Title: Quality Of Care And Patient Outcomes In Breast Cancer
1Quality Of Care And Patient Outcomes In Breast
Cancer
- Steven Katz M.D., M.P.H.
- Professor
- Departments of Medicine and Health Management and
Policy - Sarah Hawley Ph.D.
- Assistant Professor
- Department of Medicine
- University of Michigan
2Research Goals
- Advance methods to use cancer registries to
perform population studies of quality of cancer
care - Describe the context, process, and outcomes of
cancer treatment decisions - Evaluate the impact of clinician and delivery
system factors on the treatment experiences of
patients - Design interventions to improve quality
3The Quality Gap
Optimal Practice
Health outcomes
Structure
Patient perspectives about care
Quality Gap
Community Practice
use of effective treatment
4Opportunities
- Partnered with SEER registries to perform
population-based research to evaluate quality of
care - Engaged patients and their clinicians in the
community - Promoted the use of SEER cancer registries
- Advanced research
- Measures
- Sampling
- Data collection
- Informed Clinical and Health Policy
5Research Team MD
6Articles- Katz et al R01CA12345-01
7(No Transcript)
8Breaking The Mastectomy Over-treatment Myth
9- Compared to BCS w/radiation
- No difference in survival
- Little difference in local recurrence
- NCI, professional groups and advocates have
endorsed BCS
10Receipt of Mastectomy1 by Race and Year
1. for women with early stage disease, Source
SEERstat
11U.S. legislation on informed consent
- 20 states have passed legislation that mandate
physician disclosure of treatment alternatives
for breast cancer - Physician are required to give patients oral and
written summaries of alternative
Lantz P, Zemencuk J, Katz SJ. Is Mastectomy
Over-Utilized? A Call for a New Perspective.
Health Services Research. 2002 37(2) 417-431
12(No Transcript)
13Etiology of Overuse
- High variation in patterns of surgical
treatment for breast cancer is evidence of
failure to involve women about the treatment they
prefer.1
Persistent widespread regional variation in the
performance of breast conserving surgery would
appear to indicate that many women are not being
offered a choice2
- Wennberg JE. 13th annual Coggeshall lecture at
the Univ of Chicago, April 2002. - Institute of Medicine, National Research
Council 1999
14Research Questions
- What is the relationship between patient
involvement and receipt of surgical therapy? - Why do women receive mastectomy?
15Research Design
- Retrospective survey of patients recently
diagnosed with breast cancer and reported to
Detroit and Los Angeles SEER in 2002 - Over-sampled DCIS and African American women
- Surveyed attending surgeons
- Medical record and survey data combined
16Response Rate
- Patients
- 2,384 selected
- 1844 responded
- 77.3 response rate
- Surgeons
- 456 identified
- 365 responded
- 80.0 response rate
17Patient Sample Characteristics (N1835)
Figures are weighted to account for differential
selection by stage, ethnicity, and non-response
18Who made the surgery decision?
- Percent
- Doctor 10
- Doctor, considered patient opinion 13
- Made decision together 37
- Patient, considered doctor opinion 40
- Patient 3
19Receipt of Mastectomy by Decision Control and
Ethnicity
Women with AJCC stage 0,1 or 2 . Proportions
adjusted for age, marital status, education,
number of surgeons visited, medical comorbidity,
tumor behavior, tumor size, histological grade,
and SEER site. Interaction between racial
groups and decision control groups is significant
(Wald test 14.1, p.007) Katz et al. J Clin Onc.
200523(4)5526-5533 Katz et al. J Clin
Onc.200523(13)3001-3007.
20Level Of Patient Concern By Dimension
Women with AJCC stage 0,1 or 2 and who perceived
choice between surgical treatment alternatives
(N1079).
21Receipt Of Mastectomy By Level of Patient Concern
plt.001
plt.001
p.231
p.014
Among women with AJCC stage 0,1 or 2 and who
perceived choice between surgical treatment
alternatives (N1079), adjusted by age,
education, ethnicity, medical comorbidity,
tumor behavior, tumor size, histological grade..
