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Racial/ethnic differences in patient experiences with health care in association with the Gleason’s score level at prostate cancer diagnosis: findings from the SEER-CAHPS data
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Racial/ethnic differences in patient experiences with health care in association with the Gleason’s score level at prostate cancer diagnosis: findings from the SEER-CAHPS data
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Content
RACIAL/ETHNIC DIFFERENCES IN PATIENT EXPERIENCES WITH HEALTH CARE IN
ASSOCIATION WITH THE GLEASON’S SCORE LEVEL AT PROSTATE CANCER
DIAGNOSIS:
FINDINGS FROM THE SEER-CAHPS DATA
By
Xiaohui Hu
A Thesis Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
BIOSTATISTICS
May 2020
Copyright 2020 Xiaohui Hu
ii
Table of Contents
List of Tables ................................................................................................................................. iii
List of Figures ................................................................................................................................. iv
Abstract ............................................................................................................................................ v
1 Introduction ............................................................................................................................. 1
2 Method ..................................................................................................................................... 2
2.1 Data Source ..................................................................................................................... 2
2.2 Study cohort ..................................................................................................................... 3
2.2.1 Race/ethnicity .............................................................................................................. 3
2.2.2 Patient experiences with components of their healthcare ............................................ 3
2.2.3 Gleason score ............................................................................................................... 4
2.2.4 Health care utilization .................................................................................................. 4
2.2.5 Potential confounding .................................................................................................. 4
2.3 Statistical Analysis .......................................................................................................... 5
3 Results ..................................................................................................................................... 6
3.1 Regression Analyses ........................................................................................................ 7
3.1.1 Patient experience with care and number of doctor visits ........................................... 7
3.1.2 Patient experience with care and race/ethnicity .......................................................... 8
3.1.2.1 Composite scores ................................................................................................. 8
3.1.2.2 Global Ratings of Care ........................................................................................ 9
3.2 Ordinal logistic regression ............................................................................................... 9
3.2.1 Health care experience and Gleason score .................................................................. 9
4 Discussion .............................................................................................................................. 10
References ..................................................................................................................................... 21
iii
List of Tables
Table 1. Distribution of sociodemographic characteristics by race/ethnicity for men diagnosed
with prostate cancer from 1997-2011 ............................................................................................ 15
Table 2. Description of patient demographics and report of their experiences with the health care
delivery system (composite ratings). ............................................................................................. 16
Table 3. Description of patient demographics and report of their mean rating of experiences with
the health care delivery system (global ratings). ........................................................................... 17
Table 4. Multivariable ordinal logistic regression model of patient experiences with rating of
health care and earlier stage at diagnosis, by race/ethnicity. ......................................................... 18
iv
List of Figures
Figure 1. Adjusted mean difference of patient experiences with aspects of their health care by
number of doctor visits in prior 6 months compared to one-time doctor visit (composite scores
and ratings). ................................................................................................................................... 19
Figure 2. Adjusted mean difference of patient experiences with aspects of their health care by
race/ethnicity compared to non-Hispanic white patients (composite scores and ratings). ............ 20
v
Abstract
Background
Hispanic men are more likely to be diagnosed with advanced stage of prostate cancer
compared to non-Hispanic white men potentially due to genetic differences and/or issues related
to access to urology care. Therefore, our objective was to ascertain racial/ethnic disparities in
patient experiences with medical care and to ascertain the relationship between the self-reported
quality of their patient experience and stage at diagnosis (using the Gleason score for prostate
cancer).
Methods
We used the SEER-CAHPS linked database for questionnaires completed prior to the
prostate cancer diagnosis date. We investigated patient responses about various aspects of their
medical care, such as the quality of physician communication and the ability to get care quickly.
Our study used multivariable linear regression to investigate racial/ethnic differences in patient
experience, and a multivariable ordinal logistic regression to examine the relationship between
patient experience and lower Gleason score level at prostate cancer diagnosis.
Results
Of the 11,791patients, 77.1% were non-Hispanic white patients, 9.2% were Hispanic
patients, 8.8% were non-Hispanic black patients, and 5.0% were Asian patients. After adjusting
for potential confounders and compared to non-Hispanic white patients, Hispanic patients had
significantly lower adjusted mean scores for customer service (β=-4.13,95%CI (-7.11,-1.16)),
getting care quickly (β=-3.49, 95%CI (-5.57,-1.41)), getting needed care ((β=-3.72), 95%CI (-
vi
5.25,-2.18)), getting needed prescription drugs (β=-2.79, 95%CI (-4.67,-0.90)), and lower rating
for overall health care ((β=-1.72, 95%CI (-3.03,-0.41)). More importantly, Hispanic patients who
reported a 1-unit increase in rating for getting care quickly were less likely to have a higher
Gleason scores at diagnosis (OR 0.99, 95%CI (0.98,1.00)).
Conclusion
Compared to non-Hispanic white patients, Hispanic patients reported poorer patient
experiences with care prior to prostate cancer diagnosis. Worse ratings in the ability to get care
quickly among Hispanic patients were related with higher Gleason scores at diagnosis.
1
1 Introduction
Cancer is the second leading cause of death in the U.S. Prostate cancer is the most common
cancer for U.S. males, although the incidence rate has declined about 7% per year over the past
decade
1
. Compared to non-Hispanic white men, Black and Hispanic men are more likely to
progress to a clinically advanced stage of prostate cancer and have higher mortality
2-7
. These
differences may be partially explained by racial biological diversity and health behaviors. Some
findings also show that Black and Hispanic men have poorer access to urology care and prostate-
specific antigen (PSA) tests
8
and require a longer time to recover after their cancer-related
treatments than non-Hispanic white men
9
. Receiving appropriate treatments and following timely
recommended surveillance can contribute to racial/ethnic disparities in cancer mortality
10,11
.
