title: Differences in Breast Cancer Survival between Public and Private Care in New Zealand: Which Factors Contribute?
abstract: BACKGROUND
  Patients who received private health care appear to have better survival from breast cancer compared to those who received public care. This study investigated if this applied to New Zealand women and identified factors that could explain such disparities.
  
  
  METHODS
  This study involved all women who were diagnosed with primary breast cancer in two health regions in New Zealand, covering about 40% of the national population, between June 2000 and May 2013. Patients who received public care for primary treatment, mostly surgical treatment, were compared with those who received private care in terms of demographics, mode of presentation, disease factors, comorbidity index and treatment factors. Cox regression modelling was performed with stepwise adjustments, and hazards of breast cancer specific mortality associated with the type of health care received was assessed.
  
  
  RESULTS
  Of the 14,468 patients, 8,916 (61.6%) received public care. Compared to patients treated in private care facilities, they were older, more likely to be Māori, Pacifika or Asian and to reside in deprived neighbourhoods and rural areas, and less likely to be diagnosed with early staged cancer and to receive timely cancer treatments. They had a higher risk of mortality from breast cancer (hazard ratio: 1.95; 95% CI: 1.75, 2.17), of which 80% (95% CI: 63%, 100%) was explained by baseline differences, particularly related to ethnicity, stage at diagnosis and type of loco-regional therapy. After controlling for these demographic, disease and treatment factors, the risk of mortality was still 14% higher in the public sector patients.
  
  
  CONCLUSIONS
  Ethnicity, stage at diagnosis and type of loco-regional therapy were the three key contributors to survival disparities between patients treated in public and private health care facilities in New Zealand. The findings underscore the need for more efforts to improve the quality, timeliness and equitability of public cancer care services.
authors.affiliation: Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand.
authors.forename: Sandar
authors.initials: S
authors.lastname: Tin Tin
authors.affiliation: Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand.
authors.forename: J Mark
authors.initials: JM
authors.lastname: Elwood
authors.affiliation: Waikato Clinical School, University of Auckland, Hamilton, New Zealand.
authors.forename: Ross
authors.initials: R
authors.lastname: Lawrenson
authors.affiliation: Waikato Clinical School, University of Auckland, Hamilton, New Zealand.
authors.forename: Ian
authors.initials: I
authors.lastname: Campbell
authors.affiliation: Auckland District Health Board, Auckland, New Zealand.
authors.forename: Vernon
authors.initials: V
authors.lastname: Harvey
authors.affiliation: Waikato Clinical School, University of Auckland, Hamilton, New Zealand.|Department of Surgery, University of Colombo, Colombo, Sri Lanka.
authors.forename: Sanjeewa
authors.initials: S
authors.lastname: Seneviratne
mesh_terms: D001943:Breast Neoplasms / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D018270:Carcinoma, Ductal, Breast / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D018275:Carcinoma, Lobular / Q000401:mortality* / Q000473:pathology / Q000628:therapy; D003131:Combined Modality Therapy; D003695:Delivery of Health Care; D005006:Ethnicity / Q000706:statistics & numerical data*; D005260:Female; D016304:Hospitals, Private; D006779:Hospitals, Public; D006801:Humans; D008875:Middle Aged; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000378:metabolism; D015996:Survival Rate; D061665:Time-to-Treatment
chemical_list: D018719:Erb-b2 Receptor Tyrosine Kinases; C508053:ERBB2 protein, human