Can regionalization improve outcomes and reduce disparities related to breast cancer care? An Evaluation of the NY Medicaid regionalization experiment

有证据表明，在大容量设施中接受治疗的乳腺癌患者有更好的长期- 长期生存，纽约州卫生部颁布了一项强制性的区划政策，根据该政策，它不会 报销低数量的设施，即那些每年接受不到30例全额乳腺癌手术的机构， 为其受益人提供的乳腺癌手术。在此应用程序中，我们利用自然的 纽约州医疗补助区域化裁决(此处称为政策)提供的实验，以检查其影响 关于大约15,000名纽约居民的数量、结果和获得护理的机会的分布情况 每年都会因乳腺癌而接受手术。具体来说，我们的目标是：1.确定 该政策在多大程度上导致了平均而言，医疗补助乳腺癌患者得到了更高的治疗量 设施；2.通过检查患者存活的程度来评估该政策对患者结局的影响 与政策实施前相比，纽约医疗补助计划的乳腺癌患者人数有所改善；以及3.对意外情况进行量化 通过评估该政策对获得治疗的影响，并模拟贸易-- 在不同的“低容量”阈值下的生存和获取之间的偏差。使用差值-差值-差值 不同的技术，我们将纽约医疗补助乳腺癌患者的经历与历史和 同时对纽约联邦医疗保险和商业保险的乳腺癌患者以及新泽西州的观察数据 医疗补助乳腺癌患者，以评估该政策对结果的影响，即5年全因 和特定于乳腺癌的死亡率和存活率，以及获取措施，即距离/治疗时间 从诊断到初步治疗的便利和时间，根据患者的社会人口统计、肿瘤和市场进行调整 特点。对结直肠癌患者进行的系列队列分析将提供额外的 比较组。尽管兴趣与日俱增，但纽约政策中体现的方法并不是 没有争议的命题，所以举出证据证明它的影响将对 支持(或反对)其更广泛传播的论点。考虑到乳腺癌患者的数量很大， 患者的社会经济地位和预后持续存在差异的证据 医院数量，以及关于区域化乳房的挑战和价值的悬而未决的问题 在癌症治疗方面，这项研究的结果将对政策和计划的发展产生重大影响。

Prompted by evidence suggesting that breast cancer patients treated in high-volume facilities have better long- term survival, the NY State Dept of Health enacted a mandatory regionalization policy whereby it would not reimburse low-volume facilities, defined as those with less than 30 all-payer breast cancer surgeries per year, for breast cancer surgeries provided to its beneficiaries. In this application, we take advantage of the natural experiment afforded by NY's Medicaid regionalization ruling (referred here as The Policy) to examine its impact on the distribution by volume, outcomes, and access to care for the approximately 15,000 NY residents undergoing surgery for an incident breast cancer every year. Specifically, our aims are: 1. To determine the extent to which The Policy led to Medicaid breast cancer patients, on average, being treated in higher volume facilities; 2. To evaluate the impact of The Policy on patient outcomes by examining the extent to which survival of NY Medicaid breast cancer patients improved relative to pre-Policy levels; and 3. To quantify unanticipated adverse consequences of The Policy by estimating its impact on access to treatment, and to simulate trade- offs between survival and access at different “low-volume” thresholds. Using difference-in-difference-in- difference techniques, we contrast the experience of NY Medicaid breast cancer patients to historical and concurrent observational data on NY Medicare and commercially-insured breast cancer patients, as well as NJ Medicaid breast cancer patients, to estimate the effect of The Policy on outcomes, namely 5-year all-cause and breast-cancer-specific mortality and survival, and access measures, namely distance/time to treating facility and time from diagnosis to initial treatment, adjusting for patient's sociodemographic, tumor, and market characteristics. Analyses conducted with serial cohorts of patients with colorectal cancer will provide additional comparison groups. Despite increasing interest, the approach embodied in NY's Policy is not an uncontroversial proposition, so that adducing evidence of its impact would make a significant contribution to arguments for (or against) its broader diffusion. Given the large numbers of breast cancer patients, the evidence of consistent and persistent disparities in outcomes by the patients' socioeconomic status and hospital volume, and the unresolved questions concerning the challenges and value of regionalized breast cancer care, the results of this study will have significant implications for both policy and program development.