22New Studies
- 3800 patients with breast cancer diagnosed in
2006 will be accrued in Detroit and Los Angeles
metro areas - Patients will be surveyed shortly after diagnosis
- SEER data will be merged to survey data
- All attending surgeons and oncologists will be
surveyed - Preliminary findings on LA sample presented
23Surgery Option Los Angeles Preliminary Sample
n1106
24Surgeon Recommendations
25Outcome of Attempted BCS
26Limitations
- Preliminary sample
- Later stage disease could not be excluded
- Findings unadjusted for over-sampling of selected
racial/ethnic groups - Patient self-report of treatment experience
27Conclusions
- Receipt of mastectomy is largely the result of
clinical contraindications to BCS and, to a
lesser extent, patient preferences - Infrequent discordance in surgical opinions about
the need for mastectomy and low rates of
mastectomy after BCS suggest that surgeons have
accepted BCS and standard contra-indications to
the procedure - Initiatives to improve surgical treatment
decision-making should focus on patient
perspectives about risks and benefits of surgical
options and predictors of failure of re-excision
after initial attempts at BCS
28Latina Patient Perspectives about Informed
Decision Making for Surgical Breast Cancer
TreatmentSarah T. Hawley, PhD, MPH
29Research Questions
- What is the degree to which Latina women (Spanish
and English speaking) with breast cancer
participate in informed treatment decision making
relative to Caucasian women? - What factors are associated with achieving the
desired amount of involvement in and informed
decision making for breast cancer treatment among
racial/ethnic minority women with breast
cancer?
30Decision Outcomes
- Involvement in the decision from Control
Preferences Scale (surgeon-based, shared, patient
based) - Concordance between actual-preferred amount of
involvement (too little, just right, too much) - Decision satisfaction 5-item scale
- Decision regret 5-item scale
31Decision Satisfaction Scale
- I am satisfied I was adequately informed about
the issues important to the decision about what
kind of surgery to have - I am satisfied with the decision about what kind
of surgery to have - I wish I had given more consideration to other
surgical treatment options - I would have liked more information when the
decision about surgery was made - I would like to have participated more in making
the decision about what kind of surgery to have
32Decision Regret Scale
- If I had to do it over
- I would make a different decision about what type
of surgery to have - I would choose a different surgeon for my surgery
- I would take more time to make decisions about my
treatment - I would consult more doctors about my treatment
before making a decision - I would do everything the same
33Patient Variables
- Race/ethnicity (Latina-Spanish speaking,
Latina-English speaking, African American,
Caucasian) - Education (less than high school, high school
graduate, some college, college graduate or more) - Age
34Analysis
- Descriptive and bivariate associations between
independent variables and involvement and
decision outcomes - Multinomial and logistic regression of
involvement and discordance to confirm results of
bivariate analyses
35Patient Characteristics
- Mean age 57 yrs (25-81)
- Race/ethnicity ()
- Latina-SP 25
- Latina-E 19
- African American 25
- Caucasian 28
- Education ()
- Less than high school 25
- High school graduate 18
- Some college 33
- College graduate 23
36Decision Involvement
Percentages adjusted for age and education
37Discordance Between Actual and Preferred
Involvement
Adjusted percentages controlling for age and
education Plt0.001
38Decision Dissatisfaction
Adjusted percentages controlling for age and
education Plt0.001
39Decision Regret
Adjusted percentages controlling for age and
education Plt0.001
40Conclusions
- Latina women, especially those who prefer
Spanish, are particularly vulnerable to poor
breast cancer treatment decisions - These disparities may be related to insufficient
match in decision involvement, lower satisfaction
with the decision process, and more decision
regret
41Limitations
- Preliminary data
- Self-reported information
- Need to tease apart the relationship between
race/ethnicity, language and acculturation
42Implications
- Large racial/ethnic disparities in decision
outcomes raise concerns about the quality of
treatment decisions and care - There is a need to explore the mechanisms
underlying these racial/ethnic disparities for
example health literacy, language and
acculturation