1
|
Kowalski AE. Behaviour within a Clinical Trial and Implications for Mammography Guidelines. THE REVIEW OF ECONOMIC STUDIES 2023; 90:432-462. [PMID: 36798741 PMCID: PMC9928190 DOI: 10.1093/restud/rdac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Mammography guidelines have weakened in response to evidence that mammograms diagnose breast cancers that would never eventually cause symptoms, a phenomenon called "overdiagnosis." Given concerns about overdiagnosis, instead of recommending mammograms, US guidelines encourage women aged 40-49 to get them as they see fit. To assess whether these guidelines target women effectively, I propose an approach that examines mammography behavior within an influential clinical trial that followed participants long enough to find overdiagnosis. I find that women who are more likely to receive mammograms are healthier and have higher socioeconomic status. More importantly, I find that the 20-year level of overdiagnosis is at least 3.5 times higher among women who are most likely to receive mammograms. At least 36% of their cancers are overdiagnosed. These findings imply that US guidelines encourage mammograms among healthier women who are more likely to be overdiagnosed by them. Guidelines in other countries do not.
Collapse
|
2
|
Einav L, Finkelstein A, Oostrom T, Ostriker A, Williams H. Screening and Selection: The Case of Mammograms. THE AMERICAN ECONOMIC REVIEW 2020; 110:3836-3870. [PMID: 34305149 PMCID: PMC8300583 DOI: 10.1257/aer.20191191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
We analyze selection into screening in the context of recommendations that breast cancer screening start at age 40. Combining medical claims with a clinical oncology model, we document that compliers with the recommendation are less likely to have cancer than younger women who select into screening or women who never screen. We show this selection is quantitatively important: shifting the recommendation from age 40 to 45 results in three times as many deaths if compliers were randomly selected than under the estimated patterns of selection. The results highlight the importance of considering characteristics of compliers when making and designing recommendations.
Collapse
Affiliation(s)
- Liran Einav
- Department of Economics, Stanford University, and the National Bureau of Economic Research
| | - Amy Finkelstein
- Department of Economics, Massachusetts Institute of Technology, and the National Bureau of Economic Research
| | | | | | - Heidi Williams
- Department of Economics, Stanford University, and the National Bureau of Economic Research
| |
Collapse
|
3
|
Levine RS, Kilbourne BJ, Sanderson M, Fadden MK, Pisu M, Salemi JL, Mejia de Grubb MC, O’Hara H, Husaini BA, Zoorob RJ, Hennekens CH. Lack of validity of self-reported mammography data. Fam Med Community Health 2019; 7:e000096. [PMID: 32148699 PMCID: PMC6910732 DOI: 10.1136/fmch-2018-000096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/06/2019] [Indexed: 11/04/2022] Open
Abstract
This qualitative literature review aimed to describe the totality of peer-reviewed scientific evidence from 1990 to 2017 concerning validity of self-reported mammography. This review included articles about mammography containing the words accuracy, validity, specificity, sensitivity, reliability or reproducibility; titles containing self-report, recall or patient reports, and breast or 'mammo'; and references of identified citations focusing on evaluation of 2-year self-reports. Of 45 publications meeting the eligibility criteria, 2 conducted in 1993 and 1995 at health maintenance organisations in Western USA which primarily served highly educated whites provided support for self-reports of mammography over 2 years. Methodological concerns about validity of self-reports included (1) telescoping, (2) biased overestimates particularly among black women, (3) failure to distinguish screening and diagnostic mammography, and (4) failure to address episodic versus consistent mammography use. The current totality of evidence supports the need for research to reconsider the validity of self-reported mammography data as well as the feasibility of alternative surveillance data sources to achieve the goals of the Healthy People Initiative.
