Influence of primary care on breast cancer outcomes among Medicare beneficiaries

Effects of Medicaid managed care on early detection of cancer: Evidence from mandatory Medicaid managed care program in Pennsylvania

OBJECTIVE

To examine changes in late- versus early-stage diagnosis of cancer associated with the introduction of mandatory Medicaid managed care (MMC) in Pennsylvania.

DATA SOURCES AND STUDY SETTING

We analyzed data from the Pennsylvania cancer registry (2010-2018) for adult Medicaid beneficiaries aged 21-64 newly diagnosed with a solid tumor. To ascertain Medicaid and managed care status around diagnosis, we linked the cancer registry to statewide hospital-based facility records collected by an independent state agency (Pennsylvania Health Care Cost Containment Council).

STUDY DESIGN

We leveraged a natural experiment arising from county-level variation in mandatory MMC in Pennsylvania. Using a stacked difference-in-differences design, we compared changes in the probability of late-stage cancer diagnosis among those residing in counties that newly transitioned to mandatory managed care to contemporaneous changes among those in counties with mature MMC programs.

DATA COLLECTION/EXTRACTION METHODS

N/A.

PRINCIPAL FINDINGS

Mandatory MMC was associated with a reduced probability of late-stage cancer diagnosis (-3.9 percentage points; 95% CI: -7.2, -0.5; p = 0.02), particularly for screening-amenable cancers (-5.5 percentage points; 95% CI: -10.4, -0.6; p = 0.03). We found no significant changes in late-stage diagnosis among non-screening amenable cancers.

CONCLUSIONS

In Pennsylvania, the implementation of mandatory MMC for adult Medicaid beneficiaries was associated with earlier stage of diagnosis among newly diagnosed cancer patients with Medicaid, especially those diagnosed with screening-amenable cancers. Considering that over half of the sample was diagnosed with late-stage cancer even after the transition to mandatory MMC, Medicaid programs and managed care organizations should continue to carefully monitor receipt of cancer screening and design strategies to reduce barriers to guideline-concordant screening or diagnostic procedures.

Understanding mechanisms of racial disparities in breast cancer: an assessment of screening and regular care in the Carolina Breast Cancer Study

PURPOSE

Screening history influences stage at detection, but regular preventive care may also influence breast tumor diagnostic characteristics. Few studies have evaluated healthcare utilization (both screening and primary care) in racially diverse screening-eligible populations.

METHODS

This analysis included 2,058 women age 45-74 (49% Black) from the Carolina Breast Cancer Study, a population-based cohort of women diagnosed with invasive breast cancer between 2008 and 2013. Screening history (threshold 0.5 mammograms per year) and pre-diagnostic healthcare utilization (i.e. regular care, based on responses to "During the past ten years, who did you usually see when you were sick or needed advice about your health?") were assessed as binary exposures. The relationship between healthcare utilization and tumor characteristics were evaluated overall and race-stratified.

RESULTS

Among those lacking screening, Black participants had larger tumors (5 + cm) (frequency 19.6% vs 11.5%, relative frequency difference (RFD) = 8.1%, 95% CI 2.8-13.5), but race differences were attenuated among screening-adherent participants (10.2% vs 7.0%, RFD = 3.2%, 0.2-6.2). Similar trends were observed for tumor stage and mode of detection (mammogram vs lump). Among all participants, those lacking both screening and regular care had larger tumors (21% vs 8%, RR = 2.51, 1.76-3.56) and advanced (3B +) stage (19% vs 6%, RR = 3.15, 2.15-4.63) compared to the referent category (screening-adherent and regular care). Under-use of regular care and screening was more prevalent in socioeconomically disadvantaged areas of North Carolina.

CONCLUSIONS

Access to regular care is an important safeguard for earlier detection. Our data suggest that health equity interventions should prioritize both primary care and screening.

Missed Screening Mammography Appointments: Patient Sociodemographic Characteristics and Mammography Completion After 1 Year

OBJECTIVE

Patients who miss screening mammogram appointments without notifying the health care system (no-show) risk care delays. We investigate sociodemographic characteristics of patients who experience screening mammogram no-shows at a community health center and whether and when the missed examinations are completed.

METHODS

We included patients with screening mammogram appointments at a community health center between January 1, 2021, and December 31, 2021. Language, race, ethnicity, insurance type, residential ZIP code tabulation area (ZCTA) poverty, appointment outcome (no-show, same-day cancelation, completed), and dates of completed screening mammograms after no-show appointments with ≥1-year follow-up were collected. Multivariable analyses were used to assess associations between patient characteristics and appointment outcomes.

RESULTS

Of 6,159 patients, 12.1% (743 of 6,159) experienced no-shows. The no-show group differed from the completed group by language, race and ethnicity, insurance type, and poverty level (all P < .05). Patients with no-shows more often had: primary language other than English (32.0% [238 of 743] versus 26.7% [1,265 of 4,741]), race and ethnicity other than White non-Hispanic (42.3% [314 of 743] versus 33.6% [1,595 of 4,742]), Medicaid or means-tested insurance (62.0% [461 of 743] versus 34.4% [1,629 of 4,742]), and residential ZCTAs with ≥20% poverty (19.5% [145 of 743] versus 14.1% [670 of 4,742]). Independent predictors of no-shows were Black non-Hispanic race and ethnicity (adjusted odds ratio [aOR], 1.52; 95% confidence interval [CI], 1.12-2.07; P = .007), Medicaid or other means-tested insurance (aOR, 2.75; 95% CI, 2.29-3.30; P < .001), and ZCTAs with ≥20% poverty (aOR, 1.76; 95% CI, 1.14-2.72; P = .011). At 1-year follow-up, 40.6% (302 of 743) of patients with no-shows had not completed screening mammogram.

