The role of Federal legislation on breast cancer disparities

联邦立法对乳腺癌差异的作用

• 批准号: 7685244
• 负责人: ROBERT A LEVINE
• 金额: $ 21.89万
• 依托单位: MEHARRY MEDICAL COLLEGE
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-05-01 至 2013-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7685244
• 关键词: Accounting; Address; Adverse effects; African American; Age; Anti-Retroviral Agents; Area; Behavioral; Biological; Caring; Centers of Research Excellence; Cessation of life; Characteristics; Data; Developed Countries; Diagnosis; Disease; Elderly woman; Epidemiology; Ethnic Origin; Food; HIV; Health Insurance; Healthcare; Individual; Intervention; Laws; Licensing; Life; Life Expectancy; Logistic Regressions; Mammography; Medical; Medical Assistance; Medicare; Medicare claim; Modeling; Modification; Morbidity - disease rate; National Cancer Institute; National Center on Minority Health and Health Disparities; Nature; Patients; Persons; Policies; Positioning Attribute; Race; Relative (related person); Research Personnel; Resources; Respiratory distress; Role; Safety; Screening procedure; Services; Socioeconomic Status; Solutions; Source; Statutes and Laws; Testing; Time; Translating; United States Centers for Medicare and Medicaid Services; United States Food and Drug Administration; Woman; base; cancer health disparity; cancer information system; drug market; hazard; health disparity; human very old age (85+); innovation; low socioeconomic status; malignant breast neoplasm; mortality; older women; premature; programs; psychologic; social; socioeconomics; surfactant

Each year, the US spends a larger percentage of its gross domestic product on health care than any other nation.1 Yet, rather than achieving a higher standing among industrialized nations for such key indicators as life expectancy, the US position has declined2. Numerous investigators assert that this occurs, in part, because the nation's preoccupation with health care diverts resources from potentially more important targets such as the solution of social, psychological, behavioral and environmental problems.2"9' ¿'n In the present proposal, we suggest that difficulties posed by the magnitude and nature of US health care spending go beyond diversion. We hypothesize that federal laws and policies related to health care inadvertently promote racial disparities in mortality by favoring the acquisition of life saving innovations by those of higher socioeconomic status. The resulting premature loss of life may also be contributing to the declining US position relative to other industrialized nations. We have shown that Black;white disparities in US mortality increased after three lifesaving, disease-specific innovations with clear start dates, namely Surfactant for Respiratory Distress X licensed by the Food and_DmAdininistration FDA in 1 9 8 9 i h . A : t w e Anti-Retroviral Therapy for Human Immunodeficiency Virus (HIV disease) licensed by the FDA from December 1995 to March 1996 ; and mammography re-imbursement by Medicare in 1991. For RDS, mean (+/-standard deviation) 5 year pre- and post-innovation black:white Mortality Rate Ratios (MRRs) were 1.92 (+/-0.26) and 2.70 (+/-0.37) (p=0.005). The corresponding MRRs were 3.98 +/-0.51 and 7.98 +/-0.37 (p < 0.001) for HIV mortality (age-adjusted, 25-64 years) and 0.93 +/-0.05 and 1.04 +/-0.04 (p=0.003) for breast cancer (age-adjusted, 65-85+ year old women).12 Thus, after each innovation, rates declined less in blacks than whites, translating into as many as 18,995 premature deaths among blacks through 2004. These descriptive data are compatible with the hypothesis that Medicare law (which defines medical assistance (health insurance) as a cash benefit regardless of the extent to which cash is a barrier to service acquisition) and administrative policies of the Food and Drug Administration (basing drug marketing decisions on biological safety/efficacy without considering possible adverse social effects) contribute to disparities in black:white mortality, in part, by actively (Medicare) and passively (Food and Drug Administration) helping to assure that the benefits of life-saving innovations are more likely to accrue to persons of higher socioeconomic status. This is not to deny the beneficial effects of these programs, but rather to suggest that any health-related intervention may have unintended, adverse effects. The present collaborative study will focus on breast cancer in order to address the overarching hypotheses as they pertain to Medicare law. We will purchase Medicare claims data from the Center for Medicare and Medicaid Services (CMS) and SEER-Medicare data. We shall also use data from the Area Resource File and the National Cancer Institute's Cancer Information System (CIS) to locate medical resources and programs that support utilization of screening mammography. We shall then pursue the following aims and hypotheses: Specific Aim 1: To determine the importance of regional level characteristics on the utilization of mammography by elderly women in the years 1992 to 1995 and 2002 to 2005. We will use the Medicare data to identify patient level information (e.g., age, race, co-morbidity, regular source of care), and both ARF and CIS to identify regional level data. We will use multilevel logistic regression to model women clustered within regions and states. The hypothesis to be tested will be: H-l: Regional and state level characteristics will have a significant effect on mammography utilization after adjusting for individual factors. H-2: The effect of regional and state level characteristics on mammography utilization will be different for African American and White women. H-3: The region having the greatest equitability for screening mammography utilization will be more likely to have programs in place aiming to increase mammography utilization and reduce disparities. Specific Aim 2: To examine the association between screening mammography utilization and breast cancer survival of women age 67 and older. For the years 1992 through 2005, we will use Statistical Epidemiology and End Results (SEER)-Medicare data to take potential confounding (e.g., age at diagnosis) and effect modification (e.g., race/ethnicity) of this association into account. Using Cox proportional hazard regression, we will test the following hypotheses: H-4: Relative to moderately successful or relatively unsuccessful places, highly unsuccessful places will be more likely to have lower contextual socioeconomic status, low survival from breast cancer, and greater percentage increase in racial disparity in survival over time. H-5: Relative to places that are jTighIy_unsuccessful, moderately successful or relatively unsuccessful with regard to screening mammography utilization, exceptionally successful places will be more likely to have high survival from breast cancer, and to have greater percentage reduction in racial disparity in survival over time. Socioeconomic status is not given as a part of this hypothesis to allow for the possibility that, under present conditions, exceptionally successful places may be those that overcome contextual socioeconomic barriers.

