The Impact of Structure on Quality of Breast Cancer Care

Institution: University of California, Los Angeles
Investigator(s): Katherine  Kahn , M.D. -
Award Cycle: 2001 (Cycle VII) Grant #: 7PB-0126S Award: $891,916
Award Type: Request for Applications
Research Priorities
Community Impact of Breast Cancer>Health Policy and Health Services: better serving women's needs



Initial Award Abstract (2001)
Quality of health care is usually conceptualized in terms of the structure of care (e.g., setting, financial and organizational arrangements), process of care (e.g. education, diagnosis and treatment), and outcomes of care (e.g. survival, recurrence, quality of life). Understanding how structure impacts processes and outcomes is vital to quality improvement efforts, yet little is known about the structure of care for patients with breast cancer. The study of structure is necessary to understand how well the health care system is meeting the needs of breast cancer patients, to distinguish the types of medical organizations that deliver adequate and optimal care from those that do not, and to distinguish groups of patients who systematically do and do not receive adequate and optimal support from their health care organizations.

The goal of this study is to understand how the different structural aspects of care impact the quality of care for breast cancer patients. The findings of this work will help policymakers, healthcare organizations, providers and patients to understand ways in which structure of care influences processes and outcomes, identify barriers to optimal care delivery and will result in recommendations about how to eliminate those barriers and most effectively target quality improvement interventions.

With input from patients and providers in the community, we will develop a valid survey to collect data about the structure of care for breast cancer from individuals at three levels of the healthcare system responsible for providing care: the medical office, the medical group, and the health insurance plan. Topics will include financial incentives and organizational policies that support patients, providers, and coordination of care. Data about the structure of care will be merged with patient data about baseline characteristics, treatments, and outcomes 14 months after diagnosis for a cohort of newly diagnosed breast cancer patients (enrolled in an ongoing study of breast cancer care), and analyzed to learn what aspects of structure enhance or diminish the quality of care that patients receive.

Although the medical marketplace has begun to recognize that consumers demand quality, many healthcare organizations remain focused on strategies to contain costs. Previous studies examining structure and the quality of care have tended to measure structure very broadly (e.g., comparing fee-for-service to managed care). Few have addressed the effects of the many new, complex arrangements on quality, particularly in the context care for breast cancer. Without more precise and detailed information, the ability of policymakers and organizations to design and implement effective quality improvement interventions is severely compromised. The strengths of our study design include: 1) development of a survey based on previous research and the input of community patient and physician advisors to address specific details of structure for breast cancer care; 2) measurement of structural characteristics at not just one, but three important organizational levels of healthcare delivery: the actual provider's office, the medical group, and the health plan; and 3) data collection from multiple physician specialties essential to high quality breast cancer care (oncologists, radiation therapists, surgeons, primary care). These findings will provide a comprehensive view of the quality of care for women with breast cancer and inform policymakers about opportunities for interventions to improve the quality of care and outcomes for breast cancer patients.


Final Report (2006)
Introduction: Understanding how the structure of care (e.g. setting, organizational context) impacts what health care providers do for patients and the outcomes of care is vital to quality improvement efforts, yet little is known about the structure of care for patients with breast cancer. The purpose of this study is to measure and examine the structure of care for breast cancer patients enrolled in an ongoing study of quality of care, to supplement the patient-level data (already collected as part of an ongoing NCI-funded study of patient and medical record reports of processes and outcomes of care) with data regarding the structure of care, and to analyze the effects of structure on the quality of care that breast cancer patients receive.

Topic Addressed: The specific aims of this project are unchanged and are two-fold: 1) to develop reliable and valid measures of structural characteristics pertinent to breast cancer care; and 2) to evaluate the impact of structure on quality of care patients receive.

Progress toward specific aims: Three provider-level surveys (medical oncology, radiation oncology, and surgeon), were developed and fielded to 477 physicians, with a 77% response rate. Survey items drew upon the literature, the cognitive interviews, and review and discussion offered by community advisors. Data were de-identified. Data cleaning, internal consistency and validity checks and preliminary analyses have been performed. We created sampling weights make results more representative of the population. We have presented abstracts and are preparing manuscripts describing the structure of care characteristics, financial incentives and their variations across specialty and organization types, and neighborhood types in Los Angeles County.

