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Med Care. 2017 Dec;55(12):1030-1038. doi: 10.1097/MLR.0000000000000822.

Regional Medicare Expenditures and Survival Among Older Women With Localized Breast Cancer.

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*Yale School of Medicine†Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine‡Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University§Division of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT∥Health Research and Educational Trust, Chicago, IL¶Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine#Department of Chronic Disease Epidemiology, Yale School of Public Health**Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT.



Despite evidence on large variation in breast cancer expenditures across geographic regions, there is little understanding about the association between expenditures and patient outcomes.


To examine whether Medicare beneficiaries with nonmetastatic breast cancer living in regions with higher cancer-related expenditures had better survival.


A retrospective cohort study of women with localized breast cancer from the Surveillance, Epidemiology, and End Results-Medicare linked database. Hospital referral regions (HRR) were categorized into quintiles based on risk-standardized per patient Medicare expenditures on initial phase of breast cancer care. Hierarchical generalized linear models were estimated to examine the association between patients' HRR quintile and survival.


In total, 12,610 Medicare beneficiaries diagnosed with stage II-III breast cancer during 2005-2008 who underwent surgery.


Outcome measures for our analysis were 3- and 5-year overall survival.


Risk-standardized per patient Medicare expenditures on initial phase of breast cancer care ranged from $13,338 to $26,831 across the HRRs. Unadjusted 3- and 5-year survival varied from 66.7% to 92.2% and 50.0% to 84.0%, respectively, across the HRRs, but there was no significant association between HRR quintile and survival in bivariate analysis (P=0.08 and 0.28, respectively). After adjustment for sociodemographic and clinical characteristics, quintiles of regional cancer expenditures remained unassociated with patients' 3-year (P=0.35) and 5-year survival (P=0.20). Further analysis adjusting for treatment factors (surgery type and receipt of radiation and systemic therapy) and stratifying by cancer stage showed similar results.


For Medicare beneficiaries with nonmetastatic breast cancer, residence in regions with higher breast cancer-related expenditures was not associated with better survival. More attention to value in breast cancer care is warranted.

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