title: The association of socioeconomic status and access to low-volume service providers in breast cancer.
abstract: BACKGROUND
  No large-scale study has explored the combined effect of patients' individual and neighborhood socioeconomic status (SES) on their access to a low-volume provider for breast cancer surgery. The purpose of this study was to explore under a nationwide universal health insurance system whether breast cancer patients from a lower individual and neighborhood SES are disproportionately receiving breast cancer surgery from low-volume providers.
  
  
  METHODS
  5,750 patients who underwent breast cancer surgery in 2006 were identified from the Taiwan National Health Insurance Research Database. The Cox proportional hazards model was used to compare the access to a low-volume provider between the different individual and neighborhood SES groups after adjusting for possible confounding and risk factors. Hosmer-Lemeshow goodness-of-fit statistic was used to determine how well the model fit the data.
  
  
  RESULTS
  Univariate analysis data shows that patients in disadvantaged neighborhood were more likely to receive breast cancer surgery at low-volume hospitals; and lower-SES patients were more likely to receive surgery from low-volume surgeons. In multivariate analysis, after adjusting for patient characteristics, the odds ratios of moderate- and low-SES patients in disadvantaged neighborhood receiving surgery at low-volume hospitals was 1.47 (95% confidence interval=1.19-1.81) and 1.31 (95% confidence interval=1.05-1.64) respectively compared with high-SES patients in advantaged neighborhood. Moderate- and low-SES patients from either advantaged or disadvantaged neighborhood had an odds ratios ranging from 1.51 to 1.80 (p<0.001) to receiving surgery from low-volume surgeons. In Hosmer-Lemeshow goodness-of-fit test, p>0.05 that shows the model has a good fit.
  
  
  CONCLUSIONS
  In this population-based cross-sectional study, even under a nationwide universal health insurance system, disparities in access to healthcare existed. Breast cancer patients from a lower individual and neighborhood SES are more likely to receive breast cancer surgery from low-volume providers. The authorities and public health policies should keep focusing on these vulnerable groups.
authors: Department of Surgery, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan ; School of Medicine, Tzu Chi University, Hualian, Taiwan.
authors: Chun-Ming
authors: CM
authors: Chang
authors: Wen-Yao
authors: WY
authors: Yin
authors: Chang-Kuo
authors: CK
authors: Wei
authors: Chun-Hung
authors: CH
authors: Lin
authors: Kuang-Yung
authors: KY
authors: Huang
authors: Shih-Pin
authors: SP
authors: Lin
authors: Cheng-Hung
authors: CH
authors: Lee
authors: Pesus
authors: P
authors: Chou
authors: Ching-Chih
authors: CC
authors: Lee
mesh_terms: D000368:Aged; D001943:Breast Neoplasms; D005260:Female; D006282:Health Personnel / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D012111:Residence Characteristics / Q000706:statistics & numerical data; D012923:Social Class; D019472:Universal Health Insurance