Preliminary results indicate: 1) the settings in which Los Angeles breast cancer specialists practice are quite varied. Although many are in solo or single-specialty group practice as expected, many now work in more integrated settings with other provider types, such as managed care settings. Reimbursement mechanisms are varied, with fewer physicians than expected receiving payment in a single form (e.g., capitation, FFS). Many specialists reported facing financial incentives to provide more or fewer of certain services; incentives to do less appear positively associated with managed care involvement; 2) patient survey response was positively associated with volume of the patient’s treating hospital and negatively associated with neighborhood poverty, controlling for other patient characteristics. Patients’ use of hospitals with characteristics associated with high quality care varies by patient race/ethnicity and neighborhood characteristics including poverty, education, and percentages of foreign-born and limited-English speaking populations; 3) providing routine symptom evaluation services to breast cancer patients varies with specialty type, with medical oncologists providing the most routine evaluation and surgeons providing the least. Physician female gender, higher breast cancer volume, beliefs, single-specialty practice type and longer visit duration were associated with more symptom evaluation service delivery. Female gender and practice type appear associated with longer visit duration, which in turn is associated with more symptom evaluation; 4) physicians reported frequent barriers to arranging services and referrals imposed by health plan or medical organization policies; 5) radiation oncologists, and physicians practicing in staff/group model HMOs are more likely to report treating limited-English speaking breast cancer patients. Hispanic and Asian physician race/ethnicity is associated with serving higher proportions of limited-English speaking breast cancer patients. Having a high proportion of limited-English speaking patients is highly correlated with a high proportion of uninsured and Medicaid patients.

Future Direction: We are working on the data linkage and analyses necessary to complete Aim 2. We anticipate completing analyses linking provider and patient data sets in 2007 and priority manuscript writing in 2007 and 2008. Priority analyses with the linked data sets will explore the relationships between: 1) physician practice style regarding symptom evaluation and patient self-report of physician symptom evaluation and patient self-report of unmet needs regarding symptoms; 2) physician self-report of barriers to care and patient self-reported health status outcomes, and 3) physician self report of financial incentives and their association with patient self-reported health status outcomes.


Symposium Abstract (2003)
Introduction: Quality of health care is usually conceptualized as a model including the structure of care (e.g. setting, organizational context), the process of care (e.g. diagnosis, treatment), and outcomes of care (e.g. survival, quality of life). Understanding how structure impacts process and outcomes is vital to quality improvement efforts, yet little is known about the structure of care for patients with breast cancer. We developed a conceptual framework to guide the construction of reliable and valid measures of structural characteristics of breast cancer care to evaluate the impact of structure on the quality of care patients receive.

Methods: To develop our conceptual framework, we conducted the following: (1) a review of clinical and health services literature regarding structural characteristics and quality of care; (2) in depth cognitive interviews with 14 key informants: one medical organization quality director and 13 physicians including surgeons, medical oncologists, and radiation oncologists. Informants were selected from varying geographic locations in the Los Angeles region. Each interview lasted approximately one hour and covered topics including practice characteristics, access to medical information, decision support, patient education, access and barriers to referrals, coordination of care, and financial issues.

Results: We organized aspects of structure of care into a number of conceptual domains: Business Structure, Facilities and Resources, Physician Support, Patient Support, Coordination, Continuity, Financial Incentives, and Culture. Certain themes, such as access to patient medical information and provider-provider communications, were found in cognitive interviews to be less concerning to physicians than expected. Value placed on access and adherence to clinical practice guidelines varied. Other themes that emerged included the degree of integration of the physician’s practice with other disciplines, the role of tumor boards, variations in the use of care coordinators and linkages to community-based support groups, reimbursement mechanisms and restrictions on referral choices. Informants suggested we also investigate issues including physician burnout, reimbursement for new therapies, and shortages of important support personnel.

Next Steps: We will: (1) describe the epidemiology of structural characteristics of breast cancer providers in Los Angeles County, and (2) merge structural data with data from a cohort of breast cancer patients including health status, processes of care, and outcomes, to study the contribution of conceptually and clinically meaningful domains of structure to the quality of care received. We believe these analyses will provide a basis for improving the quality of care breast cancer patients receive by identifying mutable factors to target for quality improvement interventions.


