Patterns of Patient Care in Appalachia

描述（由申请人提供）：阿巴拉契亚山脉崎岖的地形在地理上描绘了被称为阿巴拉契亚的多样化地区。阿巴拉契亚地区的大多数县被指定为医疗服务不足，医疗资源稀少，缺乏综合医疗系统，尽管在阿巴拉契亚境内或附近发现了一些高度城市化，更繁荣的地区。我们认为，阿巴拉契亚地区普遍缺乏综合性医疗服务与最近报道的癌症发病率和死亡率过高有关，尽管没有研究系统地检查癌症治疗模式，如治疗使用不足和护理差距。这项为期三年的研究将记录和描述2006-2008年间诊断出的女性乳腺癌和结直肠癌的护理模式，这些数据来自阿巴拉契亚一大片地区的州癌症登记处、人口普查和医疗保险索赔数据文件。研究人群将包括宾夕法尼亚州、俄亥俄州、肯塔基州和北卡罗来纳州阿巴拉契亚县居民中所有估计的（N= 7800）例女性乳腺癌病例和（N= 8700）例结直肠癌病例。将对研究数据进行处理、补充和质量保证，以确定接受国家综合癌症网络（NCCN）指南乳腺癌和结直肠癌协调治疗的病例比例。这些结果将与研究州的乳腺癌和结直肠癌护理的估计率进行比较，分别和汇总。对Appalachia数据的回归分析将寻求确定患者、肿瘤、提供者和设施因素，这些因素导致乳腺癌和结直肠癌接受指南一致护理的显著差异，包括：1)年龄、种族、性别（仅结直肠癌）、合并症状况和医疗补助双登记和患者居住人口普查区的社会经济地位所代表的社会经济地位；2)设施类型和提供者特征；3)从患者住所到特定类型提供者（例如，高容量癌症护理，综合治疗中心和肿瘤学家实践）的旅行时间距离。对特定类型的提供者（例如，大量的癌症护理，综合癌症服务）的不同距离的影响将被建模为校正选择性转诊的工具变量。次要目标包括探索与治疗延迟和获得新的或领先的治疗相关的患者、设施和提供者特征。研究结果将分发给阿巴拉契亚社区、决策者、保健提供者和科学界。

DESCRIPTION (provided by applicant): The rugged topography of the Appalachian Mountains geographically delineates the diverse region known as Appalachia. Most counties within Appalachia are designated as medically underserved, have sparse health care resources and lack integrated care systems, though a few highly urbanized, more prosperous areas found within or near the borders of Appalachia. We believe that a general lack of proximity to comprehensive medical services is associated with the recently reported excess cancer incidence and mortality in Appalachia, though no studies have systematically examined cancer treatment patterns, such as underuse of therapies and gaps in care. This three-year study will document and describe patterns of care for female breast and colorectal cancers diagnosed in 2006-2008 from state cancer registry, census and Medicare claims data files for a large region of Appalachia. The study population will include all estimated (N=7,800) cases of female breast cancer and (N=8,700) cases of colorectal cancer cases in among residents of Appalachian counties of PA, OH, KY, and NC. Study data will be processed, supplemented and quality assured necessary to determine the proportion of cases receiving National Comprehensive Cancer Network (NCCN) guideline concordant care for breast and colorectal cancer. These results will be compared to estimated rates of breast and colorectal cancer care for the study states, separately and pooled. Regression analyses of Appalachia data will seek to identify patient, tumor, provider, and facility factors that contribute to significant variation in receipt of the guideline-concordant care for breast and colorectal cancers including: 1) Age, race, gender (colorectal cancer only), comorbidity status, and socioeconomic status as proxied by dual enrollment in Medicaid and the socioeconomic status of patient's census tract of residence, 2) Facility typology and provider characteristics; and 3) Travel time distance from patients residence to specific types of providers (e.g., high volume of cancer care, comprehensive treatment center and oncologist practice). The effects of differential distance to specific types of providers (e.g., high volume of cancer care, comprehensive cancer services) will be modeled as an instrumental variable that corrects for selective referral. Secondary aims include exploring patient, facility and provider characteristics associated with delays in treatment and access to new or leading therapies. Study findings will be disseminated to Appalachian communities, policy makers, health care providers and to the scientific community. PUBLIC HEALTH RELEVANCE: This study seeks to identify patient, tumor, provider, and facility factors that contribute to significant variation in receipt of the guideline-concordant care for approximately 15,000 breast and colorectal cancers in a large region of Appalachia. Study aims will focus on the contributions of : i) Age, race, gender (colorectal cancer only), comorbidity status, and socioeconomic status (ii) Travel time distance from patients residence to specific types of providers (e.g., high volume of cancer care, comprehensive treatment center and oncologist practice); and (iii) Facility volume, type, comprehensiveness and accredited status, and surgeon case volume, training status, and vintage.