Journal of the National Cancer Institute Advance Access originally published online on November 25, 2008
JNCI Journal of the National Cancer Institute 2008 100(23):1717-1723; doi:10.1093/jnci/djn387
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© The Author 2008. Published by Oxford University Press.
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A Tracking and Feedback Registry to Reduce Racial Disparities in Breast Cancer Care
Affiliations of authors: Department of Health Policy, Mount Sinai School of Medicine, New York, NY (NAB, KS, KF); Department of Surgery, Harlem Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY (SO); Department of Surgery, North General Hospital, New York, NY (HG); Department of Surgery, Bellevue Hospital and New York University School of Medicine, New York, NY (KH); Department of Surgery, Metropolitan Hospital Center, New York, NY (AS); Department of Surgery, New York University School of Medicine, New York, NY (AAG)
Correspondence to: Nina A. Bickell, MD, MPH, Department of Health Policy, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, PO Box 1077, New York, NY 10029 (e-mail: nina.bickell{at}mssm.edu).
Background: Black and Hispanic women with early-stage breast cancer are more likely than white women to experience fragmented care and less likely to see medical oncologists to get effective adjuvant treatment. We implemented a tracking and feedback registry to close the referral loop between surgeons and oncologists.
Methods: We compared completed oncology consultations and use of adjuvant treatment among a group of 639 women with newly diagnosed stage I or II breast cancer who had undergone surgery at one of six New York City hospitals from 1999 to 2000 with the same outcomes for a different group of 300 women with breast cancer whose surgeries occurred in 2004–2006, after the implementation of the tracking registry. Underuse of adjuvant treatment was defined as no radiotherapy after breast-conserving surgery, no chemotherapy for estrogen receptor (ER)–negative tumors, or no hormonal therapy for ER-positive tumors 1 cm or larger. We used hierarchical modeling to adjust for clustering within hospital and surgeon practice. Odds ratios were converted to adjusted relative risks (aRRs). All statistical tests were two-sided.
Results: Implementation of the tracking and feedback registry was accompanied by a statistically significant increase in oncology consultations (83% before vs 97% after the intervention; difference = 14%; 95% confidence interval [CI] = 11% to 18%; P < .001) and decrease in underuse of adjuvant treatment (23% before vs 14% after the intervention; difference = –9%, 95% CI = –12% to –6%; P < .001). Underuse declined from 34% to 14% among black women, from 23% to 13% among Hispanic women, and from 17% to 14% among white women (chi-square of change in underuse from before to after among the three racial groups; P = .001). In multivariable models adjusting for clustering by hospital and surgeon, the intervention was associated with increased rates of oncology consultation (aRR = 1.6, 95% CI = 1.3 to 1.8), and reduced underuse of adjuvant treatment (aRR = 0.75, 95% CI = 0.6 to 0.9). Compared with the preintervention findings, minority race was no longer a risk factor for low rates of oncology consultation (aRR = 1.0, 95% CI = 0.7 to 1.3) or for underuse of adjuvant therapy (aRR = 1.0, 95% CI = 0.8 to 1.3).
Conclusions: A tracking and feedback registry that enhances completed oncology consultations between surgeons and oncologists also appears to reduce rates of adjuvant treatment underuse and to eliminate the racial disparity in treatment.
| CONTEXT AND CAVEATS Prior knowledge Black and Hispanic women with newly diagnosed stage I or II breast cancer are less likely than white women to visit an oncologist and receive adjuvant therapy after surgery, a problem attributable to system failure. That is, even though their surgeons have recommended adjuvant treatment and the patients have not refused, many women end up not getting treated. Study design A program that tracked whether breast cancer patients successfully completed oncology referrals and received adjuvant treatment and that sent out reminders to surgeons of patients who had not visited an oncologist was implemented in September 2004 in conjunction with breast cancer surgeons at six New York City hospitals. Rates of oncology referral completion and adjuvant underuse among a retrospectively reviewed preintervention cohort of 639 women who had breast cancer surgery in 1999–2000 were compared with those for a postintervention cohort of 300 women who had breast cancer surgery in 2004–2006. Contribution Overall, the percentage of breast cancer patients who visited an oncologist rose from 83% to 97% and the number who did not receive adjuvant therapy declined, from 23% to 14%. Among black and Hispanic women, the postintervention decline in underuse of adjuvant therapy (30%–13%) was even more marked than among white and Asian women (19%–15%). Implications Implementation of such a tracking and feedback registry can help to overcome racial disparities in breast cancer outcomes. Limitations This was not a randomized study, so there may have been important confounding factors that influenced the observed results. From the Editors
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Manuscript received May 8, 2008; revised September 4, 2008; accepted September 30, 2008.
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J Natl Cancer Inst 2008 100: 1657.
J Natl Cancer Inst 2008 100: 1657.
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