Reply to M.H. Kanter et al

VOLUME NUMBER OCTOBER J OURNAL OF C LINICAL O NCOLOGY C O R R E S P O N D E N C E Reply to M.H. Kanter et al Kim F. Rhoads, Manali I. Patel, and Yifei Ma The critique by Kanter et al 1 suggests that something more than system-level integration is required for best outcomes, perhaps in- cluding care teams, outreach, case management, and health care pro- viders working to their full level of training. Although we can imagine this possibility, no actual evidence is provided to support this specu- lation. Published results on the Veterans Healthcare Administration facilities, a form of integrated health delivery system quite different from the one we studied, 2 found results similar to our own. 3,4 The Veterans Administration system also operates under a single-payer system that works to minimize variations in care, such as promoting adherence to clinical guidelines, the active ingredient that our study suggests can make a difference in colon cancer disparities. 2 Our com- parison cohort was one in which hospitals and provider groups may be networked but have highly variable administrative structures and re- spond to diverse incentives from multiple payers and purchasers— not exactly optimal conditions for reducing variations in care. Nonetheless, we still found that even these fragmented systems were associated with closure of the racial disparity gap when we accounted for the delivery of evidence-based care. Future studies should delve more deeply into the granular mech- anisms that allow integrated systems to achieve the same clinical out- comes for patients regardless of race. But as they currently stand, our results should be regarded as actionable evidence supporting a critical role for health care systems to eliminate cancer disparities. Promoting the widespread adoption of evidence-based guidelines is a clear step that any health system committed to reducing disparities can, and should, act on now. Laura A. Schmidt Stanford University School of Medicine, Stanford, CA University of California, San Francisco Philip R. Lee Institute for Health Policy Studies, San Francisco, CA ACKNOWLEDGMENT Supported by Grant No. 1R21CA161786-01 from the National Cancer Institute and a Harold Amos Medical Faculty Development award from the Robert Wood Johnson Foundation (K.F.R.). AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Disclosures provided by the authors are available with this article at www.jco.org. REFERENCES 1. Kanter MH, Schottinger JE, Copeland R: Integration alone does not reduce health care disparities. J Clin Oncol 33:3519, 2015 2. Rhoads KF, Patel MI, Ma Y, et al: How do integrated health care systems address racial and ethnic disparities in colon cancer? J Clin Oncol 33:854-860, 3. Zullig LL, Carpenter WR, Provenzale DT, et al: Examining potential colorectal cancer care disparities in the Veteran Affairs health care system. J Clin Oncol 4. Zullig LL, Carpenter WR, Provenzale DT, et al: The association of race with timeliness of care and survival among Veterans Affairs health care system patient with late-stage non-small cell lung cancer. Cancer Manag Res DOI: 10.1200/JCO.2015.62.5640; published online ahead of print at www.jco.org on July 27, 2015 Journal of Clinical Oncology, Vol 33, No 30 (October 20), 2015: pp 3519-3520 © 2015 by American Society of Clinical Oncology Information downloaded from jco.ascopubs.org and provided by at UCSF Library on June 30, 2016 from 128.218.186.107 Copyright © 2015 American Society of Clinical Oncology. All rights reserved.