Therefore, the quality of health care that contributes to racial/ethnic disparities in prostate cancer
incidence should be evaluated.
An effective way to assess the quality of patient healthcare experiences is directly asking
patients to rate the care that they received. Previous research suggested that Black and Hispanic
patients reported worse patient-provider interactions than non-Hispanic whites
12
. The poor rating
of patient experiences usually relates to perceptions of lower quality of treatment, inadequate
communication, and unmet needs, which may account for the negative effect of their health
status
12-14
, for example a worsened condition. Access and use of health care, which may be
associated with cancer diagnosis, are also problems for minority groups
15,16
. Therefore, this study
aims to determine whether there are racial/ethnic disparities in patient experiences with medical
2
care and to ascertain the relationship between the self-reported quality of their patient experience
and stage at diagnosis (using the Gleason score for prostate cancer).
2 Method
2.1 Data Source
Data come from the National Cancer Institute’s Surveillance, Epidemiology and End Results
(SEER) program that is linked to the Centers for Medicare and Medicaid Services (CMS)
Medicare enrollment data, administrative claims, and the Consumer Assessment of Healthcare
Providers and Systems (CAHPS) patient experience survey. Detailed information about the
SEER-CAHPS linked database can be found elsewhere
17
. Briefly, the SEER cancer registry data
were used to obtain demographic, socioeconomic, prognostic, cancer diagnosis, and initial
treatment factors. The SEER cancer registry program collects and maintains patient demographic
(race/ethnicity, sex, date of birth, marital status), tumor and clinical prognostic information (e.g.,
date of diagnosis, tumor stage (clinical and pathologic) and size, cell differentiation, axillary
lymph node involvement, receptor-status, histology) and treatment information (surgery,
radiation) on all individuals diagnosed with cancer while residing in participating cancer registry
areas
17
. The data also includes neighborhood-level socioeconomic information. Our purpose was
to determine racial/ethnic disparity in the patient experiences with the quality of their healthcare
and satisfaction with their providers by using data from the SEER registry-CAHPS Survey
linked data. The CAHPS survey measures patient experiences with health care providers and the
care that patients received as a way to assess the perceived quality of care. Since 1998, CMS has
annually conducted a nationwide survey of random samples of beneficiaries representing health
3
insurance across the country, covering various indicators of perceived quality and access to
health care. The average Medicare patients’ response rate is 71%
17
.
2.2 Study cohort
We conducted a retrospective cohort analysis of men ≥ 65 years old diagnosed with prostate
cancer from 1997-2011. Patients were included if they completed a CAHPS survey on their
experiences with medical care before their cancer diagnosis. We excluded patients younger than
65 years old at the time of survey and those with missing race/ethnicity information. For patients
with more than one completed CAHPS survey, we used the record that was closest to the first
prostate cancer diagnosis.
2.2.1 Race/ethnicity
According to the race/ethnicity identified in SEER, we created a mutually exclusive variable
with five racial/ethnicity categories: Hispanic, Non-Hispanic white, Non-Hispanic Asian, Non-
Hispanic black, and other. If an individual was classified as Hispanic in either CAHPS,
Medicare, or SEER datasets, then this person was categorized as Hispanic. We used CAHPS’s
self-reported race variable as our primary rule to classify the race/ethnicity of patients. We took
the racial information from the SEER registry as the second choice and Medicare as the third, for
patients whose ethnicity information was missing. Because of the small sample size (N=14), we
did not include the ‘Other’ race category in our analyses.
2.2.2 Patient experiences with components of their healthcare
Five composite measures from CAHPS survey responses were utilized to assess patient
experiences with: 1) customer service, 2) physician communication, 3) getting care quickly, 4)
4
getting needed care, and 5) getting needed prescription drugs
17
. Four additional single-items
(“global”) were used to assess patients’ experiences with their overall care, health plan, personal
doctor, and specialist physician. The rating scale of these global items is 0-to-100. Missing
values ranged from 6% for rating for health plan to 61% for experience with customer service
because the items included in the questionnaire varied by survey year, did not apply to a
particular patient, and/or to the Medicare plan type. We only analyzed patients having both
composite and global measures.
2.2.3 Gleason score
We identified Gleason score from the NCI SEER dataset. The Gleason score is a scoring
system, which ranges from 1 to 10, used to define the aggressiveness of prostate cancer. Higher
Gleason score is associated with higher risk for aggressive cancer. We included three levels of
Gleason score: 6 or lower, 7, and 8-10 to correspond with major treatment and prognosis.
2.2.4 Health care utilization
We defined the number of doctor visits as the number of patient-reported personal doctor
and specialist visits number in the prior six months. We included four groups of doctor visits: 0,
1, 2 and 3 or more visits.
2.2.5 Potential confounding
We identified some factors that were potential confounders. CAHPS data provided
information on age at the time of survey administration (65-70, 70-75, 75-80, 80-85, and 80 or
older), time from survey to diagnosis (less than or equal to 3 years and greater than 3 years),
individual-level education (high school or less, college and higher, and missing), Medicare
5
insurance type (fee-for-service (FFS) and Medicare Advantage (MA) with and without part D
coverage), and count of self-reported comorbidities other than cancer (0, 1, and 2 or more).
SEER registry data provided information on marital status (married, not married, unknown),
geographical region (West, Midwest, Northeast, South), and neighborhood poverty level (based
on the census tract of the address at diagnosis of prostate cancer).
