Lung Cancer:
The impact of multiple chronic conditions
Introduction:
Lung cancer (ICD9 162.2-162.9) is the leading cause of cancer death for both men and women. It is estimated that in the year 2003, about 157,200 people will die of lung cancer[1].
Although considerable research has been devoted to the diagnosis and treatment of lung cancer, less attention has been given to the impact of treating lung cancer patients with other chronic conditions and how these conditions could cause additional burden to the patient.
Most people with Lung Cancer Have 5 or More Chronic Conditions
97 percent of Medicare beneficiaries and/or people older than 65 years of age with lung cancer have another chronic condition (Figure 1) and 60% of lung cancer patients have five or more other chronic conditions. As a result, treatment of chronic conditions is an important concern when treating lung cancer patients.
The most prominent co-morbidities are hypertension, other secondary cancers, and heart disease, as seen in Table 1.
Table 1
Conditions / percent of lung cancerpatients affected
COPD / 50.1%
Hypertension / 49.0%
Secondary malignancies * / 39.5%
Coronary atherosclerosis and other heart disease / 29.1%
Other lower respiratory disease ** / 26.3%
Source: RIF SAF 5% Medicare files for CY 2001
* Secondary malignancies include secondary malignant neoplasm in the digestive organs, lymphatic system, reproductive organs, other respiratory organs, and other sites
** other lower respiratory disease are post inflammatory pulmonary fibrosis, alveolar and parieto alveolar pneumonopathies, lung involvement in systemic sclerosis, and other diseases of the lung and/or the respiratory system
1 Comorbidities are defined using the Clinical Classification System (CCS), a set of mutually exclusive categories for ICD9 codes. Visit http://www.ahcpr.gov/data/hcup/ccsfact.htm for a description of CCS and the actual groupings themselves
Clinical studies have shown that the presence of COPD in lung cancer patients “is an acceptable predictor of postoperative pulmonary complications,”[2] and these complications are associated with higher mortality rates.[3] Other studies have shown that COPD in lung cancer patients are at significantly higher risk for supraventricular arrhythmias, which may lead to a longer hospitalization.[4] One study which focused on the treatment of lung cancer and COPD concluded that “adequate palliative care to provide quality survival would be the primary goal of therapy for lung cancer patients with COPD.”[5] Another study also found that hypertension may result in a higher postoperative mortality.[6]
Number of hospitalizations increases as number of chronic conditions increases
Lung cancer patients often have one or more ambulatory care-sensitive conditions, ACSCs. ACSCs are defined as conditions for which “diagnoses for which timely and effective outpatient care can help to reduce the risks of hospitalization by either preventing the onset of an illness or condition, controlling an acute episodic illness or condition (such as bacterial pneumonia), or managing a chronic disease or condition (such as asthma and hypertension).”[7] It has been observed that “better primary care, especially coordination of care, could reduce avoidable hospitalization rates, especially for individuals with multiple chronic conditions.”[8]
Hospitalization for conditions (ACSCs) that are preventable can be used to indicate whether the patient is receiving adequate and quality outpatient care.[9] It has been observed that as the number of chronic conditions increase, the period of hospitalization increases dramatically, as seen in table 2 below.
Table 2
Number of Chronic / Hospitalizations forConditions in / ACSC Admissions
Addition to lung cancer / per 1000
Patients over age 65
0 / 15.6
1 / 45.2
2 / 68.2
3 / 104.7
4 / 161.8
5+ / 383.8
Source: RIF SAF 5% Medicare files for CY 2001
Health Care spending increases with more chronic conditions
People with chronic conditions in addition to lung cancer have higher health care expenses. Figure 2 shows all Medicare spending by number of chronic conditions. Medicare beneficiaries with lung cancer and five or more additional chronic conditions have almost fourteen times higher expenditures per beneficiary compared to beneficiaries with only lung cancer.
Utilization increases with more chronic conditions
People with multiple chronic conditions in addition to lung cancer utilize more healthcare resources. As Figure 3 shows, lung cancer patients with other chronic conditions visit the doctor more often. As Figure 4 shows, patients with 5 or more chronic conditions see an average of 20 unique physicians during the year. It may be easier for physicians to communicate with each other if a single physician is in charge of the patient.
Conclusion:
Treatment has become increasingly difficult when lung cancer patients have other chronic conditions. Research suggests that patients have better outcomes at lower cost when care is coordinated[10]. Care coordination becomes essential to improvements in care for patients with lung cancer.
About Partnership for Solutions
Partnership for Solutions, led by Johns Hopkins University and The Robert Wood Johnson Foundation, is an initiative to improve the care and quality of life for the estimated 125 million Americans with chronic health conditions. The Partnership is engaged in three major activities: conducting original research and identifying existing research that clarifies the nature of the problem; communicating these research findings to policymakers, business leaders, health professionals, advocates, and others; and working with public and private programs to identify promising solutions to the problems faced by people with chronic conditions.
[1] How many people get lung cancer? American Cancer Society, Accessed June 2003, <http://www.cancer.org/docroot/CRI/content/CRI_2_2_1X_How_many_people_get_lung_cancer_26.asp?sitearea=>.
[2] Behnia M., Fujisawa T., and.Sekine Y.(2002) Impact of COPD on pulmonary complications and on long-term survival of patients undergoing surgery for NSCLC Lung Cancer.37(1): 95-101 Abstract [online] PubMed, NCBI [Accessed July 1, 2003]
[3] Francisco Algar et al. (2003) Predicting pulmonary complications after pneumonectomy for lung cancer European Journal of Cardio-Thoracic Surgery 23(2): 201-208 Abstract [online] PubMed, NCBI [Accessed July 1, 2003]
[4] Yasuo Sekine et al. (2001) COPD May Increase the Incidence of Refractory Supraventricular Arrhythmias Following Pulmonary Resection for Non-small Cell Lung Cancer Chest. 120(6): 1783-90 Abstract [online] PubMed, NCBI [Accessed July 1, 2003]
[5] K. Kurishima et al. (2001) Lung cancer patients with chronic obstructive pulmonary disease Oncol Rep. 8(1): 63-5 Abstract [online] PubMed, NCBI [Accessed July 1, 2003]
[6] Drukin E., Zarkh SA., and Paikin MD., (1981) Surgical treatment of lung cancer in patients with concurrent cardiovascular system diseases Voprosy Onkologii27(2): 74-8 Abstract [online] PubMed, NCBI [Accessed July 1, 2003]
[7] Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE, Newman L. Impact of socioeconomic status on hospital use in New York City Heath Affairs(Millwood). 1993:12: p.163-166
[8]Anderson G, Starfield B, and Wolff J.(2002) Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly Arch Intern. Med. 162(20): 2269-76 Abstract [online] PubMed, NCBI [Accessed July 1, 2003]
[9] Millman M. Access to Health Care in America Washington, DC: National Academy Press; 1993
[10] Anderson G, Starfield B, and Wolff J. Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly Arch Intern. Med. Vol. 162, Nov. 2002, p. 2275