Skip to main content

Advertisement

SpringerLink
Log in

Breast cancer outcomes among older women

HMO, fee-for-service, and delivery system comparisons

  • Populations At Risk
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

OBJECTIVE: To analyze the relationship of health insurance status and delivery systems to breast cancer outcomes — stage at diagnosis, treatment selected, survival — focusing on comparisons among women aged 65 or more having Medicare alone, Medicare/Medicaid, or Medicare with group model HMO, non-group model HMO, or private fee-for-service (FFS) supplement.

DESIGN: Retrospectively defined cohort from Sacramento, Calif, regional cancer registry.

SETTING: Thirteen-county region in northern California with mature managed care market.

PATIENTS: Female invasive breast cancer patients aged 65 or more (N=1,146), diagnosed 1987–1993.

MEASUREMENTS AND MAIN RESULTS: Health insurance was determined from hospital records. Outcomes were analyzed with multivariate regression models, controlling for age, ethnicity, time, and SES measures. Stage I diagnosis was more likely among group model HMO patients than among private FFS insured (odds ratio [OR], 1.42; 95% confidence interval [CI], 0.84 to 2.40). Stage I tumors were significantly less likely for Medicaid patients (OR, 0.50; 95% CI, 0.31 to 0.82). Use of breast-conserving surgery plus radiation (BCS+) varied significantly by hospital type (including HMO-owned and various-sized community hospitals) and time. Survival of patients with private FFS, group-, and non-group model HMO insurance was not significantly different, but was for those with Medicaid or Medicare alone.

CONCLUSIONS: This study sheds new light on the relationship of insurance to stage and survival among older breast cancer patients, highlighting the importance of distinguishing types of HMOs and types of FFS plans. These outcomes do not differ significantly between women with Medicare who are in HMOs and those with private FFS supplemental insurance. However, patients with Medicare/Medicaid or Medicare alone are at risk for poorer outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Hoechst Marion Roussel. HMO-PPO/Medicare-Medicaid Digest. Managed Care Digest Series 1997. Kansas City, Mo: Hoechst Marion Roussel; 1997.

    Google Scholar 

  2. Hoechst Marion Roussel. HMO-PPO/Medicare-Medicaid Digest. Managed Care Digest Series 1998. Kansas City, Mo: Hoechst Marion Roussel; 1998.

    Google Scholar 

  3. Ries LAG, Kosary CL, Hankey BF, Miller BA, Edwards BK, eds. SEER Cancer Statistics Review, 1973–1995. Bethesda, Md: National Cancer Institute; 1998.

    Google Scholar 

  4. Ries LAG, Kosary CL, Hankey BF, Harras A, Miller BA, Edwards BK, eds. SEER Cancer Statistics Review, 1973–1993: Tables and Graphs. Bethesda, Md: National Cancer Institute; 1996.

    Google Scholar 

  5. Morris CR, Cohen R, Perkins CI, Allen M, Kwong SL, Schlag R, Wright WE. Cancer in California: 1988–1996. Sacramento, Calif: California Department of Health Services, Cancer Surveillance Section; March 1999.

    Google Scholar 

  6. Breen N, Kessler L. Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys. Am J Public Health. 1994;84:62–7.

    PubMed  CAS  Google Scholar 

  7. Morris CR, Wright WE, eds. Breast Cancer in California. Sacramento, Calif: California Department of Health Services, Cancer Surveillance Section; March 1996.

    Google Scholar 

  8. Centers for Disease Control. Self-reported use of mammography among women aged ≥40 years — United States, 1989 and 1995. MMWR. 1997;46:937–41.

    Google Scholar 

  9. Veronesi U, Saccozzi R, DelVecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radio-therapy in patients with small cancer of the breast. N Engl J Med. 1981;305:6–11.

