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，美国在医疗保健方面的支出占其国内生产总值的比例都高于美国。 然而，与其在工业化国家中取得更高的地位， 在预期寿命等关键指标方面，美国的地位有所下降2。众多调查人员 我断言，这种情况发生的部分原因是，国家对医疗保健的关注转移了 资源从潜在的更重要的目标，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， 美国医疗保健支出的规模和性质所带来的困难不仅仅是转移。 我们假设，与医疗保健有关的联邦法律和政策无意中促进了种族歧视， 死亡率的差异，因为更高收入的人更倾向于获得救生创新， 社会经济地位。由此造成的过早死亡也可能导致 美国相对于其他工业化国家的地位下降。 我们已经表明，在三次拯救生命后，美国死亡率的黑人和白色差异增加了， 具有明确开始日期的疾病特异性创新，即用于呼吸窘迫的表面活性剂 美国食品和药物管理局于1989年批准了X。A：我们 FDA许可的人类免疫缺陷病毒（HIV疾病）抗逆转录病毒治疗 1995年12月至1996年3月; 1991年医疗保险报销乳房X线照相术。 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）为1.92（+/-0.26）和2.70（+/-0.37）（p=0.005）。相应的MRR HIV死亡率（年龄调整后，25-64岁）分别为3.98 +/-0.51和7.98 +/-0.37（p < 0.001）， 0.93乳腺癌为+/-0.05和1.04 +/-0.04（p=0.003）（年龄调整后，65-85岁+ 因此，在每一次创新之后，黑人的比率下降幅度小于白人，转化为 到2004年，黑人中有多达18,995人过早死亡。这些描述性数据是 与医疗保险法（定义医疗援助（健康））的假设一致， 保险）作为现金福利，而不管现金在多大程度上是服务的障碍 采购）和食品药品监督管理局的行政政策（基础药物 生物安全性/有效性的营销决策，而不考虑可能的不良社会影响 影响）导致黑人：白色死亡率的差异，部分原因是积极（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。这并不是 否认这些计划的有益影响，而是建议任何与健康有关的 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，以解决总体问题， 假设，因为他们涉及医疗保险法。我们将从医疗保险公司购买医疗保险索赔数据。 医疗保险和医疗补助服务中心（CMS）和SEER-Medicare数据。我们还将使用 来自地区资源文件和国家癌症研究所癌症信息系统的数据 (CIS)找到支持筛查利用的医疗资源和项目 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，老年妇女接受乳房X光检查的情况。我们将使用 Medicare数据以识别患者级别信息（例如，年龄、人种、合并症、常规 护理来源），以及东盟区域论坛和独联体，以确定区域一级的数据。我们将使用多层次 逻辑回归，以模拟区域和州内聚集的妇女。假设是 将测试： H-l：区域和州一级的特征将对乳腺X射线摄影术产生重大影响 调整个别因素后的使用率。 H-2：区域和州一级特征对乳腺X射线摄影利用率的影响将是 非洲裔美国人和白色女性的情况不同。 H-3：乳腺X线摄影筛查使用最公平的地区是 更有可能制定旨在提高乳腺X射线摄影利用率和减少 差距。 具体目标2：检查筛查性乳腺X线摄影使用与 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）-采用潜在混杂因素的医疗保险数据 (e.g.,诊断时的年龄）和效果改变（例如，种族/民族）， 帐户.使用考克斯比例风险回归，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，高度不成功 地方将更有可能有较低的社会经济地位，低生存率， 乳腺癌，随着时间的推移，生存率的种族差异增加的百分比更大。 H-5：相对于那些不太成功、中等成功或相对成功的地方， 在乳房X光检查方面不成功的，特别成功的 更有可能从乳腺癌中获得更高的生存率， 随着时间的推移，种族生存差异减少。社会经济地位不作为 这一假设允许的可能性，在目前的条件下， 成功的地方可能是那些克服了背景社会经济障碍的地方。