2.3 Statistical Analysis
We first examined the distribution of demographic and prognostic factors by race/ethnicity.
T-tests and chi-square analysis were used to compare the mean patient experiences with care. We
ran separate linear regression analysis for each composite and global rating of care to obtain
adjusted least-square estimates and standard errors in order to determine the association between
race/ethnicity and mean ratings of patient experiences, and the association between number of
doctor visits and mean ratings of patient experiences. Because there was a significant interaction
between race/ethnicity and patient experiences with care and Gleason score at diagnosis
(p<0.05), we conducted adjusted ordinal logistic regressions, stratified by race/ethnicity for
Gleason score at diagnosis for each composite and global measure controlling for the
confounding variables. An odds ratio greater than 1 reflects a positive association with higher
Gleason score at diagnosis. We did not adjust for multiple comparisons because our hypotheses
were not simultaneously tested
18
. Each hypothesis is independent. All analyses were performed
using SAS statistical software version 9.4 (SAS Institute Inc, Cary NC). We considered p values
less than 0.05 to be statistically significant.
6
3 Results
A total of 11,791 subjects were identified after applying inclusion and exclusion criteria. A
majority of the cohort were non-Hispanic white patients (77.1%), followed by Hispanic patients
(9.2%), non-Hispanic black patients (8.8%), and Asian patients (5.0%). Table 1 describes the
baseline characteristics of subjects by race. The mean age of the total cohort was 76.4 (±5.9)
years. For all four racial/ethnic groups, more than half of the patients were married (65.2%).
The high-level poverty rates varied considerably by race and were highest for non-Hispanic
black patients (44.5%) and Hispanic patients (26.0%) compared to non-Hispanic white patients
(10.7%) and Asian patients (11.8%). Non-Hispanic black patients (26.5%) and Hispanic patients
(24.4%) were less likely to report completing some college or higher education than other race
groups. Over 50% of the cohort (56.3%) lived in the West region, and the smallest proportion of
patients (7.5%) lived in the Midwest region. However, the regions varied by racial and ethnic
groups. Compared with other racial/ethnic groups, a relatively large portion of non-Hispanic
black patients lived in the South (42.9%). Non-Hispanic black patients had the lowest percentage
of people with FFS PDP (fee-for-service with part D coverage) (56.8%) compared to Asian
patients (63.5%). For MA PDP (Medicare Advantage with part D coverage), Hispanic patients
had the smallest proportion (16.9%). Most of the cohort did not have comorbidities when they
completed the survey (82.3%). About half of the cohort had at least 3 doctor visits in the prior 6
months (46.1%). Non-Hispanic white patients had a relatively larger proportion of multiple
doctor visits (47.2%) and a smaller proportion of no doctor visits (19%).
7
The mean composite score and rating of care in patients’ experiences with the health care
delivery system are shown in Table 2 for composite ratings and Table 3 for global ratings. Each
outcome has a different number of subjects since the valid response rate for each item varied by
time from survey to diagnosis, visit experiences, and Medicare programs. The number of
subjects included in the analyses ranged from 4,761 (customer service) to 11,176 (health plan)
and the mean rating of experiences varied from 81.9 (customer service) to 89.7 (getting needed
care). There were significant racial/ethnic differences in mean composite scores and global
ratings. Asian patients reported the lowest mean score for all the five composite scores, health
care and specialist physician (74.37 (±2.47) for customer service, 84.80 (±1.13) for physician
communication, 75.73 (±1.55) for getting care quickly, 84.07 (±1.17) for getting needed care,
84.08 (±1.43) for getting needed prescription drugs, 82.06 (±0.99) for health care and 88.37
(±1.32) for specialist physician) compared to other racial/ethnic groups (p<0.05). Additionally,
non-Hispanic white patients reported the lowest mean score for primary physician (88.39
(±0.53), p<0.05)) compared to other racial/ethnic groups.
3.1 Regression Analyses
3.1.1 Patient experience with care and number of doctor visits
Adjusted linear regression analyses for composite scores and global ratings by number of
doctor visits are presented in Figure 1. Each score/rating represents a regression model adjusted
for covariates. Coefficients reflect the mean difference in composite score or global rating for
each number of doctor visits compared to patients with one doctor visit. Patients who never
visited a doctor in the prior 6 months had significantly lower adjusted mean score for physician
8
communication (β=-5.48, 95%CI (-9.15,-1.82)), getting care quickly (β=-3.01, 95%CI (-5.52,-
0.50)), getting needed care(β=-3.92, 95%CI (-5.53,-2.31)), getting needed prescription drugs
(β=-3.66, 95%CI (-5.60,-1.71)) and overall health care (β=-4.93, 95%CI (-7.35,-2.50)) compared
to those with one doctor visit. Patients who visited a doctor at least 3 times had significantly
lower adjusted mean score for physician communication (β=-2.55, 95%CI (-3.61,-1.49)), getting
needed care (β=-1.80), getting needed prescription drugs (β=-1.71, 95%CI (-3.18,-0.42)) and
overall health care (β=-1.19, 95%CI (-2.15,-0.23)) compared to those with one doctor visit.
