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Regional Medicare Expenditures and Survival Among Older Women With Localized Breast Cancer

Tannenbaum, Sara BA*; Soulos, Pamela R. MPH†,‡; Herrin, Jeph PhD‡,§,∥; Mougalian, Sarah MD‡,¶; Long, Jessica B. MPH†,‡; Wang, Rong PhD‡,#; Ma, Xiaomei PhD‡,#; Gross, Cary P. MD†,‡; Xu, Xiao PhD‡,**

doi: 10.1097/MLR.0000000000000822
Original Articles
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Background: Despite evidence on large variation in breast cancer expenditures across geographic regions, there is little understanding about the association between expenditures and patient outcomes.

Objectives: To examine whether Medicare beneficiaries with nonmetastatic breast cancer living in regions with higher cancer-related expenditures had better survival.

Research Design: A retrospective cohort study of women with localized breast cancer from the Surveillance, Epidemiology, and End Results-Medicare linked database. Hospital referral regions (HRR) were categorized into quintiles based on risk-standardized per patient Medicare expenditures on initial phase of breast cancer care. Hierarchical generalized linear models were estimated to examine the association between patients’ HRR quintile and survival.

Subjects: In total, 12,610 Medicare beneficiaries diagnosed with stage II–III breast cancer during 2005–2008 who underwent surgery.

Measures: Outcome measures for our analysis were 3- and 5-year overall survival.

Results: Risk-standardized per patient Medicare expenditures on initial phase of breast cancer care ranged from $13,338 to $26,831 across the HRRs. Unadjusted 3- and 5-year survival varied from 66.7% to 92.2% and 50.0% to 84.0%, respectively, across the HRRs, but there was no significant association between HRR quintile and survival in bivariate analysis (P=0.08 and 0.28, respectively). After adjustment for sociodemographic and clinical characteristics, quintiles of regional cancer expenditures remained unassociated with patients’ 3-year (P=0.35) and 5-year survival (P=0.20). Further analysis adjusting for treatment factors (surgery type and receipt of radiation and systemic therapy) and stratifying by cancer stage showed similar results.

Conclusions: For Medicare beneficiaries with nonmetastatic breast cancer, residence in regions with higher breast cancer–related expenditures was not associated with better survival. More attention to value in breast cancer care is warranted.

*Yale School of Medicine

Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine

Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University

§Division of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT

Health Research and Educational Trust, Chicago, IL

Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine

#Department of Chronic Disease Epidemiology, Yale School of Public Health

**Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT

The collection of the California cancer incidence data used in this study was supported by the California Department of Public Health as part of the statewide cancer reporting program mandated by California Health and Safety Code Section 103885; the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program under contract N01-PC-35136 awarded to the Northern California Cancer Center, contract N01-PC-35139 awarded to the University of Southern California, and contract N02-PC-15105 awarded to the Public Health Institute; and the Centers for Disease Control and Prevention’s National Program of Cancer Registries, under agreement #U55/CCR921930-02 awarded to the Public Health Institute. The ideas and opinions expressed herein are those of the author(s) and endorsement by the State of California Department of Public Health, the National Cancer Institute, and the Centers for Disease Control and Prevention or their Contractors and Subcontractors is not intended nor should be inferred. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database. The interpretation and reporting of the SEER-Medicare data are the sole responsibility of the authors.

Supported by the National Cancer Institute at the National Institutes of Health (grant number R01CA149045, PI: C.P.G.).

C.P.G. and P.R.S. receive research funding from 21st Century Oncology LLC. C.P.G. has also received funding from Medtronic and Johnson & Johnson and from the National Comprehensive Cancer Network-Pfizer. S.M. receives research funding from Pfizer through a joint NCCN-Pfizer research grant. X.M. consulted for Celgene and Incyte. S.M. receives consulting fees from HylaPharm LLC and Eisai Pharmaceuticals. The remaining authors declare no conflict of interest.

Reprints: Xiao Xu, PhD, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, 310 Cedar Street, LSOG 205B, New Haven, CT 06520. E-mail: xiao.xu@yale.edu.

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