Symposium Abstract (2005)
Introduction: Health care costs and quality are of concern nationally. Health care organizational arrangements have been evolving rapidly to respond to increasing financial pressures and to demands to enhance quality. These changes have been shown to impact primary care delivery, yet little is known about how new organizational and financial arrangements impact the delivery of breast cancer care. This is important, as breast cancer is 1) a complex, chronic disease involving multiple providers over time, and 2) often costly, making it a potential target for cost-containment efforts. We conducted a survey to describe the clinical epidemiology of the structure of breast cancer care in Los Angeles County.

Methods: To develop our conceptual framework, we conducted: 1) a review of clinical and health services literature regarding structural characteristics and quality of care; 2) cognitive interviews with 14 key informants including surgeons, medical oncologists, and radiation oncologists selected from varying geographic locations in the Los Angeles region. Interviews lasted one hour and covered topics including practice characteristics, barriers to referrals, coordination of care, patient and provider support, and financial issues. We revised the survey based on input from breast cancer specialists and community advisors. We organized survey topics into the following conceptual domains: Facilities and Resources, Referrals and Coordination, Physician Support, Patient Support, Continuity, and Financial Incentives. We mailed the self-administered survey to 477 medical oncologists, radiation oncologists and surgeons in 2004 (response rate=76%).

Results: Self-report data from 111 medical oncologist respondents indicated they were predominantly male (74%) and white (66%), with mean age = 53 (SD=9). Breast cancer represented 37% of their incident cancer cases. On average, medical oncologist respondents worked 50 hours per week in direct patient care in 2 unique offices. Respondents were asked to report about the office in which they see the most patients. The majority were in single or multi-specialty group (51%), HMO (14%) or university-based practices (9%). The following were present within their practice settings: oncology certified nurses (85%), surgeons (43%), nutritionists (41%), radiation oncologists (39%), primary care physicians (33%) and physical therapists (33%). Other available services included clinical trials (68%), care coordinators or navigators (45%), and patient support groups (34%). Respondents rarely reported that key clinicians or services were unavailable in the their area, with the exception of care coordinators or navigators (27%).

Provider network restrictions imposed by health plans or medical organizations were reported to sometimes, often, or always pose barriers to referrals to high quality mental health providers (41%), plastic surgeons (37%), medical oncologists for second opinions (31%), general surgeons (30%), and radiation oncologists (28%). Other organizational policies reported to always or often pose a barrier to arranging services included pre-authorization requirements (41%) and gatekeeper requirements (27%).

Conclusions: Provider settings and available services are varied. Cancer care providers report frequent barriers to delivering care. Further analyses are planned to determine the impact of the structural characteristics of care on the processes and outcomes of care that women with breast cancer ultimately experience.


Symposium Abstract (2007)
Research objective: Understanding whether physicians, nurses, paraprofessionals, or support staff complete prevalent tasks during patient visits with physicians could reveal useful insights into variations in care and outcomes. Physicians vary in the strategies they use to assure the delivery of high quality care at the lowest costs. Some physicians delegate tasks, while others complete the tasks themselves to optimize efficiency. Little is known about the clinical epidemiology of how office tasks are completed and how variations in who completes these tasks influence patient care and outcomes.

Study design: Using a cross-sectional survey, we queried physicians associated with a population-based cohort of women with incident breast cancer in Los Angeles County. We asked “Who usually performs clinically relevant tasks in your office setting?” (e.g., who: documents medication use, takes vital signs, monitors catheter use, monitors patient signs/symptoms, administers treatment ,monitors patient’s progress). Response options were: themselves, other health professionals (RN, LVN, administrative staff or no set policy).

We present the proportion of tasks (n=8) reported as performed by physicians themselves. We tested for bivariate and multivariate associations with physician age, gender, specialty, practice setting (county or medical school; HMO; solo practice; single specialty group, multispecialty group) and large practice size (>=50 physicians). Analyses were weighted for survey non-response and controlled for clustering at the office level.

Population studied: We surveyed all medical oncologists, radiation oncologists, and surgeons practicing in Los Angeles County identified by a population-based cohort of women with breast cancer retrieved from the cancer registry (76% response rate, n=348).

