National Trends in Pancreatic Cancer Outcomes and Pattern of Care among Medicare Beneficiaries, 2000–2010

Abstract

BACKGROUND

Pancreatic cancer is a major cause of morbidity and mortality in the Medicare population. Whether the health care burden for pancreatic cancer has changed over the last decade is unknown.

METHODS

We used 2000 to 2010 Medicare data to identify beneficiaries aged 65 years and older who were hospitalized for management of pancreatic cancer. We estimated annual trends in age-sex-race-adjusted initial hospitalization rate, age-sex-race-comorbidity adjusted 1-year mortality rate following initial hospitalization, age-sex-race-comorbidity adjusted procedure rates, 1-year all-cause rehospitalizations after initial pancreatic cancer hospitalization, and mean inflation-adjusted Medicare payment for initial hospitalization.

RESULTS

130,728 patients had one or more hospitalizations for pancreatic cancer were identified from 56,642,071 beneficiaries during the study period. The age-sex-race-adjusted rate of initial hospitalization for pancreatic cancer was 50 per 100,000 person-years in 2010, representing a 0.5% annual increase since 2000 (95% confidence interval [CI], 0.3–0.7). In the same period the age-sex-race-comorbidity-adjusted 1-year mortality rate decreased by 4.4% (95% CI, 3.9–4.9), and the age-sex-race-comorbidity-adjusted surgical resection rate increased by 6.9% (95% CI, 6.4–7.5). The mean inflation-adjusted Medicare payment for the initial hospitalization decreased, from $14,118 in 2000 to $13,318 in 2010, and the number of 1-year all-cause rehospitalizations after the initial hospitalization increased from 0.75 per patient in 2000 to 0.82 per patient in 2009 (all p<0.001).

CONCLUSIONS

For Medicare fee-for-service beneficiaries, initial pancreatic cancer hospitalization, surgical resection, and rehospitalization rates increased, but 1-year mortality declined over the last decade.

INTRODUCTION

Pancreatic cancer is common and lethal in the elderly population, accounting for 3% of all cancers and 6% of cancer deaths. In 2013, 45,220 new cases of pancreatic cancer are projected in the United States, a relative increase of 3% from 2012.^1,2 Effective strategies for early detection of pancreatic cancer are lacking, and most cases are diagnosed at an advanced stage when surgical resection with curative intent is not possible. Resultantly, the prognosis of pancreatic cancer is poor—more than 80% of patients die within a year of diagnosis and 98% die within 5 years. The majority of pancreatic cancer patients in the United States are elderly, with a median age at diagnosis of 72 years.³ The American Cancer Society reports that the pancreatic cancer incidence rate is increasing, with annual increases of 1.0% and 0.8% per year in women and men respectively since 1998.⁴ Continued increases in incidence are expected as the U.S population continues to age. In January 2013, the Recalcitrant Cancer Research Act was signed into law to accelerate funding for pancreatic cancer research.

Little is known about how the healthcare burden has changed over the last decade for patients with pancreatic cancer, and there is a paucity of data regarding spatial variation in pancreatic cancer treatment and outcomes. Previous studies report older data with limited coverage of the entire Medicare population.^5–10 The last decade has brought a multitude of changes that affect pancreatic cancer care, including increased use of abdominal imaging, a general shift toward outpatient oncology care, a renewed emphasis on end-of-life care, and increased scrutiny on quality and cost-effectiveness of cancer care.^11–15 The effects of these changes on clinical and economic outcomes in pancreatic cancer remain largely unknown.

In this study, we used the 100% Medicare administrative claims data from the Centers for Medicare and Medicaid Services (CMS) to estimate trends in the burden of pancreatic cancer in the Medicare fee-for-service population from 2000 to 2010 across states/regions and age-sex-race subgroups. We evaluated trends in the initial pancreatic cancer hospitalization rate, the 1-year mortality rate following initial hospitalization, and patterns of care, including 1-year surgical or non-surgical procedure rates, major discharge dispositions, length of stay (LOS), Medicare expenditures, and post-diagnosis rehospitalizations. Our results describe recent changes in the patterns of care and outcomes for pancreatic cancer and provide important context to help prioritize future effectiveness research for treatment of this common and lethal malignancy.

