellent care for stroke patients, according to evidence-based guidelines.

The catalyst for every successful outcome at St. Joseph’s Hospital is a Stroke Alert, a call to action for members of the hospital’s stroke team. One goal of the stroke team is to transport the patient to the emergency center’s CT scanner within 25 minutes of the patient’s arrival in order to determine available treatment options for the patient.

For more information about the Trevo™ clinical trial, or St. Joseph’s Hospital’s Comprehensive Stroke Center, please call (813) 443-2046.

(Editor’s Note: this patient has consented to telephone/in-person interviews but has declined photo/video opportunities.)

SOURCE BayCare Health System

“Changing the Culture of Nursing Homes” By Beth Mann | Spectrum Online

Have you ever thought, “I’d rather die than go to a nursing home”? Why do nursing homes conjure up such negative images? Most nursing homes were built on the acute hospital model of delivering care; residents are living long-term in a short term setting.

A movement is underway to change the culture of nursing homes – to move from a sterile, hospital-like environment to a more home-like environment. In California, a coalition has been working with about 50 nursing homes to assist them in moving to a more resident-directed and resident-focused delivery of care.

Consistent Staff Assignments
Studies have shown that consistent assignment is a major key to improving care in nursing homes. When residents have the same staff working with them, a bond forms and staff learn the preferences of the residents – who likes to get up early, who likes to sleep in, and schedules are set up to accommodate these preferences. Some facilities serve a buffet-style breakfast to accommodate both early and late sleepers.

Following is an example of why consistent assignment is so important: Mrs. Jones is usually cheerful and always greets her CNA (certified nursing assistant) with a warm smile and a hello. This morning, Mrs. Jones is slumped over and barely responds when the CNA brings her breakfast. If the CNA had not worked with Mrs. Jones before, the CNA might assume she was always this way. A CNA who is familiar with Mrs. Jones’ habits immediately knows something is wrong and notifies the nurse.

Improved Dining Services
In a nursing home, meals are often the highlight of the day, Culture Change facilities have been experimenting with ways to improve the dining experience. The Asian Nursing Home in Sacramento serves restaurant-style meals. Residents have a choice of entrees and tables are set for small groups with linens and attractive table-settings; resident preferences are considered in planning menus.

Another facility realized their snack carts were very “hospital-looking”, and now circus wagon carts ply their halls with snacks requested by the residents. Even those residents who eat very little are tempted by the decorated carts and the festive atmosphere they project.

Several facilities have experimented with having a “celebrity chef” who cooks and serves up food for all to taste. The chef can be the administrator of the facility, a well-known member of the community, or a staff person with a flair for cooking. The residents love it and it gets them to taste foods they might not normally try.

Less Noisy
Noise reduction is also a priority. Facilities are encouraged to get rid of their overhead paging systems and use walkie talkies and other hand-held devices. Facilities are encouraging staff not to talk loudly in the halls. A result of the quieter atmosphere has been reduced agitation in residents who have a history of combative behavior.

Delicious Smells
One of my favorite innovations is a form of “aroma therapy”. Several facilities bake bread at the nurses’ station. The aroma wafts through the facility and reminds one of an old-fashioned kitchen.

Special Activities
Bill Thomas, an upper New York physician and a founding father of the Culture Change movement, lists boredom, loneliness, and helplessness as the result of living in a nursing home. To this end, he encourages facilities to allow residents to bring their pets from home. A Grass Valley facility has a dog trained to deliver the mail. Although full-time pets are not always feasible, visiting dogs can give residents something to love.

Studies have shown that all of us need the opportunity to give back and this is also true for nursing home residents. Intergenerational programs for residents who enjoy children bring much happiness to both residents and the children with whom they interact. Stonebrook, in the Bay Area, is situated next to a high school. After staff learned that several of their residents were big football fans, they contacted the school to see if these residents could be accommodated at football games. Not only do these residents go to all the home games, the football team has adopted them. Pictures of the team adorn the walls of the nursing home and team members visit regularly.

Facilities are also experimenting with gardening in raised flower beds so those in wheelchairs can tend plants. Other residents raise plants from seeds in their rooms that can then be transplanted by staff. Many of the older residents remember planting Victory Gardens during WWII so this is a very positive activity for them.

Bath Time
Bath time in nursing homes is usually very traumatic for both staff and residents. Going down the hall with a sheet draped over them and then having a stranger undress them and give them a shower can be a very demeaning experience for a nursing home resident. This is where consistent assignment is particularly important. Residents who have bonded to staff will not see bathing as such an intrusive experience.