3.1.2 Patient experience with care and race/ethnicity
3.1.2.1 Composite scores
Adjusted linear regression analyses for composite scores and global ratings by race/ethnicity
are presented in Figure 2. Coefficients reflect the mean difference in composite score or global
rating for each racial/ethnic group compared to non-Hispanic white patients. Non-Hispanic black
patients had significantly higher adjusted mean scores for physician communication (β=1.58,
95%CI (0.07,3.09)) compared to Non-Hispanic white patients. Hispanic patients had
significantly lower adjusted mean composite scores for customer service (β=-4.13,95%CI (-
7.11,-1.16)), getting care quickly (β=-3.49, 95%CI (-5.57,-1.41)), getting needed care ((β=-3.72),
95%CI (-5.25,-2.18)) and getting needed prescription drugs (β=-2.79, 95%CI (-4.67,-0.90))
compared to non-Hispanic white patients. Asian patients had significantly lower adjusted mean
scores for all five composite scores (customer service (β=-4.62, 95%CI (-8.80,-0.44)), physician
communication (β=-2.52, 95%CI (-4.35,-0.69)), getting care quickly (β=-6.91, 95%CI (-9.60,-
9
4.21)), getting needed care (β=-3.96, 95%CI (-5.92,-1.99)) and getting needed prescription drugs
(β=-3.31, 95%CI (-5.77,-0.84))) compared to Non-Hispanic white patients.
3.1.2.2 Global Ratings of Care
There were significant racial/ethnic differences in adjusted mean global ratings of
healthcare, where Hispanic and Asian patients had significantly lower ratings of their overall
health care ((β=-1.72, 95%CI (-3.03,-0.41))and (β=-3.01, 95%CI (-4.69,-1.33)) compared to non-
Hispanic white patients prior to the date of diagnosis. However, non-Hispanic black and
Hispanic patients had significantly higher ratings with primary physician ((β=1.73, 95%CI
(0.46,3.01)) and (β=1.22, 95%CI (0.01,2.44))) compared to non-Hispanic white patients.
3.2 Ordinal logistic regression
3.2.1 Health care experience and Gleason score
The results from the adjusted ordinal logistic regression models are presented in Table 4,
which show the associations of composite and global ratings of care with the Gleason scores
level of prostate cancer among each racial/ethnic group. Hispanic patients who had a one-unit
increase in rating for getting care quickly had 1.2 percent decreased odds of having higher
Gleason scores at diagnosis (OR 0.99; 95% CI 0.98-1.00; p<0.05). However, we did not find a
significant association between any of the patient experiences with care and the Gleason scores
level at diagnosis among non-Hispanic white, non-Hispanic black, or Asian prostate cancer
patients prior to their diagnosis.
10
4 Discussion
We present the results of a large retrospective cohort study that used data from the SEER-
CAPHS linked dataset to examine racial/ethnic differences in prostate cancer patient experiences
with medical care before their diagnosis and the possible association with the stage at diagnosis.
In this study, we used categorized Gleason score instead of the stage of prostate cancer. We also
investigated the relationship between medical care utilization (number of doctor visits) and
patient experiences.
We found that for physician communication, getting needed care, getting needed
prescription drugs, and ratings of overall health care, patients who had no doctor visits had the
lowest mean adjusted rating scores and patients who had one doctor visit had the highest scores.
The results from our research indicate that significant differences exist among patients with
different number of doctor visits for physician communication, getting needed care, getting
needed prescription drugs, and overall health care patient experience. For the composite
measures, physician communication, getting needed care, and getting needed prescription drugs
all follow the same pattern, where patients with one doctor visit have the highest scores. This
pattern indicates that with more doctor visits, the ratings decreased. A possible explanation for
this might be that more visits might indicate that patients did not have their health problems
solved at the first visit, they likely did not get tests ordered properly, or their doctor did not
properly diagnosis them. These results seem to be consistent with other studies that found
association between better patient experience and less health care utilization
19
. Another possible
explanation for this is that patients with higher number of doctor visits may have more serious
11
health issue or are more concerned about their health status so that they might have more
negative emotion than others, which would be associated with lower ratings.
After adjusting for patients’ sociodemographic characteristics, number of comorbidities, and
number of doctor visits, the results show that there are racial/ethnic differences in mean adjusted
rating scores between non-Hispanic white patients and the other three racial/ethnic groups (non-
Hispanic black, Hispanic and Asian). All of these three racial/ethnic groups had significantly
lower mean rating scores of customer service, getting care quickly, getting needed care, getting
needed prescription drugs, ratings of overall health care, and ratings of overall primary physician
prior to their time of diagnosis. Finally, patient experiences with care are associated with
Gleason score level at prostate cancer diagnosis for Hispanic patients where patients with a one-
unit higher ratings on getting care quickly had decreased odds of having a higher Gleason score
level at prostate cancer diagnosis.
Our results suggest that for customer service, getting care quickly, getting needed care,
getting needed prescription drugs, overall health care, and overall primary physician, Asian and
Hispanic patients reported significantly lower scores than non-Hispanic white patients. In our
previous study on breast cancer, we also found similar results
20
. These results corroborate the
ideas of Weech‐Maldonado and colleagues, who suggested that non-English speakers have worse
experiences compared to whites
21,22
. According to these findings, we could infer that patients’
access to health care service is different by race/ethnicity. It further supports the research of
Chen and colleagues, which show that patients’ health care access is one of the major factors that
contributed to racial/ethnic disparities
23
. It is interesting to note that Asian patients have the
12
lowest score for most of our rating categories. The finding is in line with previous studies that
Asian patients are less likely to report extreme responses (include high score) and less satisfied
than other racial/ethnic groups
24-27
.
Our study reveals that racial/ethnic disparities exist in patient experiences with care and for
Hispanics, patient experiences with care could be an important factor in predicting the Gleason
score level of prostate cancer for this group. Lower ratings reflect poorer quality of patient
experiences with care
28
; getting care quickly and getting needed care reflect the ability to access
health care resources. Patients who could not access health care resources may have a difficult
time getting their screening test and have a longer time to prostate cancer diagnosis and then
progress to a higher Gleason score. Our results show that for Hispanic patients, poorer
experiences with care (getting care quickly) are associated with the Gleason score level at
prostate cancer diagnosis. To our knowledge, no studies have determined the relationship
between patient care experiences and Gleason score level at prostate cancer diagnosis.
