Mechanisms Underlying SES Disparities in Breast Cancer Mortality

乳腺癌死亡率中社会经济地位差异的潜在机制

基本信息

批准号：
8634755
负责人：
Ann B Nattinger
金额：
$ 37.53万
依托单位：
MEDICAL COLLEGE OF WISCONSIN
依托单位国家：
美国
项目类别：
财政年份：
2013
资助国家：
美国
起止时间：
2013-03-11 至 2016-02-29
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/8634755
关键词：
Accounting Adherence Adjuvant Adjuvant Therapy Advocacy Aromatase Inhibitors Attention Breast Cancer Treatment Breast-Conserving Surgery Cancer Patient Caring Censuses Characteristics Classification Code Data Data Analyses Databases Disease Drug Insurance Drug Prescriptions Elderly woman Eye Goals Health system Hospitals Incidence Individual Inequality Insurance Intervention Lead Literature Malignant Neoplasms Mammography Mastectomy Medical Medicare Methodology Neighborhoods Operative Surgical Procedures Oral Outcome Patients Pattern Patterns of Care Persons Pharmaceutical Preparations Policies Population Postmenopause Process Process Measure Public Health Public Policy Radiation therapy Research Personnel Resources Simulate Societies Socioeconomic Status Tamoxifen Treatment outcome Trees Woman Work base cancer care cohort cost design experience follow-up health care delivery hormone therapy improved innovation interest low socioeconomic status malignant breast neoplasm mortality programs public health relevance screening simulation social socioeconomics

Accounting Adherence Adjuvant Adjuvant Therapy Advocacy Aromatase Inhibitors Attention Breast Cancer Treatment Breast-Conserving Surgery Cancer Patient Caring Censuses Characteristics Classification Code Data Data Analyses Databases Disease Drug Insurance Drug Prescriptions Elderly woman Eye Goals Health system Hospitals Incidence Individual Inequality Insurance Intervention Lead Literature Malignant Neoplasms Mammography Mastectomy Medical Medicare Methodology Neighborhoods Operative Surgical Procedures Oral Outcome Patients Pattern Patterns of Care Persons Pharmaceutical Preparations Policies Population Postmenopause Process Process Measure Public Health Public Policy Radiation therapy Research Personnel Resources Simulate Societies Socioeconomic Status Tamoxifen Treatment outcome Trees Woman Work base cancer care cohort cost design experience follow-up health care delivery hormone therapy improved innovation interest low socioeconomic status malignant breast neoplasm mortality programs public health relevance screening simulation social socioeconomics

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项目摘要

DESCRIPTION (provided by applicant): Socioeconomic (SES) disparities in survival from breast cancer developed during the 1980's and 1990's, and have persisted into the early 2000's. The existing literature and/or our preliminary data provide evidence of process disparities among SES groups in the use of screening and follow-up mammography, the use of breast conserving surgery with radiotherapy, the choice and use of alternative adjuvant endocrine therapy (aromatase inhibitors vs. tamoxifen) and possibly persistence with endocrine therapy once initiated. There is also evidence that SES disparities may exist among breast cancer patients in the use of low-volume hospitals, which are associated with worse survival. What is unclear is the extent to which these process factors inter-relate to lead to the observed survival disparities, and which public policy or health care delivery interventions deserve greatest attention in a program designed to reduce these disparities. In this application, we propose to show empirically the extent to which each of these factors contribute to the observed SES disparities in mortality among women with breast cancer. Specifically, our aims are to: (1) To document SES disparities in patterns of breast cancer care, and in 3- and 5-year mortality using a contemporary cohort of elderly women with incident breast cancer; (2) To decompose the factors underlying SES disparities in breast cancer mortality, most notably, (i) screening, (ii) extent of disease; (iii) initial treatment; (iv) adjuvant and follow-up care; and (v) health system structural and policy factors; and (3) To simulate the effect of alternative public policies on cancer mortality and their implications for SES disparities therein. These aims will be carried out by analyzing data from the 2005-2007 SEER-Medicare-Part D data and followed until 2012. We propose to first identify patterns of breast cancer care, defined over the 60-month post-surgery treatment continuum, using the Classification and Regression Tree (CART) methodology. We will then apportion the observed SES disparities in mortality according to the contribution of each structural and process measures comprising these patterns of care, using the Oaxaca-Blinder regression-based decomposition approach, quantifying the portion explained by each, and the differences that remain unexplained. Finally, we will use parameter estimates generated by these analyses to simulate the anticipated effect of alternative proposals currently under consideration (e.g., increasing Part D premiums and co-pays, eliminating the coverage gap) in offsetting or exacerbating disparities in breast cancer treatments and outcomes. The proposed study will not only provide mechanistic information to focus efforts to remediate SES disparities in breast cancer mortality, but will also provide an innovative policy simulation that will inform efforts to determine how best to allocate the resources of public medical and prescription drug insurance programs in order to obtain the greatest value.

描述（由申请人提供）：1980年代和1990年代在乳腺癌生存中的社会经济（SES）差异，并一直持续到2000年代初。现有的文献和/或我们的初步数据提供了SES组之间的过程差异的证据，在使用筛查和随访乳房X线摄影，使用放射疗法的乳房保存手术，选择和使用替代性辅助内分泌疗法（芳香酶抑制剂vs. tamoxifen vs. tamoxifen）以及可能持续进行内部分泌治疗。也有证据表明，在使用低量医院的乳腺癌患者中可能存在SES差异，这与较差的生存有关。尚不清楚的是，这些过程相互关系导致观察到的生存差异的程度，哪些公共政策或医疗保健提供干预措施在旨在减少这些差异的计划中应受到最大的关注。在此应用中，我们建议从经验上表明这些因素中的每一个都在多大程度上导致乳腺癌女性死亡率的SES差异。具体而言，我们的目标是：（1）记录乳腺癌护理模式的SES差异，以及使用当代患有入射乳腺癌的老年妇女的3年和5年死亡率；（2）分解乳腺癌死亡率中SES差异的因素，最著名的是（i）筛查，（ii）疾病程度；（iii）初始治疗；（iv）辅助和后续护理；（v）卫生系统结构和政策因素；（3）模拟替代公共政策对癌症死亡率及其对SES差异的影响的影响。这些目标将进行通过分析2005 - 2007年SEER-MEDICARE-PART D数据的数据，并遵循2012年。我们建议使用分类和回归树（CART）方法首先确定乳腺癌护理的模式，该模式定义在手术后的60个月后处理。然后，使用基于Oaxaca-blinder回归的分解方法，根据每个结构和过程措施的贡献，根据每个结构和过程措施的贡献，将观察到的SES差异分配给死亡率的SES差异。最后，我们将使用这些分析产生的参数估计值来模拟当前正在考虑的替代提案的预期影响（例如，增加D部分的保费和共付额，消除覆盖范围）在抵消或加剧乳腺癌治疗中的差异或加剧。拟议的研究不仅将提供机械信息，以集中精力来补救乳腺癌死亡率中的SES差异，而且还将提供创新的政策模拟，以确定如何最好地分配公共医疗和处方药保险计划的资源，以获得最大的价值。