DISCUSSION

Screening mammogram no-shows is a health equity issue in which socio-economically disadvantaged and racially and ethnically minoritized patients are more likely to experience missed appointments and continued delays in screening mammogram completion.

Interactive multidisciplinary pilot workshop to improve medical student perception of and interest in breast surgical oncology

BACKGROUND

Exposure to breast surgical oncology (BSO) and the multidisciplinary management of patients with breast cancer is limited in medical school. The purpose of this study was to assess changes in student perceptions of BSO as a career following an interactive multidisciplinary workshop.

METHODS

Pre-clinical medical students participated in a multidisciplinary, hands-on workshop, composed of breast radiology (BR), breast surgical oncology (BSO) and breast plastic reconstructive surgery (B-PRS). BR presented students screening and diagnostic breast imaging followed by hands-on ultrasound-guided biopsy on phantom simulators. BSO demonstrated lumpectomy, mastectomy, sentinel lymph node biopsy, and axillary lymph node dissections while B-PRS demonstrated oncoplastic techniques and autologous flap reconstruction with cadavers. Pre-and post-workshop surveys assessed student opinions on surgery and BSO. Results were compared using Wilcoxon Signed Rank, Wilcoxon Rank Sum, and Fisher's Exact.

RESULTS

The workshop was attended by twenty-four students. There was a statistically significant increase in interest in BSO from 52% to 86% after the workshop (p = 0.003). The event improved understanding of the work and lifestyle in BSO for 79% (19/24). All students (100%) expressed interest to further explore BSO. The most common attractors to a career in BSO were impacts on patients' lives (N = 23), intellectual stimulation (N = 22), and earnings (N = 20). The most reported deterrents were lack of personal time (N = 18) and stress (N = 15).

CONCLUSION

An interactive, anatomically based exposure to multidisciplinary breast cancer surgery improves medical student perception and interest in BSO. Medical schools should consider incorporating similar events to foster interest in BSO and other surgical subspecialties.

Patient and provider-level drivers of healthcare utilization related to a diagnosis of a precancerous condition: monoclonal gammopathy of undetermined significance (MGUS)

PURPOSE

Monoclonal gammopathy of undetermined significance (MGUS) is the precursor of multiple myeloma. This qualitative study described patient (n = 14) experiences and healthcare providers' (n = 8) opinions and practices concerning care for patients with MGUS in the US.

METHODS

Semi-structured, in-depth interviews were analyzed using thematic analysis.

RESULTS

We identified six overarching themes related to the care pathway for patients with MGUS: (1) Process of MGUS diagnosis, (2) Providers' explanations, (3) Patients' understanding, (4) Impact of the diagnosis, (5) Follow-up/management, and (6) Factors influencing healthcare utilization. Patients demonstrated a basic understanding of MGUS. However, some patients felt anxiety around the diagnosis, which may affect other aspects of their lives. Non-hematologist providers report having less MGUS-specific knowledge. Older age, high-risk MGUS, and insurance coverage/healthcare costs influenced healthcare utilization.

CONCLUSION

Patients with MGUS may have difficulty processing this premalignant diagnosis. Non-hematologist providers may have gaps in knowledge around specific care for patients with MGUS.

Association Between Opioid Tapering and Subsequent Health Care Use, Medication Adherence, and Chronic Condition Control

Importance

Opioid tapering has been associated with negative consequences, such as increased overdoses and mental health needs. Tapering could also alter use of health care services and worsen care of comorbid conditions through disruption in primary care.

Objective

To evaluate tapering of stable long-term opioid therapy (LTOT) and subsequent health care service use and chronic condition care.

Design, Setting, and Participants

A retrospective cohort study was conducted from January 1, 2008, to December 31, 2019. Data analysis was performed from July 9, 2020, to December 9, 2022. Data from the Optum Labs Data Warehouse, which contains deidentified retrospective administrative claims data and linked electronic health record data for commercial and Medicare Advantage enrollees, were used. Adults aged 18 years or older prescribed stable doses of LTOT at 50 morphine milligram equivalents or more per day during a 12-month baseline period were included, including subcohorts with hypertension or diabetes.

Exposures

Opioid tapering, with 15% or more relative reduction in mean daily dose in 6 overlapping periods during 6 months.

Main Outcomes and Measures

Emergency department visits, hospitalizations, primary care and specialist visits, antihypertensive or antiglycemic medication adherence, and blood pressure and hemoglobin A1c levels during up to 12 months' follow-up. Covariates included sociodemographic characteristics, comorbidities, health care use, and chronic condition control.

