Variation in breast cancer care quality in New York and California based on race/ethnicity and Medicaid enrollment.
Variation in breast cancer care quality in New York and California based on race/ethnicity and Medicaid enrollment.
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DOI：
10.1002/cncr.29777
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发表时间：
2016-02-01
期刊：
影响因子：
6.2
通讯作者：
Schrag D
中科院分区：
文献类型：
--
作者：
Hassett MJ;Schymura MJ;Chen K;Boscoe FP;Gesten FC;Schrag D
种族/族裔和社会经济差距之所以持续存在，部分原因是我们对向少数群体和弱势群体提供的护理的了解有限。我们评估了两个大州的乳腺癌护理质量，以了解非洲裔美国人、西班牙裔、亚洲/太平洋岛民(API)和参加医疗补助的人所经历的差异，并确定补救策略的优先顺序。2004-2009年诊断为0-III期乳腺癌的80,436名纽约州和121,233名CA女性的全州癌症登记数据被用来评估手术、放射、化疗和激素治疗的使用不足和过度使用，基于34项质量指标。对种族/民族和医疗补助登记群体的协调值进行了比较。多变量模型量化了每个州每个治疗组之间的差异。总体上，使用不足的一致性为76%，过度使用的一致性为87%。接受护理符合所有相关措施的患者比例，纽约为35%，CA为33%。与白人相比，非洲裔美国人接受建议的手术、放射和激素治疗的可能性较小；西班牙裔和原料药通常更有可能接受建议的化疗。在各州，同样的种族/民族群体并不总是经历同样的差异。在这两个州，参加医疗补助与接受除化疗外的所有推荐治疗的可能性降低有关。过度使用在激素治疗和腋窝手术中很明显，但与种族/民族或医疗补助登记无关。患者水平的质量衡量标准确定了护理质量的实质性问题和有意义的差异。要纠正这些问题，就需要优先采取低绩效措施，并针对高危人群，可能针对不同地区采取不同的方式。
Racial/ethnic and socioeconomic disparities persist in part because our understanding of the care provided to minority and disadvantaged populations is limited. We evaluated the quality of breast cancer care in two large states to understand the disparities experienced by African-American, Hispanic, Asian/Pacific Islander (API), and Medicaid-enrollees and to prioritize remediation strategies. Statewide cancer registry data for 80,436 NY and 121,233 CA women diagnosed 2004-2009 with stage 0-III breast cancer were used to assess underuse and overuse of surgery, radiation, chemotherapy, and hormone therapy based on 34 quality measures. Concordance values were compared across racial/ethnic and Medicaid-enrollment groups. Multivariable models quantified disparities across groups for each treatment in each state. Overall concordance was 76% for underuse and 87% for overuse measures. The proportions of patients who received care concordant with all relevant measures were 35% in NY and 33% in CA. Compared to whites, African-Americans were less likely to receive recommended surgery, radiation, and hormone therapy; Hispanics and APIs were usually more likely to receive recommended chemotherapy. Across states, the same racial/ethnic groups did not always experience the same disparities. Medicaid enrollment was associated with decreased likelihood of receiving all recommended treatments, except chemotherapy, in both states. Overuse was evident for hormone therapy and axillary surgery, but was not associated with race/ethnicity or Medicaid enrollment. Patient-level measures of quality identify substantial problems with care quality and meaningful disparities. Remediating these problems will require prioritizing low-performing measures and targeting high-risk populations, possibly in different ways for different regions.