Abstract
BackgroundGeographical variations in medical practice are expected to be small when the evidence about the effectiveness and safety of a particular technology is abundant. This would be the case of the prescription of conservative surgery in breast cancer patients. In these cases, when variation is larger than expected by need, socioeconomic factors have been argued as an explanation. Objectives: Using an ecologic design, our study aims at describing the variability in the use of surgical conservative versus non-conservative treatment. Additionally, it seeks to establish whether the socioeconomic status of the healthcare area influences the use of one or the other technique.Methods81,868 mastectomies performed between 2002 and 2006 in 180 healthcare areas were studied. Standardized utilization rates of breast cancer conservative (CS) and non-conservative (NCS) procedures were estimated as well as the variation among areas, using small area statistics. Concentration curves and dominance tests were estimated to determine the impact of income and instruction levels in the healthcare area on surgery rates. Multilevel analyses were performed to determine the influence of regional policies.ResultsVariation in the use of CS was massive (4-fold factor between the highest and the lowest rate) and larger than in the case of NCS (2-fold), whichever the age group. Healthcare areas with higher economic and instruction levels showed highest rates of CS, regardless of the age group, while areas with lower economic and educational levels yielded higher rates of NCS interventions. Living in a particular Autonomous Community (AC), explained a substantial part of the CS residual variance (up to a 60.5% in women 50 to 70).ConclusionThe place where a woman lives -income level and regional policies- explain the unexpectedly high variation found in utilization rates of conservative breast cancer surgery.
Highlights
Geographical variations in medical practice are expected to be small when the evidence about the effectiveness and safety of a particular technology is abundant
A total of 81,868 breast cancer interventions were performed across all the age groups: 44,648 were CS and 38,067 non-conservative treatment (NCS)
The statistics detect large variability in utilization of CS: in terms of variation, the areas in the upper side of the distribution perform 4 times more conservative interventions than those in the lower end; in turn, NCS shows more moderate levels of variability with a ratio around 2 between the areas with highest and lowest utilization; in systematic component of variation (SCV) terms, systematic variation was 1.91 times higher in the case of conservative surgery compared to non-conservative interventions
Summary
Geographical variations in medical practice are expected to be small when the evidence about the effectiveness and safety of a particular technology is abundant. This would be the case of the prescription of conservative surgery in breast cancer patients. Objectives: Using an ecologic design, our study aims at describing the variability in the use of surgical conservative versus non-conservative treatment. It seeks to establish whether the socioeconomic status of the healthcare area influences the use of one or the other technique. CS is recommended, at any stage of breast cancer [5,6], confining the use of NCS to those situations where the tumor’s size relative to total breast mass prevents conservative resection
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