Relating local health care delivery system characteristics to late-stage breast cancer risk and mortality in women in Georgia

Public health activities are designed to promote population health. Medical care represents one class of resources used to improve health; the remaining improvements in health status since the turn of the twentieth century were potentially due to public health activities. A focus on increasing access to health services among the underserved without special attention to type of health services does not necessarily lead to the most appropriate and adequate care. This study uses secondary data to develop insights into how public health systems can more effectively address the major public health problems of preventing and controlling breast cancer. The main hypothesis is that patients residing in communities with low socioeconomic status, poor public health infrastructure, less frequent primary care utilization, and high medical care utilization have higher late-stage cancer risk and mortality and experience more racially disparate outcomes. This study used cross-sectional and follow-up data from the Georgia cancer registry for individual-level factors, cancer incidence, receiving first course treatment (radiation and/or surgery), cancer mortality, and county of residence; the Area Resource File (ARF) from the Health Resources and Services Administration for population characteristics and health care delivery system characteristics. The study sample includes all women in Georgia's 159 counties who are diagnosed with first primary invasive breast cancer between the years 2000 and 2009. Multilevel logistic regression (late-stage cancer risk) and survival analyses using shared frailty approach (to control for intraclass county correlations) were used to estimate associations between population characteristics, race, local health care delivery system characteristics, health care utilization, and cancer outcomes with patient as the unit of analysis. Results from this study (1) describe levels of variation in late-stage breast cancer risk and mortality between various counties included in the analyses. (2) Describe differences in health care delivery system and utilization pattern between communities with high-risk and low-risk late-stage cancer and high-hazard and low-hazard of dying from the breast cancer. (3) Explore sources of variation in late-stage cancer risk and mortality and (4) identify factors that are associated with higher risk of late-stage cancer and mortality. This study address a gap within the organization and structure of the public health system by exploring the key elements and characteristics of the public health system that are associated with worse breast cancer outcomes.