ingest cdrApp 2018-08-23T18:09:52.939Z d39a25df-af15-48e9-aec2-c9af81a997a2 modifyDatastreamByValue RELS-EXT fedoraAdmin 2018-08-23T18:10:44.703Z Setting exclusive relation addDatastream MD_TECHNICAL fedoraAdmin 2018-08-23T18:10:56.102Z Adding technical metadata derived by FITS addDatastream MD_FULL_TEXT fedoraAdmin 2018-08-23T18:11:19.247Z Adding full text metadata extracted by Apache Tika modifyDatastreamByValue RELS-EXT fedoraAdmin 2018-08-23T18:11:41.386Z Setting exclusive relation modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2018-09-27T14:36:27.651Z modifyDatastreamByValue MD_DESCRIPTIVE cdrApp 2019-03-21T15:32:10.034Z Mihaela Georgieva Author Department of Health Policy and Management Gillings School of Global Public Health APPROPRIATE USE AND VALUE OF SURVEILLANCE AMONG MEDICARE PATIENTS WITH NON-MUSCLE-INVASIVE BLADDER CANCER Bladder cancer patients have the highest median age at diagnosis of 73 years compared with all other cancer types and often live with substantial disease and comorbidity burden. Due to high recurrence rates, intensive surveillance strategies, and expensive therapies, bladder cancer has the highest lifetime costs per patient from diagnosis to death. Regular surveillance cystoscopy is recommended for patients with non-muscle invasive bladder cancer (NMIBC) of all ages to detect potential recurrences, despite a lack of large randomized controlled trials examining how the use of cystoscopy affects patient outcomes. The overall objectives of this dissertation were (1) to investigate factors associated with receipt of surveillance cystoscopy; (2) to characterize survival outcomes of NMIBC patients undergoing surveillance; and (3) to examine the cost-effectiveness of three different risk-stratified and uniform surveillance recommendations. We used the Surveillance Epidemiology and End Results (SEER)-Medicare data from 2000 to 2014 to assess disease characteristics and outcomes. We also developed a patient-level simulation model to quantify the health-economic impact of different frequencies of surveillance over five years. In Aim 1, we found that NMIBC patients aged ≥85 years, those with poor disability status, and those having ≥3 comorbidities at diagnosis were least likely to undergo recommended (≥7 cystoscopies) or low-intensity (≥4 cystoscopies) surveillance over the first two years post-diagnosis. As the age at diagnosis and the number of comorbid conditions increased, the odds of receiving recommended cystoscopy frequency as well as the rate of cystoscopy decreased. In Aim 2, older patients (≥75 vs. 66-74 years) and those with poor disability status at diagnosis had higher cumulative incidence of both bladder-cancer and other-cause death, regardless of frequency of cystoscopy. In Aim 3, low-intensity risk-stratified surveillance, with cystoscopy frequency increasing progressively with risk, was associated with different trade-offs such as lower costs and fewer false positive cases per patient, compared with a more frequent high-intensity risk-stratified approach and uniform surveillance. This research highlights the importance of age, comorbidities, functional status, and risk-stratification on receipt of surveillance and outcomes of NMIBC patients. Additionally, findings from our study suggest intermediate-risk patients may benefit from less frequent surveillance than high-risk patients. Summer 2018 2018 Public health bladder cancer, competing risks, cost-effectiveness research, multilevel modelling, SEER-Medicare, surveillance eng Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Health Policy and Management Stephanie Wheeler Thesis advisor Matthew Nielsen Thesis advisor Justin Trogdon Thesis advisor Michaela Dinan Thesis advisor Morris Weinberger Thesis advisor text Mihaela Georgieva Creator Department of Health Policy and Management Gillings School of Global Public Health APPROPRIATE USE AND VALUE OF SURVEILLANCE AMONG MEDICARE PATIENTS WITH NON-MUSCLE-INVASIVE BLADDER CANCER Bladder cancer patients have the highest median age at diagnosis of 73 years compared with all other cancer types and often live with substantial disease and comorbidity burden. Due to high recurrence rates, intensive surveillance strategies, and expensive therapies, bladder cancer has the highest lifetime costs per patient from diagnosis to death. Regular surveillance cystoscopy is recommended for patients with non-muscle invasive bladder cancer (NMIBC) of all ages to detect potential recurrences, despite a lack of large randomized controlled trials examining how the use of cystoscopy affects patient outcomes. The overall objectives of this dissertation were (1) to investigate factors associated with receipt of surveillance cystoscopy; (2) to characterize survival outcomes of NMIBC patients undergoing surveillance; and (3) to examine the cost-effectiveness of three different risk-stratified and uniform surveillance recommendations. We used the Surveillance Epidemiology and End Results (SEER)-Medicare data from 2000 to 2014 to assess disease characteristics