Principal findings: Of eight tasks studied, we noted substantial variations in physician report of completing tasks themselves: Physicians reported completing 0 tasks (5%), 1-2 tasks (23%), 3-4 tasks (34%), 5-6 tasks (32%), and 7-8 (6%) of 8 tasks. In bivariate analyses, older physicians reported performing a higher proportion of tasks (p<0.01); radiation oncologists and surgeons reported performing more tasks compared to medical oncologists (p<0.001). Physicians in large practices reported performing fewer tasks (p<0.05). In multivariable analyses, radiation oncologists and surgeons were more likely to report performing a higher proportion of tasks compared to medical oncologists (p<0.001). Physicians in single specialty groups were associated with a smaller proportion of tasks compared to physicians in solo practice (p<0.001).

Conclusions: Significant specialty and practice setting differences exist in the proportion of tasks reported as performed by cancer physicians themselves, as compared with by their designees. Physicians in solo practice appear less likely to delegate tasks compared to other physicians. Medical oncologists appear more likely to delegate tasks compared to other cancer specialists. In multivariate regression, large practice size did not appear to predict proportion of work done by physicians.

Implications for policy, delivery or practice: Understanding variations in practice style and predictors of those variations are the first step in understanding how structure influences care and outcomes. Next steps include linking these data to patient-level data to determine if differences in tasks performed by physicians as compared with their designee influences care or outcomes.


Symposium Abstract (2007)
Objectives Health care quality is of concern nationally, and health care structural arrangements have been evolving rapidly to respond to increasing financial pressures and demands to enhance quality. These changes have been shown to impact primary care delivery, yet little is known about how evolving organizational and financial arrangements affect the delivery of breast cancer care. We sought to better understand how physicians characterize their own financial incentives to perform various practices and services.

Methods Cross-sectional, observational study of physician self-reported financial arrangements from a 2004 survey of breast cancer care providers. We surveyed medical oncologists (n=111), radiation oncologists (n=66) and surgeons (n=171) practicing in Los Angeles County, identified by a population-based cohort of women with newly diagnosed breast cancer identified by the cancer registry (76% physician response rate, n=348). Physicians were asked to describe their overall, individual financial incentives with respect to selected clinical practices and services pertinent to breast cancer care (n=8 for medical oncologists, 6 for radiation oncologists, 3 for surgeons). For example, medical oncologists were asked to describe their individual financial incentives regarding the use of office-based parenteral chemotherapy. Respondents were asked to indicate whether on balance, incentives favor reducing the practice or service, expanding it, or neither. We examined the prevalence of self-reported incentives to reduce or expand each practice or service. Descriptive analyses were weighted for physician survey non-response.

Principle Findings Self-reports of implicit financial incentives to reduce or expand practices or services varied by specialty type and item. For example, among medical oncologists, rates of incentives either to reduce or expand practices or services ranged from 42% for office-based chemotherapy to 16% for use of in-dwelling venous catheter. Among radiation oncologists, rates ranged from 21% for CT-based treatment planning to 14% for stereotactic radiosurgery. Among surgeons, rates ranged from 11% for hospitalization to 6% for patient enrollment in clinical trials. Among medical oncologists who reported any incentives, incentives to expand services were reported for 4 out of 8 items (e.g., office-based chemotherapy) and incentives to reduce services were reported for 2 of 8 items (e.g., referral to other cancer care providers). Among radiation oncologists who reported any incentives, 4 of 6 services examined were associated with incentives to expand services. Among surgeons who reported any incentives, incentives were equally likely to be associated with service reduction (e.g., hospitalization) as with more service use (e.g., clinical trial enrollment).

Conclusions The majority of physicians delivering specific cancer treatments in Los Angeles County reported perceiving no overall personal financial incentives to reduce or expand the practices or services studied. However, notable proportions of physicians did report financial incentives either to reduce or expand performance of certain practices and services. Of these items, incentives were more often reported to favor expanding the practice or service. Further research is needed to determine whether such incentives change breast cancer care and outcomes, and what if any associations exist between implicit financial incentives (e.g., capitation or fee-for-service reimbursements) and performance on quality indicators.