Results

Among 113 604 patients (60 764 [53.5%] women; mean [SD] age, 58.1 [11.8] years) prescribed LTOT, 41 207 had hypertension and 23 335 had diabetes; in all cohorts, approximately half were women, and half were aged 50 to 65 years. In the overall cohort, tapering was associated with more emergency department visits (adjusted incidence rate ratio [aIRR], 1.19; 95% CI, 1.16-1.21) and hospitalizations (aIRR, 1.16; 95% CI, 1.12-1.20), with similar magnitude associations in the hypertension and diabetes subcohorts. Tapering was associated with fewer primary care visits in the overall cohort (aIRR, 0.95; 95% CI, 0.94-0.96) and hypertension subcohort (aIRR, 0.98; 95% CI, 0.97-0.99). For the hypertension or diabetes subcohorts, tapering was associated with reduced medication adherence (hypertension: aIRR, 0.60; 95% CI, 0.59-0.62; diabetes: aIRR, 0.69; 95% CI, 0.67-0.71) and small increases in diastolic blood pressure and hemoglobin A1c level.

Conclusions and Relevance

In this cohort study of patients prescribed LTOT, opioid tapering was associated with more emergency department visits and hospitalizations, fewer primary care visits, and reduced antihypertensive and antidiabetic medication adherence. These outcomes may represent unintended negative consequences of opioid tapering for policy makers and clinicians to consider.

Impact of a pre-existing diagnosis of mental illness on stage of breast cancer diagnosis among older women

PURPOSE

Having a mental illness increases risk of mortality for women with breast cancer, partly due to barriers to accessing recommended care (e.g., cancer screening). Early detection is one important factor in breast cancer survival. To further understand this disparity in survival, we examined whether older women with mental illness are more likely to be diagnosed with later-staged breast cancers compared to women without mental illnesses.

METHODS

We used 2005-2015 SEER-Medicare data to identify AJCC stage I-IV breast cancer patients with and without a history of mental illness prior to cancer diagnosis. We used generalized ordinal regression to examine associations between mental illness diagnoses and stage at diagnosis, controlling for age, race/ethnicity, income, comorbidities, primary care use, rurality, and marital status.

RESULTS

Among 96,034 women with breast cancer, 1.7% have a serious mental illness (SMI), 19.9% depression or anxiety, and 7.0% other mental illness. Those with SMI have 40% higher odds of being diagnosed with AJCC Stages II, III than Stage I; women with depression/anxiety have 25% lower odds of being diagnosed with Stage IV cancer than Stage I; and women with other mental illnesses have similar odds of being diagnosed in later stages.

CONCLUSION

Women with SMI have higher odds of being diagnosed at later stages, which likely contributes to higher mortality after breast cancer. Surprisingly, women with depression and anxiety have a lower risk of being diagnosed with Stage IV cancer. Earlier breast cancer diagnosis in women with SMI is an important goal for reducing disparities breast cancer survival.

A Mixed Method Approach to Examine Surveillance Mammography Experiences in Black and White Breast Cancer Survivors

PURPOSE

The use of surveillance mammography following a breast cancer (BC) diagnosis is associated with early detection of disease relapse and increased overall survival; yet Black women compared to White women have the lowest surveillance mammography rates, with limited explanation. To further understand this racial disparity the present study examines the association of mammography beliefs, knowledge, and healthcare delivery factors on receipt of surveillance mammography among Black and White breast cancer survivors.

METHODS

This is a convergent parallel mixed method study design of an online survey and online focus groups among Black and White BC survivors (N = 266) recruited from community engagement. The online focus groups consisted of a series of theory-informed questions via social media platforms (eg Breastcancer.org, Quora, Reddit). An in-depth thematic analysis approach was used to extract themes from online focus group data. Bivariate (χ²) and multivariable logistic regression analyses were conducted using the survey data to examine associated factors with receipt of a surveillance mammography within 12 months (yes vs. no).

RESULTS

76% (n = 177) of women were Black, 62% were <5 years since diagnosis, 98% had health insurance, with an age range from 23 to 79 (mean = 55) years. 72% of the sample received a surveillance mammogram relative to 27%. Women more frequently received a surveillance mammogram if they reported perceived mammography benefits (<.001), underwent lumpectomy (P< .001) and had health insurance (P = .04). Black women without communication about surveillance care with providers had a lower likelihood of receiving a surveillance mammogram (OR:0.09,95% CI: 0.01-0.45, P = .003). Thematic findings from online focus groups included motivators for receipt of surveillance mammograms: physician recommendation, regular physical exams, and knowledge of recommended guidelines. Barriers of non-receipt of surveillance mammograms included: transportation, medical cost/financial barriers, feeling ignored from providers, and medical mistrust.

CONCLUSION

Women may require more individualized information regarding their surveillance care to support routine guideline concordant follow-up. Patient-provider-communication is an integral part of Black survivors' surveillance care needs. Improving patient-provider communication for Black women's is necessary to address this group cancer care needs.

Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients

BACKGROUND

Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics.

OBJECTIVES

To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics.

DESIGN

Electronic medical record review of abnormal screening mammograms.

SUBJECTS

Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337).

MAIN MEASURES

Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors.

KEY RESULTS

Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively.

CONCLUSIONS

A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.

OUP accepted manuscript

Background

Disrupted and delayed Medicaid coverage has been consistently associated with lower rates of cancer screening and early-stage cancer diagnosis compared with continuous coverage. However, the relationships between Medicaid coverage timing, breast cancer treatment delays, and survival are less clear.