To help reduce resistance to bathing, Asian Nursing Home turned its shower room into a spa. New paint, attractive furnishings, a towel warmer, and warm terrycloth robes have made bathing a positive experience. Residents who previously did not want to take a shower, now ask when it is their turn. Many local nursing homes have visited Asian Nursing Home to see how to replicate the spa.

These are just a few of the innovations currently underway in many nursing homes. The following websites have extensive information on the culture change movement:www.pioneernetwork.net and www.edenalt.org.

Beth Mann was the State Long-Term Care Ombudsman (retired) for the California Department of Aging, the chief advocate for residents of nursing and residential care homes for the elderly. She also has been a facilitator for and Past President of the California Culture Change Coalition, working with local nursing homes to assist them in moving to resident-directed care. She is currently Vice Chair of the Adult and Aging Commission.

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“2 States Survey Nursing Home Residents To Assess Care” By Susan Jaffe | KHN

BOSTON – When choosing the right nursing home, most consumers lack one of the best sources of inside information about the facilities – from the residents themselves.

But at the annual meeting of the Gerontological Society of America, researchers from Minnesota and Ohio explained how consumers in those states can find summaries of nursing home residents’ online reviews. More than 3,800 researchers, educators, scientists and health professionals attended the five-day conference held in Boston last week.

“This is institutionalized word of mouth,” said Jane Karnes Straker, a senior research scholar at Scripps Gerontology Center at Miami University in Ohio.  Straker and the Benjamin Rose Institute, a social service agency in Cleveland, created a questionnaire that has been used by an independent research firm since 2001 for an annual survey of a representative sample of the state’s nursing home residents.

The residents are asked about a range of quality-of-life issues, including the cleanliness and safety of their homes, whether they can go to bed when they like and choose their own clothes, and their opinion of the food.  Some 961 facilities are currently included.

University of Minnesota researchers also discussed their resident satisfaction survey, which is part of the web-based report card for the state’s 379 nursing homes. It not only provides consumers with an inside view of the home’s operations but also exposes potential problems, said Robert Kane, who leads the effort at the university’s School of Public Health.

“Our basic premise is that things that go unmeasured, go unattended,” he said.  The same firm Ohio hired also conducts Minnesota’s survey, which includes questions about residents’ comfort, privacy, access to activities, and “food enjoyment,” among other things.

The Minnesota survey was created under a contract from the U.S. Centers for Medicare and Medicaid Services (CMS), which offers a separate “nursing home compare” website.  It provides inspection results as well as performance details reported by the facility operators. However, the agency, which oversees the country’s nursing homes, never adopted Minnesota’s resident satisfaction survey nationwide as researchers had hoped.

Kane told conference attendees that the Minnesota survey costs less than 1 percent of the state’s Medicaid nursing home budget and can be emulated in other states at a reasonable cost.

“It is not a huge expense and has been effective in changing the nature of the dialogue with providers as well as providing information to consumers,” he said.

In both states, the resident satisfaction surveys supplement an array of other nursing home information available on the CMS website.

The federal government is studying whether consumer satisfaction surveys could be used nationwide and posted on its website, Don McLeod, a CMS spokesman said in an e-mail.

“It is particularly important in the nursing home setting to be able to collect both resident and family input in an objective manner,” the spokesman said. “A number of states have developed some initial approaches to solving this challenge.”

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PROCLAMATION

For Immediate Release:
November 1, 2011 | NHPCO.com

WHEREAS, hospice and palliative care offer the highest quality services and support to patients and family caregivers facing serious and life-limiting illness;

WHEREAS, hospice care and palliative care providers take the time to ask what’s important to those they are caring for – and listen to what their patients and families say;

WHEREAS, skilled and compassionate hospice and palliative care professionals—including physicians, nurses, social workers, therapists, counselors, health aides, and clergy—provide comprehensive care focused on the wishes of each individual patient;

WHEREAS, through pain management and symptom control, caregiver training and assistance, and emotional and spiritual support, allowing patients to live fully up until the final moments, surrounded and supported by the faces of loved ones, friends, and committed caregivers;

WHEREAS, the provision of quality hospice and palliative care reaffirms our belief in the essential dignity of every person, regardless of age, health, or social status, and that every stage of human life deserves to be treated with the utmost respect and care;

WHEREAS, every year more than 1.5 million Americans living with life-limiting illness, and their families, received care from the nation’s hospice programs in communities throughout the United States;

WHEREAS, more than 468,000 trained volunteers contribute 22 million hours of service to hospice program annually;

WHEREAS, hospice and palliative care providers encourage all people to learn more about options of care and to share their wishes with family, loved ones, and their healthcare professionals;

WHEREAS, the National Hospice and Palliative Care Organization and our family of affiliate organizations based at the National Center for Care at the End of Life all work to help NHPCO’s more than 44,000 members work towards a shared vision of a world where individuals and families facing serious illness, death, and grief will experience the best that humankind can offer.