In addition to race/ethnicity and the number of doctor visits, we also adjusted for other
factors related to Gleason score at prostate diagnosis including low income
29
and lower levels of
education
30
, health insurance status
29,31
, count of comorbidities
31,32
and neighborhood context
such as areas of residence socioeconomic status (SES)
31,33
. Our study provides some additional
information to this literature by illustrating the relationship between patient experiences with
care and the stage of cancer (Gleason score level of prostate cancer). However, additional
research should be undertaken to investigate this relationship further.
13
This cohort study involved an abundant sample size (over 10,000 prostate cancer patients).
Among this large sample, each subgroup also had a substantial proportion of patients, which
could be representative of racial/ethnic minorities. Our analyses of our study also controlled for a
large number of demographic and health characteristics. However, this study also had several
limitations. First, some data we analyzed for patient experiences with care are for a relatively
short time period, such as six months prior to their prostate cancer diagnosis, and scores may
change over-time. However, our sensitivity analysis shows that the relationship between patient
experiences with care and Gleason score level at prostate cancer diagnosis does not significantly
differ by the time from survey to diagnosis. Second, for the number of doctor visits, we only
included the number of personal doctor and specialist visits in our analysis. Other types of
hospital visits, such as hospital emergency room, and routine care, may also affect the patients’
experiences with care. Furthermore, the study population only includes SEER-registered area
patients who were at least 65 years of age and diagnosed with prostate cancer with participation
in Medicare fee-for-service and Medicare Advantage; therefore, results may not be generalizable
to prostate cancer survivors who are younger than 65 years of age.
In conclusion, our findings indicate that there are racial/ethnic disparities in patient
experiences with care prior to a prostate cancer diagnosis. And among Hispanic patients,
improving the ratings of patient experiences with care for prostate cancer survivors may be
related to a lower Gleason score level of prostate cancer at diagnosis and could reduce the
disparities in Gleason score level of prostate cancer. Moreover, further research is needed to
examine why and how patient experiences are related to lower Gleason score levels. For
14
example, it may help to increase the efficiency of diagnosis after abnormal screening to build a
better patient-centric healthcare system.
15
Table 1. Distribution of sociodemographic characteristics by race/ethnicity for men diagnosed with
prostate cancer from 1997-2011
Total
Non-Hispanic
white
Non-Hispanic
Black
Hispanic Asian
No. of subjects n (%) 11791 9087 (77.1) 1037 (8.8) 1080 (9.2) 587 (5.0)
Mean age at diagnosis (±SD) 76.4 (±5.9) 76.5 (±5.9) 75.0 (±5.5) 75.8 (±5.7) 77.3 (±6.1)
Age at diagnosis
65-70 1296 (11.0) 963 (10.6) 154 (14.8) 133 (12.3) 46 (7.8)
70-75 3706 (31.4) 2792 (30.7) 380 (36.6) 373 (34.5) 161 (27.4)
75-80 3658 (31.0) 2816 (31.0) 311 (30.0) 328 (30.4) 203 (34.6)
80-85 1912 (16.2) 1524 (16.8) 127 (12.2) 162 (15.0) 99 (16.9)
85 or older 1223 (10.4) 995 (11.0) 66 (6.4) 84 (7.8) 78 (13.3)
Mean age at survey (±SD) 73.2 (±5.7) 73.3 (±5.7) 72.1 (±5.1) 72.7 (±5.3) 74.2 (±6.1)
Age at survey
65-70 3882 (32.9) 2976 (32.7) 395 (38.1) 361 (33.4) 150 (25.6)
70-75 3944 (33.4) 2966 (32.6) 374 (36.0) 413 (38.2) 191 (32.5)
75-80 2341 (19.9) 1826 (20.1) 176 (17.0) 193 (17.9) 146 (24.9)
80-85 1136 (9.6) 922 (10.1) 72 (6.9) 76 (7.0) 66 (11.2)
