Organizational Factors Affect Safety-Net Hospitals' Breast Cancer Treatment Rates

Abstract

Objective: To identify key organizational approaches associated with underuse of breast cancer care.

Setting: Nine New York City area safety-net hospitals.

Study design: Mixed qualitative-quantitative, cross-sectional cohort.

Methods: We used qualitative comparative analysis (QCA) of key stakeholder interviews, defined organizational "conditions," calibrated conditions, and identified solution pathways. We defined underuse as no radiation after lumpectomy in women <75 years or mastectomy in women with ≥4 positive nodes, or no systemic therapy in women with tumors ≥1 cm. We used hierarchical models to assess organizational and patient factors' impact on underuse.

Principal findings: Underuse varied by hospital (8-29 percent). QCA found lower underuse sites designated individuals to track and follow-up no-shows; shared clinical information during handoffs; had fully integrated electronic medical records enabling transfer of responsibility across specialties; had strong system support; allocated resources to cancer clinics; had a patient-centered culture paying close organizational attention to clinic patients. High underuse sites lacked these characteristics. Multivariate modeling found that hospitals with strong approaches to follow-up had low underuse rates (RR = 0.28; 0.08-0.95); individual patient characteristics were not significant.

Conclusions: At safety-net hospitals, underuse of needed cancer therapies is associated with organizational approaches to track and follow-up treatment. Findings provide varying approaches to safety nets to improve cancer care delivery.

Trial registration: ClinicalTrials.gov NCT01544374.

Keywords: Cancer care quality; breast cancer; coordination; organizational approaches; qualitative comparative analysis.