Collapse
Affiliation(s)
- Robert S Levine
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara J Kilbourne
- Department of Sociology, Tennessee State University, Nashville, Tennessee, USA
| | - Maureen Sanderson
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Mary K Fadden
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Maria Pisu
- University of Alabama School of Medicine at Birmingham, Birmingham, Alabama, USA
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Heather O’Hara
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Baqar A Husaini
- Department of Sociology, Tennessee State University, Nashville, Tennessee, USA
| | - Roget J Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Charles H Hennekens
- Charles E Schmidt School of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
| |
Collapse
|
4
|
Cooper GS, Kou TD, Dor A, Koroukian SM, Schluchter MD. Cancer preventive services, socioeconomic status, and the Affordable Care Act. Cancer 2017; 123:1585-1589. [PMID: 28067955 DOI: 10.1002/cncr.30476] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/04/2016] [Accepted: 11/07/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Out-of-pocket expenditures are thought to be an important barrier to the receipt of cancer preventive services, especially for those of a lower socioeconomic status (SES). The Affordable Care Act (ACA) eliminated out-of-pocket expenditures for recommended services, including mammography and colonoscopy. The objective of this study was to determine changes in the uptake of mammography and colonoscopy among fee-for-service Medicare beneficiaries before and after ACA implementation. METHODS Using Medicare claims data, this study identified women who were 70 years old or older and had not undergone mammography in the previous 2 years and men and women who were 70 years old or older, were at increased risk for colorectal cancer, and had not undergone colonoscopy in the past 5 years. The receipt of procedures in the 2-year period before the ACA's implementation (2009-2010) and after its implementation (2011 to September 2012) was also identified. Multivariate generalized estimating equation models were used to determine the independent association and county-level quartile of median income and education with the receipt of testing. RESULTS For mammography, a lower SES quartile was associated with less uptake, but the post-ACA disparities were smaller than those in the pre-ACA period. In addition, mammography rates increased from the pre-ACA period to the post-ACA period in all SES quartiles. For colonoscopy, in both the pre- and post-ACA periods, there was an association between uptake and educational level and, to some extent, income. However, there were no appreciable changes in colonoscopy and SES after implementation of the ACA. CONCLUSIONS The removal of out-of-pocket expenditures may overcome a barrier to the receipt of recommended preventive services, but for colonoscopy, other procedural factors may remain as deterrents. Cancer 2017;123:1585-1589. © 2017 American Cancer Society.
Collapse
Affiliation(s)
- Gregory S Cooper
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Tzuyung Doug Kou
- Division of Gastroenterology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Avi Dor
- Department of Health Policy, George Washington University, Washington, DC
| | - Siran M Koroukian
- Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mark D Schluchter
- Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
5
|
McPherson E, Hedden L, Regier DA. Impact of oncologist payment method on health care outcomes, costs, quality: a rapid review. Syst Rev 2016; 5:160. [PMID: 27653974 PMCID: PMC5031322 DOI: 10.1186/s13643-016-0341-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 09/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of cancer and the cost of its treatment continue to rise. The effect of these dual forces is a major burden on the system of health care financing. One cost containment approach involves changing the way physicians are paid. Payers are testing reimbursement methods such as capitation and prospective payment while also evaluating how the changes impact health outcomes, resource utilization, and quality of care. The purpose of this study is to identify evidence related to physician payment methods' impacts, with a focus on cancer control. METHODS We conducted a rapid review. This involved defining eligibility criteria, identifying a search strategy, performing study selection according to the eligibility criteria, and abstracting data from included studies. This process was accompanied by a gray literature search for special topics. RESULTS The incentives in fee-for-service payment systems generally lead to health care services being applied inconsistently because providers practice independently with few systems in place for developing treatment protocols and practice reviews. This inconsistency is pronounced in cancer care because much of the total per patient spending occurs in the last month of life. Some insurers are predicting that this variation can be reduced through the use of prospective or bundled payments combined with decision support systems. Workload, recruitment, and retention are all affected by changes to physician payment models; effects seem to be magnified in the specialist context as their several extra years of training lower their overall supply. CONCLUSIONS Experimentation with physician payment methods has tended to neglect cancer care providers. Policymakers designing cancer-focused physician reimbursement pilot programs should incorporate quality measurement since very ill patients may receive too little treatment when payment models do not cover oncologists' total costs, e.g., fee-for-service systems whose prices do not account for the possible presence of other diseases.
