Disparities in Utilization of Minimally Invasive Breast Biopsy – Illinois, Julia Fenlon Howland, MPH CPH 1, 2 Barbara Fischer, RN 2 1 CDC/CSTE Applied Epidemiology Fellow 2 Illinois Department of Public Health – Division of Patient Safety and Quality

Background: Definitions A breast biopsy is procedure to remove a small sample of breast tissue for laboratory testing – Used to evaluate a suspicious lesion – Determines whether a lesion is malignant Minimally invasive breast biopsy (MIBB) or percutaneous breast biopsy – Stereotactic – Ultrasound guided – Vacuum assisted Surgical biopsy – Incisional – Excisional

Background: MIBB A hollow needle is inserted into the breast to remove samples of tissue Local anesthesia Performed in outpatient settings

Percutaneous: Image-guided StereotacticUltrasound guided

Incisional and excisional Incision made on breast to remove tissue sample, or entire lesion Patient receives local or general anesthetic Procedure is done in OR and lasts about an hour

Advantages of MIBB Shorter recovery time Fewer operations and re-operations Fewer surgery-associated complications – Infection – Scarring Less expensive Accuracy equivalent to surgical biopsy

“ 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

Study questions Determine the rate of MIBB in Illinois Identify disparities in utilization of MIBB Examine charge data associated with MIBB and surgical biopsy Explore possible reasons for elevated rate of surgical biopsy and disparities in MIBB

Methods: Data Collection From the Illinois Hospital Discharge Database – Current Procedural Terminology codes 19100, 19102, and for MIBB and and for surgical biopsy – Demographic data – Charge data – Facility data BRFSS* geographic strata to classify address *BRFSS: Behavioral Risk Factor Surveillance System

BRFSS strata

Methods: Analysis Chi-square tests: test the significance of the relationships between demographic variables and the rate of MIBB Logistic regression: test the significance of increases in MIBB rate over time, and the increases in procedure charge over time Logistic regression: model factors associated with MIBB We used SAS 9.1 to complete all analysis

Sample characteristics Patient 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, % (12769) $50,000 - <$80, % (19862) $80,000 - <$120, % (22746) >= $120, % (9252) BRFSS strataCook County35.9% (23177) Collar counties25.2% (16295) Urban counties22.4% (14472) Rural counties16.5% (10685)

Results

Results: charge

Results: Chi-square tests Patient characteristicGroupPercent MIBBp value Age<=4076.0%< %< %<.05 >6172.1%Ref. RaceWhite72.9%Ref Black76.3%<.01 Latina70.2%<.01 Income< $50, %ns $60,000- $79, %<.01 $80,000 - $119, %ns >= $120, %Ref. PayerPrivate insurance74.0%Ref. Medicaid72.5%<.05 Medicare71.7%<.01 Uninsured72.7%ns

Result: geography County strataMIBB ratep value* Cook County 77.8%Ref. Collar counties 72.0%p<.01 Urban counties 72.3%p<.05 Rural counties 69.6%p<.01 *Completed using chi-square tests

Results: Logistic Regression Modeling VariableDegrees of freedom Wald chi-square value p value Home zip code strata <.01 Race <.01 Payer <.01 BRFSS strata*race <.01 Hosmer and LemeshowGoodness-of-FitTest Chi-SquareDFPr > ChiSq

Stratified Analysis: Cook County Patient characteristic GroupPercent MIBBOdds ratio (CI)p-value RaceWhite76.7%Reference Black78.5%1.12 (1.04 – 1.21) <.01 Latina77.4%ns PayerPrivate insurance 78.3%Reference Medicare75.6%0.86 ( ) <.01 Medicaid76.6%ns Uninsured62.4%0.5 (0.38 – 0.67) <.01

Stratified Analysis: Collar Counties Patient characteristic GroupOdds ratiop-value RaceWhiteReference Black Latina PayerPrivate insuranceReference Medicare Medicaid Uninsured Patient characteristic GroupPercent MIBBOdds ratiop-value RaceWhite72.5%Reference Black69.0%ns Latina58.7%0.54 (0.48 – 0.61) <.01 PayerPrivate insurance 72.2%Reference Medicare70.0%0.89 (0.82 – 0.98) <.01 Medicaid67.9%ns Uninsured73.5%ns

Stratified Analysis: Urban Counties Patient characteristic GroupOdds ratiop-value RaceWhiteReference Black Latina PayerPrivate insuranceReference Medicare Medicaid Uninsured Patient characteristic GroupPercent MIBBOdds ratiop-value RaceWhite72.0%Reference Black72.2%ns Latina62.4%0.63 (0.46 – 0.86) <.01 PayerPrivate insurance 71.7%Reference Medicare72.0%ns Medicaid72.8%ns Uninsured86.9%2.55 (1.68 – 3.87) <.01

Stratified Analysis: Rural Counties Patient characteristic GroupOdds ratiop-value RaceWhiteReference Black Latina PayerPrivate insuranceReference Medicare Medicaid Uninsured Patient characteristic GroupPercent MIBBOdds ratiop-value RaceWhite69.6%Reference Black65.0%ns Latina66.1%ns PayerPrivate insurance 70.1%Reference Medicare66.5%0.85 (0.77 – 0.93) <.01 Medicaid66.4%ns Uninsured71.5%ns

Rural Facility Analysis

MIBB rate by facility type Fifteen (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 value Teaching hospital 83.85%Ref Non-teaching hospital 71.26%p<.01 Critical access hospital 46.61%p<.01

Access to stereotactic equipment by BRFSS region Fifty-nine of the 80 rural hospitals (74%) do not have any stereotactic machinery. Urban counties: 38% no stereotactic equipment Collar counties: 33% no stereotactic machinery Cook County: 23% no stereotactic equipment

Conclusions MIBB is safer, less costly, and yields comparable diagnostic results to surgical biopsy The rate of MIBB is increasing in Illinois Despite increases, it remains below the recommended rate of 90-95%

Conclusions: Disparities Identified Latina women Women who live outside of Cook County, especially in rural counties Access to stereotactic equipment

Conclusions: Action Steps Provider training Funding for stereotactic machinery Referral 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

Acknowledgments Barbara Fischer, Illinois Department of Public Health Dr. Craig Conover, Illinois Department of Public Health The Division of Patient Safety and Quality The CDC/CSTE Applied Epidemiology Fellowship Program

Author contact Julia Howland Illinois Department of Public Health