    Article  PubMed  CAS  Google Scholar 

  10. Sarrazin D, Le M, Rouesse J, et al. Conservative treatment versus mastectomy in breast cancer tumors with macroscopic diameter of 20 millimeters or less. Cancer. 1984;53:1209–13.

    Article  PubMed  CAS  Google Scholar 

  11. Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation. N Engl J Med. 1985;312:665–73.

    Article  PubMed  CAS  Google Scholar 

  12. NIH Consensus Conference. Treatment of early-stage breast cancer. JAMA. 1991;265:391–5.

    Article  Google Scholar 

  13. Lazovich D, White E, Thomas DB, Moe RE. Underutilization of breast-conserving surgery and radiation therapy among women with stage I or II breast cancer. JAMA. 1991;266:3433–8.

    Article  PubMed  CAS  Google Scholar 

  14. Farrow DC, Hunt WC, Samet JM. Geographic variation in the treatment of localized breast cancer. N Engl J Med. 1992;326:1097–101.

    Article  PubMed  CAS  Google Scholar 

  15. Hunter CP, Redmond CK, Chen VW, et al. Breast cancer: factors associated with stage at diagnosis in black and white women. J Natl Cancer Inst. 1993;85:1129–37.

    Article  PubMed  CAS  Google Scholar 

  16. Eley JW, Hill HA, Chen VW, Austin DF, et al. Racial differences in survival from breast cancer. Results of the National Cancer Institute Black/White Cancer Survival Study. JAMA. 1994;272:947–54.

    Article  PubMed  CAS  Google Scholar 

  17. Lee-Feldstein A, Anton-Culver H, Feldstein PJ. Treatment differences and other prognostic factors related to breast cancer survival. Delivery systems and medical outcomes. JAMA. 1994;271:1163–8.

    Article  PubMed  CAS  Google Scholar 

  18. Riley GF, Potosky AL, Lubitz JD, Brown ML. Stage of cancer at diagnosis for Medicare HMO and fee-for-service enrollees. Am J Public Health. 1994;84:1598–604.

    Article  PubMed  CAS  Google Scholar 

  19. Foster RS, Farwell ME, Costanza MC. Breast-conserving surgery for breast cancer: patterns of care in a geographic region and estimation of potential applicability. Ann Surg Oncol. 1995;2:275–80.

    Article  PubMed  Google Scholar 

  20. Johantgen ME, Coffey RM, Harris DR, Levy H, Clinton JJ. Treating early-stage breast cancer: hospital characteristics associated with breast-conserving surgery. Am J Public Health. 1995;85:1432–4.

    PubMed  CAS  Google Scholar 

  21. Ballard-Barbash R, Potosky AL, Harlan LC, Nayfield SG, Kessler LG. Factors associated with surgical and radiation therapy for early stage breast cancer in older women. J Natl Cancer Inst. 1996;88:716–26.

    Article  PubMed  CAS  Google Scholar 

  22. Potosky AL, Merrill RM, Riley GF, Taplin SH, Barlow W, Fireman VH, Ballard-Barbash R. Breast cancer survival and treatment in health maintenance organization and fee-for-service settings. J Natl Cancer Inst. 1997;89:1683–91.

    Article  PubMed  CAS  Google Scholar 

  23. Riley GF, Potosky AL, Klabunde CN, Warren JL, Ballard-Barbash R. Stage at diagnosis and treatment patterns among older women with breast cancer: an HMO and fee-for-service comparison. JAMA. 1999;281:720–4.

    Article  PubMed  CAS  Google Scholar 

  24. Osteen RT, Winchester DP, Hussey DH, et al. Insurance coverage of patients with breast cancer in the 1991 Commission on Cancer Patient Care evaluation study. Ann Surg Oncol. 1994;1:462–7.

    Article  PubMed  CAS  Google Scholar 

  25. Gabel R. Ten ways HMOs have changed during the 1990s. Health Aff. 1997;16:134–45.

    Article  CAS  Google Scholar 

  26. Nattinger AB, Gottlieb MS, Veum J, Yahnke D, Goodwin JS. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med. 1992;326:1102–7.

