Patterns of Patient Care in Appalachia

描述（由申请人提供）：阿巴拉契亚山脉的崎岖地形在地理上描绘了被称为阿巴拉契亚的多样化地区。阿巴拉契亚内的大多数县被指定为医疗服务不足，医疗保健资源稀少，缺乏综合保健系统，尽管在阿巴拉契亚边界内或附近发现了一些高度城市化，更繁荣的地区。我们认为，普遍缺乏接近全面的医疗服务是与最近报道的过高的癌症发病率和死亡率在阿巴拉契亚，虽然没有研究系统地检查癌症治疗模式，如治疗不足和护理差距。这项为期三年的研究将记录和描述2006-2008年从阿巴拉契亚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中诊断出的女性乳腺癌和结直肠癌的护理模式。研究人群将包括PA、OH、KY和NC的阿巴拉契亚县居民中的所有估计（N= 7，800）女性乳腺癌病例和（N= 8，700）结直肠癌病例。将对研究数据进行必要的处理、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。这些结果将与研究状态的乳腺癌和结直肠癌护理估计率进行比较，分别和汇总。对阿巴拉契亚数据的回归分析将寻求确定导致乳腺癌和结直肠癌指南一致性护理接受显著变化的患者、肿瘤、提供者和机构因素，包括：1）年龄、种族、性别（仅结直肠癌）、合并症状况和社会经济状况（由医疗补助中的双重登记和患者居住地人口普查区域的社会经济状况代表），2）设施类型和提供者特征;以及3）从患者住所到特定类型的提供者的旅行时间距离（例如，大量癌症护理、综合治疗中心和肿瘤学家实践）。与特定类型的提供者的距离不同的影响（例如，高容量的癌症护理、全面的癌症服务）将被建模为校正选择性转诊的工具变量。次要目的包括探索与治疗延迟和获得新的或领先的治疗方法相关的患者，设施和提供者特征。研究结果将分发给阿巴拉契亚社区，政策制定者，卫生保健提供者和科学界。 公共卫生相关性：本研究旨在确定患者、肿瘤、提供者和设施因素，这些因素导致阿巴拉契亚大区域约15，000例乳腺癌和结直肠癌接受指南一致性护理的显著差异。研究目的将集中在以下因素的贡献：i）年龄、种族、性别（仅结直肠癌）、合并症状态和社会经济状态（ii）从患者住所到特定类型的提供者（例如，高容量的癌症护理、综合治疗中心和肿瘤学家实践）;以及（iii）设施容量、类型、综合性和认证状态，以及外科医生病例量、培训状态和年份。

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.