Health System and Contextual Factors Associated with Racial Equity in Lung Cancer Care

意义：非小细胞肺癌（NSCLC）是美国癌症死亡的主要原因，是 在医疗服务的各个方面都存在种族差异。尽管种族癌症差异很长- 长期存在的、明确描述的基本知识差距依然存在。首先，种族差异的程度 不同地理区域的NSCLC治疗和结局差异尚未得到充分研究。其次， 了解背景因素如何在区域一级造成种族差异。历史上，健康 服务研究集中在医疗保健系统作为种族差异的主要驱动力， 探索背景因素，如医疗隔离和结构性种族主义。此外，目前还不清楚 医疗保健和社区环境中的关键利益相关者如何解决和克服障碍， 公平的NSCLC治疗。目标：我们将解决这些关键的知识差距，总体目标是 通过确定可改变的结构， 以及影响肺癌治疗公平性的卫生系统/中介因素和策略。我们打算 进行一项解释性序贯混合方法研究，结合新颖的回顾性、基于人群的 肺癌护理中种族差异的研究，采用正偏差分析。通过定性访谈 我们将与种族差异高与低地区的主要利益相关者一起，揭示战略和结构， 影响肺癌治疗和结果的公平性。我们的假设是， 各县之间的差距很大，这种差异不是偶然出现的-有具体的 背景因素，如结构性种族主义，隔离和卫生系统因素，加剧 差距。具体目的：我们提出了一个解释性的顺序混合方法研究医疗保险 2013年至2017年诊断为NSCLC的受益人：（1）评估 SEER区域内各县的NSCLC治疗（非拉丁黑人vs.非拉丁白色）。(2)评估 与地区一级的种族歧视有关的结构性/基础性因素（如结构性种族主义、社会经济不平等） NSCLC治疗中的种族差异。(3)评估卫生系统/中介决定因素（如医院 特征和竞争，患者隔离）的地区水平的种族差异在NSCLC治疗。(4)到 确定利益相关者策略，以确保在具有类似非小细胞肺癌治疗的县中提供公平的非小细胞肺癌治疗。 社会经济特征，但更高与更低的种族差异。建议的混合方法研究 将产生很大的影响，使用创新方法的组合，超越传统的卫生系统 确定导致肺癌的可改变的结构、社会经济和社会因素 差距。此外，我们将阐明利益相关者用来减少种族差异的战略， 确定可以更广泛采用的方法，以提高NSCLC护理的公平性。

Significance: Non-small cell lung cancer (NSCLC), the leading cause of death from cancer in the U.S., is plagued by racial disparities across the spectrum of care. Despite the fact that racial cancer disparities are long- standing and well-described, fundamental knowledge gaps remain. First, the degree to which racial disparities in NSCLC care and outcomes vary across geographic regions has not been thoroughly explored. Second, little is known about how contextual factors contribute to racial disparities at the regional level. Historically, health services research has focused on the healthcare system as the primary driver of racial disparities, with a limited exploration of contextual factors such as health care segregation and structural racism. Further, it is unclear how key stakeholders within the healthcare and community settings address and overcome barriers to equitable NSCLC care. Objective: We will address these critical knowledge gaps, with the overarching goal of mitigating racial disparities in NSCLC diagnosis, treatment, and outcomes, by identifying modifiable structural and health system/intermediary factors and strategies that influence equity in lung cancer care. We intend to conduct an explanatory sequential mixed methods study, combining novel retrospective, population-based studies of racial disparity in lung cancer care with a positive deviance analysis. Through qualitative interviews with key stakeholders in regions with high versus low racial disparities, we will reveal strategies and structures that influence equity in lung cancer care and outcomes. Our hypothesis is that the magnitude of racial disparities varies substantially across counties, and this variation does not arise by accident – there are specific contextual factors, such as structural racism, segregation, and health system factors, that exacerbate disparities. Specific Aims: We propose an explanatory sequential mixed methods study of Medicare beneficiaries diagnosed with NSCLC from 2013 through 2017: (1) To assess variation in racial disparities in NSCLC care (non-Latinx Black vs. non-Latinx White) across counties within SEER regions. (2) To assess structural/foundational factors (e.g. structural racism, socioeconomic inequality) associated with area-level racial disparities in NSCLC care. (3) To assess health system/intermediary determinants (e.g. hospital characteristics and competition, patient segregation) of area-level racial disparities in NSCLC care. (4) To identify stakeholder strategies associated with ensuring equitable NSCLC care in counties that have similar socioeconomic characteristics, yet higher versus lower racial disparities. The proposed mixed methods study will have a high impact, using a combination of innovative methods to move beyond traditional health system factors to identify modifiable structural, socioeconomic, and social factors that contribute to lung cancer disparities. Furthermore, we will elucidate strategies that stakeholders have used to decrease racial disparities, identifying approaches that can be adopted more broadly to improve equity in NSCLC care.