William E. Lafferty, MD; Patrick T. Tyree, AA; Sean M. Devlin, MA; M. Robyn Andersen, PhD, MPH; and Paula K. Diehr, PhD
Objective: To assess the use of complementary and alternative medicine (CAM) providers and the associated expenditures by specific treatment phases among patients with cancer.
Study Design: Cross-sectional analysis of medical services utilization and expenditures during the 3 therapeutic phases of initial, continuing, and end-of-life life treatment.
Methods: Analysis of an insurance claims database that had been matched to the Washington State Surveillance, Epidemiology, and End Results cancer registry.
Results: Of 2900 registry-matched patients, 63.2% were female, the median age was 54 years, and 92.7% were of white race/ethnicity. Breast cancer was the most frequent diagnosis (52.7%), followed by prostate cancer (24.7%), lung cancer (10.1%), colon cancer (7.0%), and hematologic malignancies (5.6%). Patients using CAM providers represented 26.5%. The proportion of patients using CAM was similar during each treatment phase. All patients used some conventional care. Age, female sex, breast cancer diagnosis, and white race/ethnicity were significant predictors of CAM use. Diagnosis of a musculoskeletal problem occurred at some time during the study for 72.1% of patients. CAM provider visits represented 7.2% of total outpatient medical visits, and 85.1% of CAM visits resulted in a musculoskeletal diagnosis. Expenditures for CAM providers were 0.3%, 1.0%, and 0.1% of all expenditures during the initial, continuing, and end-of-life phases, respectively.
Conclusions: For patients with cancer, musculoskeletal issues were the most commonly listed diagnosis made by a CAM provider. Although expenditures associated with CAM are a small proportion of the total, additional studies are necessary to determine the importance that patients place on access to these services.
(Am J Manag Care. 2008;14(5):326-334)
Cancer is the second leading cause of death in the United States.1
The American Cancer Society2
estimated that in 2007 more than 1.4 million new cancer cases would be diagnosed and that more than 500,000 persons would die of this disease. Cancer treatment costs are substantial because of the direct cost of new increasingly expensive treatments3
and the enormous indirect costs associated with time spent during treatment for patients and their family members.4
Patient surveys have shown that some of these expenditures are for complementary and alternative medicine (CAM) providers, as more than 70% of patients with cancer will use some form of CAM after the diagnosis of cancer and at least 16% of patients with cancer visit a CAM provider.5
The use of CAM by patients with cancer is associated with treatment of specific symptoms,6-11
female sex, diagnosis of breast cancer, and white race/ethnicity.12
Previous health services research studies have grouped conventional provider utilization and expenditures for cancer care based on intervals after diagnosis. To accomplish this, Medicare datasets have been matched to cancer registry data.13,14
This adds diagnostic detail and mortality end points that are present in registry data to claim-based administrative data. These registry-matched cancer studies have documented healthcare utilization by treatment phase (during the initial 12 months following diagnosis, during the last year of life, and during the continuing period between these 2 phases).4
Utilization analysis during each phase captures a different picture of cancer care than a single cross-sectional evaluation. To our knowledge, this type of evaluation has not been performed to assess the use of CAM providers for cancer treatment.