Methods

Using the linked Missouri Cancer Registry-Medicaid claims data, we identified 4583 women diagnosed with breast cancer between 2007 and 2016. We used logistic regression to estimate odds ratios (ORs) of late-stage diagnosis and treatment delays for prediagnosis (>30 days, >90 days, and >1 year before diagnosis) vs peridiagnosis enrollment. Cox proportional hazards models were used to estimate the hazard ratio (HR) of breast cancer-specific mortality for pre- vs postdiagnosis enrollment.

Results

Patients enrolled in Medicaid more than 30 days before diagnosis were less likely to be diagnosed at a late stage compared with those enrolled in Medicaid peridiagnosis (OR = 0.69, 95% confidence interval [CI] = 0.60 to 0.79). This result persisted using enrollment 90-day (OR = 0.64, 95% CI = 0.56 to 0.74) and 1-year thresholds (OR = 0.55, 95% CI = 0.47 to 0.65). We did not observe a difference in the likelihood of treatment delays between the 2 groups. After adjustment for sociodemographic factors, there was no statistically significant difference in the risk of breast cancer mortality for patients enrolled more than 30 days prediagnosis relative to patients enrolled peridiagnosis (HR = 0.98, 95% CI = 0.83 to 1.14), but a lower risk was observed for patients enrolled prediagnosis when using 90 days (HR = 0.85, 95% CI = 0.72 to 0.999) or 1 year (HR = 0.79, 95% CI = 0.66 to 0.96) as the threshold.

Conclusions

Women with breast cancer who enroll in Medicaid earlier may benefit from earlier diagnoses, but only longer-term enrollment may have survival benefits.

Primary Care Continuity and Wait Times to Receiving Breast Cancer Chemotherapy: A Population-Based Retrospective Cohort Study Using CanIMPACT Data

(1) Background: Wait times to chemotherapy are associated with morbidity and mortality in breast cancer patients; however, it is unclear how primary care physician (PCP) continuity impacts these wait times, or whether this association is different in immigrants, who experience cancer care inequities. We assessed the association between PCP continuity and the contact-to-chemotherapy interval (wait time from when a patient first presents to healthcare to the first day of receiving breast cancer chemotherapy), with a specific look at the immigrant population. (2) Methods: Population-based, retrospective cohort study of women who were diagnosed with stage I–III breast cancer in Ontario who received surgery and adjuvant chemotherapy. We used quantile regression at the median and 90th percentile to quantify the effect of PCP continuity on the contact-to-chemotherapy interval, performing a separate analysis on the immigrant population. (3) Results: Among 12,781 breast cancer patients, including 1706 immigrants, the median contact-to-chemotherapy interval (126 days) was 3.21 days shorter (95% confidence interval (CI) 0.47–5.96) in symptom-detected patients with low PCP continuity, 10.68 days shorter (95% CI 5.36–16.00) in symptom-detected patients with no baseline PCP visits and 17.43 days longer (95% CI 0.90–34.76) in screen-detected immigrants with low PCP continuity compared to the same groups with high PCP continuity. (4) Conclusions: Higher PCP continuity was not associated with a change in the contact-to-chemotherapy interval for most of our study population, but was associated with a marginally longer interval in our symptom-detected population and a shorter contact-to-chemotherapy interval in screen-detected immigrants. This highlights the importance of PCP continuity among immigrants with positive screening results. Additionally, having no PCP visits at baseline was associated with a shorter contact-to-chemotherapy interval in symptom-detected patients.

Incidence and Predictors of Diabetes Mellitus after a Diagnosis of Early-Stage Breast Cancer in the Elderly Using Real-World Data

PURPOSE

The incidence and predictors of diabetes (DM) in patients with breast cancer (BC) were evaluated. We compared DM incidence and physician access in BC patients to matched controls.

METHODS

We identified women with stage I-III BC diagnosed from 2005 to 2013 in the SEER-Medicare database, with ≥ 2 years of follow-up after diagnosis, without previous DM claims. Incident DM was determined by ≥ 1 DM claims after BC diagnosis. Multivariable analysis was used to identify factors associated with incident DM. Age- and race-matched non-cancer controls were obtained from a 5% random sample and assigned an index date. Physician and PCP visits per-patient-per-year were compared between cases and controls in the two-year period prior to and after the index date.

RESULTS

Among 14,506 eligible BC patients, 3234 (22.3%) developed DM versus 16.5% of controls. Among BC patients, factors associated with incident DM included race (Black OR 1.63 95% CI 1.39-1.93, Hispanic OR 3.03 95% CI 1.92-4.81; vs. Caucasians), SES (Quintile 0 vs. Quintile 4 OR 1.55 95% CI 1.33-1.78), and receipt of chemotherapy (vs. none OR 1.19 95% CI 1.08-1.31). Among cases and controls, respectively, median physician visits per-patient-per-year were 19 and 17 prior to the index date, and 46 and 19 after the index date; median PCP visits were 2 for both groups in both periods.

CONCLUSION

About 22% of BC patients developed DM, more than controls in the same period. While there were differences in healthcare access, there weren't differences in PCP access between groups. This represents an opportunity for better comorbidity management in BC patients.

