Breast cancer: Does where you get treated affect survival?

28 Background: Under the ACA, more women are insured with Medicaid which should improve access to cancer care. However, Disproportionate Share Hospitals (DSH) are due to receive reduced subsidies thereby threatening resource stressed facilities and poorer hospitals are experiencing greater financial penalties due to higher readmission rates. In NYS, 83% of Medicaid breast cancer patients got their cancer surgery at DSH hospitals. As women gain more choice and access, they will require information about hospitals’ quality and outcomes of cancer care. We sought to determine whether there are survival advantages among breast cancer patients treated at hospitals with varying proportions of Medicaid patients. Methods: We used non-obstetric delivery Medicaid discharges from NYS hospitals in 2005-13 to create quintiles of hospitalized patients with Medicaid. Women treated for breast cancer were identified with a diagnostic and procedure code for breast cancer. Based on NYS hospital discharge database linked with vital statistics death records, we calculated hazard ratios using marginal Cox model with a robust sandwich variance estimator controlling for clustering of patients within the hospital, age and comorbidity. Results: Quintiles of Medicaid hospitals ranged from low (0-15%), to low medium (15-22%), medium (22-29%), medium-high (29-50%), to high ( > 50%). 26% of breast cancer patients were treated at the low; 22% at the low medium; 20% at the medium; 21% at the medium-high and 11% at high quintile hospitals. Patients treated in hospitals with > 50% Medicaid patients had a higher long-term mortality (HR = 1.51; 95%CI: 1.19-1.93) compared to those treated at the lowest quintile hospitals. Sensitivity analyses to adjust for stage are underway. Conclusions: While the ACA may improve access to breast cancer treatment, the long term impact on survival remains questionable as women with breast cancer treated at hospitals with high proportions of Medicaid patients may have worse survival. Analyses to control for stage are underway. Pending these results, hospitals with high proportions of Medicaid patients may need to target cancer quality improvement efforts to assure equitable outcomes.