Understanding reasons for underuse: An approach to improve quality and reduce disparities in breast cancer treatment

Objective: Effective adjuvant treatments proven to prolong survival for breast cancer exist, yet many women, particularly minority women, do not receive them. Little work has focused on improving the quality of, and reducing racial disparities in, cancer treatment. We describe the application of a conceptual model to direct, design, and implement trials to reduce underuse of effective adjuvant breast cancer treatments. Methods: Content analysis of extensive interviews and focus groups was used to construct a framework of patient, physician, and system-level reasons for underuse. Use of the model then directed development of targeted interventions aimed at ameliorating underlying causes. Results: The process of identifying patient, physician, and system-level reasons for underuse involved patients, surgeons, surgeon's office staff, and providers of patient assistance. Engaging these individuals both informed the design of our multifocused interventions and generated interest in trial participation. All 38 surgeons in six unaffiliated institutions and all 25 patient assistance programs approached agreed to participate in the intervention trials. Interpretation: identifying reasons for underuse by interviewing patients, physicians, physician office staff, and allied care providers about episodes in which needed care failed to occur helps engage key individuals, and can inform the design and implementation of interventions targeting barriers to delivering high quality breast cancer care to all. Mt Sinai J Med 75.23-30, 2008. (c) 2008 Mount Sinai School of Medicine