Envisioning a Better U.S. Health Care System for All: Health Care Delivery and Payment System Reforms

The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Fundamental restructuring of payment policies and delivery systems is required to achieve a health care system that puts patients' interests first and supports physicians and their care teams to deliver high-value, patient- and family-centered care. The ACP calls for reform of U.S. payment, delivery, and information technology systems to achieve this vision. The ACP's recommendations include increased investment in primary care; alignment of financial incentives to achieve better patient outcomes, lower costs, reduce inequities in health care, and facilitate team-based care; freeing patients and physicians of inefficient administrative and billing tasks and documentation requirements; and development of health information technologies that enhance the patient-physician relationship.

Challenges in Cancer Control Services Provided by Family Physicians in Primary Care: A Qualitative and Quantitative Study From Karabuk Province in Turkey

Background

Family physicians (FPs) play an important role in cancer control. The aim of this study was to understand the functions of FPs in cancer control and to explore FPs’ perceptions of their own roles and the difficulties they face in cancer control in Karabuk province, Turkey.

Methods

The study consisted of two methodological parts. The qualitative part included a descriptive study in which data were collected from 87.5% (n=56) out of all FPs in Karabuk using a questionnaire. In the quantitative part, in-depth interviews with 15 FPs were conducted and analyzed through content analysis.

Results

Half of the FPs (50.0%) provided cancer prevention information for their registered people, focusing on especially smoking cessation. In the last three months, the proportion of FPs who had not invited anyone to screenings was 37.5% for the pap test, 26.8% for the mammography, 19.0% for the fecal occult blood test and 34.5% for the colonoscopy. Only 16.1% of them reported that they made home visits for cancer patients. In the qualitative part of study, the following themes were highlighted: the perceived responsibilities of FPs regarding cancer control; the effect of geographically undefined working area of FPs; the issues with coordination between FPs and specialists; the effect of the number of primary care team members.

Conclusions

Cancer control services provided by FPs have significant problems in terms of the FPs’ approach to the services and their content, continuity and coordination.

Association between primary care coverage and breast cancer mortality in Brazil

Breast cancer early detection is the major strategy for mortality rates reduction. In Brazil, Primary Health Care is an important strategy for public health promotion. To analyse the association between breast cancer mortality and primary health care indicators in Brazilian municipalities, data on breast cancer mortality and primary healthcare coverage of the 5,700 Brazilian municipalities were collected from the Department of Informatics of the Brazilian Unified Health System. We collected data on the deaths of women living in Brazil in 2010 with breast cancer. Breast cancer mortality was calculated by 100,000 women and age-standardised from the World Health Organisation population. We studied the coverage of primary health care, family health team and community health agents. We found that increase of both primary care indexes was related to increasing of the breast cancer mortality. Additionally, improving the scholarly and reducing the income inequality was related to reducing the breast cancer mortality. Strategies to improve the quality of primary care, reduce the income inequality and improve elementary scholarly should be taken into account in the development of public policies in the Brazilian municipalities to reduce breast cancer in Brazilian municipalities.

The impact of improving access to primary care

OBJECTIVES

To measure the size and timing of changes in utilization and costs for employees and dependents who had major access barriers to primary care removed, across an 8-year period (2007 to 2014).

STUDY DESIGN AND METHODS

Retrospective observational study examining patterns of utilization and costs before and after the implementation of a worksite medical office in 2010. The worksite office offered convenient primary care services with no travel from work, essentially guaranteed same day access, and no co-pay. Trends in visit rates and costs were compared for an intervention fixed cohort group (employees and dependents) at the employer (n = 1211) with a control fixed cohort group (n = 542 162) for 6 types of visits (primary, urgent, emergency, inpatient, specialty, and other outpatient). Difference-in-differences methods assessed the significance of between-group changes in utilization and costs.

RESULTS

The worksite medical office intervention group had an increase in primary care visits relative to the control group (+43% vs +4%, P < 0.001). This was accompanied by a reduction in urgent care visits by the intervention group compared with the control group (-43% vs -5%, P < 0.001). There were no differences in the other types of visits, and the total visit costs for the intervention group increased 5.7% versus 2.7% for the control group (P = 0.008). A sub-group analysis of the intervention group (comparing dependents to employees) found that that the dependents achieved a reduction in costs of 2.7% (P < 0.001) across the study period.

CONCLUSIONS

The potential for long-term reduction in utilization and costs with better access to primary care is significant, but not easily nor automatically achieved.

Breast Cancer Care in California and Ontario: Primary Care Protections Greatest Among the Most Socioeconomically Vulnerable Women Living in the Most Underserved Places

BACKGROUND

Better health care among Canada's socioeconomically vulnerable versus America's has not been fully explained. We examined the effects of poverty, health insurance and the supply of primary care physicians on breast cancer care.

METHODS

We analyzed breast cancer data in Ontario (n = 950) and California (n = 6300) between 1996 and 2000 and followed until 2014. We obtained socioeconomic data from censuses, oversampling the poor. We obtained data on the supply of physicians, primary care and specialists. The optimal care criterion was being diagnosed early with node negative disease and received breast conserving surgery followed by adjuvant radiation therapy.

RESULTS

Women in Ontario received more optimal care in communities well supplied by primary care physicians. They were particularly advantaged in the most disadvantaged places: high poverty neighborhoods (rate ratio = 1.65) and communities lacking specialist physicians (rate ratio = 1.33). Canadian advantages were explained by better health insurance coverage and greater primary care access.