MATERIALS AND METHODS

Study Sample

Using Medicare beneficiary denominator files from CMS, we identified all Medicare beneficiaries aged 65 years or older who were enrolled in the Medicare fee-for-service plan between January 2000 and December 2010. We calculated person-years for beneficiaries to account for new enrollment, disenrollment, or death during the study period. We linked beneficiaries with Medicare inpatient claims data from CMS to identify pancreatic cancer patients with a principal discharge diagnosis of 157.xx, according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We identified all unique patients who had at least one hospitalization for pancreatic cancer between January 1, 2000 and December 31, 2010. If a patient had more than one pancreatic cancer hospitalization during the entire study period, the first one was selected.

Patient Characteristics and Comorbidities

Patient demographic information includes age, sex, race (white, black, other), and the state of residence. Common clinical comorbidities for elderly patients were identified using the Hierarchical Condition Categories method¹⁶ that uses principal and secondary diagnosis codes from hospitalizations in the 12 months prior to the index hospitalization. Data from 1999 was used for patients hospitalized with pancreatic cancer in 2000.

Outcomes

We defined the pancreatic cancer initial hospitalization rate by dividing the total number of pancreatic cancer patients in each year by the corresponding person-years of Medicare fee-for-service beneficiaries for that year. We defined the 1-year mortality rate as all-cause deaths within 365 days from the date of the initial pancreatic cancer admission divided by the total number of pancreatic cancer patients with an index hospitalization in a given year. Procedures included 1) resections (total pancreatectomy, radical pancreaticoduodenectomy, proximal, distal, radical subtotal, and partial pancreatectomy), 2) palliative surgical bypass (gastrojejunostomy, biliary-enteric bypasses, hepaticojejunostomy, or gastrojejunostomy and biliary-enteric bypasses together), and 3) stent/biliary drainage procedures (duct exploration for relief of obstruction other than calculus, insertion of choledochohepatic tube for decompression, incision of other bile ducts for relief of obstruction, endoscopic insertion of tube into bile duct, replacement of tube in biliary or pancreatic duct, and biliary drainage [percutaneous or endoscopic]) according to the ICD-9-CM codes listed in the online supplementary appendix (Table S1)^17,18 within 1-year from the initial date of pancreatic cancer hospitalization. Major discharge dispositions included discharge to home, homecare, intermediate care facility/skilled nursing facility, hospice, and inhospital death. LOS was defined as the difference between discharge and admission dates plus 1. Patients with LOS > 100 days were considered as outliers and excluded from the LOS analysis. Medicare expenditures were calculated as the mean Medicare reimbursement per patient for the initial hospitalization, adjusting for the annual Consumer Price Index inflation rate reported by the Bureau of Labor Statistics, United Stated Department of Labor (http://www.bls.gov/data/inflation_calculator.htm) and using the 2000 expenditure as a baseline. The number of rehospitalizations was defined as 1-year cumulative unplanned all-cause hospitalizations after the initial hospitalization. Data from 2010 was used for reporting the 1-year mortality, procedure rates, and number of rehospitalizations for patients hospitalized in 2009.

Statistical Analysis

The hospitalization rate at the national and state levels was age-standardized to the 2000 Medicare population age 65 years or older population and expressed as per 100,000 person-years. We fitted a mixed effects model with a Poisson link function and state-specific random intercepts to estimate the trend in the initial hospitalization rate, adjusting for age-sex-race. Time was modeled as an ordinal variable ranged from 0 to 10, corresponding to years 2000 to 2010. The incidence rate ratio (IRR) for the time variable was used to represent the age-sex-race-adjusted annual trend in hospitalization rate. We used a mixed model with a logit link function to estimate the trend in 1-year mortality rate from the initial hospitalization, adjusted for age-sex-race and comorbidities. The time variable in the model was restricted to 0 to 9, corresponding to years 2000 to 2009. We used the odds ratio (OR) of the time variable to represent the risk-adjusted annual trend in 1-year mortality. We repeated this model for each of the four surgical and non-surgical procedure outcomes separately. Using the mixed models, we conducted stratified analyses to estimate trends in hospitalization, 1-year mortality, and 1-year procedure rates by age-sex-race subgroups.

