Mechanisms Underlying SES Disparities in Breast Cancer Mortality

描述（由申请人提供）：社会经济（SES）的差距，从乳腺癌的生存发展在20世纪80年代和90年代，并一直持续到21世纪初。现有文献和/或我们的初步数据提供了SES组在使用筛查和随访乳腺X线摄影、使用保乳手术联合放疗、选择和使用替代辅助内分泌治疗（芳香酶抑制剂vs.他莫昔芬）以及开始后可能持续使用内分泌治疗方面的过程差异的证据。也有证据表明，在使用低容量医院的乳腺癌患者中可能存在SES差异，这与生存率降低有关。目前尚不清楚的是，这些过程因素相互关联的程度，导致观察到的生存差异，以及公共政策或卫生保健提供干预措施值得最大的关注，旨在减少这些差距的计划。在这个应用程序中，我们建议经验性地显示这些因素中的每一个在多大程度上有助于观察到的SES女性乳腺癌死亡率的差异。具体而言，我们的目标是：（1）记录SES在乳腺癌护理模式方面的差异，以及使用当代老年乳腺癌患者队列的3年和5年死亡率;（2）分解SES在乳腺癌死亡率方面差异的潜在因素，最值得注意的是，（i）筛查，（ii）疾病程度，（iii）初始治疗，（iv）辅助和随访护理;（五）卫生系统 结构和政策因素;（3）模拟不同公共政策对癌症死亡率的影响及其对社会经济地位差异的影响。这些目标将得到实现 通过分析2005-2007年SEER-Medicare-Part D数据的数据，并跟踪到2012年。我们建议首先使用分类和回归树（CART）方法确定乳腺癌护理模式，定义为术后60个月的连续治疗。然后，我们将根据构成这些护理模式的每个结构和过程措施的贡献，使用Oaxaca-Blinder基于回归的分解方法，量化每个解释的部分，以及仍然无法解释的差异，来分配观察到的SES死亡率差异。最后，我们将使用这些分析产生的参数估计来模拟目前正在考虑的替代方案的预期效果（例如，增加D部分保费和共同支付，消除覆盖差距），以抵消或加剧乳腺癌治疗和结果的差异。这项拟议的研究不仅将提供机制信息，以集中精力弥补SES在乳腺癌死亡率方面的差异，而且还将提供一个创新的政策模拟，以确定如何最好地分配公共医疗和处方药保险计划的资源，以获得最大的价值。

DESCRIPTION (provided by applicant): Socioeconomic (SES) disparities in survival from breast cancer developed during the 1980's and 1990's, and have persisted into the early 2000's. The existing literature and/or our preliminary data provide evidence of process disparities among SES groups in the use of screening and follow-up mammography, the use of breast conserving surgery with radiotherapy, the choice and use of alternative adjuvant endocrine therapy (aromatase inhibitors vs. tamoxifen) and possibly persistence with endocrine therapy once initiated. There is also evidence that SES disparities may exist among breast cancer patients in the use of low-volume hospitals, which are associated with worse survival. What is unclear is the extent to which these process factors inter-relate to lead to the observed survival disparities, and which public policy or health care delivery interventions deserve greatest attention in a program designed to reduce these disparities. In this application, we propose to show empirically the extent to which each of these factors contribute to the observed SES disparities in mortality among women with breast cancer. Specifically, our aims are to: (1) To document SES disparities in patterns of breast cancer care, and in 3- and 5-year mortality using a contemporary cohort of elderly women with incident breast cancer; (2) To decompose the factors underlying SES disparities in breast cancer mortality, most notably, (i) screening, (ii) extent of disease; (iii) initial treatment; (iv) adjuvant and follow-up care; and (v) health system structural and policy factors; and (3) To simulate the effect of alternative public policies on cancer mortality and their implications for SES disparities therein. These aims will be carried out by analyzing data from the 2005-2007 SEER-Medicare-Part D data and followed until 2012. We propose to first identify patterns of breast cancer care, defined over the 60-month post-surgery treatment continuum, using the Classification and Regression Tree (CART) methodology. We will then apportion the observed SES disparities in mortality according to the contribution of each structural and process measures comprising these patterns of care, using the Oaxaca-Blinder regression-based decomposition approach, quantifying the portion explained by each, and the differences that remain unexplained. Finally, we will use parameter estimates generated by these analyses to simulate the anticipated effect of alternative proposals currently under consideration (e.g., increasing Part D premiums and co-pays, eliminating the coverage gap) in offsetting or exacerbating disparities in breast cancer treatments and outcomes. The proposed study will not only provide mechanistic information to focus efforts to remediate SES disparities in breast cancer mortality, but will also provide an innovative policy simulation that will inform efforts to determine how best to allocate the resources of public medical and prescription drug insurance programs in order to obtain the greatest value.