NOW, THEREFORE, be it resolved that the leadership of the National Hospice and Palliative Care Organization do hereby proclaim November 2011 as National Hospice and Palliative Care Month and encourage citizens to increase their understanding and awareness of care at the end of life and to observe this month with appropriate activities and programs.

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National Hospice Palliative Care Month Resources – new outreach materials for NHPCO members featuring the 2011 Hospice and Palliative Care Month theme, “We Listen, We Care!”
Non-members will find select outreach materials on the Caring Connections website.

Resources:

• Proclamation for H/PC Month
• Hospice and Palliative Care: Making a Difference
• Don’t Wait to Talk about the Care You Would Want
• Ten Things You May Not Know About Hospice

• NHPCO’s Facts & Figures on Hospice (PDF)
• Hospice Provides What Americans Want at the End of Life
• Common Misconceptions About Hospice
• The Medicare Hospice Benefit

Hospice care is as much about attitudes and agreement as the process.

Having a loved one pass away is a difficult and emotional time for everyone. Having this phase of everyone’s life be less stressful, with the minimum of pain, suffering and turmoil will make the process easier for all those involved.

We can’t plan how or when someone will come to the end of life, but we can be open about discussing it and reviewing the options for care that may be appropriate under differing circumstances. It is important that the thoughts and wishes of the elder be communicated, understood, and agreed upon long before circumstances are demanding an answer immediately as the end is suddenly in sight.

Be sure any advanced directives properly reflect these wishes and that they will allow the planned actions to be carried out. Of course many times there will be no options as death comes quickly or circumstances require continued hospitalization.

If you have ever had the opportunity to talk with someone who has been through the end of live process with a Hospice organization, almost universally, they will relate what a good experience it was and will recommend it to other families.

The most direct and efficient way to learn more about Hospice is to contact a Hospice in your area. You can click here on Find A Hospice to locate one near you. Call them and ask for information and help in learning more. That you do not having an immediate need for their services will not keep them from being helpful. Everyone who works in the Hospice field is passionate about their work and will be happy to assist. Don’t put this off, as a weight will be removed from everyone when the plan and agreement is in place.

Now that you have this issue worked out you can begin on funeral planning. But that will a subject for another issue of Caregiver Tips.

email: caregivertips@elderissues.com

Purposeful Visits for Hospitalized Elderly Patients: Program Impact on Orientation, Agitation and Mood

2011 NICHE Conference Poster Presentation – Authors: Jan Hagman, RN, MS; Deborah Ford, RN, BSN, OCN; Laura Satorie, RN, BSN; University of Colorado Hospital, Aurora, Colorado

• Signs reminding patients to call for help getting to the bathroom
• Coloring the call light to improve visibility
• Fall risk identified on white boards

• Involving the patient and family on daily rounds
• Intensive volunteer involvement with patients
• Implementation of the SBAR (Situation, Background, Assessment, and Recommendation) method of standardizing communication

From the Division of Population Sciences, Center for Outcomes and Policy Research, Breast Oncology Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.

Address reprint requests to Craig C. Earle, MD, Center for Outcomes and Policy Research, Dana-Farber Cancer Center, 44 Binney St., Boston, MA, 02115; email: craig_earle@dfci.harvard.edu.

BREAST CANCER is the most common cancer in women. With advances in both screening and treatment, the 5-year survival rate is now 85%,¹ and 61% of these women are still alive at 15 years.² As a result, there are an estimated 2 million women in the United States who are breast cancer survivors,^3,4 a number that is expected to continue to grow as the incidence of breast cancer increases, breast cancer mortality declines, and our population ages.

Previous studies have indicated that there are important competing risks for women with breast cancer.^5,6 In one study of breast cancer survivors identified through the Connecticut tumor registry, heart disease and gynecological cancers were identified as significant contributors to mortality.⁷ Analysis of public release data from the National Cancer Institute (NCI) Survival, Epidemiology, and End Results (SEER) program indicates that the major causes of non–breast cancer mortality among women with a history of breast cancer are heart disease and stroke; colorectal, lung, and gynecologic cancers; chronic lung disease; and complications of diabetes. These do not differ from the causes of death seen in matched controls drawn from the National Center for Vital Statistics.