Collapse
Affiliation(s)
- Emily McPherson
- Canadian Centre for Applied Research in Cancer Control (ARCC), School of Population and Public Health, University of British Columbia, 675 West 10th Avenue, Vancouver, British Columbia, V5Z 1G1, Canada.
| | - Lindsay Hedden
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, 828 West 10th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada
| | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control (ARCC), School of Population and Public Health, University of British Columbia, 675 West 10th Avenue, Vancouver, British Columbia, V5Z 1G1, Canada
| |
Collapse
|
6
|
Smith-Gagen J, Loux T, Drake C, Pérez-Stable EJ. How Does Managed Care Improve the Quality of Breast Cancer Care Among Medicare-Insured Minority Women? J Racial Ethn Health Disparities 2016; 3:496-507. [PMID: 27294748 DOI: 10.1007/s40615-015-0167-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/07/2015] [Accepted: 09/08/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE The aim of this study is to investigate if evidence-based clinical guidelines are implemented equitability among ethnic minority breast cancer patients using Medicare Advantage and investigate if presumed advantages of managed care over fee-for-service are greater for minorities than for Whites. METHODS Data from the Surveillance, Epidemiology, and End Results and Medicare were used to examine 70,755 women over age 65 diagnosed with early stage breast cancer between 2005 and 2009. Implementation of two clinical guidelines was assessed: receipt of radiation therapy after breast conserving surgery and estrogen receptor status documentation. Multilevel logistic regression and inverse propensity weighting controlled for confounding. RESULTS African Americans are still less likely than Whites to receive radiation therapy after breast-conserving surgery, whether they use Medicare fee-for-service (OR 95 % CI) = 0.90 (0.83, 0.98) or managed care (OR 95 % CI) = 0.87 (0.76, 1.00). Differences between receipt of radiation therapy by insurance plan type was nonexistent. Relative to FFS, the use of managed care improved the odds of having estrogen receptor status documented by 44 % in African Americans, (OR 95 % CI) = 1.44 (1.15, 1.83) and by 42 % in Latina patients (OR 95 % CI) = 1.42 (1.17, 1.78). CONCLUSIONS Compared to Medicare fee-for-service, ethnic and racial disparities among Medicare Advantage users were reduced. We observed fewer disparities, but not an elimination of disparities, among Medicare Advantage enrollees receiving breast cancer care with an organizational and patient component of care. This suggests managed care may still need to focus on minority patient empowerment and involvement in care.
Collapse
Affiliation(s)
- Julie Smith-Gagen
- School of Community Health Sciences, University of Nevada, 1664 North Virginia Street/MS 274, Reno, NV, 89557, USA.
| | - Travis Loux
- College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO, USA
| | - Chris Drake
- Division of Statistics, University of California, Davis, CA, USA
| | - Eliseo J Pérez-Stable
- Division of General Internal Medicine, Department of Medicine, Medical Effectiveness Research Center for Diverse Populations, University of California, San Francisco (UCSF) School of Medicine, San Francisco, CA, USA.,National Institute of Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
7
|
Cooper GS, Kou TD, Schluchter MD, Dor A, Koroukian SM. Changes in Receipt of Cancer Screening in Medicare Beneficiaries Following the Affordable Care Act. J Natl Cancer Inst 2015; 108:djv374. [PMID: 26640244 DOI: 10.1093/jnci/djv374] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 11/02/2015] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The Affordable Care Act (ACA) removed copayments for screening mammography and colonoscopy in Medicare beneficiaries, but its clinical impact is unknown. METHODS Using a 5% random sample of Medicare claims from 2009 through 2012 in individuals age 70 years or older who were due for screening, we examined claims for screening mammography and screening or surveillance colonoscopy for two years prior to ACA (2009-2010) and two years post-ACA (2011-2012). Receipt of the procedures at the patient level was compared across years using generalized estimating equations. Statistical tests were two-sided. RESULTS Compared with 2009, we found an increase in mammography uptake during the ACA coverage period, with multivariable odds ratios (MOR) of 1.22 (95% confidence interval [CI] = 1.20 to 1.25, P < .001) for 2011 and 1.17 (95% CI = 1.15 to 1.20, P < .001) for 2012 and less change in 2010 (OR = 1.03, 95% CI = 1.01 to 1.05, P = .01). In contrast to mammography, uptake of screening or surveillance colonoscopy decreased in 2012 (MOR = 0.95, 95% CI = 0.92 to 0.98, P = .002) compared with 2009, with no change in 2010 (MOR = 1.01, 95% CI = 0.99 to 1.04, P = .47) or 2011 (MOR = 1.01, 95% CI = 0.99 to 1.04, P = .34). Other factors associated with procedure receipt included younger age and prior preventive health visits. In an analysis restricted to patients age 70 to 74 years, colonoscopy use increased slightly in 2011 but was unchanged in 2012, and the findings by year for mammography were consistent with the main analysis. CONCLUSIONS Following ACA implementation with concomitant reduction in out-of-pocket expenditures, there was a statistically significant increment in mammography uptake but not colonoscopy. This suggests that affordability is a necessary but not sufficient facilitator of preventive services.
