Julia Fenlon Howland MPH CPH 1 2 Barbara Fischer RN 2 1 CDCCSTE Applied Epidemiology Fellow 2 Illinois Department of Public Health Division of Patient Safety and Quality Background Definitions ID: 1009716
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1. Disparities in Utilization of Minimally Invasive Breast Biopsy – Illinois, 2008-2010Julia Fenlon Howland, MPH CPH1, 2Barbara Fischer, RN 21CDC/CSTE Applied Epidemiology Fellow2Illinois Department of Public Health – Division of Patient Safety and Quality
2. Background: DefinitionsA breast biopsy is procedure to remove a small sample of breast tissue for laboratory testingUsed to evaluate a suspicious lesionDetermines whether a lesion is malignantMinimally invasive breast biopsy (MIBB) or percutaneous breast biopsyStereotacticUltrasound guidedVacuum assistedSurgical biopsyIncisionalExcisional
3. Background: MIBBA hollow needle is inserted into the breast to remove samples of tissue Local anesthesia Performed in outpatient settings
4. Percutaneous: Image-guidedStereotacticUltrasound guided
5. Incisional and excisionalIncision made on breast to remove tissue sample, or entire lesionPatient receives local or general anestheticProcedure is done in OR and lasts about an hour
6. Advantages of MIBBShorter recovery timeFewer operations and re-operationsFewer surgery-associated complicationsInfectionScarring Less expensive Accuracy equivalent to surgical biopsy
7. “ It was the Panel’s unanimous opinion that percutaneous needle biopsy represents “best practice” and should be the new “gold standard” for initial diagnosis. It should essentially replace open biopsy in this role. The Panel called on the medical community to change their current practice if they are using open surgical breast biopsy as a standard diagnostic procedure. Surgeons should audit their practice and make adjustments to decrease their rate of open biopsy for initial diagnosis to less than 5% to 10%.”- Consensus Conference III, International Breast Cancer Consensus Conference, June 2009
8. Study questionsDetermine the rate of MIBB in IllinoisIdentify disparities in utilization of MIBBExamine charge data associated with MIBB and surgical biopsyExplore possible reasons for elevated rate of surgical biopsy and disparities in MIBB
9. Methods: Data CollectionFrom the Illinois Hospital Discharge DatabaseCurrent Procedural Terminology codes 19100, 19102, and 19103 for MIBB and 19101 and 19125 for surgical biopsyDemographic dataCharge dataFacility dataBRFSS* geographic strata to classify address *BRFSS: Behavioral Risk Factor Surveillance System
10. BRFSS strata
11. Methods: AnalysisChi-square tests: test the significance of the relationships between demographic variables and the rate of MIBBLogistic regression: test the significance of increases in MIBB rate over time, and the increases in procedure charge over timeLogistic regression: model factors associated with MIBBWe used SAS 9.1 to complete all analysis
12. Sample characteristicsPatient characteristicGroupPercent of sample (n)RaceWhite79.4% (47295)Black13.9% (8282)Latina6.7% (4014)Age<=4012.9% (8304)40 - <=5027.5% (17800)50 - <=6025.6% (16527)>6034.0% (21998)PayerMedicare24.9 % (15596)Medicaid5.9% (3682)Private insurance68% (42614)Uninsured1.3% (801)Zip code median income<$50,00018.0% (12769)$50,000 - <$80,00032.9% (19862)$80,000 - <$120,00034.7% (22746)>= $120,00014.4% (9252)BRFSS strataCook County35.9% (23177)Collar counties25.2% (16295)Urban counties22.4% (14472)Rural counties16.5% (10685)
13. Results
14. Results: charge
15. Results: Chi-square testsPatient characteristicGroupPercent MIBBp valueAge<=4076.0%<.0141-5073.4%<.0151-6073.1%<.05>6172.1%Ref.RaceWhite72.9%RefBlack76.3%<.01Latina70.2%<.01Income< $50,00073.6%ns$60,000- $79,99971.2%<.01$80,000 - $119,99974.6%ns>= $120,00073.6%Ref.PayerPrivate insurance74.0%Ref.Medicaid72.5%<.05Medicare71.7%<.01Uninsured72.7%ns
