THE QUALITY OF BREAST-CANCER CARE IN LOCAL-COMMUNITIES - IMPLICATIONSFOR HEALTH-CARE REFORM

Despite many advances in the treatment of breast cancer during the las t decade, many breast cancer patients still do not receive appropriate treatment. The year 2000 cancer control objectives for the nation req uire a 50% decrease in breast cancer mortality. This goal cannot be ac hieved unless appropriate care is provided to all women with breast ca ncer. This study examines the role of patient characteristics, health insurance, physician characteristics, competition and local environmen t factors on the quality of care provided by physicians to breast canc er patients. Developed from a theoretical model of physician behavior, an empirical model was tested to demonstrate how these factors affect the quality of care provided for two specific breast cancer practice patterns: 1) whether a two-step surgical technique was performed and, 2) whether post-mastectomy rehabilitation and/or education was provide d. Data from the National Cancer Institute Community Cancer Care Evalu ation, from 1985-1986 were used and included information about the inp atient and outpatient care provided to 3,972 women with local or regio nal stage breast cancer from local communities across the United State s. Multivariable regression results indicate older patients were signi ficantly less likely to receive appropriate care for both surgical and rehabilitation practice patterns studied: patients 80 years and older were two to three times less likely to receive appropriate care. Howe ver, effects for other variables differed for the two practice pattern s studied: competition had a significant positive impact on surgical c are (Odds ratio (OR) = 1.37, P <0.01), but a negative impact on rehabi litation care (OR = 0.76, P <0.01), and only having Medicaid coverage had a significant positive impact on whether rehabilitation care was p rovided (OR 1.93, P <0.03), but no effect for whether a two-step proce dure was performed. The results from this study have implications for program design and policy initiatives aimed at assuring equity in acce ss to treatment for older women. Moreover, the differential effects of competition on these breast cancer practice patterns may have implica tions for health care reform efforts that rely exclusively on competit ive models without performance-based incentives to ensure appropriate care.