Objective To examine the effect on BRCA testing and mastectomy rates of a widely viewed 2013 New York Times editorial by public figure Angelina Jolie that endorsed BRCA testing and announced Jolie’s decision to undergo preventive mastectomy.
Design Observational study with difference-in-difference analysis.
Setting Commercially insured US population.
Participants Women aged 18-64 years with claims in the Truven MarketScan commercial claims database (n=9 532 836).
Main outcome measures Changes in BRCA testing rates in the 15 business days before versus after 14 May 2013 (editorial date) compared with the change in the same period in 2012; mastectomy rates in the months before and after publication, both overall and within 60 days of BRCA testing among women who were tested; national estimates of incremental tests and expenditures associated with Jolie’s article in the 15 days after publication.
Results Daily BRCA test rates increased immediately after the 2013 editorial, from 0.71 tests/100 000 women in the 15 business days before to 1.13 tests/100 000 women in the 15 business days after publication. In comparison, daily test rates were similar in the same period in 2012 (0.58/100 000 women in the 15 business days before 14 May versus 0.55/100 000 women in the 15 business days after), implying a difference-in-difference absolute daily increase of 0.45 tests/100 000 women or a 64% relative increase (P<0.001). The editorial was associated with an estimated increase of 4500 BRCA tests and $13.5m (£10.8m; €12.8) expenditure nationally among commercially insured adult women in those 15 days. Increased BRCA testing rates were sustained throughout 2013. Overall mastectomy rates remained unchanged in the months after publication, but 60 day mastectomy rates among women who had a BRCA test fell from 10% in the months before publication to 7% in the months after publication, suggesting that women who underwent tests as a result of to the editorial had a lower pre-test probability of having the BRCA mutation than women tested before the editorial.
Conclusions Celebrity endorsements can have a large and immediate effect on use of health services. Such announcements can be a low cost means of reaching a broad audience quickly, but they may not effectively target the subpopulations that are most at risk for the relevant underlying condition.
Celebrity endorsements of healthcare products and behaviours are ubiquitous. We studied the effect of a major announcement by actress Angelina Jolie, who in a 2013 New York Times editorial urged women to consider BRCA1/2 genetic testing and announced that she had undergone preventive mastectomy.1 The editorial is one of the most viewed health related articles in the social media age.2 3 To date, analyses of the editorial’s effects have been limited to showing greater testing or referrals in small and specific subpopulations.4 5 Using data from a large commercially insured US population, we analysed rates of BRCA testing and mastectomy before and after Jolie’s editorial.
Our study included women aged 18-64 years in the United States who were continuously enrolled in commercial insurance during 2012-13. Data came from the Truven MarketScan Analytics Commercial Claims and Encounters Database, which comprises de-identified health insurance claims for inpatient care, outpatient care, and prescription drugs for more than 50 million people covered by self insured employers and health plans. Details of this database have been published elsewhere.6
We identified BRCA gene testing according to Current Procedural Terminology codes 81211-81217 in outpatient claims.5 We estimated changes in BRCA testing after the editorial by using an individual level difference-in-difference model that compared the change in probability of BRCA testing in the 15 business days before versus the 15 business days after 14 May with the change in the same period in 2012 (to account for potential seasonal trends). We selected this relatively narrow time window to attenuate concern that factors other than Jolie’s editorial would confound our estimates. In a sensitivity analysis, however, we extended the time window to 30 days. Individual covariates included patient’s age (18-25, 26-35, 36-45, 46-55, and 56-64 years), US Census region of residence (Northeast, North Central, South, West, unknown), and health plan type (preferred provider organisation (PPO), health maintenance organisation, consumer directed health plan, or other). Monthly BRCA testing rates in 2013, adjusted for number of days in the month, were reported to examine longer term trends. We estimated short term changes in spending on BRCA testing nationally (see online appendix).
We also graphically analysed changes in mastectomy rates after Jolie’s editorial to assess whether any additional BRCA gene testing led to subsequent preventive mastectomies.7 As our data did not contain modifier codes that would indicate whether a mastectomy was preventive, we calculated monthly mastectomy rates in the overall study population as well as rates in the 60, 90, and 180 days after the test among women who underwent BRCA testing in 2013. If women responded to Jolie’s editorial with more intensive treatment choices, we would expect rates of mastectomies to increase in the months after publication of the editorial. We included 90 and 180 day follow-up periods to allow sufficient time for women testing positive for BRCA to undergo mastectomy.
No patients were involved in setting the research question or the outcome measures, nor were they involved in developing plans for the design or implementation of the study. No patients were asked to advise on interpretation or writing up of results. There are no plans to disseminate the results of the research to study participants or the relevant patient community.
Our sample included 9 532 836 women, of whom 2 546 635 (27%) were aged 46-55 and 2 018 218 (21%) were aged 56-64 in 2012 (table 1 ⇓ ). Additionally, 3 118 836 (33%) women resided in the South, and 5 555 048 (58%) were in PPO plans. During the study period, 32 945 (0.35%) women had a BRCA test. Women who had BRCA tests were somewhat older (BRCA tested, 36% of women aged 46-55 and 22% aged 56-64; non-tested, 27% of women aged 46-55 and 21% aged 56-64), more heavily represented in the West (24% v 22%), and more likely to be covered by a PPO health plan (67% v 58%). Of 32 945 women who had a BRCA test during 2012-13, almost half (15 233) had the test in the 231 remaining days of the year after the Jolie editorial was published (14 May 2013), which represented less than a third of the two year study period. Characteristics of women who had the test before publication of the editorial compared with those who had the test after it are shown in appendix 1. Women were similar in most characteristics, except that those who had the test after the editorial were slightly more likely to be covered under a PPO plan (70% v 64%).
Study population. Values are numbers (percentages)