Historically, third-party payment records have been a poor choice for studying CAM provider services because CAM care has traditionally been paid for out-of-pocket15
and because large public payers (such as Medicare) do not cover most CAM provider services. Some states have taken legislative steps to change this and to integrate CAM providers into mainstream healthcare finance.16,17
In 1996, Washington State passed legislation requiring every category of licensed healthcare provider to be covered by private insurance. This mandated the inclusion of acupuncturists, naturopathic physicians, and massage therapists into commercial insurance products; legislative mandates in 1983 had already covered chiropractors.18
Therefore, Washington State’s mandate for CAM coverage created a large bank of insurance claims data in which CAM providers have been consistently covered since 2000. Matching enrollment and claims data from a subset of individuals who were privately insured from 2000 to 2004 to the Fred Hutchinson Cancer Research Center’s western Washington State Surveillance, Epidemiology, and End Results (SEER) cancer registry identified a cohort of patients with insurance claims and registry information. These data were used to assess the factors that predict CAM use by distinct therapeutic phases, the medical reasons for CAM use during these phases, and the proportion of expenditures resulting from CAM provider care.METHODSPopulation
This study was approved by the institutional review boards of the University of Washington and the Fred Hutchinson Cancer Research Center. Eligible participants consisted of registry-matched patients with cancer aged 18 to 64 years who were diagnosed as having breast, colorectal, hematologic, lung, or prostate cancer from January 2000 through December 2003 and had no prior cancer diagnosis. In addition, eligibility criteria included having insurance coverage at the time of diagnosis and maintaining coverage at least 12 months after diagnosis or (in the situation of survival of <1 year) maintaining contiguous coverage from diagnosis to death. A large private provider of multiple insurance product types supplied the insurance data.Data
The researchers received separate insurance files with enrollment and medical claims (utilization and expenditures) data for 2000 through 2004. The techniques used to process these data and to define study variables have been previously described.19
CAM providers included chiropractors, naturopathic physicians, massage therapists, and acupuncturists. CAM and conventional provider visits were defined as outpatient if they occurred at a hospital-based outpatient clinic or at a provider’s office.20
The participants’ ZIP codes of residence were classified as urban vs nonurban using the rural-urban commuting area method.21 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were categorized into major diagnosis categories using The Johns Hopkins Adjusted Clinical Groupings Case-Mix System software.22
All expenditures represent adjusted 2004 dollars based on the consumer price index for medical care.23
Chemotherapy, radiation therapy, and surgery were defined by Current Procedural Terminology24
codes (eAppendix; available at http://www.ajmc.com
Participants were identified through a confidential link of the insurance data and the SEER cancer registry. At the time of the link, SEER maintained diagnosis and death information from 1974 though 2006 and covered 13 western Washington State counties. The features of this registry have been previously described.25
Cancer site and stage at diagnosis, as well as the diagnosis and death dates, were taken from the SEER records. Cancer stage was grouped as local (in situ and localized) and as all other.
Participants’ healthcare utilization data were categorized into the following 3 clinically relevant therapeutic phases: initial, continuing, and end-of-life treatment. The treatment phase definitions were based on the study by Yabroff et al4
; exceptions to their model are described herein. The initial phase represented the first 12 months after diagnosis, the end-of-life phase represented the 12 months preceding death, and the continuing phase represented the time between initial and end-of-life treatment. For patients surviving less than 24 months, the last 12 months were assigned to end-of-life treatment, and the remaining months were assigned to the initial phase; the continuing phase was not represented in this scenario. Unlike Yabroff et al,4
the end-of-life phase was defined as diagnosis through death when survival was 12 months or less. When participants survived longer than 12 months after the available insurance data, the end point for the continuing phase was December 2004; otherwise, the end point was 12 months before the date of death. The number of continuing months ranged from 1 to 48 months (median, 16 months; mean, 19.0 months). To approximate the length of the initial and end-of-life phases for analysis of expenditures, the data in the continuing phase were adjusted to an annual figure by taking each individual’s monthly mean in that phase and multiplying by 12. Data were not adjusted in the initial or end-of-life phases. Unlike Yabroff et al,4
no modifications were made to the length of initial stage based on cancer diagnosis.Statistical Analysis
Logistic regression analysis assessed the potential predictors of CAM use during each study phase. Separate regression analyses were performed for each predictor of interest because no adjustments were made for other covariates. Odds ratios were considered statistically significant at P <.05, corresponding to a 95% confidence interval (CI) not containing 1.0. No adjustments were made for multiple comparisons. All analyses were performed using commercially available statistical software (STATA version 9.2; StataCorp LP, College Station, Texas).26RESULTSPopulation and Sample
Of 900,000 persons with private insurance coverage from 2000 to 2004, 2900 were registry-matched patients with cancer who met the study criteria. The study population is summarized in Table 1
. In the cohort, 93.0%, 84.8%, and 10.7% of participants had data for the initial, continuing, and end-of-life phases, respectively. Most participants were urban, female, and of white race/ethnicity. Breast cancer accounted for more than 52.7% of all cancer diagnoses, followed by prostate, lung, colorectal, and hematologic malignancies. Patients with lung cancer accounted for 58.7% of patients in the end-of-life treatment phase. The median age of all patients at diagnosis was 54 years, and almost two-thirds of participants were diagnosed as having localized cancer. Point-of-service plans, preferred provider organizations, and group policies were the predominant forms of coverage. Patients with at least 1 claim from a CAM provider accounted for 26.5% of the cumulative cohort of patients with cancer. The use of different CAM provider types was not mutually exclusive. Chiropractors were the most commonly used CAM provider. The prevalence of CAM claims was higher, although not statistically significantly so, in the continuing phase (21.8%) and in the initial phase (19.5%) compared with the end-of-life phase (17.7%). All patients used some form of conventional care.
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