To assess spatial trends and variations in outcomes, we fitted a mixed effects model with a Poisson link function and state-specific random intercepts and state-specific random slope of the time variable to assess whether a state-specific annual trend in the pancreatic cancer hospitalization rate was significantly different from the national average, adjusting for age-sex-race. A state-specific annual trend was expressed as a deviation of the state-specific slope of the time variable from the national overall slope of the time variable. We used a mixed model with a logit link function to assess state-specific annual trends in 1-year mortality and procedure rates following initial hospitalization, adjusting for age-sex-race-comorbidity and restricting the time variable to 0 to 9. We mapped the age-standardized pancreatic cancer initial hospitalization rates for years 2000 and 2010 for each state. All analyses were conducted using SAS version 9.3, 64-bit (SAS Institute Inc, Cary, North Carolina). All statistical testing was 2-sided, at a significance level of 0.05. To facilitate data presentation, hospitalization, patient characteristics, mortality, and procedure rates were reported in two-year intervals by 2000–2001, 2005–2006, and 2009–2010 (2009 for mortality and procedure rates), which represented baseline, middle, and end points of the study period. The Human Investigation Committee at Harvard School of Public Health determined that institutional review board approval was not required for this analysis.

RESULTS

Study Sample

From 2000 to 2010, we identified 130,728 unique pancreatic cancer patients from 56,642,071 Medicare fee-for-service beneficiaries. Over the 11-year period, the mean age at initial hospitalization increased slightly, from 77.7 (SD=7.3) in 2000 to 77.8 (SD=7.7) in 2010. The proportion of female patients decreased from 56.2% in 2000 to 54.1% in 2010 (p<0.001). Table S2 summarizes patient characteristics and common comorbidities in two-year intervals.

Trends in Initial Hospitalization

The observed initial hospitalization rates have increased by all race groups (Figure S1). The age-standardized initial hospitalization rate increased from 47 to 50 per 100,000 person-years between 2000 and 2010 (Table 1). Among demographic subgroups, black women had the highest hospitalization rate. Figure 1A (left panel) shows the age-sex-race adjusted annual trends, represented by IRRs, in pancreatic cancer initial hospitalization rates. There was an increase in the hospitalization rate across most subgroups; the risk-adjusted annual increases were 0.5% (95% CI 0.3 to 0.7) for the entire population, 0.4% (95% CI 0.2 to 0.7) for men, and 0.6% (95% CI 0.3 to 0.9) for women.

Table 1.

Pancreatic cancer hospitalization and mortality rates, 2000 to 2010/2009

Age-sex-race groups	Hospitalization rate, per 100 000 (95% CI) person-years			One year mortality rate, % (95% CI)
	2000–2001	2005–2006	2009–2010	2000–2001	2005–2006	2009
Overall	47 (46.5–47.6)	47 (46.7–47.9)	50 (49.5–50.7)	82.4 (81.8–82.8)	78.9 (78.4–79.4)	78.5 (77.8–79.2)
64<Age<75	38 (37.0–38.5)	38 (36.9–38.3)	41 (39.8–41.3)	75.7 (74.8–76.6)	71.5 (70.5–72.4)	69.2 (67.9–70.6)
74<Age<85	56 (55.1–57.3)	58 (56.7–58.8)	62 (61.1–63.4)	83.8 (83.1–84.6)	80.0 (79.2–80.8)	80.3 (79.2–81.4)
Age>84	60 (58.6–62.4)	59 (57.0–60.6)	59 (57.0–60.4)	91.5 (90.6–92.3)	90.4 (89.5–91.2)	91.2 (90.0–92.2)
Female	45 (44.1–45.6)	45 (44.7–46.2)	48 (46.8–48.4)	83.1 (82.5–83.8)	79.6 (78.9–80.3)	78.8 (77.8–79.8)
Male	50 (49.3–51.2)	50 (49.0–50.7)	53 (52.5–54.3)	81.3 (80.6–82.1)	78.0 (77.2–78.8)	78.1 (77.0–79.2)
Black	67 (64.6–69.5)	66 (63.3–68.1)	73 (70.3–75.4)	85.2 (83.8–86.6)	83.3 (81.8–84.8)	82.6 (80.5–84.6)
Other race	38 (35.2–39.9)	36 (33.7–37.8)	42 (39.5–43.8)	82.2 (79.7–84.6)	79.5 (77.0–81.9)	78.9 (75.5–82.0)
White	46 (45.2–46.4)	46 (45.8–47.0)	49 (48.0–49.3)	82.0 (81.4–82.5)	78.3 (77.8–78.9)	77.9 (77.1–78.7)
Black-female	69 (65.8–72.2)	68 (65.1–71.3)	74 (70.8–77.5)	84.0 (82.1–85.8)	82.9 (81.0–84.7)	82.8 (80.0–85.3)
Black-male	37 (33.7–39.8)	34 (31.6–37.0)	40 (37.1–42.7)	83.8 (80.4–86.7)	80.1 (76.7–83.3)	77.7 (72.8–82.1)
Other-race-female	43 (42.2–43.8)	44 (43.2–44.7)	46 (44.8–46.4)	83.0 (82.2–83.7)	79.1 (78.4–79.9)	78.3 (77.2–79.4)
Other-race-male	64 (60.0–67.9)	62 (58.2–65.6)	71 (67.0–75.0)	87.4 (85.0–89.5)	84.1 (81.6–86.4)	82.3 (78.8–85.5)
White-female	39 (35.2–42.5)	38 (34.5–41.0)	44 (40.7–47.4)	80.2 (75.9–83.9)	78.8 (74.9–82.3)	80.1 (75.2–84.5)
White-male	50 (48.8–50.8)	50 (48.7–50.6)	53 (51.6–53.6)	80.8 (79.9–81.6)	77.4 (76.5–78.2)	77.5 (76.3–78.7)