Collapse
Affiliation(s)
- Gregory S Cooper
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD).
| | - Tzuyung D Kou
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD)
| | - Mark D Schluchter
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD)
| | - Avi Dor
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD)
| | - Siran M Koroukian
- Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH (GSC, TDK); Comprehensive Cancer Center (GSC, MDS, SMK) and the Department of Epidemiology and Biostatistics (SMK), Case Western Reserve University School of Medicine, Cleveland, OH; Department of Health Policy, George Washington University, Washington, DC (AD)
| |
Collapse
|
8
|
Sanderson M, Levine RS, Fadden MK, Kilbourne B, Pisu M, Cain V, Husaini BA, Langston M, Gittner L, Zoorob R, Rust GS, Hennekens CH. Mammography Screening Among the Elderly: A Research Challenge. Am J Med 2015; 128:1362.e7-14. [PMID: 26169884 PMCID: PMC4658221 DOI: 10.1016/j.amjmed.2015.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Randomized trials demonstrate clear benefits of mammography screening in women through age 74 years. We explored age- and race-specific rates of mammography screening and breast cancer mortality among women aged 69 to 84 years. METHODS We analyzed Medicare claims data for women residing within Surveillance, Epidemiology and End Results geographic areas from 1995 to 2009 from 64,384 non-Hispanic women (4886 black and 59,498 white) and ascertained all primary breast cancer cases diagnosed between ages 69 and 84 years. The exposure was annual or biennial screening mammography during the 4 years immediately preceding diagnosis. The outcome was breast cancer mortality during the 10 years immediately after diagnosis. RESULTS After adjustment for stage at diagnosis, radiation therapy, chemotherapy, comorbid conditions, and contextual socioeconomic status, hazard ratios (and 95% confidence intervals) for breast cancer mortality relative to no/irregular mammography at 10 years for women aged 69 to 84 years at diagnosis were 0.31 (0.29-0.33) for annual mammography and 0.47 (0.44-0.51) for biennial mammography among whites and 0.36 (0.29-0.44) for annual mammography and 0.47 (0.37-0.58) for biennial mammography among blacks. Trends were similar at 5 years overall and stratified by ages 69 to 74 years, 75 to 78 years, and 79 to 84 years. CONCLUSIONS In these Medicare claims and Surveillance, Epidemiology and End Results data, elderly non-Hispanic women who self-selected for annual mammography had lower 10-year breast cancer mortality than corresponding women who self-selected for biennial or no/irregular mammography. These findings were similar among black and white women. The data highlight the evidentiary limitations of data used for current screening mammography recommendations.
