Multilevel Determinants of Racial/Ethnic Disparities in Lung Cancer Screening Utilization

摘要 自2013年12月以来，美国预防服务工作组一直建议进行肺癌筛查 (LCS)对有吸烟史的高危个体进行低剂量计算机断层扫描，提供主要的 减少肺癌死亡率的机会，特别是在符合以下条件的种族/族裔和弱势群体中 不成比例地受到疾病的影响。然而，有人担心LCS没有得到有效的交付和 公平地说，鉴于其许多独特的执行挑战。LCS利用率仍然较低。新兴数据也 与白人相比，黑人对LCS的吸收较差。对种族/民族的了解更少 戒烟的差异，尽管戒烟咨询是LCS的一个组成部分 进程。确定与使用LCS有关的因素，特别是那些有助于种族/民族的因素 因此，要以最佳方式提供LCS，关键是要解决差异问题。遵循成熟的概念框架，在这些框架中 多层次的影响影响癌症筛查行为，我们假设LCS的利用率受以下因素影响 个人、社区、提供者和卫生设施级别的因素。识别多水平因素的研究 由于数据源中的已知限制，与LCS利用率相关联的数据到目前为止都是有限的 可用于评估LCS，特别是在筛查开始之前的步骤。电子健康记录(EHR)是 已识别但在很大程度上未开发的数据源，用于解决LC。与其他数据源相比，集成了 卫生系统电子病历从确定的人群中获取关于临床服务的全面纵向数据， 提供了一种强大而有效的手段来调查LC使用率差异的多层次决定因素。在……里面 我们的基础性工作使用EHR数据来表征LCS使用的早期模式，我们发现有证据表明 在筛查开始后的过程中存在种族/族裔差异。在这项建议中，我们的目标是确定和 了解LCS使用中种族/民族差异的多层次决定因素 启动筛选。具体地说，我们将确定个人、邻居、 提供商和设施水平对LCS使用率的差异，从要筛选的机会开始，如 以关于吸烟史的EHR文件的完整性来衡量，以评估LCS资格(目标1)， 其次是LCS转介和启动(目标2)以及转介和使用戒烟服务(目标3)。我们 将从社会人口统计学角度对可用的EHR、调查问卷和地理空间数据进行编译、链接和分析 从2014年到2023年，在综合卫生系统中的130多万成年人中的不同人口。总的来说，我们的 多层次分析将对种族/民族差异的主要和可改变的驱动因素产生宝贵的洞察 在LCS中的关键步骤，从资格评估到筛选启动。这些发现将提供一个经验性的 指导卫生系统制定多层次干预措施，以改善初级保健服务的推广和利用； 既有效又公平。

ABSTRACT Since December 2013, the U.S. Preventive Services Task Force has recommended lung cancer screening (LCS) with low-dose computed tomography for high-risk individuals with a smoking history, affording a major opportunity to reduce lung cancer mortality, especially in racial/ethnic and disadvantaged populations that are disproportionately affected by the disease. Yet, there is concern that LCS is not being delivered effectively and equitably, given its many unique implementation challenges. LCS utilization remains low. Emerging data also suggest poorer uptake of LCS in Black versus white individuals. Even less is known about racial/ethnic disparities in smoking cessation, although smoking cessation counseling is an integral component of the LCS process. Identifying factors associated with LCS utilization, particularly those that contribute to racial/ethnic disparities, is thus critical to deliver LCS optimally. Following well-established conceptual frameworks in which multiple levels of influence affect cancer screening behaviors, we posit that LCS utilization is affected by individual-, neighborhood-, provider-, and health facility-level factors. Studies to identify multilevel factors associated with LCS utilization have been limited to date, due in part to known constraints in the data sources available to evaluate LCS, especially at steps before screening initiation. Electronic health records (EHR) are a recognized but largely untapped data source to address LCS. Compared to other data sources, integrated health system EHRs capture comprehensive longitudinal data on clinical services from a defined population, providing a robust and efficient means to investigate multilevel determinants of disparities in LCS utilization. In our foundational work using EHR data to characterize early patterns of LCS utilization, we found evidence of racial/ethnic disparities in the process after screening initiation. In this proposal, we aim to identify and understand multilevel determinants of racial/ethnic disparities in LCS utilization, before and up through screening initiation. Specifically, we will determine the influence of factors at the individual, neighborhood, provider, and facility levels on disparities in LCS utilization, starting from the opportunity to be screened, as measured by the completeness of EHR documentation on smoking history to assess LCS eligibility (Aim 1), followed by LCS referral and initiation (Aim 2) and referral and use of smoking cessation services (Aim 3). We will compile, link, and analyze available EHR, questionnaire, and geospatial data from a sociodemographically diverse population of over 1.3 million adults in an integrated health system from 2014 to 2023. Overall, our multilevel analysis will generate valuable insight into the major and modifiable drivers of racial/ethnic disparities at key steps in LCS from eligibility assessment to screening initiation. These findings will provide an empirical basis to guide health systems in developing multilevel interventions that improve LCS outreach and utilization, both effectively and equitably.