SAN FRANCISCO-A patient's decision where to go to treat breast cancer can be a life-or-death choice-especially if the cancer treatment requires excision, researchers said here at the first Cancer Survivorship Symposium (Abstract 28).
"It does make a difference where you get treated surgically," said Rebeca Franco, MPH, a research project manager at the Center for Health Equity and Community Engaged Research at the Mount Sinai School of Medicine, New York City.
"I get that not everybody can go to a specialist hospital," Franco told OT, "but you should at least try to get to a specialist who can refer you. The specialty institutions have seen it all, and they know how to treat you."
Startling Statistics
Compared to hospitals that have the lowest percentage of Medicaid patients, the risk of dying within two years after breast cancer surgery at hospitals with the highest quintile of Medicaid patients in New York State is 11 times more likely, Franco reported in her poster presentation.
All-cause mortality and cancer-specific mortality, two-year overall mortality, and 30-day mortality are all significantly more likely to occur if breast cancer surgery is performed at facilities with the highest percentage of Medicaid patients, the researchers determined. About 99 percent of the women treated in the lowest quintile were alive at two years compared to about 93 percent of the women in the highest quintile of Medicaid patients.
Deaths due to cancer after two years had a similar finding. About 99 percent of the women from the lowest quintile did not succumb to cancer after two years, compared with about 92 percent of women in the highest percentile.
About 1 percent of women treated at the hospitals with the highest percentage of Medicaid use died within 30 days of treatment, compared to less than .01 percent of the women treated in the hospitals with the lowest percentages of Medicaid use.
"Efforts to identify and improve quality of care at high Medicaid hospitals should be undertaken," Franco and her fellow researchers suggested. "Such effort may be hampered by the increasing volumes of patients and potential reductions in reimbursement. Increasing volume of patients through the Affordable Care Act may add further strain to already resource-strained hospitals and impact quality of care and patient outcome."
Study Details
In performing the study, Franco and colleagues divided the hospitals into five quintiles based on Medicaid utilization:
* The lowest quintile had 0 to 15 percent of patients on Medicaid;
* The low-medium group had 15 percent to 22 percent of patients with Medicaid coverage;
* The medium group had 22 percent to 29 percent of patients with Medicaid coverage;
* The medium-high group had 29 percent to 50 percent Medicaid coverage; and
* The highest quintile had greater than 50 percent of patients with Medicaid coverage.
The researchers found that 26 percent of breast cancer patients were treated at the hospitals in the low quintile; 22 percent were treated at the low medium; 20 percent at the medium; 21 percent at the medium-high; and 11 percent at high quintile hospitals.
'See a Specialist'
In commenting on the study, Jacqueline Barrientos, MD, an investigator at the Feinstein Institute for Medical Research in Manhasset, New York, and Assistant Professor of Medicine at Hofstra University-LIJ School of Medicine, said, "For difficult-to-treat or rare conditions, definitely my recommendation would be to see a specialist that sees the disease more than once per year," adding that experts who see diseases such as hairy cell leukemia, for example, "may have breakthrough therapies available only through participation in clinical trials.
"In these regards, the Internet may be a great resource for patients, as they may learn about centers specializing in these diseases this way," she told OT.
Outcomes Evaluated
In Franco's study, researchers poured over the records from the New York State Hospital Discharge Data from 2005-2013. They evaluated outcomes of 60,590 women diagnosed with breast cancer during that time who were treated at 241 facilities-197 hospitals and 44 free-standing ambulatory surgery centers. The patient population was limited to women over the age of 21 who were treated with mastectomy, lumpectomy, or axillary node dissection, identified through hospital coding.
The hospital data allowed them to determine the number of patients who were treated under Medicaid formulas, and from that they were able to calculate the percentage of Medicaid patients in each hospital.
The researchers found that as the percentage of patients using Medicaid increased, so did the percentage of patients who identified themselves as black. The lowest quintile of hospitals with Medicaid patients had 9.9 percent black utilization compared to 29.5 percent of the patients with breast cancer treated in hospitals with the highest Medicaid population (P<0.001).
At the lowest quintile, about 5.6 percent of women identified as being of Hispanic ethnicity compared with 16.3 percent of the women with the high Medicaid usage.
In addition, co-morbidity scores were significantly higher in the highest quintile of Medicaid usage (0.33) compared to 0.16 in the lowest quintile (P<0.001), Franco reported.
"Minority and sicker patients are more likely to be treated at hospitals with a higher proportion of Medicaid patients," she said.
Despite that, the women treated at the facilities with highest Medicaid usage also tended to be younger, with a median age of 59 years compared to women treated in the hospitals with the lowest Medicaid population who had a median age of 62 years (P<0.001).
The symposium is co-sponsored by the American Academy of Family Medicine, the American College of Physicians, and the American Society of Clinical Oncology