Disparities in Utilization of Minimally Invasive Breast Biopsy – Illinois, 2008-2010

Disparities in Utilization of Minimally Invasive Breast Biopsy – Illinois, 2008-2010

Julia Fenlon Howland, MPH CPH1, 2

Barbara Fischer, RN 2

1CDC/CSTE Applied Epidemiology Fellow2Illinois 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

Stereotactic Ultrasound 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 19103 for MIBB and 19101 and 19125 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 characteristicsPatient characteristic Group Percent of sample (n)

Race White 79.4% (47295)

Black 13.9% (8282)

Latina 6.7% (4014)

Age <=40 12.9% (8304)

40 - <=50 27.5% (17800)

50 - <=60 25.6% (16527)

>60 34.0% (21998)

Payer Medicare 24.9 % (15596)

Medicaid 5.9% (3682)

Private insurance 68% (42614)

Uninsured 1.3% (801)

Zip code median income <$50,000 18.0% (12769)

$50,000 - <$80,000 32.9% (19862)

$80,000 - <$120,000 34.7% (22746)

>= $120,000 14.4% (9252)

BRFSS strata Cook County 35.9% (23177)

Collar counties 25.2% (16295)

Urban counties 22.4% (14472)

Rural counties 16.5% (10685)

Results

2008 2009 20100

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

66.00%

68.00%

70.00%

72.00%

74.00%

76.00%

78.00%

70.23%72.83%

77.11%

MIBB and Surgical Biopsies and Percent of MIBB by Year -- Illinois, 2008-2010

MIBB Surgical Rate of MIBB

Year

Num

ber o

f bio

psie

s

Perc

ent M

IBB

Results: charge

2008 2009 20100.00

2000.00

4000.00

6000.00

8000.00

10000.00

12000.00

$4380.56 $4423.30 $4641.17

$8218.21

$10030.24$11281.63

Average charge by biopsy type and year -- Illinois 2008-2010

MIBB charge Surgical biopsy charge

Results: Chi-square testsPatient characteristic Group Percent MIBB p valueAge <=40 76.0% <.01

41-50 73.4% <.0151-60 73.1% <.05>61 72.1% Ref.

Race White 72.9% RefBlack 76.3% <.01Latina 70.2% <.01

Income < $50,000 73.6% ns$60,000- $79,999 71.2% <.01$80,000 - $119,999 74.6% ns>= $120,000 73.6% Ref.

Payer Private insurance 74.0% Ref.Medicaid 72.5% <.05Medicare 71.7% <.01Uninsured 72.7% ns

Result: geographyCounty strata MIBB rate p 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 ModelingVariable Degrees of

freedomWald chi-square value

p value

Home zip code strata

4 153.1169 <.01

Race 2 30.7164 <.01

Payer 3 26.4428 <.01

BRFSS strata*race 8 102.9482 <.01

Hosmer and LemeshowGoodness-of-FitTestChi-Square DF Pr > ChiSq

5.1128 7 0.6462

Stratified Analysis: Cook CountyPatient characteristic

Group Percent MIBB Odds ratio (CI) p-value

Race White 76.7% Reference Reference

Black 78.5% 1.12(1.04 – 1.21)

<.01

Latina 77.4% ns

Payer Private insurance

78.3% Reference Reference

Medicare 75.6% 0.86(0.80 - 0.93)

<.01

Medicaid 76.6% ns

Uninsured 62.4% 0.5 (0.38 – 0.67)

<.01

Stratified Analysis: Collar CountiesPatient characteristic

Group Odds ratio p-value

Race White Reference Reference

Black

Latina

Payer Private insurance Reference Reference

Medicare

Medicaid

Uninsured

Patient characteristic

Group Percent MIBB Odds ratio p-value


Black 69.0% ns

Latina 58.7% 0.54(0.48 – 0.61)

<.01



Medicare 70.0% 0.89(0.82 – 0.98)

<.01

Medicaid 67.9% ns

Uninsured 73.5% ns

Stratified Analysis: Urban CountiesPatient characteristic



Black

Latina


Medicare

Medicaid

Uninsured




Black 72.2% ns

Latina 62.4% 0.63(0.46 – 0.86)

<.01



Medicare 72.0% ns

Medicaid 72.8% ns

Uninsured 86.9% 2.55(1.68 – 3.87)

<.01

Stratified Analysis: Rural CountiesPatient characteristic



Black

Latina


Medicare

Medicaid

Uninsured




Black 65.0% ns

Latina 66.1% ns



Medicare 66.5% 0.85(0.77 – 0.93)

<.01

Medicaid 66.4% ns

Uninsured 71.5% 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 type MIBB rate P 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 QualityThe CDC/CSTE Applied Epidemiology Fellowship

Program

Author contact

Julia HowlandIllinois Department of Public Health

[email protected]

mailto:[email protected]

Date post:	22-Feb-2016
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Disparities in Utilization of Minimally Invasive Breast Biopsy – Illinois, 2008-2010

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