Browsing by Author "Mullins, Megan A."

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    Continuity of care and receipt of aggressive end of life care among women dying of ovarian cancer
    (Elsevier, 2021) Mullins, Megan A.; Ruterbusch, Julie J.; Clarke, Philippa; Uppal, Shitanshu; Cote, Michele L.; Wallner, Lauren P.; Medicine, School of Medicine
    Objective: To evaluate the association between post-diagnosis continuity of care and receipt of aggressive end of life care among women dying of ovarian cancer. Methods: This retrospective claims analysis included 6680 Medicare beneficiaries over age 66 with ovarian cancer who survived at least one year after diagnosis, had at least 4 outpatient evaluation and management visits and died between 2000 and 2016. We calculated the Bice-Boxerman Continuity of Care Index (COC) for each woman, and split COC into tertiles (high, medium, low). We compared late or no hospice use, >1 emergency department (ED) visit, intensive care unit (ICU) admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive and/or life extending procedures among women with high or medium vs. low COC using multivariable adjusted logistic regression. Results: In this sample, 49.8% of women received aggressive care in the last month of life. Compared to women with low COC, women with high COC had 66% higher odds of chemotherapy (adjusted OR 1.66 CI 1.23-2.24) in the last two weeks of life. Women with high COC also had 16% greater odds of not enrolling in hospice compared to women with low COC (adjusted OR 1.16 CI 1.01-1.33). COC was not associated with late enrollment in hospice, hospital utilization, or aggressive procedures. Conclusions: COC at the end of life is complicated and may pose unique challenges in providing quality end of life care. Future work exploring the specific facets of continuity associated with quality end of life care is needed.
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    Difference‐Makers for Collecting Sexual Orientation and Gender Identity Data in Oncology Settings
    (Wiley, 2025) Pratt-Chapman, Mandi L.; Miech, Edward J.; Mullins, Megan A.; Chang, Shine; Quinn, Gwendolyn P.; Maingi, Shail; Schabath, Matthew B.; Kamen, Charles; Emergency Medicine, School of Medicine
    Purpose: The purpose of this analysis was to identify key difference-making conditions that distinguish oncology institutions that collect sexual orientation and gender identity (SOGI) data across a sample of American Society of Clinical Oncology (ASCO) members. Methods: From October to November 2020, an anonymous 54-item web-based survey was distributed to ASCO members. Coincidence analysis was used to identify difference-making conditions for the collection of SOGI data. Results: ASCO members' responses to just three items consistently distinguished practices that reported collecting both SO and GI data (n = 25) from those who did not (n = 20): (1)."Do you ask your patients what pronouns they want you to use for them?"; (2) "Institutional leadership supports collecting SOGI data from patients"; and (3)"Does the electronic health record (EHR) at your institution have a specific section to collect information about patients' SOGI?" The positive model exhibited both reliability (consistency = 0.87, or 20/23) and explanatory breadth (coverage = 0.80, or 20/25). The negative model for SOGI data collection consisted of different responses to the same three items and likewise showed both reliability (consistency = 0.94, or 16/17) and explanatory breadth (coverage = 0.80, or 16/20). Conclusions: Specific levels of leadership support, frequency of asking patients about pronouns, and the presence or absence of EHR record structure were difference-makers for collecting SOGI data in this sample. The study underscores the importance of leadership support, structured data fields, and attention to patient pronouns, which are aligned with the ASCO and National Institutes of Health calls to action.
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    Emergency department involvement in the diagnosis of cancer among older adults: a SEER-Medicare study
    (Oxford University Press, 2024) Thompson, Caroline A.; Sheridan, Paige; Metwally, Eman; Peacock Hinton, Sharon; Mullins, Megan A.; Dillon, Ellis C.; Thompson, Matthew; Pettit, Nicholas; Kurian, Allison W.; Pruitt, Sandi L.; Lyratzopoulos, Georgios; Emergency Medicine, School of Medicine
    Background: Internationally, 20% to 50% of cancer is diagnosed through emergency presentation, which is associated with lower survival, poor patient experience, and socioeconomic disparities, but population-based evidence about emergency diagnosis in the United States is limited. We estimated emergency department (ED) involvement in the diagnosis of cancer in a nationally representative population of older US adults, and its association with sociodemographic, clinical, and tumor characteristics. Methods: We analyzed Surveillance, Epidemiology, and End Results Program-Medicare data for Medicare beneficiaries (≥66 years old) with a diagnosis of female breast, colorectal, lung, and prostate cancers (2008-2017), defining their earliest cancer-related claim as their index date, and patients who visited the ED 0 to 30 days before their index date to have "ED involvement" in their diagnosis, with stratification as 0 to 7 or 8 to 30 days. We estimated covariate-adjusted associations of patient age, sex, race and ethnicity, marital status, comorbidity score, tumor stage, year of diagnosis, rurality, and census-tract poverty with ED involvement using modified Poisson regression. Results: Among 614 748 patients, 23% had ED involvement, with 18% visiting the ED in the 0 to 7 days before their index date. This rate varied greatly by tumor site, with breast cancer at 8%, colorectal cancer at 39%, lung cancer at 40%, and prostate cancer at 7%. In adjusted models, older age, female sex, non-Hispanic Black and Native Hawaiian or Other Pacific Islander race, being unmarried, recent year of diagnosis, later-stage disease, comorbidities, and poverty were associated with ED involvement. Conclusions: The ED may be involved in the initial identification of cancer for 1 in 5 patients. Earlier, system-level identification of cancer in non-ED settings should be prioritized, especially among underserved populations.