每年，美国在医疗保健上的支出占其国内生产总值的比例比 任何其他国家1还没有在工业化国家中取得更高的地位 在预期寿命等关键指标上，美国的地位已经下降2。无数调查人员 断言这种情况的发生，部分是因为国家对医疗保健的关注转移了 来自潜在更重要目标的资源，如解决社会、心理、 行为和环境问题2“9‘’n在本提案中，我们建议 美国医疗支出的规模和性质带来的困难远远超出了分流的范围。 我们假设，与医疗保健相关的联邦法律和政策无意中促进了种族 死亡率的差异，因为更高的人倾向于获得救生创新 社会经济地位。由此造成的过早生命损失也可能是导致 相对于其他工业化国家，美国的地位正在下降。 我们已经表明，在三次拯救生命后，美国黑人和白人死亡率的差异增加， 明确开始日期的针对疾病的创新，即用于呼吸窘迫的表面活性物质 X由食品和药物管理局批准，于1 9 8 9 1小时内使用。A：T W E FDA批准用于人类免疫缺陷病毒(HIV病)的抗逆转录病毒疗法 从1995年12月到1996年3月；1991年由联邦医疗保险重新支付乳房X光检查费用。 对于RDS，创新前和创新后5年的平均(+/-标准差)黑色：白色死亡率 率比(MRR)分别为1.92(+/-0.26)和2.7(+/-0.37)(P=0.005)。相应的MRR 艾滋病毒死亡率分别为3.98+/-0.51和7.98+/-0.37(p&lt；0.001)(年龄调整后，25岁-)和 乳腺癌(年龄调整后，65-85岁以上)分别为0.93+/-0.05和1.04+/-0.04(p=0.003) 12因此，在每一次创新之后，黑人的比率下降得比白人少，转化为 截至2004年，黑人过早死亡的人数多达18,995人。这些描述性数据是 与医疗保险法律(它定义了医疗援助(健康))的假设一致 保险)作为一种现金福利，不管现金在多大程度上阻碍了服务 收购)和食品和药物管理局的管理政策(基础药物 在不考虑可能的不良社会影响的情况下，关于生物安全性/有效性的营销决策 影响)造成黑人的差异：白人的死亡率，部分是由于积极的(医疗保险)和 被动地(食品和药物管理局)帮助确保拯救生命的好处 社会经济地位较高的人更有可能获得创新。这不是为了 否认这些计划的有益影响，而是建议任何与健康相关的 干预可能会产生意想不到的不利影响。 目前的合作研究将集中在乳腺癌上，以解决主要的 与医疗保险法律相关的假设。我们将从以下网站购买联邦医疗保险索赔数据 医疗保险和医疗补助服务中心(CMS)和SEER-联邦医疗保险数据。我们还将使用 来自区域资源文件和国家癌症研究所癌症信息系统的数据 (CI)查找支持筛查利用的医疗资源和计划 乳房X光检查。然后，我们将追求以下目标和假设： 具体目标1：确定区域一级特征对利用的重要性 1992年至1995年和2002年至2005年老年妇女乳房X光检查的情况。我们将使用 用于识别患者级别信息的Medicare数据(例如，年龄、种族、合并症、正常 护理来源)，以及东盟地区论坛和独联体，以确定区域一级的数据。我们将使用多个级别 Logistic回归对聚集在地区和州内的女性进行建模。假设是 测试将包括： H-L：地区和州的特征将对乳房X光检查产生重大影响 经个别因素调整后的利用率。 H-2：地区和州一级的特征对乳房X光检查使用的影响将是 对于非裔美国人和白人女性来说不同。 H-3：在筛查乳房X光检查使用方面具有最大公平性的地区将是 更有可能制定旨在提高乳房X光检查利用率和减少 差距。 具体目标2：检查筛查乳房X光检查的使用率和 67岁及以上女性的乳腺癌存活率。从1992年到2005年，我们将使用 统计流行病学和最终结果(SEER)-医疗保险数据可能会产生混淆 (例如，确诊时的年龄)和这种关联的影响修改(例如，种族/民族) 帐号。使用COX比例风险回归，我们将检验以下假设： H-4：相对于中等成功或相对不成功的地方，非常不成功 地方更有可能具有较低的社会经济地位，低存活率 乳腺癌，随着时间的推移，存活率的种族差异增加了更大的百分比。 H-5：相对于jTighIy_不成功、中等成功或相对成功的地方 在筛查乳房X光检查利用方面不成功，特别成功的地方 将更有可能有更高的乳腺癌存活率，并有更大的百分比 随着时间的推移，生存方面的种族差距正在缩小。社会经济地位不是作为 这一假设允许在目前情况下，例外地 成功的地方可能是那些克服了特定社会经济障碍的地方。