The association of ambulatory care with breast cancer stage at diagnosis among Medicare beneficiaries

Abstract

Objective: Although nearly all elderly Americans are insured through Medicare, there is substantial variation in their use of services, which may influence detection of serious illnesses. We examined outpatient care in the 2 years before breast cancer diagnosis to identify women at high risk for limited care and assess the relationship of the physicians seen and number of visits with stage at diagnosis.

Design: Retrospective cohort study using cancer registry and Medicare claims data.

Patients: Population-based sample of 11,291 women aged > or =67 diagnosed with breast cancer during 1995 to 1996.

Measurements and main results: Ten percent of women had no visits or saw only physicians other than primary care physicians or medical specialists in the 2 years before diagnosis. Such women were more often unmarried, living in urban areas or areas with low median incomes (all P> or =.01). Overall, 11.2% were diagnosed with advanced (stage III/IV) cancer. The adjusted rate was highest among women with no visits (36.2%) or with visits to physicians other than primary care physicians or medical specialists (15.3%) compared to women with visits to either a primary care physician (8.6%) or medical specialist (9.4%) or both (7.8%) (P<.001). The rate of advanced cancer also decreased with increasing number of visits (P<.001).

Conclusions: Even within this insured population, many elderly women had limited or no outpatient care in the 2 years before breast cancer diagnosis, and these women had a markedly increased risk of advanced-stage diagnosis. These women, many of whom were unmarried and living in poor and urban areas, may benefit from targeted outreach or coverage for preventive care visits.

FIGURE 1

Model of patient and provider factors associated with stage at diagnosis.