85 or older 492 (4.2) 400 (4.4) 21 (2.0) 37 (3.4) 34 (5.8)
Marital status
Unmarried 2421 (20.5) 1781 (19.6) 329 (31.7) 220 (20.4) 91 (15.5)
Married 7684 (65.2) 6024 (66.3) 558 (53.8) 677 (62.7) 425 (72.4)
Unknown 1690 (14.3) 1285 (14.1) 151 (14.6) 183 (16.9) 71 (12.1)
Census Tract Poverty
0% to <5% (low poverty) 3432 (29.1) 2987 (32.9) 97 (9.3) 178 (16.5) 170 (29.0)
5% to <10% 3350 (28.4) 2748 (30.2) 159 (15.3) 247 (22.9) 196 (33.4)
10% to <20% 3045 (25.8) 2262 (24.9) 308 (29.7) 332 (30.7) 143 (24.4)
20% to 100% (high poverty) 1788 (15.2) 976 (10.7) 462 (44.5) 281 (26.0) 69 (11.8)
Missing 180 (1.5) 117 (1.3) 12 (1.2) 42 (3.9) 9 (1.5)
Education level
High school or less 5665 (48.0) 3943 (43.4) 674 (64.9) 761 (70.5) 287 (48.9)
College and higher 5568 (47.2) 4755 (52.3) 275 (26.5) 263 (24.4) 275 (46.9)
Missing 562 (4.8) 392 (4.3) 89 (8.6) 56 (5.2) 25 (4.3)
Region
West 6638 (56.3) 4949 (54.4) 260 (25.1) 881 (81.6) 548 (93.4)
Midwest 882 (7.5) 770 (8.5) 94 (9.1) 13 (1.2) 5 (0.9)
Northeast 2151 (18.2) 1761 (19.4) 239 (23.0) 128 (11.9) 23 (3.9)
South 2124 (18.0) 1610 (17.7) 445 (42.9) 58 (5.4) 11 (1.9)
Medicare type
FFS only * 1130 (9.6) 781 (8.6) 134 (12.9) 157 (14.5) 58 (9.9)
FFS PDP 6949 (58.9) 5318 (58.5) 589 (56.7) 669 (61.9) 373 (63.5)
MA only 719 (6.1) 552 (6.1) 65 (6.3) 71 (6.6) 31 (5.3)
MA PDP 2997 (25.4) 2439 (26.8) 250 (24.1) 183 (16.9) 125 (21.3)
Time from survey to diagnosis
Less than or equal to 3 years 6283 (53.3) 4774 (52.5) 594 (57.2) 585 (54.2) 330 (56.2)
Greater than 3 years 5512 (46.7) 4316 (47.5) 444 (42.8) 495 (45.8) 257(43.8)
Count of comorbidities
0 9711 (82.3) 7522 (82.8) 837 (80.6) 863 (79.9) 489 (83.3)
1 1506 (12.8) 1137 (12.5) 140 (13.5) 154 (14.3) 75 (12.8)
2+ 578 (4.9) 431 (4.7) 61 (5.9) 63 (5.8) 23 (3.9)
Gleason score
6 or lower 3508 (29.7) 2710 (29.8) 281 (27.1) 363 (33.6) 154 (26.2)
7 4789 (40.6) 3693 (40.6) 448 (43.2) 429 (39.7) 219 (37.3)
8, 9, or 10 2536 (21.5) 1929 (21.2) 223 (21.5) 215 (19.9) 169 (28.8)
Unknown 962 (8.2) 758 (8.3) 86 (8.3) 73 (6.8) 45 (7.7)
Number of Doctor visits
0 2417 (20.5) 1726 (19.0) 278 (26.8) 279 (25.8) 134 (22.8)
1 1901 (16.1) 1477 (16.3) 154 (14.8) 168 (15.6) 102 (17.4)
2 2034 (17.3) 1593 (17.5) 151 (14.6) 181 (16.8) 109 (18.6)
3+ 5439 (46.1) 4291 (47.2) 454 (43.8) 452 (41.8) 242 (41.2)
* Fee-for-service (FFS) and Medicare Advantage (MA) with and without part D coverage.
16
Table 2. Description of patient demographics and report of their experiences with the health care delivery
system (composite ratings).
Customer
Service
Physician
communication
Getting care
quickly
Getting needed
care
Getting needed
prescription
drugs
No. analyzed n (%) 4761 (40.4) 8646 (73.3) 8113 (68.8) 9867 (83.7) 8977 (76.1)
Mean score (±SD) 81.90 (±27.40) 87.53 (±17.48) 83.51 (±20.34) 89.70 (±20.34) 88.96 (±24.13)
Race/ethnicity
Non-Hispanic white 78.71 (±1.49) 87.75 (±0.72) 82.39 (±0.86) 87.86 (±0.69) 87.56 (±0.82)
Non-Hispanic black 76.82 (±1.98) 89.41 (±0.94) 80.30 (±1.25) 86.80 (±0.97) 86.11 (±1.16)
Hispanic 74.63 (±1.96) 86.58 (±0.95) 79.00 (±1.26) 84.29 (±0.96) 84.48 (±1.16)
Asian 74.37 (±2.47) 84.80 (±1.13) 75.73 (±1.55) 84.07 (±1.17) 84.08 (±1.43)
Age at survey
65-70 75.74 (±1.62) 87.50 (±0.79) 79.64 (±0.98) 86.19 (±0.78) 84.39 (±0.93)
70-75 74.58 (±1.62) 87.05 (±0.79) 78.91 (±0.98) 86.34 (±0.76) 85.20 (±0.93)
75-80 76.19 (±1.74) 86.70 (±0.83) 78,72 (±1.06) 85.39 (±0.83) 85.12 (±0.99)
80-85 78.21 (±1.97) 86.70 (±0.94) 78.03 (±1.24) 85.69 (±0.96) 86.82 (±1.16)
85 or older 75.93 (±2.54) 87.72 (±1.17) 81.47 (±1.60) 85.16 (±1.21) 86.25 (±1.47)
Marital status
Unmarried 75.34 (±1.73) 86.46 (±0.83) 78.21 (±1.07) 85.40 (±0.83) 85.08 (±1.00)
Married 76.47 (±1.62) 87.16 (±0.78) 79.85 (±0.97) 86.01 (±0.76) 85.16 (±0.91)
Unknown 76.58 (±1.79) 87.79 (±0.86) 80.01 (±1.10) 85.85 (±0.87) 86.43 (±1.04)
