Richard W. DeClue, PhD, MPH; Dana Drzayich Antol, MS; Adrianne W. Casebeer, PhD, MS, MPP; Todd Michael, PharmD, RPh; Marina Sehman, PharmD; Andrew Renda, MD, MPH; Sarika Ogale, PhD; Stephen Stemkowski, PhD, MHA; and Bryan Loy, MD
The authors established a claims-based mechanism for identifying patients with lung cancer with more severe patient-reported cancer-related symptoms who could benefit from engagement with health care programs.
Objectives: The goal of this study was to establish a claims-based mechanism for identifying patients with metastatic non–small cell lung cancer (mNSCLC) and high levels of patient-reported cancer-related symptoms who could benefit from engagement with health care programs.
Study Design: A cross-sectional survey of patients with mNSCLC was conducted from July 2017 to May 2018. Surveys were mailed to patients who were within 3 months of cancer treatment and enrolled in a Medicare Advantage health plan.
Methods: Pain, fatigue, and sleep disturbance were measured using the Patient-Reported Outcomes Measurement Information System. Depression was assessed using the Patient Health Questionnaire-2. Medical claims were linked to survey results to identify comorbidities and assess preindex health care resource utilization. Cluster analysis was used to differentiate patients based on patient-reported pain interference, pain intensity, depression, and sleep disturbance. Logistic regression was used to identify claims-based measures associated with more severe symptoms.
Results: For 698 respondents, 2 distinct symptom clusters were identified: a less severe (38.4%) cluster and a more severe (61.6%) cluster. Patients in the more severe cluster were younger, were more frequently dually eligible for Medicare and Medicaid, and more frequently had prescription fills for opioids. Claims-based factors associated with the more severe cluster included 2 or more 30-day fills for opioids in the prior 6 months, age younger than 75 years, depression diagnosis or antidepressants, bone metastases, and pain-related outpatient visits.
Conclusions: The claims-based factors associated with the severe symptom cluster can enable identification of patients with mNSCLC who could benefit from clinical outreach programs to enhance the care and support provided to these patients.
Am J Manag Care. 2020;26(6):In Press
Takeaway PointsWe established a claims-based mechanism for identifying patients with metastatic non–small cell lung cancer with more severe patient-reported cancer-related symptoms who could benefit from engagement with health care programs.
- Two distinct pain, fatigue, depression, and sleep disturbance clusters were identified.
- Depression, 2 or more 30-day opioid fills in a 6-month period, age younger than 75 years, bone metastases, and pain-related outpatient visits were associated with the more severe symptom cluster in adjusted analysis.
- This information could be used to identify patients using administrative claims for programs to improve symptom management or for referral to interventions linking patients to needed resources.
The symptoms experienced by these patients tend to present in clusters as opposed to in isolation, and these clusters have been defined as 2 or more symptoms that are often related and occur together.13-17 Few studies have examined symptom clusters in relation to specific disease states16,18; however, for patients with lung cancer, the cluster of pain, depression, and fatigue is by far the most common symptom cluster that has been identified.19 This particular cluster has been recognized as significant, with a call for research at the National Institutes of Health State-of-the-Science Conference to help understand how to identify patients with lung cancer at risk for this cluster of symptoms and to identify specific interventions that have been effective.19
For both men and women, lung cancer dominates in causes of cancer mortality and is the second most common cancer diagnosed in the United States.20 In 2017, it was estimated that 225,000 lung cancer cases were diagnosed, comprising 25% of all cancer cases in the United States.20 The diagnosis of non–small cell lung cancer (NSCLC) accounts for approximately 80% to 85% of all lung cancer cases, with small cell lung cancer making up the remaining 15% to 20%.21 The 5-year overall survival rate for patients with this disease, often diagnosed after metastasis, is less than 5%, and more than half of all patients with metastatic NSCLC (mNSCLC) die within a year of receiving their diagnosis.20
mNSCLC can place extreme burdens on patients and their families. In contrast to patients with other types of cancer, patients with lung cancer have been documented as experiencing a greater symptom burden, as well as higher levels of psychological distress.22,23 A study by Sung and colleagues24 in 2017 demonstrated that the unmet needs of patients with lung cancer have remained unchanged over the last 10 years and include physical and psychological issues, support with daily living, and the need for help in obtaining information about their disease.24,25
The objective of this study was to develop a mechanism for identification of patients with mNSCLC and advanced cancer-related symptoms in administrative claims data who may benefit from cancer-specific outreach programs to ameliorate symptoms and improve health-related quality of life.
METHODS
Study Design
To conduct a cross-sectional survey of patients with mNSCLC, paper surveys were mailed to patients with mNSCLC, aged 50 to 89 years, who had received cancer treatment within 3 months prior to the survey date and were enrolled in a Humana Medicare Advantage health plan with a pharmacy benefit. Cancer treatment was defined as National Comprehensive Cancer Network–recommended systemic biologic or cytotoxic therapy, radiotherapy, or cancer-related surgery for the treatment of mNSCLC. Eligible patients were identified from pretreatment authorization requests for NSCLC biologic or chemotherapy infusions made by the treating physician between January 2017 and May 2018. Receipt of infusion therapy, radiotherapy, or cancer-related surgery within 3 months of survey completion was confirmed using medical and pharmacy claims.
Patient metastatic status was established using either data from provider pretreatment authorization requests or medical claims. Metastatic status in claims was identified as having at least 2 medical claims with codes for a secondary malignant neoplasm (International Classification of Diseases, Ninth Revision, Clinical Modification: 196.x, 197.x, 198.x; International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM]: C77.x, C78.x, C79.x) occurring on separate days within 2 years prior to the anticipated survey date.
Eligibility required enrollment in the health plan at index date (ie, the survey date), as well as continuous enrollment for 6 months prior. Patients who initiated hospice in the preindex period were excluded from the study. This study was approved by the Advarra Institutional Review Board.
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