    Article  PubMed  CAS  Google Scholar 

  27. Nattinger AB, Gottlieb MS, Hoffman RG, Walker AP, Goodwin JS. Minimal increase in use of breast-conserving surgery from 1986 to 1990. Med Care. 1996;34:479–89.

    Article  PubMed  CAS  Google Scholar 

  28. Young WW, Marks SM, Kohler SA, Hsu AY. Dissemination of clinical results. Mastectomy versus lumpectomy and radiation therapy. Med Care. 1996;34:1003–17.

    Article  PubMed  CAS  Google Scholar 

  29. Kotwall CA, Covington DL, Rutledge R, Churchill MP, Meyer AA. Patient, hospital, and surgeon factors associated with breast conservation surgery. A statewide analysis in North Carolina. Ann Surg. 1996;224:419–29.

    Article  PubMed  CAS  Google Scholar 

  30. Perkins CI, Morris CR, Wright WE. Cancer Incidence and Mortality in California by Race/Ethnicity, 1988–1993. Sacramento, Calif: California Department of Health Services, Cancer Surveillance Section; March 1996.

    Google Scholar 

  31. Percy C, Van Holten V, Muir C, eds. International Classification of Diseases for Oncology. 2nd ed. Geneva, Switzerland: World Health Organization; 1990.

    Google Scholar 

  32. American Joint Committee on Cancer. Manual for Staging of Cancer. 4th ed. Philadelphia, Pa: JB Lippincott, 1992.

    Google Scholar 

  33. Seiffert J, ed. SEER Program Comparative Staging Guide for Cancer, Version 1.1. Bethesda, Md: National Institutes of Health; 1993. NIH publication 93-3640.

    Google Scholar 

  34. Hayward RA, Shapiro MF, Freeman HE, Corey CR. Who gets screened for cervical and breast cancer? Results from a new national survey. Arch Intern Med. 1988;148:1177–81.

    Article  PubMed  CAS  Google Scholar 

  35. Krieger N. Social class and the black/white crossover in the age-specific incidence of breast cancer: a study linking census-derived data to population-based registry records. Am J Epidemiol. 1990;131:804–14.

    PubMed  CAS  Google Scholar 

  36. Lerman C, Rimer B, Trock B, Balshem A, Engstrom PF. Factors associated with repeat adherence to breast cancer screening. Prev Med. 1990;19:279–90.

    Article  PubMed  CAS  Google Scholar 

  37. Mandelblatt J, Andrews H, Kerner J, Zauber A, Burnett W. Determinants of late stage diagnosis of breast and cervical cancer: the impact of age, race, social class, and hospital type. Am J Public Health. 1991;81:646–9.

    PubMed  CAS  Google Scholar 

  38. Wells BL, Horm JW. Stage at diagnosis in breast cancer: race and socioeconomic factors. Am J Public Health. 1992;82:1383–5.

    PubMed  CAS  Google Scholar 

  39. Katz SJ, Hofer TP. Socioeconomic disparities in preventive care persist despite universal coverage. Breast and cervical cancer screening in Ontario and the United States. JAMA. 1994;272:530–4.

    Article  PubMed  CAS  Google Scholar 

  40. Breen N, Figueroa JB. Stage of breast and cervical cancer diagnosis in disadvantaged neighborhoods: a prevention policy perspective. Am J Prev Med. 1996;12:319–36.

    PubMed  CAS  Google Scholar 

  41. Michalski TA, Nattinger AB. The influence of black race and socioeconomic status on the use of breast-conserving surgery for Medicare beneficiaries. Cancer. 1997;79:314–9.

    Article  PubMed  CAS  Google Scholar 

  42. Krieger N, Williams DR, Moss NE. Measuring social class in US public health research: concepts, methodologies, and guidelines. Annu Rev Public Health. 1997;18:341–78.

