Geographic patterns of change over time in mammography: Differences between Black and White U.S. Medicare enrollees
Introduction
In previous years, U.S. Black women had lower incidence rates of breast cancer compared to Whites, but recently, the rates have converged [1]. Black women also had a lower breast cancer mortality rate than Whites in the past; however, in the 1980s, Black women’s breast cancer mortality rate became higher than any other racial/ethnic group, and the disparity between Black and White women’s mortality rates has since widened [1]. This difference in mortality is likely due to 1) the fact that Black women across all ages are more likely to be diagnosed with late-stage breast cancer than Whites [2], [3]; and/or 2) Black women receiving poorer quality of care compared to Whites once diagnosed.
Some argue that racial disparities in care are the result of geographic variations in care, as Black people disproportionately live in areas with low-quality healthcare; at the same time, however, these patterns of disparities are varied and inconsistent [4]. For example, trends in breast cancer mortality vary widely by state: while death rates decreased in all states for White women between 1975 and 2004, they declined in less than one third of the states analyzed for Black women, and increased in two [5]. Similarly, from 1990 to 2009, breast cancer mortality disparities between Black and White women worsened in 24% of 762 U.S. counties with enough data to be studied [6]. City-level disparities also exist: from 2005 to 2007, the mortality rates of non-Hispanic Black women were higher than those of non-Hispanic White women in the majority of 24 large U.S. cities, which may be related to income differences and racial segregation [7].
The role of increased screening mammography in reducing breast cancer mortality among women is under debate [8], [9], [10]; however, screening mammography is the best method currently available for detecting breast cancer early. In combination with improved treatment, early detection by mammography is related to improved breast cancer survival outcomes [11].
In recent years, Black women have had equal or slightly higher rates of ever having had a mammogram compared to Whites [12], [13]. However, though the overall gap between these groups has closed across the nation as a whole, screening rates vary by geographic location. For example, a recent analysis found the proportion of Black women ages 45 and above receiving a mammogram in the last two years ranged from 68 to 89 percent (by state), and that of Whites from 66 to 86 percent [1]. In another study, researchers found the proportion of 65–69 year old women with Medicare receiving a mammogram in the last two years ranged from 21 to 77 percent across the nation (by hospital referral region) [14]. The main aim of this study was to assess geographic variations in U.S. screening mammography using small area analysis. Examining the changes in screening that took place over time by geographic area, and comparing between Black and White women, offers additional insight into national screening trends. We argue that by exploring the issue of screening mammography utilization from a spatial perspective, the effects of race, place, and healthcare geography can be simultaneously taken into account. Our specific objective was to formally assess the geographic pattern of change in mammography utilization for Black and White female Medicare enrollees ages 67–69 from 2008 to 2012 across the contiguous U.S.
Section snippets
Methods
The study population included Black and White female Medicare enrollees ages 67–69.Data was obtained from The Dartmouth Atlas of Health Care (DAHC), a project based at The Dartmouth Institute for Health Policy and Clinical Practice, which utilizes Medicare data to provide information on the U.S. healthcare system. Integrating multiple databases, DAHC offers data on services used by the Medicare population, ages 65 to 99, who are not enrolled in a risk-bearing health maintenance organization
Results
A total of 247 HRRs (see Table 1) had sufficient data to be included in the analyses; HRRs with insufficient data were the same for Black and White women.
Fig. 1, Fig. 2, Fig. 3 display the geographic distributions of screening rates and changes in screening utilization overall, for Black women, and for White women, respectively.
Discussion
This study assessed geographic variations in screening mammography, accounting for both race and geographic context. This paper highlights the importance of exploring this health-seeking behavior from a spatial perspective: indeed, nation-wide averages of changes in mammography do not uncover the more complete story of stark differences between Black and White women when assessing data using a method that incorporates geography. This study also adds to existing disparities research by assessing
Conflicts of interest
None.
Authorship contributions
Stiel, Soret, and Montgomery each contributed to the manuscript in accordance with the four criteria of the International Committee of Medical Journal Editors, contributing substantially to the conception and design of the work; the acquisition, analysis, and interpretation of data for the work; drafting or critically revising the work for content; and providing approval of the final version and agreeing to be accountable for the work, ensuring questions are appropriately investigated and
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In memoriam.