CONCLUSIONS

Policy makers ought to ensure that the newly insured are adequately insured. The Medicaid program should be expanded, as intended, across all 50 states. Strengthening America's system of primary care will probably be the best way to ensure that the Affordable Care Act's full benefits are realized.

The Relationship Between the Supply of Primary Care Physicians and Measures of Breast Health Service Use

BACKGROUND

To investigate whether women are more likely to report receipt of a mammography recommendation from a doctor or mammography use if they reside in primary care service areas (PCSAs) having a greater number of clinically active primary care physicians.

MATERIALS AND METHODS

The analysis used a nationally representative sample of women, aged 40 years and above (n = 10,706 unweighted respondents), extracted from the 2005 National Health Interview Survey. The restricted geocoded addresses of the respondents were linked to PCSA data on physician density at a secure research data center. Multivariable logistic regression was used to determine whether, after adjustment, specific measures of primary care providers (e.g., the number of obstetricians and gynecologists [Ob-GyNs] per 10,000 population) were associated with either recommendation receipt or mammography use.

RESULTS

After adjusting for other factors, a one-unit increase in the PCSA number of Ob-GyNs per 10,000 population increased the odds of mammography recommendation receipt by 9% and the odds of mammography use by 9%. The ratio of international medical graduate Ob-GyNs to US-trained Ob-GyNs in a PCSA was negatively associated with mammography use.

CONCLUSION

The results from this nationwide study underscore the importance of using physician density measures estimated from within bounded medical markets, where women reside and actually seek preventive breast health services. Results support the hypothesis that PCSA physician supply is independently associated with both mammography recommendation receipt and mammography utilization.

Emergency Presentation and Short-Term Survival Among Patients With Colorectal Cancer Enrolled in the Government Health Plan of Puerto Rico

Objective:

In this study, we examine factors associated with the use of the emergency room (ER) as an entry point into the health-care system to initiate a cancer diagnosis among Puerto Rico’s Government Health Plan (GHP) patients and compare the 1-year survival of GHP patients that initiated cancer diagnosis in the emergency room (ER) presentation with those that initiated the diagnosis in a physician’s office.

Methods:

Data for patients with colorectal cancer (CRC) aged 50 to 64 years and diagnosed in 2012 were obtained from the Puerto Rico Central Cancer Registry and linked to the Puerto Rico Health Insurance Administration database (n = 190). Crude odds ratio, adjusted odds ratio, and their 95% confidence intervals were reported. We used the Kaplan-Meier method to generate survival curves. Multivariate Cox regression analysis was performed to evaluate the association between ER presentation and 1-year cause-specific survival.

Results:

We found that 37.37% of the study population had an ER presentation. Male patients had a higher occurrence of having an ER presentation (66.20%), while 76.06% of the patients with an ER presentation were diagnosed in late stage. Emergency room presentation was a highly predictive factor for cancer mortality in the year following the diagnosis. These patients had between 3.99 to 4.24 times higher mortality risk than non-ER presentation patients (P < .05).

Conclusion:

Late presentation for CRC diagnosis through an ER visit is a significant concern that influences negatively on the patient’s outcome. Efforts at increasing primary care visits and routine screening tests among GHP beneficiaries could improve survival.

Predicting Late-stage Breast Cancer Diagnosis and Receipt of Adjuvant Therapy: Applying Current Spatial Access to Care Methods in Appalachia

PURPOSE

The 2-step floating catchment area (2SFCA) method of measuring access to care has never been used to study cancer disparities in Appalachia. First, we evaluated the 2SFCA method in relation to traditional methods. We then examined the impact of access to mammography centers and primary care on late-stage breast cancer diagnosis and receipt of adjuvant hormonal therapy.

METHODS

Cancer registries from Pennsylvania, Ohio, Kentucky, and North Carolina were linked with Medicare data to identify the stage of breast cancer diagnosis for Appalachia women diagnosed between 2006 and 2008. Women eligible for adjuvant therapy had stage I, II, or III diagnosis; mastectomy or breast-conserving surgery; and hormone receptor-positive breast cancers. Geographically weighted regression was used to explore nonstationarity in the demographic and spatial access predictor variables.

RESULTS

Over 21% of 15,299 women diagnosed with breast cancer had late-stage (stages III-IV) diagnosis. Predictors included age at diagnosis [odds ratio (OR)=0.86; P<0.001], insurance status (OR=1.32; P<0.001), county primary care to population ratio (OR=0.95; P<0.001), and primary-care 2SFCA score (OR=0.96; P=0.006). Only 46.9% of eligible women received adjuvant hormonal therapy, and predictors included comorbidity status (OR=1.18; P=0.047), county economic status (OR=1.32; P=0.006), and mammography center 2SFCA scores (OR=1.12; P=0.021).

CONCLUSIONS

Methodologically, the 2SFCA method offered the greatest predictive validity of the access measures examined. Substantively, rates of late-stage breast cancer diagnosis and adjuvant hormonal therapy are substandard in Appalachia.

Geographic disparities in late stage breast cancer incidence: results from eight states in the United States

Background

Late stage of cancer at diagnosis is an important predictor of cancer mortality. In many areas worldwide, cancer registry systems, available data and mapping technologies can provide information about late stage cancer by geographical regions, offering valuable opportunities to identify areas where further investigation and interventions are needed. The current study examined geographical variation in late stage breast cancer incidence across eight states in the United States with the objective to identify areas that might benefit from targeted interventions.