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    Physician Influence on Variation in Receipt of Aggressive End-of-Life Care Among Women Dying of Ovarian Cancer
    (American Society of Clinical Oncology, 2022) Mullins, Megan A.; Uppal, Shitanshu; Ruterbusch, Julie J.; Cote, Michele L.; Clarke, Philippa; Wallner, Lauren P.; Epidemiology, Richard M. Fairbanks School of Public Health
    Purpose: End-of-life care for women with ovarian cancer is persistently aggressive, but factors associated with overuse are not well understood. We evaluated physician-level variation in receipt of aggressive end-of-life care and examined physician-level factors contributing to this variation in the SEER-Medicare data set. Methods: Medicare beneficiaries with ovarian cancer who died between 2000 and 2016 were included if they were diagnosed after age 66 years, had complete Medicare coverage between diagnosis and death, and had outpatient physician evaluation and management for their ovarian cancer. Using multilevel logistic regression, we examined physician variation in no hospice enrollment, late hospice enrollment (≤ 3 days), > 1 emergency department visit, an intensive care unit stay, terminal hospitalization, > 1 hospitalization, receiving a life-extending or invasive procedure, and chemotherapy (in the last 2 weeks). Results: In this sample of 6,288 women, 51% of women received at least one form of aggressive end-of-life care. Most common were no hospice enrollment (28.9%), an intensive care unit stay (18.6%), and receipt of an invasive procedure (20.7%). For not enrolling in hospice, 9.9% of variation was accounted for by physician clustering (P < .01). Chemotherapy had the highest physician variation (12.4%), with no meaningful portion of the variation explained by physician specialty, volume, region, or patient characteristics. Conclusion: In this study, a meaningful amount of variation in aggressive end-of-life care among women dying of ovarian cancer was at the physician level, suggesting that efforts to improve the quality of this care should include interventions aimed at physician practices and decision making in end-of-life care.
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    Trends and racial disparities in aggressive end of life care for a national sample of women with ovarian cancer
    (Wiley, 2021) Mullins, Megan A.; Ruterbusch, Julie J.; Clarke, Philippa; Uppal, Shitanshu; Wallner, Lauren P.; Cote, Michele L.; Epidemiology, Richard M. Fairbanks School of Public Health
    Background: The clinical landscape has moved toward less aggressive end-of-life care for women with ovarian cancer. However, whether there has been a decline in the use of aggressive end-of-life services is unknown. The authors evaluated current national trends and racial disparities in end-of-life care among women with ovarian cancer using the Surveillance, Epidemiology, and End Results-Medicare-linked data set. Methods: In total, 7756 Medicare beneficiaries aged >66 years with ovarian cancer who died between 2007 and 2016 were identified. The authors examined trends and racial disparities in late hospice or no hospice use, >1 emergency department (ED) visit, intensive care unit admission, >1 hospitalization, terminal hospitalization, chemotherapy, and invasive and/or life-extending procedures using multivariable logistic regression. Results: The median hospice length of stay did not change over time; however, women were increasingly admitted to the intensive care unit and had multiple ED visits in the last month of life (P < .001). Not enrolling in hospice at the end of life and terminal hospitalizations decreased over time (P < .001). Non-White women were more likely to receive aggressive end-of-life care, particularly for hospital-related utilization and life-extending procedures, whereas non-Hispanic Black women were more likely to have >1 ED visit (odds ratio, 2.04; 95% CI, 1.57-2.64) or life-extending procedures (odds ratio, 1.89; 95% CI, 1.45-2.48) compared with non-Hispanic White women. Conclusions: Despite clinical guidelines and increasing emphasis on reducing aggressive end-of-life care, the use of aggressive end-of-life care for women with ovarian cancer persists, and care is most aggressive for non-White women.
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    Trends in hospice referral timing and location among individuals dying of ovarian cancer: persistence of missed opportunities
    (BMJ, 2023-07-03) Mullins, Megan A.; Ruterbusch, Julie J.; Cote, Michele L.; Uppal, Shitanshu; Wallner, Lauren P.; Epidemiology, Richard M. Fairbanks School of Public Health
    Objective: To evaluate trends, racial disparities, and opportunities to improve the timing and location of hospice referral for women dying of ovarian cancer. Methods: This retrospective claims analysis included 4258 Medicare beneficiaries over age 66 diagnosed with ovarian cancer who survived at least 6 months after diagnosis, died between 2007 and 2016, and enrolled in a hospice. We examined trends in timing and clinical location (outpatient, inpatient hospital, nursing/long-term care, other) of hospice referrals and associations with patient race and ethnicity using multivariable multinomial logistic regression. Results: In this sample, 56% of hospice enrollees were referred to a hospice within a month of death, and referral timing did not vary by patient race. Referrals were most commonly inpatient hospital (1731 (41%) inpatient, 703 (17%) outpatient, 299 (7%) nursing/long-term care, 1525 (36%) other), with a median of 6 inpatient days prior to hospice enrollment. Only 17% of hospice referrals were made in an outpatient clinic, but participants had a median of 1.7 outpatient visits per month in the 6 months prior to hospice referral. Referral location varied by patient race, with non-Hispanic black people experiencing the most inpatient referrals (60%). Hospice referral timing and location trends did not change between 2007 and 2016. Compared with individuals referred to a hospice in an outpatient setting, individuals referred from an inpatient hospital setting had more than six times the odds of a referral in the last 3 days of life (OR=6.5, 95% CI 4.4 to 9.8) versus a referral more than 90 days before death. Conclusion: Timeliness of hospice referral is not improving over time despite opportunities for earlier referral across multiple clinical settings. Future work delineating how to capitalize on these opportunities is essential for improving the timeliness of hospice care.