MULTILEVEL COMPLIANCE MODEL OF BREAST CANCER TREATMENTS

传统上，提供者遵守治疗指南一直是 被描述为主要涉及以下临床行为的问题： 医生 经常被用来研究或干预的模型 医生的治疗模式是以个人为基础的，并侧重于 与学习或同伴有关的各种社会心理机制， 压力 然而，影响遵守的因素 推荐的治疗指南实际上构成了一个复杂的网络， 心理、人际、组织和社区为基础的 变量 美国早期（I或II期）乳腺癌治疗指南 自1985年以来，老年妇女问题一直得到明确和一贯的阐述。 在 简单的，推荐的主要治疗方法是保乳手术 (BCS)加放射治疗（RT）或改良根治性乳房切除术。 尽管如此，BCS使用的地理和医院差异， 很大一部分妇女，特别是老年妇女，接受BCS， 放射治疗在文献中已有报道。 先前 对这些治疗指南依从性的研究可能已经 由于难以确定放射治疗是否 由于提供商的位置多种多样， 提供RT和不同的医疗保险索赔文件，其中这些数据 可以找到。 我们建议将一些现存的数据文件与宏观层面的 背景数据（创建与NCI社区临床联系的索引 肿瘤学计划（CCOP），NCI综合癌症中心（CCC）和 放射治疗研究网络; AHA数据;区域资源档案与普查 数据），以样本的老年妇女与早期阶段癌症从SEER- 医疗保险链接数据库，以开发一个国家样本， 这些患者的治疗和社区信息 设置. 我们的主要兴趣是测试连接的影响， 主要治疗部位（手术和/或RT）到研究网络， 控制患者特征，其他组织变量， 和社区环境，对治疗依从性的影响。 我们提出了一个 分层多分类回归模型估计3 接受治疗的协变量水平。 这项研究将促进我们对环境的理解， 发生治疗指南的依从性。 特别是，这项研究 将提供关于背景相互作用的重要信息 （组织和社区）和老龄化临床决策 患有乳腺癌的妇女-这一人群很少在 合规文献。

Provider compliance with treatment guidelines has traditionally been depicted as an issue primarily concerning the clinical behavior of physicians. The models often invoked to study or intervene in the treatment patterns of physicians are individual-based, and focus on various social-psychological mechanisms related to learning or peer- pressure. However, the factors which influence compliance with recommended treatment guidelines in fact constitute a complex web of psychological, interpersonal, organizational, and community-based variables. The guidelines for treatment of early stage (I or II) breast cancer in older women have been clearly and consistently stated since 1985. In brief, recommended primary treatment has been breast conserving surgery (BCS) plus radiation therapy (RT), or modified radical mastectomy. Nonetheless, geographic and hospital variation in the use of BCS, and a high portion of women, particularly older women, receiving BCS without radiation therapy have been reported in the literature. Previous studies of compliance with these treatment guidelines may have been hampered by the difficulty of determining whether radiation therapy was received following BCS, due to the variety of provider locations which provide RT and the different Medicare claims files in which these data could be found. We propose to link a number of extant data files with macro-level contextual data (created indices on linkage to NCI Community Clinical Oncology Programs (CCOP), NCI Comprehensive Cancer Centers (CCC) and radiotherapy research networks; AHA data; Area Resource File and Census data) to a sample of older women with early stage cancer from the SEER- Medicare linked data bases, in order to develop a national sample of such patients with information on their treatments and community settings. Our major interest is to test for the influence of linkage of the primary treatment sites (surgery and/or RT) to research networks, controlling for patient characteristics, other organizational variables, and community context, on treatment compliance. We propose a hierarchical polytomous regression model to estimate the effects of 3 levels of covariates on treatment received. This research will advance our understanding of the context in which compliance with treatment guidelines occurs. In particular, this study will provide important information on the interaction of context (organization and community) and clinical decision-making for aging women with breast cancer- a population that is seldom studied in the compliance literature.