Applying a Novel Measure of Community-Level Healthcare Access to Assess Breast Cancer Care Timeliness

Abstract

Background: Geographic disparities in breast cancer outcomes exist. Few studies have examined community- and health system-level factors associated with care timeliness, an important measure of care quality.

Methods: The Carolina Breast Cancer Study is a population-based cohort of 2,998 women with invasive breast cancer (2008-2013). Using latent class modeling, patients' census tracts of residence were characterized by healthcare accessibility and affordability. Centers for Medicare and Medicaid Services ratings were used to classify hospitals as low- or high-quality. Six timeliness outcomes were assessed: (i) lacking prediagnostic regular care, (ii) being underscreened, (iii) late-stage diagnosis, (iv) delayed treatment initiation, (v) prolonged treatment duration, and (vi) lacking receipt of Oncotype DX genomic testing. Associations of geographic accessibility, healthcare affordability, and hospital-level quality with care timeliness were evaluated with relative frequency differences (RFD) and 95% confidence intervals (CI).

Results: Compared with "high-accessibility, high-affordability" census tracts, patients residing in "low-accessibility, low-affordability" areas were more likely to be underscreened (RFD = 18.7%, CI, 13.0, 24.3), have late-stage diagnosis (RFD = 6.2%, CI, 2.4, 10.1), and experience prolonged treatment (RFD = 6.9%, CI, 1.4, 12.3). "High-accessibility, low-affordability" areas had the highest frequency of treatment delay (RFD = 9.3%, CI, 3.9, 14.7). Initial surgery at a high-quality facility was associated with less delayed treatment (RFD = -3.9%, CI, -7.5, -0.4) and prolonged treatment (RFD = -5.9%, CI, -9.9, -1.9).

Conclusions: Community- and health system-level factors were associated with timely breast cancer care.

Impact: Policy efforts to improve access in communities should consider multiple dimensions of access, including geospatial accessibility and affordability.