Quality Of Breast Cancer Care In The US Territories: Insights From Medicare

Abstract

The quality of breast cancer care among Medicare beneficiaries in the US territories-where federal spending for health care is lower than in the continental US-is unknown. We compared female Medicare beneficiaries who were residents of the US territories and had surgical treatment for breast cancer in 2008-14 to those in the continental US in terms of receipt of recommended breast cancer care (diagnostic needle biopsy and adjuvant radiation therapy [RT] following breast-conserving surgery) and the timeliness (time from needle biopsy to surgery and from surgery to adjuvant RT) of that care. Residents of the US territories were less likely to receive recommended care (24 percent lower odds of receiving diagnostic needle biopsy and 34 percent lower odds of receiving adjuvant RT) and to receive timely care (45 percent lower odds of receiving surgery and 82 percent lower odds of receiving adjuvant RT, both within three months). Further research is needed to identify barriers to the provision of adequate and timely breast cancer care in this unique population.

Keywords: Breast cancer; Disparities; Medicare; Quality Of Care; US Territories.

EXHIBIT 2. Receipt and timeliness of recommended breast cancer care among women in the continental US and the US territories

SOURCE Authors’ analysis of data from the Chronic Conditions Data Warehouse of the Centers for Medicare and Medicaid Services. NOTES Adjuvant RT is radiation therapy within six months after breast surgery. BCS is breast-conserving surgery. ^aDifference between the continental US (explained in the notes to exhibit 1) and the US territories (listed in the notes to exhibit 1) is significant (p < 0:001). ^bAmong women ages 66–74. ^cExcluding women who received neo-adjuvant chemotherapy (explained in the notes to exhibit 1). ^dExcluding women who received adjuvant chemotherapy (explained in the notes to exhibit 1).

EXHIBIT 3. Multivariate odds ratios for receipt of recommended breast cancer care among women in the US territories compared to those in the continental US

SOURCE Authors’ analysis of data from the Chronic Conditions Data Warehouse of the Centers for Medicare and Medicaid Services. NOTES The whiskers show 95% confidence intervals. Needle biopsy logistic regression models include all women who had breast surgery and were adjusted for age range at surgery (ages 70–74, 75–79, 80–84, and 85–94; ref: 65–69), individual binary indicators for a primary care visit and screening mammography in the year before surgery, and comorbidities (1–2 conditions and 3 or more conditions; ref: 0 conditions). Adjuvant radiation therapy (RT; explained in the notes to exhibit 2) logistic regression models include women younger than 75 who had BCS and did not receive adjuvant chemotherapy (explained in the notes to exhibit 1) and were adjusted for the factors listed above and an indicator for the use of neo-adjuvant chemotherapy (explained in the notes to exhibit 1): yes versus no chemotherapy used. The continental US and US territories are explained in the notes to exhibit 1.

EXHIBIT 4. Multivariate odds ratios for timeliness of recommended breast cancer care among women in the US territories compared to those in the continental US

SOURCE Authors’ analysis of data from the Chronic Conditions Data Warehouse of the Centers for Medicare and Medicaid Services. NOTES The whiskers show 95% confidence intervals. Breast surgery logistic regression models include all women who had breast surgery and did not receive neo-adjuvant chemotherapy (explained in the notes to exhibit 1) before and were adjusted for age range at surgery, individual binary indicators for a primary care visit and screening mammography in the year before surgery; comorbidities, and type of surgery (breast-conserving surgery [BCS] or mastectomy). Adjuvant radiation therapy (RT; explained in the notes to exhibit 2) logistic regression models include women described in the notes to exhibit 2 and were adjusted for the factors described above except for type of breast surgery, as well as an indicator for use of neo-adjuvant chemotherapy. The continental US and US territories are explained in the notes to exhibit 1.