Correlates of between-surgeon variation in breast cancer treatments.
BACKGROUND
Determinants of between-surgeon variation in breast cancer treatment utilization are not well understood.


OBJECTIVE
The objectives of this study were to evaluate variation in receipt of surgical treatment (ie, mastectomy or breast-conserving surgery with or without radiation) for women with stage I, II, or III breast cancer and receipt of breast reconstruction attributable to surgeons, and to assess factors associated with this between-surgeon variation.


METHODS
We surveyed all attending surgeons (n = 456) of a population-based sample of patients with breast cancer diagnosed in Detroit and Los Angeles during 2002 (n = 1844). Our analytic dataset linked data from 1477 patients with that of 311 surgeons. We used random-effects modeling to account for the multilevel dataset and evaluated 2 outcomes: 1) primary surgical treatment (mastectomy vs. BCS); and 2) receipt of reconstruction before being surveyed (yes vs. no). Independent variables included patient-related factors (clinical and demographic), surgeon-related factors (breast procedure volume, practice setting, and demographics), surgeon treatment recommendation, and referral propensity.


RESULTS
Surgeons explain some variation in use of both mastectomy and reconstruction (9.9% and 26%, respectively). Patient clinical factors and surgeon volume together explain approximately one-third of the between-surgeon variation in mastectomy. Patient factors and surgeon demographics explain approximately 60% of between-surgeon variation in reconstruction, and surgeon referral propensity explains an additional 15%.


CONCLUSIONS
Our findings suggest that similar patients may get different treatment depending on their surgeon. Broader dissemination of guidelines coupled with increasing patient access to consultations before definitive surgery may reduce between-surgeon variation. Contributing factors such as patient-physician communication should be explored.
Hawley
Sarah T
ST
Division of General Medicine, Department of Internal Medicine, University of Michigan, 300 N. Ingalls, Ann Arbor, MI 48109, USA. sarahawl@med.umich.edu
Hofer
Tim P
TP
Janz
Nancy K
NK
Fagerlin
Angela
A
Schwartz
Kendra
K
Liu
Lihua
L
Deapen
Dennis
D
Morrow
Monica
M
Katz
Steven J
SJ
D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D015141:Los Angeles; D016462:Mammaplasty / Q000706:statistics & numerical data*; D008408:Mastectomy / Q000706:statistics & numerical data*; D008824:Michigan; D008875:Middle Aged; D009367:Neoplasm Staging; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D011787:Quality of Health Care; D018426:SEER Program; D012959:Socioeconomic Factors