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

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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.