Increased attention to timely diagnosis motivated us to study 5483 patients diagnosed with multiple myeloma using Medicare claims linked to tumor registries in the Surveillance, Epidemiology and End Results programme. We calculated the time between initial visits for anemia or back pain and for myeloma diagnosis, and used logistic regression to predict the likelihood of diagnostic delay, and also the likelihood of renal or skeletal complications. The median time between sign or symptom and myeloma diagnosis was 99 days. Patients with anemia, back pain and comorbidities were more likely to experience diagnostic delay (OR 1.6, 95% CI 1.3-2.0). Diagnosis while hospitalised (OR 2.5, 95% CI 2.2-2.9) and chemotherapy treatment within 6 months of diagnosis (OR 1.4, 95% CI 1.2-1.6) significantly predicted complications; diagnostic delay did not (OR 0.9, 95% CI 0.8-1.1). Our data suggest that complications are more strongly associated with health status and myeloma severity than with diagnostic delays.

To better understand the extent of diagnostic and referral delays from primary care providers (PCPs) for chronic hematologic malignancies, causes of these delays, and their possible effects on cancer outcomes, an extensive review of the literature was performed. Over 50 studies were reviewed, including many that concern delays in referral and diagnosis for solid tumors, as there was only sparse literature on delays specific to the liquid tumors. Delays for some chronic hematologic malignancies have been documented, mainly in centralized health care systems. Possible reasons for delays include PCPs' lack of exposure to hematologic malignancies, limited knowledge of associated signs and symptoms, and a reliance on patient symptoms to prompt referral (as opposed to signs and screening). Patient characteristics such as age, gender and race-ethnicity are also likely to play a role, although it is unclear if these exert their effect primarily via patient or provider mechanisms. Unfortunately, the outcomes associated with such delays are largely unreported, possibly because delay is complex to define and difficult to measure.

BACKGROUND: Little is known about the patterns of care relating to the diagnosis of chronic lymphocytic leukemia (CLL), including the use of modern diagnostic techniques such as flow cytometry. METHODS: The authors used the SEER‐Medicare database to identify subjects diagnosed with CLL from 1992 to 2002 and defined diagnostic delay as present when the number of days between the first claim for a CLL‐associated sign or symptom and SEER diagnosis date met or exceeded the median for the sample. The authors then used logistic regression to estimate the likelihood of delay and Cox regression to examine survival. RESULTS: For the 5086 patients analyzed, the median time between sign or symptom and CLL diagnosis was 63 days (interquartile range [IQR] = 0‐251). Predictors of delay included age ≥75 (OR 1.45 [1.27‐1.65]), female gender (OR 1.22 [1.07‐1.39]), urban residence (OR 1.46 [1.19 to 1.79]), ≥1 comorbidities (OR 2.83 [2.45‐3.28]) and care in a teaching hospital (OR 1.20 [1.05‐1.38]). Delayed diagnosis was not associated with survival (HR 1.11 [0.99‐1.25]), but receipt of flow cytometry within thirty days before or after diagnosis was (HR 0.84 [0.76‐0.91]). CONCLUSIONS: Sociodemographic characteristics affect diagnostic delay for CLL, although delay does not seem to impact mortality. In contrast, receipt of flow cytometry near the time of diagnosis is associated with improved survival. Cancer 2011. © 2010 American Cancer Society.

