Critical Evaluation Of Factors Contributing To Time To Mastectomy Within A Single Healthcare System
Jenna C. Bekeny, BA1, Kyle Luvisa, MPH2, Peter Wirth, BA2, Alex J. Bartholomew, BA2, David H. Song, MD, MBA1, Aviram Giladi, MD, MS3, Eleni Tousimis, MD1, Kenneth L. Fan, MD1.
1MedStar Georgetown University Hospital, Washington, DC, USA, 2Georgetown University School of Medicine, Washington, DC, USA, 3MedStar Union Memorial Hospital, Baltimore, MD, USA.
Purpose: Prolonged time to mastectomy (TTM) after a breast cancer diagnosis is associated with higher mortality. Yet, certain underserved populations are subject to patient, provider, and system level disparities, which contribute to increases in TTM. Through analysis of the largest healthcare provider system in the District of Columbia and Maryland, this study examines vulnerable populations that experience delay in TTM with the goal of improved understanding of barriers to care.
Methods: Patients undergoing mastectomy for breast cancer between 2014 to 2018 across 10 hospitals in a single healthcare system were retrospectively reviewed. Our cohort includes patients treated at academic, urban, community, and rural hospitals. Patients exceeding 365 days from diagnosis to mastectomy or with incomplete demographic information were excluded. The time from biopsy proven diagnosis to mastectomy was calculated. Demographic information including race, insurance type, location of hospital, median income by zip code, and disease characteristics were collected. Provider level and systems level variables, such as hospital of operation and insurance status, were determined. TTM was divided into quartiles. Univariate analysis was performed to identify which variables to include in the multivariable linear regression model evaluating factors associated with increased TTM.
Results: A population of 1375 patients was identified. Median TTM across all patients was 55 days. Statistically significant patient, provider, and system levels factors were associated with TTM. On multivariate analysis, time to surgery was 15.8% longer for patients with median salary by zip code <$75,000 when compared to those with salaries >$125,000 (65 days vs 49 days, p=0.0077). Black patients were found to have 11.8% longer TTM compared to white patients (69 days vs 56 days, p=0.0156). Patients who saw a plastic surgeon prior to mastectomy had a 20% longer time to surgery (p=0.0009). Lastly, system level factors identified in delay to
mastectomy included the type of insurance, as patients with Medicaid waited 14.6% longer compared to patients with commercial insurance (94 days vs. 62 days, p=0.0149).
Conclusion: In our review of care across a large healthcare system we identified patient, provider, and systems level disparities in surgical care after breast cancer diagnosis. Factors leading to increased TTM may explain differences in breast cancer survival amongst at risk populations. Identification of these disparities offers valuable insight to process improvement and intervention.
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