Methods

Data from the Surveillance Epidemiology and End Results Program on late stage breast cancer incidence was used as dependent variable in regression analysis and certain factors known to contribute to high rates of late stage cancer (socioeconomic characteristics, health insurance characteristics, and the availability and utilization of cancer screening) as covariates. Geographic information systems were used to map and highlight areas that have any combination of high late stage breast cancer incidence and significantly associated risk factors.

Results

The differences in mean rates of late stage breast cancer between eight states considered in this analysis are statistically significant. Factors that have statistically negative association with late stage breast cancer incidence across the eight states include: density of mammography facilities, percent population with Bachelor’s degree and English literacy while percent black population has statistically significant positive association with late stage breast cancer incidence.

Conclusions

This study describes geographic disparities in late stage breast cancer incidence and identifies areas that might benefit from targeted interventions. The results suggest that in the eight US states examined, higher rates of late stage breast cancer are more common in areas with predominantly black population, where English literacy, percentage of population with college degree and screening availability are low. The approach described in this work may be utilized both within and outside US, wherever cancer registry systems and technologies offer the same opportunity to identify places where further investigation and interventions for reducing cancer burden are needed.

Determinants of advanced stage presentation of breast cancer in 87,969 Brazilian women

BACKGROUND

Breast cancer is commonly diagnosed at an advanced stage in Brazil.

AIM

Analyze the determinants of advanced staging in Brazilian women with breast cancer.

METHODS

Crosssectional study, including women diagnosed with breast cancer in Brazil, between 2000 and 2009.

RESULTS

A total of 59,317 women were included, 53.5% being classified as advanced stage (≥IIB). Younger age (18 to 49 years old) (OR=1.61 95% CI 1.51 to 1.72) or between 40 and 49 years old (OR=1.08 95% CI 1.03 to 1.14), having low educational level (OR=1.53 95% CI 1.48 to 1.58), living in less developed geographical regions (OR=1.27 95% CI 1.21 to 1.33), having invasive ductal carcinoma (OR=2.70 95% CI 2.56 to 2.84) and invasive lobular carcinoma (OR=2.63 95% CI 2.42 to 2.86) were associated with advanced breast cancer.

CONCLUSION

We conclude that future interventions should focus on these high risk groups.

Complementary medicine for cancer patients in general practice: qualitative interviews with german general practitioners

BACKGROUND

The aim of this study was to investigate how general practitioners react when their cancer patients show interest in complementary medicine, and how their reaction is related to their knowledge in the field.

METHODS

We conducted semi-structured interviews with 10 German general practitioners. Interviewees came from 5 different federal states and varied in terms of urban/rural setting, single/joint practice, additional certifications, gender and length of professional experience. Interviews were electronically recorded, transcribed and then analysed using qualitative content analysis according to Mayring.

RESULTS

General practitioners feel largely responsible for providing information on complementary medicine to their cancer patients. However, uncertainty and a lack of knowledge concerning CAM lead mainly to reactive responses to patients' needs, and the general practitioners base their recommendations on personal experiences and attitudes. They wish to support their cancer patients and thus, in order to keep their patients' hopes up and maintain a trusting relationship, sometimes support complementary medicine, regardless of their own convictions.

CONCLUSION

Although general practitioners see themselves as an important source of information on complementary medicine for their cancer patients, they also speak of their uncertainties and lack of knowledge. General practitioners would profit from training in complementary medicine enabling them to discuss this topic with their cancer patients in a proactive, open and honest manner.

Cost-Effectiveness of a Low-Cost, Hospital-Based Primary Care Clinic

This study assesses the cost-effectiveness of an insurance administration-free, hospital-based clinic designed to provide a full array of primary care services to low-income individuals at little or no cost. In addition to low/no-cost visits, individuals have the option to purchase a low-cost health insurance plan similar to any traditional health plan (eg, prescriptions, primary care, specialty care, durable medical equipment, radiology, laboratory test results). We used 3 years of data (2009-2012) on emergency department (ED) visits and inpatient hospital admissions from clinic patients and patients at the community's 2 largest private physician groups to assess the cost-effectiveness of the hospital-based clinic in terms of ED and inpatient admission costs avoided and financial sustainability of the low-cost insurance plan. Estimated annual savings in hospital inpatient and ED costs were approximately 1.4 million. Insurance plan data indicated sound fiscal sustainability with modest provider reimbursement growth and zero annual premium growth.

Receipt of Regular Primary Care and Early Cancer Detection in Appalachia

PURPOSE

The objective was to examine the impact of regular primary care encounters (PCE) on early breast cancer detection in an Appalachian sample of Medicare beneficiaries diagnosed 2006-2008. Determinants of PCE were investigated and a mediation analysis was conducted where PCE was a mediator to cancer stage.

METHODS

A total of 3,589 cases were identified from Appalachian areas in Pennsylvania, Kentucky, Ohio, and North Carolina, and health care services were examined 2 months to 2 years prior to diagnosis. A regular care PCE variable was constructed with 4 ordinal levels: none, any, "annual," and "semi-annual." Association of PCE with stage, mortality and covariables was conducted using ordinal logistic regressions and Cox Proportional Hazards survival models.

