Comparative Analysis of Treatment Patterns in DoD Beneficiaries With Malignant Central Nervous System Tumors: A Focus on Care Setting.

Abstract

Introduction: Malignant brain and other central nervous system tumors (MBT) are deadly and disproportionately affect younger men and women in the age range of most active-duty service members. Timely and appropriate treatment is important to both survival and quality of life of patients. Information on treatment factors across direct care (DC) and private sector care (PSC) networks may be important for provider training and staffing for the DoD. The aim of this study was to analyze treatment patterns for patients with MBT within the DoD's universal access Military Health System (MHS), comparing DC and PSC networks.

Materials and methods: The Military Cancer Epidemiology database was used to identify patients 18 years and older who were diagnosed with an MBT between 1999 and 2014 who received primary treatment. Differences in first treatment type and time from diagnosis to initial treatment between DC and PSC were assessed using chi-square and Wilcoxon-Mann-Whitney tests, respectively. Frequency of treatment initiation beyond the 28-day TRICARE Prime access standard for Specialty Care was also compared between care settings using chi-square and Fisher's exact tests. Then logistic regression models generated odds of treatment initiation beyond 28 days and 95% confidence intervals (CIs) associated with care setting. Kaplan-Meier survival curves and log-rank tests compared survival between DC and PSC.

Results: The study included 857 patients, with n = 540 treated in DC and n = 317 treated in PSC. The proportion of patients receiving each initial treatment type did not differ by care setting (P = .622). Median time from diagnosis to initial treatment (interquartile range) varied significantly between DC at 6 (0 to 25) days and PSC at 12 (0 to 37) days for all treatment types combined (P < .001). For all years combined, treatment was initiated beyond 28 days for 21% of patients using DC compared to 31% of patients using PSC (P = .001). The odds of treatment initiation beyond 28 days for a patient treated in PSC were 1.61 (95% CI, 1.11 to 2.33, P = .012) compared to patients treated in DC when controlling for demographic, military, tumor, and patient variables. Survival did not differ by care setting (P = 1.000).

Conclusions: Based on the available data between 1999 and 2014, care setting was associated with differences in time to initial treatment and odds of treatment initiation beyond 28 days among DoD beneficiaries with MBT receiving care in the MHS. Information on these differences may help inform MHS leadership decisions on the most appropriate location for military provider training and staffing.