Breast Cancer Survival and Treatment in Health Maintenance Organization and Fee-for-Service Settings

Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD 20892-7344, USA.
JNCI Journal of the National Cancer Institute (Impact Factor: 12.58). 12/1997; 89(22):1683-91. DOI: 10.1093/jnci/89.22.1683
Source: PubMed


Enrollment in health maintenance organizations (HMOs) has increased rapidly during the past 10 years, reflecting a growing emphasis on health care cost containment. To determine whether there is a difference in the treatment and outcome for female patients with breast cancer enrolled in HMOs versus a fee-for-service setting, we compared the 10-year survival and initial treatment of patients with breast cancer enrolled in both types of plans.
With the use of tumor registries covering the greater San Francisco-Oakland and Seattle-Puget Sound areas, respectively, we obtained information on the treatment and outcome for 13,358 female patients with breast cancer, aged 65 years and older, diagnosed between 1985 and 1992. We linked registry information with Medicare data and data from the two large HMOs included in the study. We compared the survival and treatment differences between HMO and fee-for-service care after adjusting for tumor stage, comorbidity, and sociodemographic characteristics.
In San Francisco-Oakland, the 10-year adjusted risk ratio for breast cancer deaths among HMO patients compared with fee-for-service patients was 0.71 (95% confidence interval [CI] = 0.59-0.87) and was comparable for all deaths. In Seattle-Puget Sound, the risk ratio for breast cancer deaths was 1.01 (95% CI = 0.77-1.33) but somewhat lower for all deaths. Women enrolled in HMOs were more likely to receive breast-conserving surgery than women in fee-for-service (odds ratio = 1.55 in San Francisco-Oakland; 3.39 in Seattle). HMO enrollees undergoing breast-conserving surgery were also more likely to receive adjuvant radiotherapy (San Francisco-Oakland odds ratio = 2.49; Seattle odds ratio = 4.62).
Long-term survival outcomes in the two prepaid group practice HMOs in this study were at least equal to, and possibly better than, outcomes in the fee-for-service system. In addition, the use of recommended therapy for early stage breast cancer was more frequent in the two HMOs.

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    • "Where done, survival differences have been largely attributed to differences in patient's age, stage of disease at diagnosis, and the presence of metastasis. Socioeconomic factors, differential access to health care, insurance status, comorbidities, and tolerance to prescribed treament have also been suggested to determine survival [3-5]. Immigration status and ethnicity may also play a role. "
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    ABSTRACT: Patterns in survival can provide information about the burden and severity of cancer, help uncover gaps in systemic policy and program delivery, and support the planning of enhanced cancer control systems. The aim of this paper is to describe the one-year survival rates for breast cancer in two populations using population-based cancer registries: Ardabil, Iran, and British Columbia (BC), Canada. All newly diagnosed cases of female breast cancer were identified in the Ardabil cancer registry from 2003 to 2005 and the BC cancer registry for 2003. The International Classification of Disease for Oncology (ICDO) was used for coding cancer morphology and topography. Survival time was determined from cancer diagnosis to death. Age-specific one-year survival rates, relative survival rates and weighted standard errors were calculated using life-tables for each country. Breast cancer patients in BC had greater one-year survival rates than patients in Ardabil overall and for each age group under 60. These findings support the need for breast cancer screening programs (including regular clinical breast examinations and mammography), public education and awareness regarding early detection of breast cancer, and education of health care providers.
    BMC Cancer 10/2009; 9(1):381. DOI:10.1186/1471-2407-9-381 · 3.36 Impact Factor
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    • "In cancer research, insurance claims data have been used to estimate the effectiveness of cervical cancer screening [16], to assess the role of screening practices in the incidence of prostate cancer [17], and to estimate mammography participation [18]. Medicare enrollees in Seattle and San Francisco who received care from a Health Maintenance Organization (HMO) were found to receive more BCS than women in Fee-For-Service (FFS) plans [19]. Whereas a Medicare/SEER registry linked data set has been used extensively to examine treatment and screening issues in individuals 65 years and older [20], linking of insurance claims data from private health plans in younger populations has been more difficult because of the large number of health plans in most geographic areas. "
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    ABSTRACT: The purpose of this study was to use insurance claims and tumor registry data to examine determinants of breast conserving surgery (BCS) in women with early stage breast cancer. Breast cancer cases registered in the Hawaii Tumor Registry (HTR) from 1995 to 1998 were linked with insurance claims from a local health plan. We identified 722 breast cancer cases with stage I and II disease. Surgical treatment patterns and comorbidities were identified using diagnostic and procedural codes in the claims data. The HTR database provided information on demographics and disease characteristics. We used logistic regression to assess determinants of BCS vs. mastectomy. The linked data set represented 32.8% of all early stage breast cancer cases recorded in the HTR during the study period. Due to the nature of the health plan, 79% of the cases were younger than 65 years. Women with early stage breast cancer living on Oahu were 70% more likely to receive BCS than women living on the outer islands. In the univariate analysis, older age at diagnosis, lower tumor stage, smaller tumor size, and well-differentiated tumor grade were related to receiving BCS. Ethnicity, comorbidity count, menopausal and marital status were not associated with treatment type. In addition to developing solutions that facilitate access to radiation facilities for breast cancer patients residing in remote locations, future qualitative research may help to elucidate how women and oncologists choose between BCS and mastectomy.
    BMC Cancer 02/2002; 2(1):3. DOI:10.1186/1471-2407-2-3 · 3.36 Impact Factor
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    • "As a result of these studies, the BCSP now uses both reminder postcards and outreach scheduling calls. Evidence for positive functional and clinical outcomes from implementing the components above is compelling (Potosky, Merrill, Riley, et al., 1997; Thompson, Barlow, Taplin, et al. 1994). First, participation in mammography screening is improving. "
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    ABSTRACT: Practical models of ways to enhance service delivery are sorely needed to help close the gap between research and practice. An evidenced-based model of chronic-illness management is shown to apply equally to preventive interventions. Successful examples of prevention programs in cancer screening and counseling for health behavior change illustrate the utility of the model for prevention and across different types of health care organizations. Although there are some important differences between interventions required for chronic disease management and prevention, there are a greater number of common factors. They share the need to alter reactive acute-care-oriented practice to accommodate the proactive, planned, patient-oriented longitudinal care required for both prevention and chronic care.
    Milbank Quarterly 02/2001; 79(4):579-612, iv-v. · 3.38 Impact Factor
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