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

描述(申请人提供)：乳房切除后立即乳房重建未得到充分利用，存在明显的种族、经济和地理差异。尽管1998年签署成为法律的《妇女健康和癌症权利法》(WHCRA)获得通过，但仍是如此。WHCRA授权团体健康计划、健康保险公司和HMO涵盖乳房切除后的乳房重建。初步分析显示，立即乳房重建中23%的差异是由于医院之间的差异，17%是由于县之间的差异。造成这一差异的医院和县级因素尚未完全确定。这项拟议的研究旨在确定影响乳腺癌术后立即乳房重建术的医院和县级因素，以及个人因素之外的因素。来自全国住院患者样本(NIS)的个人级别的数据将与NIS、美国医院协会(AHA)和美国社区调查(ACS)的医院级别数据以及来自地区资源文件(ARF)的县级数据结合在一起。这些样本来自大约42,000名接受乳腺切除术治疗浸润性乳腺癌或导管原位癌(DCIS)的女性。这些数据集将提供有关医院内部环境的信息(例如，医院住院人口的特征、医院的所有权状况)以及关于该县的信息，如整形外科医生的密度和该县的社会人口特征。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，以衡量外部医院环境。将使用三水平广义线性混合模型(GLMM)来解释医院内嵌套患者和县内医院嵌套患者的非独立性。在这个模型中，患者将是第一级 单位、医院为二级单位、县为三级单位。结果将是一个二元变量，根据患者是否接受了立即的自然重建或扩张器/植入重建，或者没有接受任何类型的立即重建。完成这项研究将极大地帮助医疗保健经理和政策制定者了解患者、医院和县级因素在乳房切除术后立即乳房重建中的相对贡献。此外，拟议的研究将使政策制定者了解如何改革现有政策，如WHCRA，以提高利用率和消除差距。 公共卫生相关性：该项目将确定医院(例如非白人患者的比例、公共保险患者的比例和公有制地位)和县级因素(例如生活在贫困线以下的居民比例和高中学历的居民比例)是否影响立即进行乳房再造，而不受个人因素的影响。这项研究所获得的知识将使政策制定者了解如何完善现行的保健政策，如1998年实施的联邦政策《妇女健康和癌症权利法案》，以改善乳房切除后乳房重建的机会和利用。

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.