The risk of several of these illnesses can potentially be lowered by appropriate preventive services such as screening for colon cancer or cardiovascular disease, immunization to prevent influenza, and recommendations for lifestyle interventions such as diet and smoking cessation. This observation led us to question whether there were differences in the non–breast cancer medical care breast cancer survivors receive compared with the general population and how sociodemographically vulnerable subgroups of survivors fare compared with others. One could hypothesize that survivors may receive less care because of an underlying sense that their cancer is their greatest threat to life or because cancer patients may rely on specialists for their primary care. Conversely, they may receive higher-quality care because they have already been engaged in the medical system or because their physicians may be more vigilant, having already identified a serious illness. If the latter were true, a prior diagnosis of breast cancer might mitigate the usually observed poorer quality of care received by certain subgroups of patients. To address these issues, we used population-based administrative data to assess and compare the use of standard preventive services among breast cancer survivors and matched controls.

Data Sources

We primarily used two data sources: the NCI SEER and the Health Care Financing Administration (HCFA) Medicare database. The 11 tumor registries participating in the SEER program capture about 97% of their incident cases,⁸ covering a representative sample⁹ of approximately 14% of the United States population.¹⁰ Registries collect data on each patient’s age, sex, race and ethnicity, cancer site, stage, histology, date of diagnosis, and date and cause of death. They also record initial treatment data on surgery and radiation received in the first 4 months after diagnosis. However, SEER does not provide information on later treatments. To monitor these patients longitudinally, Medicare claims for patients older than age 65 years have been linked to the SEER registry data. The Medicare data set includes files through 1998 for inpatient and outpatient care, physician and laboratory billings, and bills for home health and hospice care. For patients age 65 years and older captured by the SEER registries, 94% have been linked to Medicare.¹¹ Census-level sociodemographic data have also been linked to these patient cases, allowing us to create socioeconomic quintiles on the basis of the race and age-adjusted income, wealth, and education in each patient’s census tract in the 1990 census. Combining SEER data with Medicare data provided us with information on initial diagnosis and later cancer treatment, as well as the downstream medical care for cancer survivors.

Cohort Selection

The study sample consisted of all women diagnosed with breast cancer in 1991 or 1992 while living in one of the SEER regions. We defined survivors as women that had local-regional, nonmetastatic disease at diagnosis; survived through the end of 1998; had not been diagnosed with subsequent cancers recorded in SEER; had not received chemotherapy or radiation in 1997 to 1998; had no diagnostic codes for metastatic cancer in any bills (International Classification of Disease, 9th revision [ICD-9] codes 196 to 199); and had not been enrolled in hospice.

Controls were obtained from a 5% random sample of Medicare patients with no history of cancer, as determined by having never appeared in a SEER tumor registry for any reason and having no claims for a cancer diagnosis, matched to each case on the basis of age, sex, race, and geographic location (living in the same SEER registry area). Patients were excluded if they were enrolled in a Health Maintenance Organization (HMO) at any time during the study period or if they were not eligible for both parts of Medicare, as they would not have complete treatment information.

We then compared the non–cancer-related preventive services received by survivors with those received by controls in the 2 years of 1997 and 1998. Analysis was restricted to these latter years to avoid assessing patients who may not have been considered survivors by all of their caregivers, which could potentially have biased comparisons of preventive health resource use.

Definitions of Preventive Services

Quality indicators were selected from the Health Plan Employer Data and Information Set, focusing on conditions identified in the literature as being important health threats for breast cancer survivors and those that could feasibly be assessed using administrative data. The final list to be examined between 1997 and 1998 consisted of influenza vaccination; lipid testing; cervical examination; colon examination, whether by endoscopy or fecal occult blood testing; and bone densitometry. We also looked at mammography use, but this was not considered in comparisons of preventive services because breast cancer patients would be expected to receive this as part of routine surveillance for recurrence.

Definitions of Explanatory Variables

We collapsed race and ethnicity into white, African-American, and other categories. Region-specific socioeconomic quintiles were developed on the basis of information availability, according to the following hierarchy: (1) race- and age-specific median household income by census tract (72.9% of patients); (2) unadjusted median household income by census tract (24.4%); and (3) median household wealth (2.7%).¹² For the control group, this information was only available at the county level. We identified comorbidities by looking for diagnostic billing codes for various conditions during the study period, using the Deyo implementation¹³ of the Charlson score,¹⁴ applied to both inpatient and outpatient claims as suggested by Klabunde.¹⁵ Use of chemotherapy and radiation…[Continue reading]