    Article  PubMed  CAS  Google Scholar 

  43. State of California, Department of Health Services, Medi-Cal Policy Division. Hospital Peer Grouping. Sacramento, Calif: State of California, Department of Health Services; 1991.

    Google Scholar 

  44. American Hospital Association. 1990 American Hospital Association Guide to the Health Care Field. Chicago, Ill: American Hospital Association; 1991.

    Google Scholar 

  45. SAS Institute Inc. SAS/STAT User’s Guide. Version 6. Cary, NC: SAS Institute; 1990.

    Google Scholar 

  46. SAS Institute Inc. SAS/STAT Software: Changes and Enhancements through Release 6.11. Cary, NC: SAS Institute; 1996.

    Google Scholar 

  47. Hosmer DW, Lemeshow S. Applied Logistic Regression. New York, NY: Wiley; 1989.

    Google Scholar 

  48. Stokes ME, Davis CS, Koch GG. Categorical Data Analysis Using the SAS System. Cary, NC: SAS Institute; 1995.

    Google Scholar 

  49. Cox DR. Regression models and life tables. J R Stat Soc B. 1972;34:187–220.

    Google Scholar 

  50. Allison PD. Survival Analysis Using the SAS System: A Practical Guide. Cary, NC: SAS Institute; 1995.

    Google Scholar 

  51. Kaplan EL, Meier PL. Nonparametric estimation from imcomplete observations. J Am Stat Assoc. 1958;53:457–81.

    Article  Google Scholar 

  52. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst. 1959;22:719–48.

    PubMed  CAS  Google Scholar 

  53. Makuc DM, Freid VVM, Parsons PE. Health insurance and cancer screening among women. Advance Data from Vital and Health Statistics; no. 254. Hyattsville, Md: National Center for Health Statistics; 1994.

    Google Scholar 

  54. Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med. 1995;332:1138–42.

    Article  PubMed  CAS  Google Scholar 

  55. Potosky AL, Breen N, Braubard BI, Pearsons PE. The association between health care coverage and the use of cancer screening tests. Med Care. 1998;36:257–70.

    Article  PubMed  CAS  Google Scholar 

  56. Lee-Feldstein A, Feldstein PJ, Buchmueller T, Katterhagen G. The relationship of HMOs, health insurance, and delivery systems to breast cancer outcomes. Med Care. 2000;38:705–18.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Received from the Center for Health Policy and Research, Department of Medicine, College of Medicine, USA

    Anna Lee-Feldstein PhD

  2. Graduate School of Management, University of California, Irvine, Calif

    Paul J. Feldstein PhD & Thomas Buchmueller PhD

  3. Cancer Center, Tacoma General Hospital, Tacoma, Wash

    Gale Katterhagen MD (Office of Medical Director)

Authors
  1. Anna Lee-Feldstein PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Paul J. Feldstein PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thomas Buchmueller PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gale Katterhagen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Additional information

Cancer incidence data have been provided by the California Department of Health Services and its agent, the Public Health Institute, as part of its statewide cancer reporting program, mandated by Health and Safety Code Section 103875 and 103885. The ideas and opinions expressed herein are those of the authors, and no endorsement of the State of California, Department of Health Services or the Public Health Institute, is intended or should be inferred.

This research was supported by grant number CA-71236 from the National Cancer Institute. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Cancer Institute.

Dr. Katterhagen was formerly Medical Director, Cancer Program and Breast Center, Mills-Peninsula Hospital, Burlingame, Calif.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lee-Feldstein, A., Feldstein, P.J., Buchmueller, T. et al. Breast cancer outcomes among older women. J GEN INTERN MED 16, 189–199 (2001). https://doi.org/10.1111/j.1525-1497.2001.91112.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1111/j.1525-1497.2001.91112.x

Key words

Search

Navigation