title: Earlier stage at diagnosis and improved survival among Medicare HMO patients with breast cancer.
abstract: OBJECTIVE
  We sought to evaluate differences in the stage at diagnosis and the survival of breast cancer patients enrolled in two different Medicare healthcare delivery systems: fee for service (FFS) and health maintenance organizations (HMO).
  
  
  METHODS
  We used a linkage of two national databases, the Medicare database from the Centers for Medicare and Medicaid Services (CMS), and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) program database, to evaluate differences in demographic data, stage at diagnosis, and survival in patients with breast cancers over the period 1985-2001.
  
  
  RESULTS
  Medicare patients enrolled in HMOs were diagnosed at an earlier stage of diagnosis than FFS patients. HMO patients diagnosed with breast cancer had improved survival, and these differences remained even after controlling for potential confounders. Specifically, breast cancer patients enrolled in HMOs had 9% increased probability of survival (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.88-0.93) than their counterparts enrolled in FFS. These findings persisted even when patients had a cancer diagnosis before their breast cancer.
  
  
  CONCLUSIONS
  Improved survival among breast cancer patients in HMOs compared with FFS is likely due to a combination of factors, including but not limited to earlier stage at the time of diagnosis.
authors.affiliation: Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Department of Dermatology, Miami, Florida 33136, USA. rkirsner@med.miami.edu
authors.forename: Robert S
authors.initials: RS
authors.lastname: Kirsner
authors.forename: Fangchao
authors.initials: F
authors.lastname: Ma
authors.forename: Lora E
authors.initials: LE
authors.lastname: Fleming
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Federman
authors.forename: Edward
authors.initials: E
authors.lastname: Trapido
authors.forename: Robert
authors.initials: R
authors.lastname: Duncan
authors.forename: Panta
authors.initials: P
authors.lastname: Rouhani
authors.forename: James D
authors.initials: JD
authors.lastname: Wilkinson
mesh_terms: D001943:Breast Neoplasms / Q000175:diagnosis / Q000401:mortality* / Q000473:pathology*; D042241:Early Diagnosis; D005260:Female; D006279:Health Maintenance Organizations; D006801:Humans; D053208:Kaplan-Meier Estimate; D006278:Medicare / Q000706:statistics & numerical data; D009367:Neoplasm Staging; D016609:Neoplasms, Second Primary / Q000175:diagnosis / Q000401:mortality; D018426:SEER Program; D014481:United States / Q000453:epidemiology