Stage at Diagnosis and Treatment Patterns Among Older Women With Breast Cancer: An HMO and Fee-for-Service Comparison

• Published in: JAMA : the journal of the American Medical Association Vol. 281; no. 8; pp. 720 - 726
• Main Authors: Riley, Gerald F, Potosky, Arnold L, Klabunde, Carrie N, Warren, Joan L, Ballard-Barbash, Rachel
• Format: Journal Article
• Language: English
• Published: Chicago, IL American Medical Association 24-02-1999
• Subjects: Aged; Biological and medical sciences; Breast cancer; Breast Neoplasms - diagnosis; Breast Neoplasms - economics; Breast Neoplasms - epidemiology; Breast Neoplasms - therapy; Fee-for-Service Plans - statistics & numerical data; Female; Gynecology. Andrology. Obstetrics; Health maintenance organizations; Health Maintenance Organizations - statistics & numerical data; HMOs; Humans; Logistic Models; Mammary gland diseases; Medical diagnosis; Medical sciences; Medicare; Neoplasm Staging; Older people; Practice Patterns, Physicians' - statistics & numerical data; SEER Program; Tumors; United States - epidemiology; Women; Human; Carcinoma; Prognosis; Radiodiagnosis; Mammography; Malignant tumor; Medical screening; Mammary gland diseases; Clinical stage; Treatment; Application method; Diagnosis; Mammary gland; Elderly; Comparative study
• ISSN: 0098-7484; 1538-3598
• DOI: 10.1001/jama.281.8.720

CONTEXT Few studies have compared patterns of care in health
maintenance organization (HMO) and fee-for-service (FFS) settings. OBJECTIVE To examine breast cancer stage at diagnosis and, for
those at an early stage, treatment patterns for elderly women in HMO
and FFS settings. DESIGN Cancer registry data from the Surveillance, Epidemiology,
and End Results (SEER) program linked to Medicare enrollment records. SETTINGS AND PARTICIPANTS Women aged 65 years or older
residing in 11 geographic areas who were newly diagnosed as having
breast cancer between 1988 and 1993. MAIN OUTCOME MEASURES Standardized percentage of cases diagnosed
at late stages for HMO vs FFS; standardized percentage of early-stage
cases undergoing initial treatment with breast-conserving surgery
(BCS); and, among BCS cases, standardized percentage receiving adjuvant
radiation therapy. Standardization was achieved through logistic
regression, controlling for patient demographics, cancer history,
county of residence, year of diagnosis, and educational attainment at
the census tract level. Analyses of treatment patterns were controlled
for stage at diagnosis and tumor size. RESULTS The HMO enrollees were less likely to have breast cancer
diagnosed at late stages than FFS patients (HMO, 7.6%; FFS, 10.8%;
difference, −3.2% [95% confidence interval (CI), −4.2% to
−2.2%]). Among early-stage cases, the percentages undergoing BCS
were similar in HMO and FFS settings overall (HMO, 38.4%; FFS, 36.8%;
difference, 1.6% [95% CI, 0.0%-3.2%]); percentages varied
markedly at the individual plan level. Among women undergoing BCS, HMO
enrollees were significantly more likely to receive radiation therapy
but, again, results varied by plan (HMO, 69.0%; FFS, 63.7%;
difference, 5.3% [95% CI, 2.9%-7.7%]). In general, use of BCS and
radiation therapy was substantially higher than that found in an
earlier study examining cases diagnosed between 1985 and 1989. CONCLUSIONS Treatment of early-stage breast cancer in HMOs often
differs from local FFS patterns, but not in a consistent way. During
the period of our study, elderly HMO enrollees did not appear to have
systematic access problems with adjuvant radiation therapy following
BCS compared with women in an FFS setting.