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Background: Cancer, type 2 diabetes mellitus, and hypertension are important public health issues for women in the United States given their significant disease burden and impact on mortality. Yet, clinical care management of chronic health conditions before and after a breast cancer diagnosis has not been well evaluated, especially among African American women who disproportionately bear the burden of these chronic illnesses. Specific Aims: The specific aims of this dissertation were to evaluate the influence of a breast cancer diagnosis on diabetes and hypertension clinical care management (Chapter 1) and then examine patient (Chapter 1), provider (Chapter 2), and health system (Chapter 3) factors associated with clinical care management and health outcomes after the breast cancer diagnosis. Methods: This study included African American women who participated in the Women’s Circle of Health Follow-Up Study (WCHFS), an ongoing population-based prospective cohort of breast cancer survivors recruited from ten counties in New Jersey. Women with diabetes and/or hypertension for at least one year prior to the breast cancer diagnosis (2012-2016) were included in this analytic sample (N=274). The likelihood of receiving all clinical care management measures and achieving all health outcomes after breast cancer diagnosis were compared by patient, provider, and health system factors using binomial regression models. Results: The prevalence of diabetes and hypertension diagnosed at least one year prior to the breast cancer diagnosis was 18% and 47%. Less than half (41%) of the participants had all key clinical care management measures met and only 15% reached all key health outcomes after breast cancer diagnosis. Patients who did not have optimal management before diagnosis were 29% less likely to have optimal management after breast cancer diagnosis (aRR: 0.71; 95% CI: 0.53, 0.95). Participants with shared care (i.e., cancer specialist, primary care provider, and/or medical specialist involved in patient care) were five times more likely to have all clinical care measures met compared with participants who only saw cancer specialists (aRR: 5.07; 95% CI: 1.47, 17.51). Patient and provider factors were not associated with optimal health outcomes. Participants who did not receive both primary care and cancer care within the same health system were 27% less likely to have all clinical care measures met compared with those participants who sought care at the same health system (aRR: 0.73; 95% CI: 0.56, 0.97). Accreditation of cancer program was not associated with having all clinical care measures met (aRR: 0.92; 95% CI: 0.59, 1.45). Conclusion: Findings from these studies can be used to identify gaps in care delivery, improve chronic disease management guidelines for breast cancer patients with comorbidities, and address health equity for African American women with multimorbidities. Future work is needed from a multilevel perspective – health policy, health system, organizational/practice settings, providers/medical teams, and patient level factors – to improve the delivery of care and ultimately impact health outcomes.

ETD_9648

doi:10.7282/t3-cvyp-h764

Ph.D.

Includes bibliographical references

ETD doctoral

The author owns the copyright to this work.