Collapse
Affiliation(s)
- Maureen Sanderson
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tenn.
| | - Robert S Levine
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tenn
| | - Mary K Fadden
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tenn
| | - Barbara Kilbourne
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tenn
| | - Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham
| | - Van Cain
- Center for Health Research, Tennessee State University, Nashville
| | - Baqar A Husaini
- Center for Health Research, Tennessee State University, Nashville
| | - Michael Langston
- Department of Electrical Engineering and Computer Science, University of Tennessee, Knoxville
| | - Lisa Gittner
- Department of Political Science, Texas Tech University, Lubbock
| | - Roger Zoorob
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tenn
| | - George S Rust
- Morehouse School of Medicine, National Center for Primary Care, Atlanta, Ga
| | - Charles H Hennekens
- Department of Family and Community Medicine, Meharry Medical College, Nashville, Tenn; Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| |
Collapse
|
9
|
Ayanian JZ, Landon BE, Zaslavsky AM, Newhouse JP. Racial and ethnic differences in use of mammography between Medicare Advantage and traditional Medicare. J Natl Cancer Inst 2013; 105:1891-6. [PMID: 24316600 DOI: 10.1093/jnci/djt333] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Breast cancer is a leading cause of mortality for women in all racial/ethnic groups. We compared use of mammography by race/ethnicity in Medicare health maintenance organizations (HMOs), preferred provider organizations (PPOs), and traditional Medicare. METHODS We matched 495 836 women in HMOs and 81 480 women in PPOs who were aged 65 to 69 years during 2009 to women enrolled in traditional Medicare by race/ethnicity, Medicaid eligibility status, and geographic area. We identified mammography use from the Healthcare Effectiveness Data and Information Set for Medicare HMOs and PPOs and from claims data for traditional Medicare with the same specifications. We then compared racial/ethnic differences in rates of mammography in HMOs and PPOs to matched populations in traditional Medicare and estimated differences with z tests. All statistical tests were two-sided. RESULTS Relative to matched white women, mammography rates were statistically significantly higher for black, Hispanic, and Asian/Pacific Islander women in HMOs (6.1, 5.4, and 0.9 percentage points, respectively; all P ≤ .003) and statistically significantly lower for all three groups in traditional Medicare (3.3, 7.4, and 7.7 percentage points, respectively; all P < .001). Similar improvements in mammography rates also were observed in PPOs among all minority groups relative to traditional Medicare. CONCLUSIONS Higher rates of mammography in HMOs and PPOs were associated with a reversal of racial and ethnic differences observed in traditional Medicare. These differences may be related to lower patient cost-sharing and better systems to promote preventive services in managed care plans, as well as unmeasured characteristics or beliefs of minority women who enroll in these health plans relative to those in traditional Medicare.
Collapse
Affiliation(s)
- John Z Ayanian
- Affiliations of authors: Department of Health Care Policy, Harvard Medical School, Boston, MA (JZA, BEL, AMZ, JPN); Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (JZA); Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (JZA, JPN); Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (BEL); Harvard Kennedy School, Cambridge, MA (JPN); National Bureau of Economic Research, Cambridge, MA (JPN; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI (JZA)
| | | | | | | |
Collapse
|
10
|
Yang RL, Newman AS, Lin IC, Reinke CE, Karakousis GC, Czerniecki BJ, Wu LC, Kelz RR. Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation. Cancer 2013; 119:2462-8. [PMID: 23585144 DOI: 10.1002/cncr.28050] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 01/07/2013] [Accepted: 01/28/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans. METHODS Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR. RESULTS In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P < .01). However, after adjustment for confounders, women without private insurance were less likely to undergo IBR compared with women who had private insurance (Medicaid: odds ratio [OR], 0.34; 95% confidence interval [CI], 0.32-0.37; Medicare: OR, 0.53; 95% CI, 0.49-0.58; self-pay: OR, 0.43; 95% CI, 0.37-0.50; other types of nonprivate insurance: OR, 0.64, 95% CI, 0.56-0.73). CONCLUSIONS After the enactment of policy designed to improve access to IBR, Medicaid and Medicare patients experienced the greatest relative increase in rates of IBR. Although policy changes had the most impact on traditionally underserved populations, disparities still exist. Future studies should endeavor to understand why such disparities have persisted.
Collapse
Affiliation(s)
- Rachel L Yang
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Current world literature. Curr Opin Obstet Gynecol 2008; 20:602-7. [PMID: 18989138 DOI: 10.1097/gco.0b013e32831ceeb3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
12
|
Comparison of Cancer Diagnosis and Treatment in Medicare Fee-for-Service and Managed Care Plans. Med Care 2008; 46:1108-15. [DOI: 10.1097/mlr.0b013e3181862565] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|