Figure 1.

Figure 1A left panel: Adjusted annual trend in the pancreatic cancer initial hospitalization rate, 2000–2010, overall and by age-sex-race subgroups. The trend in the adjusted initial hospitalization rate is expressed as a risk-adjusted incidence rate ratio (IRR) of a time variable. IRRs were drawn from a linear mixed effects model with a Poisson link function and state-specific random intercepts adjusting for age-sex-race.

Figure 1A right panel: Adjusted annual trends in pancreatic cancer 1-year mortality rates, 2000–2009, overall and by age-sex-race subgroups. The trend in the adjusted mortality is expressed as a risk-adjusted odds ratio (OR) of a time variable. ORs were drawn from a linear mixed effects model with a logit link function and state-specific random intercepts adjusting for age-sex-race-comorbidity.

Figure 1B top panel: Adjusted state-specific annual trends in pancreatic cancer initial hospitalization rates, 2000–2010. A state-specific trend is expressed as a deviation of the state-specific slope of the time variable from the national overall slope of the time variable. The state-specific slope of the time variables were drawn from a linear mixed effects model with a Poisson link function and state-specific random intercepts and random coefficient of the time variable, adjusting for age-sex-race. A deviation greater than 1 indicates that the state’s hospitalization rate has increased faster than the national average.

Figure 1B bottom panel: Adjusted state-specific annual trends in pancreatic cancer 1-year mortality rates from 2000 to 2009. A state-specific trend is expressed as a deviation of the state-specific slope of the time variable from the national overall slope of the time variable. The state-specific slope of the time variables were drawn from a linear mixed effects model with a logit link function and state-specific random intercepts and random coefficient of the time variable, adjusting for age-sex-race-comorbidity. A deviation greater than 1 indicates that the state’s 1-year mortality rate has increased faster than the national average.

The age-standardized hospitalization rates varied substantially by state and over time (Figure 2), ranging from a low of 21 (Puerto Rico) to 62 (District of Columbia) per 100,000 person-years in 2000 (inter-quartile range [IQR] 42–48), and from 24 (Wyoming) to 67 (Pennsylvania) per 100,000 person-years in 2010 (IQR 40–53). In the age-sex-race adjusted analyses, hospitalization rates increased significantly in 9 states and decreased significantly in 5 states between 2000 to 2010 (Figure 1B, top panel).

Figure 2.

Maps of state-specific age-standardized initial hospitalization rates (per 100,000 person-years) in 2000 (a) and 2010 (b).

Trends in 1-year Mortality Rate

The observed 1-year mortality rate decreased from 82.7% in 2000 to 78.5% in 2009 (p<0.001 for trend), a relative decline of 5.1%. The age-sex-race-comorbidity adjusted annual decrease in 1-year mortality was 4.4% (95% CI, 3.9 to 4.9). This decline was similar across all the major age-sex-race subgroups (Figure 1A right panel). The observed 1-year mortality rate varied by state and over time; in 2000 the 1-year mortality rate ranged from 74.4% (Utah) to 94.3% (Nevada) (IQR 81.2–83.9%) and in 2009 it ranged from 65.2% (Montana) to 92.3% (Wyoming) (IQR 76.1% to 80.8%). After risk-adjustment, there was no evidence of significant variation in trends for mortality across states (Figure 1B, bottom panel).

