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：
8500948
负责人：
Ann B Nattinger
金额：
$ 40.28万
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/8500948
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

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）：乳腺癌生存率的社会经济（SES）差异是在 2000 年代初和 2000 年代初期形成的。现有文献和/或我们的初步数据提供了 SES 群体在筛查和随访乳房 X 光检查、保乳手术与放疗的使用、替代辅助内分泌治疗（芳香酶抑制剂与他莫昔芬），并可能在开始后坚持内分泌治疗。还有证据表明，乳腺癌患者在使用低容量医院时可能存在社会经济地位差异，这与较差的生存率相关。目前尚不清楚的是，这些过程因素在多大程度上相互关联，从而导致观察到的生存差异，以及在旨在减少这些差异的计划中，哪些公共政策或医疗保健提供干预措施最值得关注。在此应用中，我们建议凭经验证明这些因素对观察到的乳腺癌女性死亡率差异的 SES 差异的影响程度。具体而言，我们的目标是： (1) 使用当代乳腺癌老年女性队列记录乳腺癌护理模式以及 3 年和 5 年死亡率方面的社会经济地位差异； (2) 分解乳腺癌死亡率中社会经济地位差异的潜在因素，最值得注意的是，(i) 筛查，(ii) 疾病程度； (iii) 初步治疗； (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的影响及其对社会经济地位差异的影响。这些目标将得到实现通过分析 2005-2007 年 SEER-Medicare-D 部分数据并跟踪至 2012 年。我们建议首先使用分类和回归树（分类和回归树）确定乳腺癌护理模式，在手术后 60 个月的连续治疗过程中进行定义（ CART）方法。然后，我们将使用基于 Oaxaca-Blinder 回归的分解方法，根据构成这些护理模式的每种结构和过程措施的贡献，对观察到的 SES 死亡率差异进行分配，量化每种方法解释的部分以及尚未解释的差异。最后，我们将使用这些分析生成的参数估计值来模拟当前正在考虑的替代提案（例如，增加 D 部分保费和共付额、消除覆盖范围差距）在抵消或加剧乳腺癌治疗和结果差异方面的预期效果。拟议的研究不仅将提供机制信息，以集中努力纠正社会经济地位在乳腺癌死亡率方面的差异，而且还将提供创新的政策模拟，为确定如何最好地分配公共医疗和处方药保险计划的资源提供信息。以获得最大的价值。