title: Effects of health insurance and race on breast carcinoma treatments and outcomes.
abstract: BACKGROUND
  The authors hypothesized that insurance payer and race would influence the care and outcomes for patients with breast carcinoma.
  
  
  METHODS
  The authors examined treatments and adjusted risk of death (through 1997) for all incident cases of breast carcinoma occurring in Florida in 1994 (n = 11,113) by using state tumor registry data.
  
  
  RESULTS
  Patients lacking health insurance were less likely to receive breast-conserving surgery (BCS) compared with patients who had private health insurance. Among patients insured by Medicare, those belonging to a health maintenance organization (HMO) were more likely to receive BCS but less likely to receive radiation therapy after BCS. Non-Hispanic African Americans had higher mortality rates even when stage at diagnosis, insurance payer, and treatment modalities used were adjusted in multivariate models (adjusted risk ratio [RR], 1.35; 95% confidence interval [CI], 1.12-1.61; P = 0.001). Patients who had HMO insurance had similar survival rates compared with those with fee-for-service (FFS) insurance. Among non-Medicare patients, mortality rates were higher for patients who had Medicaid insurance (RR, 1.58, 95% CI, 1.18-2.11; P = 0.002) and those who lacked health insurance (RR, 1.31; 95% CI, 1.03-1.68; P = 0.03) compared with patients who had commercial FFS insurance. There were no insurance-related differences in survival rates, however, once stage at diagnosis was controlled.
  
  
  CONCLUSIONS
  As a result of later stage at diagnosis, patients with breast carcinoma who were uninsured, or insured by Medicaid, had higher mortality rates. Mortality rates were also higher among non-Hispanic African Americans, a finding that was not fully explained by differences in stage at diagnosis, treatment modalities used, or insurance payer.
authors.affiliation: University of South Florida, Department of Family Medicine, Tampa 33612, USA. rroetzhe@hsc.usf.edu
authors.forename: R G
authors.initials: RG
authors.lastname: Roetzheim
authors.forename: E C
authors.initials: EC
authors.lastname: Gonzalez
authors.forename: J M
authors.initials: JM
authors.lastname: Ferrante
authors.forename: N
authors.initials: N
authors.lastname: Pal
authors.forename: D J
authors.initials: DJ
authors.lastname: Van Durme
authors.forename: J P
authors.initials: JP
authors.lastname: Krischer
mesh_terms: D001741:Black or African American; D044383:Black People; D001943:Breast Neoplasms / Q000208:ethnology / Q000401:mortality* / Q000628:therapy*; D005260:Female; D005431:Florida / Q000453:epidemiology; D006630:Hispanic or Latino; D006801:Humans; D007348:Insurance, Health; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D010342:Patient Acceptance of Health Care; D016016:Proportional Hazards Models; D012042:Registries; D015996:Survival Rate; D044465:White People