Trends in Patterns of Care

From 2000 to 2009, the observed surgical resection rate increased significantly, from 14.4% to 22.3% (p<0.001 for trend). In contrast, both bypass and stent/biliary drainage rates decreased, from 15.2% to 8.1% (bypass, p<0.001 for trend), and 33.3% to 29.8% (stent/biliary drainage, p<0.001 for trend) (Table S3).

The age-sex-race-comorbidity adjusted annual increase in the resection rate following initial hospitalization was 6.9% (95% CI, 6.4–7.5). For bypass and stent/biliary drainage respectively, the age-sex-race-comorbidity adjusted annual declines were 7.7% (95% CI, 7.1–8.3) and 1.8% (95% CI, 1.4–2.3). The resection rate increased significantly and bypass rate decreased significantly across all age-sex-race subgroups. The stent/biliary drainage rate also decreased significantly for all age-sex-race subgroups, except for male-non-white patients (Figure 3A). There was slight to modest spatial variation in procedure rates from 2000 to 2009 (Figure S2).

Figure 3.

Figure 3A: Adjusted annual trends in 1-year surgical and non-surgical procedure rates, 2000–2009, overall and by age-sex-race subgroups. The trends in procedure rates are expressed as age-sex-race-comorbidity-adjusted odds ratios of a time variable.

Figure 3B: Trends in major discharge dispositions, 2000–2010.

Observed 1-year mortality was low among patients receiving surgical procedures and it changed over the study period. Between 2000 and 2009, the 1-year mortality declined from 44.9% to 36.7% for resection (p<0.001), from 79.6% to 70.7% for bypass (p<0.001), and from 83.6% to 84.1% for non-surgical biliary drainage (p=0.5143). The 1-year mortalities were 91.3% in 2000 vs. 92.3% in 2009 (p=0.0598) for patients who received none of these procedures.

From 2000 to 2010, the mean (SD) LOS decreased from 10.7 (9.0) to 9.1 (7.7) days, and in-hospital mortality declined by a relative 38%, from 12.6% to 7.8%. The rates of discharge to hospice increased significantly from 2.1% to 19.3% while discharge to skilled nursing facilities decreased from 15.0% to 12.8% (all p<0.001 for trend, Figure 3B). The inflation-adjusted mean (SD) Medicare payment for the initial pancreatic cancer hospitalization decreased slightly, from $14,118 ($15,381) in 2000 to $13,318 ($17,011) in 2010 (p<0.001 for trend). The number of 1-year all-cause rehospitalizations after the initial pancreatic cancer hospitalization increased from 0.75 per patient in 2000 to 0.82 per patient in 2009 (p<0.001 for trend).

DISCUSSION

In this large observational study of trends in initial hospitalization, mortality, and patterns of care for Medicare fee-for-service beneficiaries with pancreatic cancer, we found increasing hospitalization rates, with substantial variation across age-sex-race subgroups and states. The state-level initial hospitalization rates ranged from 21 to 62 per 100,000 person-years in 2000 and 24 to 67 per 100,000 person-years in 2010. Overall, there was a 0.5% annual relative increase in the age-sex-race adjusted hospitalization rate from 2000 to 2010. While initial hospitalization rates increased, the age-sex-race-comorbidity adjusted 1-year mortality rate had an annual decline of 4.4%. There was minimal variability across states in 1-year mortality.

Significant changes were also observed in the patterns of care for pancreatic cancer over the last decade. Over time, patients were more likely to be discharged to hospice and less likely to have long hospital stays or to die in the hospital, and the cost of initial pancreatic cancer hospitalization decreased by $800 from 2000 to 2010. We observed that the resection rate increased significantly but palliative procedures, including surgical bypass and stent/biliary drainage procedures, declined significantly over the study period. We found that use of surgical bypass declined much faster than use of stenting and/or non-surgical biliary drainage. This finding suggests a potentially important shift in patterns of care for pancreatic cancer patients, with curative-intent surgical resection substituting for palliative surgical bypass. Nevertheless, other hospital-related factors, such as cancer volume, specificity (e.g., cancer center vs. non-cancer center), bed size, might impact this shift. This topic requires further examination. The increase in the resection rate, which could reflect secular trend in surgical techniques or treatment approaches, as well as the improvement in the outcome after resection, might contribute to the decrease in 1-year mortality for pancreatic cancer. Nevertheless, the resection rate remains low; in 2009 only 22.2% of patients underwent a surgical resection procedure. The low rate of resection could reflect a lack of a technique to detect pancreatic cancer earlier, but poor access to hospitals performing these complex surgeries may limit broader uptake of surgical resection for pancreatic cancer. Finks et al.¹⁹ estimated that from 1999 to 2008 the number of Medicare patients needing surgery to treat pancreatic cancer increased by 50%, but the number of hospitals performing the procedures decreased by 25%.