and outcomes. We also developed a patient-level simulation model to quantify the health-economic impact of different frequencies of surveillance over five years. In Aim 1, we found that NMIBC patients aged ≥85 years, those with poor disability status, and those having ≥3 comorbidities at diagnosis were least likely to undergo recommended (≥7 cystoscopies) or low-intensity (≥4 cystoscopies) surveillance over the first two years post-diagnosis. As the age at diagnosis and the number of comorbid conditions increased, the odds of receiving recommended cystoscopy frequency as well as the rate of cystoscopy decreased. In Aim 2, older patients (≥75 vs. 66-74 years) and those with poor disability status at diagnosis had higher cumulative incidence of both bladder-cancer and other-cause death, regardless of frequency of cystoscopy. In Aim 3, low-intensity risk-stratified surveillance, with cystoscopy frequency increasing progressively with risk, was associated with different trade-offs such as lower costs and fewer false positive cases per patient, compared with a more frequent high-intensity risk-stratified approach and uniform surveillance. This research highlights the importance of age, comorbidities, functional status, and risk-stratification on receipt of surveillance and outcomes of NMIBC patients. Additionally, findings from our study suggest intermediate-risk patients may benefit from less frequent surveillance than high-risk patients. Public health bladder cancer; competing risks; cost-effectiveness research; multilevel modelling; SEER-Medicare; surveillance Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Health Policy and Management Stephanie Wheeler Thesis advisor Matthew Nielsen Thesis advisor Justin Trogdon Thesis advisor Michaela Dinan Thesis advisor Morris Weinberger Thesis advisor 2018 2018-08 eng text Mihaela Georgieva Creator Department of Health Policy and Management Gillings School of Global Public Health Bladder cancer patients have the highest median age at diagnosis of 73 years compared with all other cancer types and often live with substantial disease and comorbidity burden. Due to high recurrence rates, intensive surveillance strategies, and expensive therapies, bladder cancer has the highest lifetime costs per patient from diagnosis to death. Regular surveillance cystoscopy is recommended for patients with non-muscle invasive bladder cancer (NMIBC) of all ages to detect potential recurrences, despite a lack of large randomized controlled trials examining how the use of cystoscopy affects patient outcomes. The overall objectives of this dissertation were (1) to investigate factors associated with receipt of surveillance cystoscopy; (2) to characterize survival outcomes of NMIBC patients undergoing surveillance; and (3) to examine the cost-effectiveness of three different risk-stratified and uniform surveillance recommendations. We used the Surveillance Epidemiology and End Results (SEER)-Medicare data from 2000 to 2014 to assess disease characteristics and outcomes. We also developed a patient-level simulation model to quantify the health-economic impact of different frequencies of surveillance over five years. In Aim 1, we found that NMIBC patients aged ≥85 years, those with poor disability status, and those having ≥3 comorbidities at diagnosis were least likely to undergo recommended (≥7 cystoscopies) or low-intensity (≥4 cystoscopies) surveillance over the first two years post-diagnosis. As the age at diagnosis and the number of comorbid conditions increased, the odds of receiving recommended cystoscopy frequency as well as the rate of cystoscopy decreased. In Aim 2, older patients (≥75 vs. 66-74 years) and those with poor disability status at diagnosis had higher cumulative incidence of both bladder-cancer and other-cause death, regardless of frequency of cystoscopy. In Aim 3, low-intensity risk-stratified surveillance, with cystoscopy frequency increasing progressively with risk, was associated with different trade-offs such as lower costs and fewer false positive cases per patient, compared with a more frequent high-intensity risk-stratified approach and uniform surveillance. This research highlights the importance of age, comorbidities, functional status, and risk-stratification on receipt of surveillance and outcomes of NMIBC patients. Additionally, findings from our study suggest intermediate-risk patients may benefit from less frequent surveillance than high-risk patients. Public health bladder cancer; competing risks; cost-effectiveness research; multilevel modelling; SEER-Medicare; surveillance Doctor of Philosophy Dissertation University of North Carolina at Chapel Hill Graduate School Degree granting institution Stephanie Wheeler Thesis advisor Matthew Nielsen Thesis advisor Justin Trogdon Thesis advisor Michaela Dinan Thesis advisor Morris Weinberger Thesis advisor 2018 2018-08 eng text Georgieva_unc_0153D_18073.pdf uuid:05668e88-f13c-48d6-8036-10bb864804a8 2020-08-23T00:00:00 2018-07-25T15:05:40Z proquest application/pdf 2359434