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， 受到各种护理领域的种族差异的困扰。尽管种族癌症的差距很长- 站得住脚，描述得很好，基本的知识差距仍然存在。第一，种族差距的程度 在非小细胞肺癌中，不同地理区域的护理和结果不同，尚未得到彻底的探索。其次，很少是 了解各种背景因素如何导致区域一级的种族差异。从历史上看，健康 服务研究的重点是医疗保健系统是种族差异的主要驱动力，有限的 探讨卫生保健隔离和结构性种族主义等背景因素。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应对和克服障碍 公平的非小细胞肺癌护理。目标：我们将解决这些关键的知识差距，总体目标是 通过确定可修改的结构来缓解非小细胞肺癌诊断、治疗和结果中的种族差异 以及影响肺癌护理公平的卫生系统/中介因素和战略。我们打算 进行解释性序贯混合方法研究，结合新的回溯性、基于人群的研究 肺癌治疗中种族差异的正偏差分析研究。通过定性访谈 与种族差距大小地区的主要利益攸关方一起，我们将揭示战略和结构 这影响了肺癌治疗和结果的公平性。我们的假设是，种族问题的严重性 不同县之间的差异很大，这种差异不是偶然产生的--有特定的 背景因素，如结构性种族主义、种族隔离和卫生系统因素，加剧了 差距。具体目标：我们提出了一种关于医疗保险的解释性序贯混合方法研究 2013至2017年间被诊断为非小细胞肺癌的受益者：(1)评估#年种族差异的差异 SEER地区内各县的NSCLC护理(非拉丁裔黑人与非拉丁裔白人)。(2)评估 与地区一级有关的结构性/基础性因素(例如结构性种族主义、社会经济不平等) 非小细胞肺癌护理方面的种族差异。(3)评估卫生系统/中介决定因素(例如医院 特征和竞争、患者隔离)非小细胞肺癌护理中地区一级的种族差异。(4)至 确定利益相关者战略，确保在拥有类似政策的县提供公平的非小细胞肺癌护理 社会经济特征，但较高的种族差距与较低的种族差距。建议的混合方法研究 将产生很高的影响，使用创新方法的组合来超越传统的医疗体系 确定导致肺癌的可改变的结构性、社会经济和社会因素的因素 差距。此外，我们将阐明利益相关者用来缩小种族差距的战略， 确定可以更广泛地采用的方法，以改善非小细胞肺癌护理的公平性。

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.