The Association of Socioeconomic Status and Access to Low-volume Service Providers in Breast Cancer 報告 : 張群明 指導 : 李清池 2013/07/02

Background Previous studies have showed that breast cancer patients treated by low volume providers have inferior outcome and survival than those treated by high volume providers. Roohan PJ, Am J Public Health. Mar 1998;88(3): Chang CM, PLoS One.7(7):e40590.

Several studies have showed that breast cancer patients of low SES, living in rural areas, far away from high volume hospitals were more likely to be treated at low-volume hospitals and by low-volume surgeons. Kong AL, Ann Surg Oncol. Oct;18(11): Gentil J, Dabakuyo TS, BMC Cancer.12:351. Low-SES patients might have less access to a high- volume provider due to their insurance status and live far away from a high volume hospital Al-Refaie WB, J Am Coll Surg. Jan;214(1):81-87

Gap No large-scale study has explored the combined effect of patients’ individual and neighborhood SES on their access to a low-volume provider in breast cancer. It has not been fully understood how significant the patients’ individual and neighborhood SES per se influences their treatment choices in breast cancer under a nationwide universal health insurance system.

Significance To explore whether breast cancer patients from a lower individual and neighborhood SES are disproportionately treated by low- volume providers under a nationwide universal health insurance system by using the Taiwan National Health Insurance Research Database (NHIRD).

Methods Database –data from 2002 from the National Health Insurance (NHI) Research Database, Definition of low-volume providers Lin CC, Surgery 143: Chang CM, PLoS One 7: e40590 Individual-level Measures –income-related insurance payment amount as a proxy measure of individual SES Braaten T, BMC Public Health 9: 178 Kwok J, Cancer 116: Chou FH-C, Schizophrenia research 129: Neighborhood-level socioeconomic status

Statistical Analysis The SPSS (version 15, SPSS Inc., Chicago, IL, USA) were used to analyze data. Univariate associations were evaluated by Pearson’s chi-square test. Multiple logistic regression was used to estimate the adjusted odds ratio for receiving breast cancer surgery based on each patient’s observed variables, which included age, individual and neighborhood SES, Charlson Comorbidity Index Score, and urbanization and regions of residence.

Results

Discussions Breast cancer patients with moderate/low SES in disadvantaged neighborhoods were more likely to receive treatment at low- volume hospitals, while individuals with moderate/low SES were more likely to visit low-volume surgeons. Even under a nationwide universal health insurance system, disparities in access to healthcare exist.

Inequalities in the utilization of medical resources may affect patients from different SES. Chang CM, PLoS One.7(8):e44325.

The SES of a patient played a key factor in treatment. High-SES breast cancer patients may use their knowledge, information, money, social connections, and other available resources to improve their health status even they live in disadvantaged neighborhoods.

A lower SES may cause stress, depression, and isolation on patients, which made it difficult for lower-SES patients to obtain useful information or advice from relatives, friends, or acquaintances. Wang JJ, Int J Nurs Stud. Jun 2001;38(3):

Our previous study showed that low-SES breast cancer patients had a higher risk of mortality. Chang CM, PLoS One 7: e44325 In the current study, we found such patients were more likely to be treated by low-volume providers, a factor for survival disparities. Chen CS, Breast Cancer Res Treat. Jul 2008;110(2): Vrijens F, Breast. Jun;21(3): Gooiker GA, Eur J Surg Oncol. Sep;36 Suppl 1:S27-35.

Application It has been suggest referral of patients to high- volume hospitals for a better application of recommended processes of care. Vrijens F, Breast. Jun;21(3): Guller U, World J Surg. Aug 2005;29(8): However, our study revealed though even our patients could receive treatment at any hospital, moderate- and low-SES patients in disadvantaged neighborhoods were more likely to be treated at a low-volume hospital. This may be the result of inconvenience and the considerable amount of expenses for a lower-SES patient to travel for surgery and adjuvant therapy.

A more important point for lower-SES breast cancer patients other than referring them to a high-volume provider is the difference in quality of treatment received when compared to high-SES patients.

If good outcomes can be demonstrated, low- volume providers who get good results should be also encouraged and supported. Authorities can also provide assistance by informing patients of providers in their area that have delivered good outcomes.

The authorities may offer a more convenient breast cancer screening programs for vulnerable groups in effort to detect breast cancer at an earlier stage.

Limitation First, the diagnosis of cancer, and any comorbidities, was completely dependent on ICD codes. Nonetheless, the National Health Insurance Bureau of Taiwan randomly reviews the charts and interviews patients in order to verify diagnosis accuracy. Second, the relationship of the stages of the breast cancer patients and provider caseloads could not be assessed because cancer stage data was not included in the database. However, Begg et al. revealed that cancer stage and patient age were independent of caseload volume in a SEER-Medicare linked database. Begg CB, JAMA. November 25, ;280(20):