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Rebecca Lobb, ScD, MPH; Jennifer D. Allen, ScD, MPH, RN; Karen M. Emmons, PhD; John Z. Ayanian, MD, MPP

Arch Intern Med. 2010;170(6):521-528. Published online March 16, 2010 (doi:10.1001/archinternmed.2010.22).

Background  Since 1990, the National Breast and Cervical Cancer Early Detection Program (BCCEDP) has funded breast cancer screening and diagnostic services for low-income, underinsured women. Case management was implemented in 2001 to address barriers to follow-up after an abnormal mammogram, and free treatment was introduced in 2004. However, the effect of these policies on timeliness of care has not been empirically evaluated.

Methods  Among 2252 BCCEDP participants in Massachusetts during 1998 through 2007, we conducted a time-to-event analysis with prepolicy-postpolicy comparisons to examine associations of case management and free treatment with diagnostic and treatment delays (>60 days and >90 days, respectively) after an abnormal mammogram.

Results  The proportion of women experiencing a diagnostic delay decreased from 33% to 23% after the introduction of case management (P < .001), with a significant reduction in the adjusted risk of diagnostic delay (relative risk [RR], 0.65; 95% confidence interval [CI], 0.53-0.79) that did not differ by race and ethnicity. However, case management was not associated with changes in treatment delay (RR, 0.93; 95% CI, 0.80-1.10). Free treatment was not associated with changes in the adjusted risk of diagnostic delay (RR, 0.61; 95% CI, 0.33-1.14) or treatment delay (RR, 0.77; 95% CI, 0.43-1.38) beyond improvements associated with case management.

Conclusions  Case management to assist women in overcoming logistic and psychosocial barriers to care may improve time to diagnosis among low-income women who receive free breast cancer screening and diagnostic services. Programs that provide services to coordinate care, in addition to free screening and diagnostic tests, may improve population health.

Author Affiliations: Harvard School of Public Health (Drs Lobb, Allen, Emmons, and Ayanian), Dana-Farber Cancer Institute (Drs Allen and Emmons), Department of Health Care Policy, Harvard Medical School (Dr Ayanian), and Division of General Internal Medicine, Brigham and Women's Hospital (Dr Ayanian), Boston, Massachusetts; and Centre for Research on Inner City Health, St Michaels Hospital, Toronto, Ontario, Canada (Dr Lobb).

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