Search

PURPOSE: Since 2012, about 80 specialty societies have released Choosing Wisely (CW) recommendations aimed at reducing the use of low-value, unproven or ineffective medical services. The extent to which these recommendations have influenced the behavior of physicians and patients remains largely unknown. METHODS: Using MarketScan Commercial Claims and Medicare Supplemental and Coordination of Benefits databases, we identified annual cohorts of women with incident, early-stage breast cancer and estimated the prevalence of four initial treatment and six surveillance metrics deemed as low-value breast cancer care by CW. Multivariable logistic regressions were subsequently used to estimate temporal trends and regional variation in the use of these metrics, with a special focus on the year of CW’s publication. RESULTS: There were 122,341 women identified as undergoing treatment for incident breast cancer between 2010 and 2014. Two of the four low-value initial treatment metrics and four of the low-value six surveillance metrics declined significantly over time. The temporal trend of declining use, however, preceded the release of CW’s guidelines. Declines ranged from 11.0% for follow-up mammography to 40.6%for receipt of surgical biopsy without an attempted needle biopsy. There were marked regional differences in use of low-value breast cancer care for all metrics, much of which persisted after publication of CW. CONCLUSIONS: With two notable exceptions, use of low-value breast cancer care has declined steadily since 2010. The declines, however, were not accelerated by the publication of CW recommendations.

To examine the relationship between patient and tumor characteristics, patterns of breast cancer care, and 5-year survival among a population-based cohort of elderly women with incident breast cancer, with a special focus on identifying sources of socioeconomic (SES) disparities in outcomes.We identified women with newly diagnosed breast cancer in 2006-2009 from the Surveillance and Epidemiology End Result study linked with Medicare claims. A Classification and Regression Tree (CART) model was applied to 13 individual indicators of neoadjuvant and adjuvant breast cancer treatment, tumor characteristics, and patient sociodemographic variables to identify patterns with the greatest discriminant value in predicting 5-year survival. We subsequently examined the extent to which these patterns varied by the patient's SES.Survival probabilities associated with the 18 unique CART-identified patterns ranged from 22 to 87%. The number of positive axillary nodes was the best single discriminator between high and lower survival outcomes. The most common discriminant factor among patterns with poor ( 25%) survival was the absence of radiation treatment, followed by the presence of comorbidities, tumor size 2 cm, and no breast surgery. Relative to high SES women, poor women were nearly four times (12.3% vs. 3.2%, p 0.001) as likely to be classified in the pattern associated with worse survival, and less likely (31.7% vs. 52.9%, p = 0.04) to receive the pattern associated with the greatest survival.Greater adoption of effective patterns of care could improve survival of elderly women with incident breast cancer overall, and reduce SES disparities therein.

There is a growing body of literature linking hospital volume to outcomes in breast cancer. However, the mechanism through which volume influences outcome is poorly understood. The purpose of this study was to examine the relationship between hospital volume of breast cancer cases and patterns of processes of care in a population-based cohort of Medicare patients. A previously described and validated algorithm was applied to Medicare claims for newly diagnosed breast cancer cases in 2003 to identify potential subjects. Breast cancer patients were recruited to participate in a survey study examining breast cancer outcomes, and data were merged with Medicare claims and state tumor registries. Hospital volume was divided into tertiles. A Classification and Regression Tree (CART) model was performed to look for statistically significant relationships between patterns of processes of care and hospital volume. Using CART analysis, eight patterns of care were identified that differentiated breast cancer care at high- versus low-volume hospitals. Sentinel lymph node dissection (SLND) was the single process of care that demonstrated the greatest differentiation across hospitals with differing volumes. Four patterns of care significantly predicted that a patient was less likely to be treated at a high-volume hospital. Our study demonstrates differences in patterns of processes of care between low- and high-volume hospitals. Hospital volume was associated with several patterns of care that reflect the most current standards of care, particularly SLND. Greater adoption of these patterns by low-volume hospitals could improve the overall quality of care for breast cancer.

Adjuvant hormone therapy (HT) based on tamoxifen (TX) or aromatase inhibitors (AIs) has become the standard of care for treating hormone receptor -positive (HR+) breast cancer (BC) over the past 20 years. Based on clinical trial results, AI use is recommended by the American Society of Clinical Oncology for treatment of postmenopausal women with HR+ breast cancer. AIs, however, are significantly more expensive than TX, raising concerns about access and use of effective treatment among women of lower socio-economic status.To examine the relationship between adjuvant HT modality and experience of financial hardship among a cohort of older BC survivors. Also, to examine the extent to which financial concerns affect the probability of switching between adjuvant HT modalities.Population-based, prospective survey study.Elderly (65+) women who had an incident BC surgery in 2003 and who reported receiving adjuvant HT during the first 12 months post-surgery.Multivariate regression models.Use of AIs was associated with a significantly higher probability of financial hardship. Women who had taken only an AI were more likely to experience financial difficulty than women who took only TX (OR = 1.4; 95% CI: 1.1-1.7), but women who switched between TX and AI were not more likely to experience financial difficulty. Breast cancer survivors with no drug coverage (OR = 4.5; 95% CI: 3.3-5.9) or partial drug coverage (OR = 3.6; 95% CI: 2.8-4.5) were more likely to experience financial difficulty compared to those with full coverage. Lack of drug coverage was also the main factor associated with the likelihood that BC survivors did not switch adjuvant HT modalities.Adjuvant HTs have important economic consequences for BC survivors. These consequences are ameliorated by full, but not partial, drug coverage.

Purpose The high expense of newer, more effective adjuvant endocrine therapy agents (aromatase inhibitors [AIs]) for postmenopausal breast cancer contributes to socioeconomic disparities in breast cancer outcomes. This study compares endocrine therapy costs for breast cancer patients during the first five years of Medicare Part D implementation, and when generic alternatives became available.