title: The influence of race/ethnicity and place of service on breast reconstruction for Medicare beneficiaries with mastectomy.
abstract: Racial disparities in breast reconstruction for breast cancer are documented. Place of service has contributed to disparities in cancer care; but the interaction of race/ethnicity and place of service has not been explicitly examined. We examined whether place of service modified the effect of race/ethnicity on receipt of reconstruction. We included women with a mastectomy for incident breast cancer in SEER-Medicare from 2005-2009. Using Medicare claims, we determined breast reconstruction within 6 months. Facility characteristics included: rural/urban location, teaching status, NCI Cancer Center designation, cooperative oncology group membership, Disproportionate Share Hospital (DSH) status, and breast surgery volume. Using multivariable logistic regression, we analyzed reconstruction in relation to minority status and facility characteristics. Of the 17,958 women, 14.2% were racial/ethnic women of color and a total of 9.3% had reconstruction. Caucasians disproportionately received care at non-teaching hospitals (53% v. 42%) and did not at Disproportionate Share Hospitals (77% v. 86%). Women of color had 55% lower odds of reconstruction than Caucasians (OR = 0.45; 95% CI 0.37-0.55). Those in lower median income areas had lower odds of receiving reconstruction, regardless of race/ethnicity. Odds of reconstruction reduced at rural, non-teaching and cooperative oncology group hospitals, and lower surgery volume facilities. Facility effects on odds of reconstruction were similar in analyses stratified by race/ethnicity status. Race/ethnicity and facility characteristics have independent effects on utilization of breast reconstruction, with no significant interaction. This suggests that, regardless of a woman's race/ethnicity, the place of service influences the likelihood of reconstruction.
authors.affiliation: Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8, Lebanon, NH 03756 USA ; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA ; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH USA.
authors.forename: Tracy
authors.initials: T
authors.lastname: Onega
authors.affiliation: Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8, Lebanon, NH 03756 USA.
authors.forename: Julie
authors.initials: J
authors.lastname: Weiss
authors.affiliation: Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, CA USA ; General Internal Medicine Section, Department of Veterans Affairs, University of California, San Francisco, CA USA.
authors.forename: Karla
authors.initials: K
authors.lastname: Kerlikowske
authors.affiliation: Group Health Research Institute, Seattle, WA USA.
authors.forename: Karen
authors.initials: K
authors.lastname: Wernli
authors.affiliation: Group Health Research Institute, Seattle, WA USA.
authors.forename: Diana Sm
authors.initials: DS
authors.lastname: Buist
authors.affiliation: Department of Radiology, The University of North Carolina, Chapel Hill, NC USA.
authors.forename: Louise M
authors.initials: LM
authors.lastname: Henderson
authors.affiliation: Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8, Lebanon, NH 03756 USA ; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA.
authors.forename: Martha
authors.initials: M
authors.lastname: Goodrich
authors.affiliation: Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, HB 7927 Rubin 8, Lebanon, NH 03756 USA ; Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Alford-Teaster
authors.affiliation: School of Public Health, University of Minnesota, Minneapolis, MN USA.
authors.forename: Beth
authors.initials: B
authors.lastname: Virnig
authors.affiliation: Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH USA ; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH USA.
authors.forename: Anna Na
authors.initials: AN
authors.lastname: Tosteson
authors.affiliation: Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-3252 USA.
authors.forename: Wendy
authors.initials: W
authors.lastname: DeMartini
authors.affiliation: Group Health Research Institute, Seattle, WA USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hubbard
keywords: Breast cancer; Disparities; Mastectomy; Reconstruction