Geographic variations in cancer incidence have been well studied and documented. Our study further demonstrated that the trend in the initial hospitalization rate for pancreatic cancer varied significantly by state. In contrast, trends in treatments and outcomes for pancreatic cancer were homogeneous across states and regions. The increase in resection rates over time was observed in almost all states and the decrease in 1-year mortality was also seen across all states concurrently. Our findings illustrate that for trends in pancreatic cancer, the between-state variance in the occurrence of cases is much bigger than the between-state variances in the treatments and outcomes for this cancer. Over the past decade, there were changes in lifestyles in the United States. These changes, such as the decrease in the size of the smoking population, the decline in the consumption of red meat, and the improvement in diabetic control, ^20–22 could all contribute to reduced risk for pancreatic cancer, and these risk factors may vary substantially by geographic and demographic subpopulations. However, a treatment, such as resection, is adapted rapidly once it becomes available.

Our study complements analyses of Surveillance Epidemiology and End Results (SEER) data and presents a robust snapshot of the population-level burden of this deadly malignancy nationwide. Our state-level analysis provides a better picture of spatial variations in the prevalence and patterns of care for pancreatic cancer. The state/region specific findings can help providers understand disease burden and may provide evidence for disease control strategies. The trends we described can also be used to allocate resources and to benchmark progress in control of this highly lethal malignancy. Our finding of an increase in the initial hospitalization rate for pancreatic cancer is consistent with previous studies,^{7, 23–26} though the finding of a substantial decline in the 1-year mortality rate contrasts with results from a recent study¹ that reported little improvement in pancreatic cancer survival over the past 30 years.

Extensive nationwide efforts have gone forward to improve cancer care over the last decade since the Institute of Medicine released its influential report, Ensuring Quality Cancer Care, in 1999.²⁷ The oncology community, in particular, has significantly increased in development, adoption, and support for evidence-based guidelines in practices. Our findings provide a better image of the patterns of pancreatic cancer care in the Medicare fee-for-service population, and inform researchers and policymakers about what is being achieved and what can be done better in pancreatic cancer care.^{28, 29}

Our study has limitations that merit mention. We were limited to the Medicare fee-for-service population, and the findings may not reflect the changes in the managed care population, a group that tends to be healthier. We accessed only the inpatient data and could not identify individuals with outpatient diagnoses of pancreas cancer. Nevertheless, the vast majority of patients treated for pancreatic cancer will have at least one hospitalization, and a sensitivity analysis using the 2007 SEER-Medicare data found that more than 98.5% of Medicare fee-for-service patients were hospitalized after diagnosis of pancreatic cancer. The lack of cancer registry information in our data precluded our ability to account for the stage or histology of pancreatic cancer cases in our risk adjustments. It also precluded our ability to assess the changes in utilization of other non-surgical therapies, such as radiotherapy and chemotherapy, which could impact on mortality rate as well. Our 1-year mortality rate measured survival from the date of the initial hospitalization for pancreatic cancer, a time point which may not correspond to the date of diagnosis. Yet, the difference in magnitude between 1-year mortality from pancreatic cancer admission and from pancreas cancer diagnosis appears to be small. The 1-year mortality for patients aged 65 or older reported from a SEER-Medicare analysis was 81.4% between 1988 and 2008⁴ whereas we found an 80.9% 1-year mortality rate from 2000 to 2009. Finally, because we relied on billing codes used by hospitals to obtain reimbursement, we cannot be certain whether the variation we described represents meaningful differences in disease burden or regional variation in coding practices. The very large size of our dataset and the availability of data over multiple years suggest that our findings are reflective of meaningful outcomes.

In conclusion, between 2000 and 2010, the initial hospitalization rate for pancreatic cancer increased considerably within the Medicare fee-for-service population, while the 1-year mortality rate declined significantly over the same period. Patients were more likely to undergo curative-intent surgical resection, substituting for palliative surgical bypass. The health and economic burden of pancreatic cancer in the United Stated is substantial, and additional nationwide efforts are required to fight this disease.