title: Income level and regional policies, underlying factors associated with unwarranted variations in conservative breast cancer surgery in Spain.
abstract: BACKGROUND
  Geographical variations in medical practice are expected to be small when the evidence about the effectiveness and safety of a particular technology is abundant. This would be the case of the prescription of conservative surgery in breast cancer patients. In these cases, when variation is larger than expected by need, socioeconomic factors have been argued as an explanation.
  
  
  OBJECTIVE
  Using an ecologic design, our study aims at describing the variability in the use of surgical conservative versus non-conservative treatment. Additionally, it seeks to establish whether the socioeconomic status of the healthcare area influences the use of one or the other technique.
  
  
  METHODS
  81,868 mastectomies performed between 2002 and 2006 in 180 healthcare areas were studied. Standardized utilization rates of breast cancer conservative (CS) and non-conservative (NCS) procedures were estimated as well as the variation among areas, using small area statistics. Concentration curves and dominance tests were estimated to determine the impact of income and instruction levels in the healthcare area on surgery rates. Multilevel analyses were performed to determine the influence of regional policies.
  
  
  RESULTS
  Variation in the use of CS was massive (4-fold factor between the highest and the lowest rate) and larger than in the case of NCS (2-fold), whichever the age group. Healthcare areas with higher economic and instruction levels showed highest rates of CS, regardless of the age group, while areas with lower economic and educational levels yielded higher rates of NCS interventions. Living in a particular Autonomous Community (AC), explained a substantial part of the CS residual variance (up to a 60.5% in women 50 to 70).
  
  
  CONCLUSIONS
  The place where a woman lives -income level and regional policies- explain the unexpectedly high variation found in utilization rates of conservative breast cancer surgery.
authors.affiliation: Instituto Aragonés de Ciencias de la Salud, Instituto de Investigación Sanitaria Aragón, Zaragoza, Spain.
authors.forename: Manuel
authors.initials: M
authors.lastname: Ridao-López
authors.forename: Sandra
authors.initials: S
authors.lastname: García-Armesto
authors.forename: Begoña
authors.initials: B
authors.lastname: Abadía-Taira
authors.forename: Salvador
authors.initials: S
authors.lastname: Peiró-Moreno
authors.forename: Enrique
authors.initials: E
authors.lastname: Bernal-Delgado
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000453:epidemiology* / Q000601:surgery*; D005260:Female; D006291:Health Policy; D006801:Humans; D015412:Mastectomy, Segmental / Q000706:statistics & numerical data; D008875:Middle Aged; D015233:Models, Statistical; D012923:Social Class; D013030:Spain