Applying a novel measure of community-level healthcare access to assess breast cancer care timeliness.

Abstract

Background: Geographic disparities in breast cancer outcomes exist. Few studies have examined community- and health system-level factors associated with care timeliness, an important measure of care quality.

Methods: The Carolina Breast Cancer Study is a population-based cohort of 2,998 women with invasive breast cancer (2008-2013). Using latent class modeling, patients' census tracts of residence were characterized by healthcare accessibility and affordability. Centers for Medicare and Medicaid Services ratings were used to classify hospitals as low- or high-quality. Six timeliness outcomes were assessed: 1) lacking pre-diagnostic regular care, 2) being under-screened, 3) late-stage diagnosis, 4) delayed treatment initiation, 5) prolonged treatment duration, and 6) lacking receipt of OncotypeDx genomic testing. Associations of geographic accessibility, healthcare affordability, and hospital-level quality with care timeliness were evaluated with frequency differences (RFDs) and 95% confidence intervals (CIs).

Results: Compared to "high accessibility, high affordability" census tracts, patients residing in "low accessibility, low affordability" areas were more likely to be under-screened (RFD= 18.7%, CI: 13.0, 24.3), have late-stage diagnosis (RFD= 6.2%, CI: 2.4, 10.1), and experience prolonged treatment (RFD=6.9%, CI: 1.4, 12.3). "High accessibility, low affordability" areas had the highest frequency of treatment delay (RFD= 9.3%, CI: 3.9, 14.7). Initial surgery at a high-quality facility was associated with less delayed treatment (RFD= -3.9%, CI: -7.5, -0.4) and prolonged treatment (RFD= -5.9%, CI: -9.9, -1.9).

Conclusions: Community- and health system-level factors were associated with timely breast cancer care.

Impact: Policy efforts to improve access in communities should consider multiple dimensions of access including geospatial accessibility and affordability.