RESULTS

Sixty-eight percent of the cases had semi-annual PCE. Regular PCE was strongly associated with late-stage cancer rates (39%-13% by increasing PCE level, P < .0001) and 5-year all-cause mortality (42%-24%, P < .0001). Subgroup analysis revealed variations by hypertension and urban status, with nonhypertensives with no PCE being at particularly increased risk. Significant determinants of PCE included age, rural/urban status, comorbidity, dual Medicaid insurance, Appalachian region economic classification, state, select comorbidities, hypertension, and minimum distance to provider. Mediation analysis results were consistent with lower number of comorbidities leading to increased late cancer detection due to patients having a decreased PCE.

CONCLUSION

PCE is an important determinant of cancer detection, with a dose-response relationship. Variations exist by geography and hypertension. Comorbidity may influence both PCE and late-stage rates with partial mediation through PCE.

Mortality outcome among medically underserved women screened through a publicly funded breast cancer control program, 1997-2007

PURPOSE

The purpose of this study was to assess treatment and mortality differences between women diagnosed with breast cancer through Nebraska's Every Woman Matters (EWM) program and women diagnosed through other sources.

METHODS

A retrospective analysis was performed using 10 years of Nebraska Cancer Registry and EWM program data on women aged 40-74 years. This study used chi-square and multivariate logistic regression with mortality as the outcome of interest.

RESULTS

From 1997 to 2007, 4,739 women were diagnosed with breast cancer, 435 (9.1 %) of whom were diagnosed through EWM. The EWM and non-EWM groups differed significantly in age, race, marital status, location of residence at the time of diagnosis, neighborhood poverty level at the time of diagnosis, tumor stage at diagnosis, and chemotherapy. No significant differences were found between the two groups in radiation therapy, surgical resection, and hormone therapy. In both 1- and 5-year multivariate mortality models, the odds of dying for those in the EWM program were not statistically significantly different from the odds of dying for those not in the EWM program. In the 1-year mortality model, residents of urban metropolitan counties (OR 2.079; 95 % CI 1.663-2.598) had an increased odds of dying compared to residents of rural counties. In the 5-year mortality model, black women (OR 2.239; 95 % CI 1.453-3.450), residents of areas with a high (more than 20 %) neighborhood poverty level at the time of diagnosis (OR 1.589; 95 % CI 1.204-2.097), and unmarried women (OR 1.334; 95 % CI 1.164-1.528) had higher odds of death. Both groups have received similar treatments.

CONCLUSIONS

Targeted outreach to vulnerable groups for cancer screening may improve cancer outcomes and reduce disparities.

The Impact of an Insurance Administration-Free Primary Care Office on Hospital Admissions: A Community-Level Comparison With Traditional Fee-for-Service Family Practice Groups

This study compares hospital admissions over a 3-year period (2009-2011) between a community's 2 major private, fee-for-service physician groups and an insurance administration-free, hospital-affiliated clinic designed to provide a full array of primary care services to low-income individuals at little or no cost. We use data on patients' chronic conditions and inpatient hospital admissions to compare patients' average number of physician office visits and overall hospital admission rates per 1000 patients. The data indicate that while clinic patients have a higher (or equal) average number of chronic conditions compared with patients in the private physician groups, they exhibit lower hospital admission rates. Clinic patients also exhibit a higher average annual frequency of physician visits. Results of this study suggest that enhanced access to primary care could help mitigate inefficient use of non-urgent care hospital resources for the uninsured and reduce costly hospitalizations even in the short run.

Racial and ethnic differences in use of mammography between Medicare Advantage and traditional Medicare

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.

The effects of primary care on breast cancer mortality and incidence among Medicare beneficiaries

BACKGROUND

Primary care physician (PCP) services may have an impact on breast cancer mortality and incidence, possibly through greater use of screening mammography.

METHODS

The authors conducted a retrospective, 1:1 matching case-control study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database to examine use of PCP services and their association with breast cancer mortality and incidence. SEER cases representing the 3 outcomes of interest (breast cancer mortality, all-cause mortality among women diagnosed with breast cancer, and breast cancer incidence) were matched to unaffected controls from the 5% Medicare random sample. Conditional logistic regression was used to examine associations between physician visits and breast cancer outcomes while controlling for other covariates.

RESULTS

Women who had 2 or more PCP visits during the 24-month assessment interval had lower odds of breast cancer mortality, all-cause mortality, and late-stage breast cancer diagnosis compared with women who had no PCP visits or 1 PCP visit while adjusting for other covariates, including mammography and non-PCP visits. Women who had 5 to 10 PCP visits had 0.69 times the odds of breast cancer mortality (95% confidence interval, 0.63-0.75), 0.83 times the odds of death from any cause having been diagnosed with breast cancer (95% confidence interval, 0.79-0.87), and 0.67 times the odds of a late-stage breast cancer diagnosis (95% confidence interval, 0.61-0.73) compared with those who had no PCP visits or 1 PCP visit.

CONCLUSIONS

The current findings suggest that PCPs play an important role in reducing breast cancer mortality among the Medicare population. Further research is needed to better understand the impact of primary care on breast cancer and other cancers that are amendable to prevention or early detection.