The influence of race/ethnicity and place of service on breast reconstruction for Medicare beneficiaries with mastectomy.

Tracy Onega,Karen Wernli,Julie Weiss,Karla Kerlikowske,Beth Virnig,Jennifer Alford-Teaster,Martha Goodrich,Anna Na Tosteson,Wendy Demartini,Rebecca Hubbard,Diana Sm Buist,Louise M Henderson

doi:10.1186/2193-1801-3-416

Abstract

Racial disparities in breast reconstruction for breast cancer are documented. Place of service has contributed to disparities in cancer care; but the interaction of race/ethnicity and place of service has not been explicitly examined. We examined whether place of service modified the effect of race/ethnicity on receipt of reconstruction.We included women with a mastectomy for incident breast cancer in SEER-Medicare from 2005–2009. Using Medicare claims, we determined breast reconstruction within 6 months. Facility characteristics included: rural/urban location, teaching status, NCI Cancer Center designation, cooperative oncology group membership, Disproportionate Share Hospital (DSH) status, and breast surgery volume. Using multivariable logistic regression, we analyzed reconstruction in relation to minority status and facility characteristics.Of the 17,958 women, 14.2% were racial/ethnic women of color and a total of 9.3% had reconstruction. Caucasians disproportionately received care at non-teaching hospitals (53% v. 42%) and did not at Disproportionate Share Hospitals (77% v. 86%). Women of color had 55% lower odds of reconstruction than Caucasians (OR = 0.45; 95% CI 0.37-0.55). Those in lower median income areas had lower odds of receiving reconstruction, regardless of race/ethnicity. Odds of reconstruction reduced at rural, non-teaching and cooperative oncology group hospitals, and lower surgery volume facilities. Facility effects on odds of reconstruction were similar in analyses stratified by race/ethnicity status.Race/ethnicity and facility characteristics have independent effects on utilization of breast reconstruction, with no significant interaction. This suggests that, regardless of a woman’s race/ethnicity, the place of service influences the likelihood of reconstruction.

Highlights

Breast reconstruction following mastectomy for breast cancer is associated with better quality of life, (Alderman et al 2006) lower decisional regret, improved self-image, and other benefits, relative to mastectomy without reconstruction (Albornoz et al 2013)
The objective of this study was to explicitly examine how Caucasian and women of color with breast cancer differ in their utilization of breast reconstruction following mastectomy and whether effects associated with the types of facilities they use vary for Caucasian and women of color
We used the Hospital File, which links to both MedPAR and Outpatient claims files at the facility level to provide facility characteristics information based on the Healthcare Cost Report Information System (HCRIS) and the Provider of Service (POS) Survey administered through the Centers for Medicaid and Medicare Services (CMS) (2014)

Summary

Introduction

Breast reconstruction following mastectomy for breast cancer is associated with better quality of life, (Alderman et al 2006) lower decisional regret, improved self-image, and other benefits, relative to mastectomy without reconstruction (Albornoz et al 2013). Based on evidence and political will, the 1999 Women’s Health et al 2008) The reasons underlying this disparity are not clear, the disparity may relate to other factors shown to decrease the likelihood of breast reconstruction, such as marital status, rural residence, comorbidities, insurance, surgeon volume, hospital volume, hospital size, (Hershman et al 2012) teaching hospital status, and cancer center designation (Kruper et al 2011a). Our understanding of how race/ethnicity and place of service interact to affect utilization of care and outcomes for cancer is lacking, but is vital to understanding and developing interventions to reduce disparities. While both race/ethnicity and facility characteristics have been examined, no studies to date have explicitly examined the interaction of race/ethnicity and hospital characteristics on utilization of breast reconstruction. The objective of this study was to explicitly examine how Caucasian and women of color with breast cancer differ in their utilization of breast reconstruction following mastectomy and whether effects associated with the types of facilities they use vary for Caucasian and women of color

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Conclusion