The relationship between cost, quality, and outcomes among women with breast cancer in SEER–Medicare.

Abstract

6001 Background: Breast cancer (BrCa) is responsible for the largest share of cancer-related spending in the US. While the cost of cancer care is substantial and increasing yearly, little is known about the relationship between cost and quality or outcomes. Methods: For women 65-70 years old diagnosed 7/97-12/05 with stage 0-III BrCa who were continuously enrolled in fee-for-service Medicare, we evaluated performance relative to 27 surgical, radiation and chemotherapy quality measures: 20 recommending for proven therapies and 7 recommending against unnecessary therapies. Using health care service area (HSA) as the unit of analysis, we derived aggregate measures of practice performance, calculated the median per-patient cost in the year after diagnosis (part A and B expenditures in 2010 inflation adjusted $US) and described 5-year overall survival (OS) rates. After stratifying the population into quintiles based the median per-patient cost per HSA, we looked for variation in measure concordance and OS by quintile (using the Kruskal-Wallis and log-rank tests, respectively). Results: We identified 15,357 women with stage 0-III BrCa and compiled quality, cost and outcomes data for 99 HSAs. The median number of patients per HSA was 85 (IQR 47-162), and the proportion of patients alive at 5 years was 87.5%. Significant relationships between cost and measure concordance/OS appear in the table (p<.01). When stratified into quintiles by measure concordance rather than cost, there was no difference in 5-year OS by quality performance quintile (p=0.14). Conclusions: There is wide variation in the cost of initial BrCa care, but only marginal difference in the quality or outcomes experienced by patients representing different cost quintiles. Additional efforts to evaluate factors that impact the relationship between cost and quality/outcomes are needed. Cost quintile Lowest Highest Number of patients 3052 3180 3022 3721 2382 Median expenditure per patient ($US) 17,319 19,719 22,217 24,574 27,233 Median proportion concordant All measures (27) 81% 80% 80% 81% 81% Measures assessing overuse (7) 90% 85% 86% 83% 85% Measures assessing underuse (20) 80% 80% 80% 81% 80% Proportion alive at 5 years 85.5% 88.3% 87.2% 89.5% 85.8%