Census Tract Poverty
0% to <5% poverty 76.24 (±1.59) 87.90 (±0.79) 80.02 (±0.99) 86.56 (±0.77) 86.37 (±0.93)
5% to <10% poverty 76.37 (±1.58) 87.72 (±0.78) 80.08 (±0.97) 86.09 (±0.76) 86.40 (±0.92)
10% to <20% poverty 76.31 (±1.56) 86.86 (±0.77) 80.00 (±0.96) 85.20 (±0.75) 85.25 (±0.90)
20% to 100% poverty 75.60 (±1.71) 86.85 (±0.82) 80.18 (±1.05) 84.29 (±0.82) 84.70 (±0.98)
Missing 76.13 (±3.82) 86.35 (±1.66) 76.49 (±2.33) 86.65 (±1.82) 85.07 (±2.16)
Education level
High school or less 76.75 (±1.51) 88.03 (±0.72) 80.16 (±0.90) 86.20 (±0.70) 85.64 (±0.82)
College and higher 75.03 (±1.59) 87.12 (±0.77) 79.33 (±0.96) 85.65 (±0.75) 85.634 (±0.89)
Missing 76.61 (±2.38) 86.25 (±1.13) 78.57 (±1.49) 85.41 (±1.18) 85.39 (±1.47)
Time from survey to diagnosis
Less than or equal to 3 years 74.95 (±1.58) 87.21 (±0.76) 78.82 (±0.94) 85.84 (±0.74) 86.66 (±0.88)
Greater than 3 years 77.31 (±1.67) 87.06 (±0.80) 79.89 (±1.02) 85.67 (±0.79) 84.45 (±0.95)
Region
West 78.25 (±1.53) 86.19 (±0.74) 78.30 (±0.92) 84.76 (±0.73) 85.49 (±0.86)
Midwest 75.77 (±2.19) 87.91 (±1.00) 80.38 (±1.32) 86.71 (±1.03) 87.33 (±1.24)
Northeast 73.85 (±1.78) 86.80 (±0.86) 80.16 (±1.10) 85.51 (±0.86) 83.32 (±1.04)
South 76.65 (±1.79) 87.65 (±0.84) 78.57 (±1.08) 86.04 (±0.85) 86.10 (±1.03)
Medicare type
FFS only * 74.29 (±1.77) 86.08 (±0.83) 82.72 (±1.08) 89.71 (±0.82) 88.97 (±1.01)
FFS PDP 70.56 (±3.26) 88.41 (±1.02) 77.87 (±1.33) 83.21 (±1.13) 83.97 (±1.24)
MA only 80.47 (±1.47) 86.39 (±0.78) 80.16 (±0.97) 87.78 (±0.75) 83.51 (±0.92)
MA PDP 79.20 (±1.80) 87.66 (±0.91) 76.68 (±1.15) 82.32 (±0.96) 85.79 (±1.08)
Count of comorbidities
0 77.20 (±1.51) 87.27 (±0.73) 79.14 (±0.88) 86.46 (±0.69) 89.50 (±0.82)
1 75.86 (±1.75) 86.59 (±0.85) 79.25 (±1.09) 85.34 (±0.86) 82.99 (±1.03)
2+ 75.33 (±2.16) 87.54 (±1.04) 79.68 (±1.37) 85.46 (±1.11) 84.18 (±1.33)
Number of Doctor visits
0 75.40 (±1.85) 84.49 (±1.79) 76.51 (±1.32) 83.42 (±0.93) 83.53 (±1.09)
1 77.28 (±1.85) 89.05 (±0.78) 79.62 (±1.12) 87.14 (±0.87) 87.01 (±1.05)
2 76.61 (±1.77) 88.43(±0.75) 80.99 (±1.07) 87.06 (±0.84) 86.34 (±1.01)
3+ 75.24 (±1.57) 86.58 (±0.66) 80.31 (±0.94) 85.41 (±0.74) 85.36 (±0.89)
Bolded means are significant different at p<0.05 among groups; * Fee-for-service (FFS) and Medicare Advantage (MA) with and
without part D coverage
17
Table 3. Description of patient demographics and report of their mean rating of experiences with the
health care delivery system (global ratings).
Health care Health plan Primary physician Specialist physician
No. analyzed n (%) 8668 (73.5) 11176 (94.8) 9647 (81.8) 6234 (52.9)
Mean score (±SD) 87.11 (±16.06) 83.58 (±19.37) 87.50 (±15.77) 87.59 (±16.45)
Race/ethnicity
Non-Hispanic white 85.32 (±0.58) 84.57 (±0.60) 88.39 (±0.53) 90.38 (±0.85)
Non-Hispanic black 84.33 (±0.81) 84.90 (±0.84) 90.30 (±0.75) 89.85 (±1.14)
Hispanic 83.52 (±0.83) 83.36 (±0.85) 89.59 (±0.76) 88.84 (±1.12)
Asian 82.06 (±0.99) 83.39 (±1.03) 88.69 (±0.92) 88.37 (±1.32)
Age at survey
65-70 83.01 (±0.66) 82.10 (±0.68) 88.21 (±0.60) 88.89 (±0.94)
70-75 83.51 (±0.66) 82.90 (±0.68) 88.52 (±0.60) 89.23 (±0.93)
75-80 83.80 (±0.70) 84.06 (±0.72) 89.28 (±0.65) 89.48 (±0.98)
80-85 83.25 (±0.81) 84.36 (±0.84) 89.38 (±0.75) 88.30 (±1.09)
85 or older 85.47 (±1.02) 86.84 (±1.08) 90.82 (±0.95) 90.90 (±1.30)
Marital status
Unmarried 83.58 (±0.70) 84.20 (±0.73) 88.91 (±0.65) 88.76 (±0.98)
Married 84.20 (±0.64) 84.19 (±0.66) 89.26 (±0.59) 89.96 (±0.92)
Unknown 83.64 (±0.73) 83.77(±0.76) 89.56 (±0.68) 88.36 (±1.01)
Census Tract Poverty
0% to <5% (low poverty) 84.33 (±0.66) 84.25 (±0.68) 89.84 (±0.60) 89.54 (±0.92)
5% to <10% 84.13 (±0.65) 83.45 (±0.67) 89.74 (±0.60) 89.28 (±0.91)
10% to <20% 83.95 (±0.64) 83.35 (±0.66) 89.02 (±0.59) 88.81 (±0.91)
20% to 100% (high poverty) 83.80 (±0.70) 83.75 (±0.71) 88.98 (±0.64) 8792 (±0.99)