1369 Poster Board I-391 Background: Timeliness of diagnosis is a quality of care measure endorsed by the Institute of Medicine. Clinical outcomes for patients with chronic myelogenous leukemia (CML) are better when tyrosine kinase inhibitors, such as imatinib, are initiated in the early stages of disease. However, the patterns of care surrounding the CML diagnosis period, as well as the relationship between diagnosis delay and overall survival in the pre-imatinib era, are unknown. Methods: The Surveillance, Epidemiology and End Results (SEER)-Medicare linked database was used to identify traditional Medicare enrollees diagnosed with CML during 1991 through May 2001 (prior to the FDA approval of imatinib). Both inpatient and outpatient claims were analyzed from one year before, through six months following, the SEER diagnosis date. Signs, symptoms, and diagnostic studies commonly encountered in CML diagnoses were identified by CPT procedure and ICD-9 diagnosis and procedure codes. We calculated the time between the first visit for a sign or symptom and the SEER diagnosis date, and defined this time period as ‘diagnostic delay’ if it met or exceeded the median number of days for the sample. An accelerated failure time model examined variables associated with diagnostic delay. Overall survival was examined using a Cox proportional hazards model. Analyses were adjusted to account for a possible lag time in SEER cancer diagnosis dates, as well as year of diagnosis. Results: We studied 768 patients who met eligibility criteria. The most frequent signs and symptoms prior to CML diagnosis were infection (29.4%), anemia (22.4%), leukocytosis (13.4%) and fatigue (11.9%). The median time between any sign or symptom and CML diagnosis date in SEER was 90 days (interquartile range = 270). The median survival time was 3.5 years. The time between sign or symptom and CML diagnosis was increased for patients with at least one comorbidity (β=0.83, p < .001), and for those diagnosed at age 75 or greater (β=0.30, p < .05). Males had shortened times to diagnosis (β=-0.41, p < .01). Diagnostic delay was not a significant predictor of overall survival (HR = 1.04, 95% CI = 0.88-1.23). Conclusions: The most common signs and symptoms older patients experience prior to CML diagnosis are nonspecific, which may impair diagnostic efforts. Prior to the approval and general availability of imatinib, differences in timeliness of diagnosis were observed by age, gender, and presence of comorbidities. Examination of patient-provider interactions stratified by these variables may aid efforts to standardize the diagnostic process, although diagnostic delay was not significantly associated with overall survival in the pre-imatinib era. Disclosures: No relevant conflicts of interest to declare.

Background: Little is known about the patterns of care related to the diagnosis of chronic lymphocytic leukemia (CLL), including the use of modern diagnostic techniques such as flow cytometry. A population-based analysis of the diagnostic process for CLL patients, including predictors and consequences of diagnostic delay, could fuel quality improvement efforts. Methods: The SEER-Medicare linked database for the years 1991–2003 was used to identify traditional Medicare enrollees diagnosed with CLL. Both inpatient and outpatient claims were analyzed from one year before, through six months following, the SEER diagnosis date. Signs, symptoms, and diagnostic studies commonly encountered in CLL diagnoses were identified by ICD-9 diagnosis and CPT procedure codes. Using the dates on claims, we calculated the time between the first visit for a sign or symptom and the SEER diagnosis date. Diagnostic delay was considered present if this time period met or exceeded the median number of days for the sample. Logistic regression models were used to estimate the likelihood of receipt of flow cytometry and of diagnostic delay, using clinical and sociodemographic predictor variables. Overall survival was examined using a Cox proportional hazards model. Analyses were adjusted to account for a known lag time in SEER cancer diagnosis dates. Results: We studied 5,086 patients who met eligibility criteria. Of those, 2,282 (48.9%) had a claim for flow cytometry during the study period, and 1,965 (38.6%) were performed within 30 days of the SEER diagnosis date. The most frequent signs and symptoms prior to diagnosis were infection (32.2%), lymphocytosis, (28.7%), and anemia (23.9%). The median survival time was 9.9 years. The median time between sign or symptom and CLL diagnosis date in SEER (defined as diagnostic delay) was 63 days (interquartile range = 251). Significant predictors of diagnostic delay included age of 75 or higher (OR=1.45, 95% CI = 1.27 to 1.65), female gender (OR = 1.22, 95% CI = 1.07 to 1.39), urban resident (OR = 1.46, 95% CI = 1.19 to 1.79), one or more comorbidities, as measured by the Charlson Comorbidity Index (OR = 2.83, 95% CI = 2.45 to 3.28), and care in a teaching hospital in the year preceding diagnosis (OR = 1.20, 95% CI = 1.05 to 1.38). Significant predictors of receipt of flow cytometry were age below 75 (OR = 1.46, 95% CI = 1.30 to 1.66), urban residence (OR = 1.27, 95% CI = 1.05 to 1.53), northeast residence (OR = 2.01, 95% CI = 1.69 to 2.39), southern residence (OR = 1.51, 95% CI = 1.22 to 1.89) and increasing number of pre-diagnosis signs or symptoms (OR = 1.15, 95% CI = 1.08 to 1.22). In multivariate models, diagnostic delay was not a significant predictor of overall survival (HR = 1.10, 95% CI = 0.98–1.25). Conclusions: In this large national cohort of older adults, age and gender both significantly impact diagnostic delay for CLL, raising a concern for sociodemographic differences in clinicians’ responses to signs and symptoms of hematologic malignancy. In addition, our analysis suggests that the presence of comorbidities may lead clinicians to overlook malignancy as an explanation for hematologic anomalies. Finally, initial use of flow cytometry varies significantly by geography and population density, which may reflect knowledge gaps in recommended diagnostic studies or lack of access to hematopathology services.