title: Racial and socio-economic disparities in breast cancer hospitalization outcomes by insurance status.
abstract: Breast cancer remains a major cause of morbidity and mortality among women in the US, and despite numerous studies documenting racial disparities in outcomes, the survival difference between Black and White women diagnosed with breast cancer continues to widen. Few studies have assessed whether observed racial disparities in outcomes vary by insurance type e.g. Medicare/Medicaid versus private insurance. Differences in coverage, availability of networked physicians, or cost-sharing policies may influence choice of treatment and treatment outcomes, even after patients have been hospitalized, effects of which may be differential by race.
  
  
  
  The aim of this analysis was to examine hospitalization outcomes among patients with a primary diagnosis of breast cancer and assess whether differences in outcome exist by insurance status after adjusting for age, race/ethnicity and socio-economic status.
  
  
  
  We obtained data on over 67,000 breast cancer patients with a primary diagnosis of breast cancer for this cross-sectional study from the 2007-2011 Healthcare Cost and Utilization project Nationwide Inpatient Sample (HCUP-NIS), and examined breast cancer surgery type (mastectomy vs. breast conserving surgery or BCS), post-surgical complications and in-hospital mortality. Multivariable regression models were used to compute estimates, odds ratios and 95% confidence intervals.
  
  
  
  Black patients were less likely to receive mastectomies compared with White women (OR: 0.80, 95% CI: 0.71-0.90), regardless of whether they had Medicare/Medicaid or Private insurance. Black patients were also more likely to experience post-surgical complications (OR: 1.41, 95% CI: 1.12-1.78) and higher in-hospital mortality (OR: 1.57, 95%: 1.21-2.03) compared with White patients, associations that were strongest among women with Private insurance. Women residing outside of large metropolitan areas were significantly more likely to receive mastectomies (OR: 1.89, 95% CI: 1.54-2.31) and experience higher in-hospital mortality (OR: 1.74, 95% CI: 1.40-2.16) compared with those in metropolitan areas, regardless of insurance type.
  
  
  
  Among hospitalized patients with breast cancer, racial differences in hospitalization outcomes existed and worse outcomes were observed among Black women with private insurance. Future studies are needed to determine factors associated with poor outcomes in this group of women, as well as to examine contributors to low BCS adoption in non-metropolitan areas.
authors.affiliation: Department of Epidemiology, University of Alabama at Birmingham, Birmingham Alabama, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham Alabama, USA. Electronic address: tomiakin@uab.edu.
authors.forename: Tomi
authors.initials: T
authors.lastname: Akinyemiju
authors.affiliation: Department of Epidemiology, University of Alabama at Birmingham, Birmingham Alabama, USA.
authors.forename: Swati
authors.initials: S
authors.lastname: Sakhuja
authors.affiliation: Rocky Mountain Cancer Rehabilitation Institute, School of Sport and Exercise Science, University of Northern Colorado, Greeley, CO, USA; School of Social Work, College of Health and Human Sciences, Colorado State University, Fort Collins, CO, USA.
authors.forename: Neomi
authors.initials: N
authors.lastname: Vin-Raviv
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000191:economics* / Q000453:epidemiology / Q000401:mortality; D003430:Cross-Sectional Studies; D005260:Female; D054625:Healthcare Disparities / Q000191:economics* / Q000208:ethnology*; D006760:Hospitalization; D006801:Humans; D019458:Insurance Coverage / Q000191:economics*; D008875:Middle Aged; D044469:Racial Groups; D012923:Social Class; D014481:United States
keywords: Insurance type; Mortality; Post-surgical complications; Race/Ethnicity; Socio-economic status