Hospital and County-Level Predictors of Immediate Breast Reconstruction Post-Mast

描述（由申请人提供）：乳房切除术后立即乳房重建未被充分利用，存在显著的种族、经济和地理差异。尽管通过了《妇女健康和癌症权利法案》（WHCRA），该法案于1998年签署成为法律。WHCRA要求团体健康计划、健康保险公司和HMO覆盖乳房切除术后的乳房重建。初步分析表明，23%的即时乳房重建的差异是由于医院之间的差异，17%是由于县与县之间的差异。造成这种差异的医院和县一级因素尚未完全确定。拟议的研究旨在确定医院和县一级的因素，影响乳房切除术后立即乳房重建的接收，超越个人水平的因素。来自全国住院患者样本（NIS）的约42000名接受乳房切除术治疗浸润性乳腺癌或导管原位癌（DCIS）的妇女的个人数据将与来自NIS、美国医院协会（AHA）和美国社区调查（ACS）的医院数据以及来自地区资源文件（ARF）的县级数据相结合。这些数据集将提供关于医院内部环境的信息（例如，医院住院人口特征、医院所有权状况）以及关于县的信息，如整形外科医生密度和县的社会人口特征。此外，ACS数据将用于开发基于地理信息系统（GIS）的医院社区社会人口特征模型，以测量医院外部环境。将使用三级广义线性混合模型（GLMM）来解释嵌套在医院内的患者和嵌套在县内的医院的非独立性。在这种模式下，病人是第一层次

DESCRIPTION (provided by applicant): Immediate breast reconstruction post-mastectomy is underutilized and there are significant racial, economic and geographic disparities. This is despite the passing of the Women's Health and Cancer Rights Act (WHCRA), which was signed into law in 1998. WHCRA mandated group health plans, health insurance companies and HMO's to cover breast reconstruction post-mastectomy. Preliminary analyses show that 23 percent of the variation in immediate breast reconstruction is due to between hospital differences and 17 percent is due to between county differences. The hospital and county-level factors that account for this variation have yet to be fully identified. The proposed research is aimed at identifying the hospital and county-level factors that influence the receipt of immediate breast reconstruction post mastectomy, above and beyond individual level factors. Individual-level data from the Nationwide Inpatient Sample (NIS) on ~42,000 women who underwent mastectomy to treat invasive breast cancer or ductal carcinoma in situ (DCIS) will be combined with hospital-level data from the NIS, the American Hospital Association (AHA) and the American Community Survey (ACS) and county-level data from the Area Resource File (ARF). These datasets will provide information on the internal hospital environment (e.g., characteristics of the hospital inpatient population, hospital ownership status) as well as information on the county such as the density of plastic surgeons and socio-demographic characteristics of the county. In addition, the ACS data will be used to develop a geographic information system (GIS) based model of the socio-demographic characteristics of hospital neighborhoods to measure the external hospital environment. A three level generalized linear mixed model (GLMM) will be used to account for the non-independence of patients nested within hospitals and hospitals nested within counties. In this model patients will be the level one unit, hospitals will be the level two unit and counties will be the level three unit. The outcome wll be a binary variable classified by whether the patient received an immediate natural or expander/implant reconstruction or did not receive any type of immediate reconstruction. Accomplishing this research will greatly aid healthcare managers and policymakers in understanding the relative contribution of patient, hospital and county-level factors in the utilization of immediate breast reconstruction post-mastectomy. In addition, the proposed research will inform policymakers about how to reform existing policies, such as WHCRA, in order to increase utilization and eliminate disparities. PUBLIC HEALTH RELEVANCE: This project will determine whether hospital (e.g., the proportion of patients that are non- white, the proportion of patients with public insurance and public ownership status) and county-level factors (e.g., the proportion of residents that live below the poverty level and the proportion of residents with < a high school degree) influence immediate breast reconstruction, independently of individual-level factors. The knowledge gained as a result of this research will inform policy makers about how to refine current healthcare policies such as the Women's Health and Cancer Rights Act, a federal policy implemented in 1998, to improve the access and utilization of breast reconstruction following mastectomy.