Variation in breast cancer care quality in New York and California based on race/ethnicity and Medicaid enrollment

Abstract

Background: Racial/ethnic and socioeconomic disparities persist in part because our current understanding of the care provided to minority and disadvantaged populations is limited. The authors evaluated the quality of breast cancer care in 2 large states to understand the disparities experienced by African Americans, Hispanics, Asian/Pacific Islanders (APIs), and Medicaid enrollees and to prioritize remediation strategies.

Methods: Statewide cancer registry data for 80,436 women in New York and 121,233 women in California who were diagnosed during 2004 to 2009 with stage 0 through III breast cancer were used to assess underuse and overuse of surgery, radiation, chemotherapy, and hormone therapy based on 34 quality measures. Concordance values were compared across racial/ethnic and Medicaid-enrollment groups. Multivariable models were used to quantify disparities across groups for each treatment in each state.

Results: Overall concordance was 76% for underuse measures and 87% for overuse measures. The proportions of patients who received care concordant with all relevant measures were 35% in New York and 33% in California. Compared with whites, African Americans were less likely to receive recommended surgery, radiation, and hormone therapy; Hispanics and APIs were usually more likely to receive recommended chemotherapy. Across states, the same racial/ethnic groups did not always experience the same disparities. Medicaid enrollment was associated with decreased likelihood of receiving all recommended treatments, except chemotherapy, in both states. Overuse was evident for hormone therapy and axillary surgery but was not associated with race/ethnicity or Medicaid enrollment.

Conclusions: Patient-level measures of quality identify substantial problems with care quality and meaningful disparities. Remediating these problems will require prioritizing low-performing measures and targeting high-risk populations, possibly in different ways for different regions.

Keywords: Medicaid; breast cancer; disparities; quality.

Figure 1. Comparisons of Concordance with Breast Cancer Quality Measures Across Racial/Ethnic and Medicaid-Enrollment Groups

Each point represents performance on one quality measure for two patient groups. Each line represents the linear best-fit solution for a two-group comparison using data from all 34 quality measures. R² is the coefficient of determination for each two-group comparison. A: Whites compared to African-Americans, Hispanics, and Asian-Pacific Islanders (NY) B: Medicaid enrollees Compared to Non-Enrollees, Stratified by Age at Diagnosis (NY) C: Whites compared to African-Americans, Hispanics, and Asian-Pacific Islanders (CA) D: Medicaid enrollees Compared to Non-Enrollees, Stratified by Age at Diagnosis (CA)

Figure 1. Comparisons of Concordance with Breast Cancer Quality Measures Across Racial/Ethnic and Medicaid-Enrollment Groups

Each point represents performance on one quality measure for two patient groups. Each line represents the linear best-fit solution for a two-group comparison using data from all 34 quality measures. R² is the coefficient of determination for each two-group comparison. A: Whites compared to African-Americans, Hispanics, and Asian-Pacific Islanders (NY) B: Medicaid enrollees Compared to Non-Enrollees, Stratified by Age at Diagnosis (NY) C: Whites compared to African-Americans, Hispanics, and Asian-Pacific Islanders (CA) D: Medicaid enrollees Compared to Non-Enrollees, Stratified by Age at Diagnosis (CA)

Figure 1. Comparisons of Concordance with Breast Cancer Quality Measures Across Racial/Ethnic and Medicaid-Enrollment Groups

Each point represents performance on one quality measure for two patient groups. Each line represents the linear best-fit solution for a two-group comparison using data from all 34 quality measures. R² is the coefficient of determination for each two-group comparison. A: Whites compared to African-Americans, Hispanics, and Asian-Pacific Islanders (NY) B: Medicaid enrollees Compared to Non-Enrollees, Stratified by Age at Diagnosis (NY) C: Whites compared to African-Americans, Hispanics, and Asian-Pacific Islanders (CA) D: Medicaid enrollees Compared to Non-Enrollees, Stratified by Age at Diagnosis (CA)

Figure 1. Comparisons of Concordance with Breast Cancer Quality Measures Across Racial/Ethnic and Medicaid-Enrollment Groups

Each point represents performance on one quality measure for two patient groups. Each line represents the linear best-fit solution for a two-group comparison using data from all 34 quality measures. R² is the coefficient of determination for each two-group comparison. A: Whites compared to African-Americans, Hispanics, and Asian-Pacific Islanders (NY) B: Medicaid enrollees Compared to Non-Enrollees, Stratified by Age at Diagnosis (NY) C: Whites compared to African-Americans, Hispanics, and Asian-Pacific Islanders (CA) D: Medicaid enrollees Compared to Non-Enrollees, Stratified by Age at Diagnosis (CA)

Figure 2. Absolute Differences in Concordance with Breast Cancer Quality Measures in NY and CA

Measures of quality are evaluated using 9 groups defined by the type of treatment (breast surgery, node surgery, chemotherapy, radiation therapy, or hormone therapy) and type of recommendation (for or against treatment). A: White versus other racial/ethnic groups B: Medicaid enrollees vs. non-enrollees stratified by age at diagnosis

Figure 3. Adjusted Odds of Receiving Concordant Care for Newly Diagnosed Breast Cancer in NY and CA (2004-9)

The figure displays the adjusted odds of receiving concordant care (i.e., getting the recommended treatment [Rec. for] or avoiding an unnecessary treatment [Rec. against]) for each of nine measure-sets defined by treatment modality (breast surgery, lymph node surgery, chemotherapy, radiation therapy, and hormone therapy) and type of recommendation (for or against therapy). All models control for age, race/ethnicity, marital status, Medicaid enrollment, urbanicity, median income, education, treatment type, and recommendation type. A: White vs. other racial/ethnic groups B: Medicaid enrollees vs. non-enrollees, stratified by age at diagnosis to account for potential Medicare eligibility

Figure 3. Adjusted Odds of Receiving Concordant Care for Newly Diagnosed Breast Cancer in NY and CA (2004-9)

The figure displays the adjusted odds of receiving concordant care (i.e., getting the recommended treatment [Rec. for] or avoiding an unnecessary treatment [Rec. against]) for each of nine measure-sets defined by treatment modality (breast surgery, lymph node surgery, chemotherapy, radiation therapy, and hormone therapy) and type of recommendation (for or against therapy). All models control for age, race/ethnicity, marital status, Medicaid enrollment, urbanicity, median income, education, treatment type, and recommendation type. A: White vs. other racial/ethnic groups B: Medicaid enrollees vs. non-enrollees, stratified by age at diagnosis to account for potential Medicare eligibility