16. Result: geographyCounty strataMIBB ratep value*Cook County77.8%Ref.Collar counties72.0%p<.01Urban counties72.3%p<.05Rural counties69.6%p<.01*Completed using chi-square tests
17. Results: Logistic Regression ModelingVariableDegrees of freedomWald chi-square valuep valueHome zip code strata4153.1169<.01Race230.7164<.01Payer326.4428<.01BRFSS strata*race8102.9482<.01Hosmer and LemeshowGoodness-of-FitTestChi-SquareDFPr > ChiSq5.112870.6462
18. Stratified Analysis: Cook CountyPatient characteristicGroupPercent MIBBOdds ratio (CI)p-valueRaceWhite76.7%ReferenceReferenceBlack 78.5%1.12(1.04 – 1.21)<.01Latina77.4%nsPayerPrivate insurance78.3%ReferenceReferenceMedicare75.6%0.86(0.80 - 0.93)<.01Medicaid76.6%nsUninsured62.4%0.5 (0.38 – 0.67)<.01
19. Stratified Analysis: Collar CountiesPatient characteristicGroupOdds ratiop-valueRaceWhiteReferenceReferenceBlack LatinaPayerPrivate insuranceReferenceReferenceMedicareMedicaidUninsuredPatient characteristicGroupPercent MIBBOdds ratiop-valueRaceWhite72.5%ReferenceReferenceBlack 69.0%nsLatina58.7%0.54(0.48 – 0.61)<.01PayerPrivate insurance72.2%ReferenceReferenceMedicare70.0%0.89(0.82 – 0.98)<.01Medicaid67.9%nsUninsured73.5%ns
20. Stratified Analysis: Urban CountiesPatient characteristicGroupOdds ratiop-valueRaceWhiteReferenceReferenceBlack LatinaPayerPrivate insuranceReferenceReferenceMedicareMedicaidUninsuredPatient characteristicGroupPercent MIBBOdds ratiop-valueRaceWhite72.0%ReferenceReferenceBlack 72.2%nsLatina62.4%0.63(0.46 – 0.86)<.01PayerPrivate insurance71.7%ReferenceReferenceMedicare72.0%nsMedicaid72.8%nsUninsured86.9%2.55(1.68 – 3.87)<.01
21. Stratified Analysis: Rural CountiesPatient characteristicGroupOdds ratiop-valueRaceWhiteReferenceReferenceBlack LatinaPayerPrivate insuranceReferenceReferenceMedicareMedicaidUninsuredPatient characteristicGroupPercent MIBBOdds ratiop-valueRaceWhite69.6%ReferenceReferenceBlack 65.0%nsLatina66.1%nsPayerPrivate insurance70.1%ReferenceReferenceMedicare66.5%0.85(0.77 – 0.93)<.01Medicaid66.4%nsUninsured71.5%ns
22. Rural Facility Analysis
23. MIBB rate by facility typeFifteen (83.3%) of the 18 teaching hospitals in Illinois are in Cook County. All of the 51 critical access hospitals are located outside of Cook County, and 92.2% are located in rural counties. Facility typeMIBB rateP valueTeaching hospital83.85%RefNon-teaching hospital71.26%p<.01Critical access hospital46.61%p<.01
24. Access to stereotactic equipment by BRFSS regionFifty-nine of the 80 rural hospitals (74%) do not have any stereotactic machinery. Urban counties: 38% no stereotactic equipmentCollar counties: 33% no stereotactic machineryCook County: 23% no stereotactic equipment
25. ConclusionsMIBB is safer, less costly, and yields comparable diagnostic results to surgical biopsyThe rate of MIBB is increasing in IllinoisDespite increases, it remains below the recommended rate of 90-95%
26. Conclusions: Disparities IdentifiedLatina womenWomen who live outside of Cook County, especially in rural countiesAccess to stereotactic equipment
27. Conclusions: Action StepsProvider trainingFunding for stereotactic machineryReferral network to nearby providers with stereotactic machinery and appropriately trained providers Additional investigation is needed to determine reason for excessive surgical biopsies among rural providers
28. Acknowledgments Barbara Fischer, Illinois Department of Public HealthDr. Craig Conover, Illinois Department of Public HealthThe Division of Patient Safety and QualityThe CDC/CSTE Applied Epidemiology Fellowship Program
29. Author contactJulia HowlandIllinois Department of Public HealthJulia.Howland@Illinois.gov312-793-0098