Missing 82.83 (±1.45) 85.47 (±1.60) 88.62 (±1.42) 91.25 (±1.91)
Education level
High school or less 84.81 (±0.59) 85.62 (±0.60) 89.90 (±0.54) 89.63 (±0.88)
College and higher 83.53 (±0.63) 82.43 (±0.66) 88.49 (±0.59) 87.99 (±0.92)
Missing 83.08 (±1.00) 84.11 (±1.05) 89.34 (±0.93) 90.47 (±1.29)
Time from survey to diagnosis
Less than or equal to 3 years 83.58 (±0.63) 83.91 (±0.65) 89.37 (±0.58) 89.13 (±0.90)
Greater than 3 years 84.04 (±0.67) 84.19 (±0.70) 89.12 (±0.62) 89.59 (±0.95)
Region
West 83.19 (±0.61) 84.10 (±0.63) 88.10 (±0.56) 88.69 (±0.89)
Midwest 84.57 (±0.87) 86.19 (±0.91) 89.64 (±0.81) 89.11 (±1.16)
Northeast 83.31 (±0.73) 81.27 (±0.76) 89.01 (±0.67) 89.85 (±1.00)
South 84.16 (±0.71) 84.66 (±0.75) 90.22 (±0.67) 89.80 (±1.00)
Medicare type
FFS only * 85.66 (±0.71) 83.67 (±0.73) 89.23 (±0.65) 89.02 (±0.98)
FFS PDP 81.82 (±0.88) 83.81(±0.95) 89.53 (±0.86) 90.46 (±1.19)
MA only 85.67(±0.66) 84.56 (±0.67) 88.41 (±0.59) 88.28 (±0.91)
MA PDP 82.07(±0.75) 84.16 (±0.80) 89.80 (±0.73) 89.67 (±1.08)
Count of comorbidities
0 84.07 (±0.60) 84.21 (±0.60) 89.24 (±0.54) 89.22 (±0.87)
1 84.31 (±0.72) 84.73 (±0.75) 89.37 (±0.68) 90.07 (±1.00)
2+ 83.04 (±0.90) 83.23 (±0.98) 89.12 (±0.87) 88.79 (±1.18)
Number of Doctor visits
0 81.06 (±1.20) 83.15 (±0.75) 88.47 (±0.71) 91.75 (±2.28)
1 85.29 (±0.71) 84.27 (±0.77) 89.39 (±0.68) 88.95 (±1.02)
2 84.67 (±0.68) 84.25 (±0.75) 89.71 (±0.66) 88.33 (±0.86)
3+ 84.22 (±0.60) 84.54 (±0.66) 89.40 (±0.58) 88.41 (±0.74)
Bolded models are significant different at p<0.05 among groups; * Fee-for-service (FFS) and Medicare Advantage (MA) with
and without part D coverage.
18
No. analyzed Non-Hispanic white Non-Hispanic black Hispanic Asian
Experience with
Customer service 4,391 0.999(0.996-1.002) 1.002(0.992-1.011) 1.005(0.996-1.014) 0.997(0.985-1.010)
Physician communication 7,989 1.000(0.996-1.003) 0.998(0.988-1.009) 1.001(0.991-1.011) 1.002(0.989-1.014)
Getting care quickly 7,510 1.000(0.997-1.002) 1.001(0.993-1.009) 0.988(0.980-0.995) 0.998(0.989-1.008)
Getting needed care 9,084 0.999(0.997-1.002) 0.995(0.988-1.003) 0.999(0.991-1.006) 1.004(0.994-1.014)
Getting needed Rx drugs 8,271 1.000(0.997-1.002) 0.999(0.992-1.006) 1.000(0.993-1.007) 1.004(0.994-1.013)
Rating for
Health care 8,012 1.000(0.996-1.004) 0.996(0.97-1.006) 0.999(0.989-1.010) 1.000(0.986-1.014)
Health plan 10,260 1.001(0.998-1.004) 1.007(0.999-1.015) 0.998(0.991-1.005) 0.998(0.988-1.008)
Primary physician 8,886 1.000(0.996-1.004) 1.008(0.996-1.020) 1.005(0.994-1.016) 1.007(0.992-1.021)
Specialist physician 5,752 0.999(0.995-1.003) 1.007(0.991-1.024) 0.999(0.985-1.012) 0.991(0.975-1.007)
Table 4. Multivariable ordinal logistic regression model of patient experiences with rating of health care and earlier stage at diagnosis, by
race/ethnicity.
Bolded models are significant at p<0.05
Note. Adjusted for age at survey, marital status at diagnosis, census tract poverty indicator, education level, time from survey to diagnosis, SEER region, Medicare type,
and comorbidities.
19
Figure 1. Adjusted mean difference of patient experiences with aspects of their health care by number of
doctor visits in prior 6 months compared to one-time doctor visit (composite scores and ratings).
Bolded models are significant at p<0.05
20
Figure 2. Adjusted mean difference of patient experiences with aspects of their health care by
race/ethnicity compared to non-Hispanic white patients (composite scores and ratings).
Bolded models are significant at p<0.05
21
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Racial/ethnic differences in patient experiences with health care in association with the Gleason’s score level at prostate cancer diagnosis: findings from the SEER-CAHPS data
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