Impacts of Neighborhood Contexts and Medicaid Policy on Lung Cancer Survival in Low-SES Patients

项目摘要/摘要 我们之前的工作表明，在ACA下扩大医疗补助与早期发现和改善有关 非小细胞肺癌患者的存活率是最常见的肺癌类型。然而，医疗补助计划 与私人保险的参与者相比，肺癌患者的存活率仍然要差得多。 这主要是因为他们在更高级的阶段被诊断出的风险更高，而且- 利用分期适当的癌症治疗。这表明平等的医疗保险是至关重要的，但 不足以确保平等地获得肺癌护理和治疗结果。医疗保健服务一直是 概念化为个人、提供者和医疗保健各个因素之间相互作用的结果 系统、社区和政策层面。然而，先前的研究解决了低收入人群中肺癌的差异。 收入患者关注的是个体层面的因素。我们和其他团体展示了这个社区 癌症护理的可及性与乳腺癌或结直肠癌患者的治疗有关。医疗补助 登记癌症前诊断与癌周诊断与早期癌症诊断相关。我们知道的要少得多 关于社区环境、医疗补助参保持续时间和医疗补助覆盖范围对肺部的影响 癌症筛查对医疗补助患者肺癌护理的影响。戒烟治疗是一项不可或缺的 是肺癌治疗的重要组成部分。还没有研究检查烟草处理的利用和其 低收入肺癌患者的决定因素，这是一个医疗服务不足的高患病率人群 尼古丁依赖。我们假设，社区环境、医疗补助政策和医院起着至关重要的作用 在肺癌护理和医疗补助患者生存中的作用。使用健壮的多层建模方法来 考虑到提供商和社区内的集群，我们将评估社区、政策、 和医院关于肺癌的早期发现和肿瘤治疗，烟草治疗的利用，以及 医疗补助患者的肺癌存活率及其对肺癌种族差异的贡献 治疗和生存。为此，我们将为被诊断患有疾病的医疗补助参与者开发综合数据集 肺癌，包括具有全国代表性的癌症数据、密苏里州医疗补助申请和登记(还 双重合格参保人的医疗保险索赔)，密苏里州癌症登记数据，年度医院调查， 我们将制定的邻里关系措施。据我们所知，这将是第一个以人口为基础的 综合评估社区、卫生政策和医院因素的贡献的研究 低收入患者的肺癌护理水平。结果将有助于通过以下方式为干预提供信息 建议潜在的可修改因素，可以有针对性地改善这一脆弱群体的癌症护理 因此，减少肺癌患者的差异。解决癌症护理的非经济障碍 医疗补助计划的参与者可以最大限度地增加对医疗补助计划扩展的大量投资将 转化为低收入患者获得癌症护理的机会和结果的真正收益。

PROJECT SUMMARY/ABSTRACT Our prior work showed that Medicaid expansion under the ACA is associated with early detection and improved survival in patients with non-small cell lung cancer, the most common type of lung cancer. However, Medicaid enrollees with lung cancer still have much worse survival compared with their privately insured counterparts, which is driven predominantly by their higher risks of being diagnosed at more advanced stages and under- utilizing stage-appropriate cancer treatment. This suggests that equal healthcare coverage is essential, but insufficient, to ensure equal access to lung cancer care and outcomes. Healthcare access has been conceptualized as a result of the interactions between factors across the individual, provider and healthcare system, neighborhood, and policy levels. However, prior studies addressing lung cancer disparities in low- income patients focused on individual-level factors. We and other groups demonstrated that neighborhood accessibility to cancer care is associated with treatment in patients with breast or colorectal cancer. Medicaid enrollment pre- vs. peri-cancer diagnosis is associated with early-stage cancer diagnoses. Much less is known about the influences of neighborhood contexts, Medicaid enrollment continuation, and Medicaid coverage of lung cancer screening on lung cancer care in Medicaid patients. Tobacco cessation treatment is an integral and essential part of lung cancer treatment. No study has examined the utilization of tobacco treatment and its determinants in low-income lung cancer patients, a medically underserved population with high prevalence of nicotine dependence. We hypothesize that neighborhood contexts, Medicaid policies, and hospitals play critical roles in lung cancer care and survival in Medicaid patients. Employing a robust multilevel modelling approach to account for clustering within providers and neighborhoods, we will assess the impacts of neighborhoods, policies, and hospitals on early detection and oncologic treatment for lung cancer, utilization of tobacco treatment, and lung cancer survival in Medicaid patients, as well as their contributions to racial disparities in lung cancer treatment and survival. To this end, we will develop integrated datasets for Medicaid enrollees diagnosed with lung cancer, which includes nationally representative cancer data, Missouri Medicaid claims and enrollment (also Medicare claims for dual eligible enrollees), Missouri Cancer Registry data, Annual Hospital Surveys, neighborhood contextual measures that we will develop. To our knowledge, this will be the first population-based study to comprehensively assess the contributions of factors at the neighborhood, health policy, and hospital levels to the lung cancer care continuum in low-income patients. The results will help inform interventions by suggesting potentially modifiable factors that could be targeted to improve cancer care in this vulnerable population and thereby reduce lung cancer disparities. Addressing non-financial barriers to cancer care in Medicaid enrollees could maximize the likelihood that substantial investments in Medicaid expansion will translate into true gains in cancer care access and outcomes for low-income patients.