Addressing Disparities in Outcomes of Screening for Colorectal Cancer in Community-Based Settings

项目摘要/摘要：结直肠癌(CRC)是#年癌症死亡的第二大原因 在美国，尽管总体的CRC死亡率一直在下降，但差距依然存在， 尤其是对黑人和美洲原住民来说。结直肠癌筛查非常有效，并受到欢迎 国家重视改善对处于社会不利地位的群体的筛查机会。然而， 筛查的好处取决于接受高质量的检测和异常时及时的后续护理。 因此，即使不同人群的筛查参与率相似，差异也可能持续存在。 最近，美国预防服务工作组强调了对儿童权利差距和 相对缺乏已证明能够消除种族和族裔差异的干预措施。目标是 这一应用的目的是通过阐明 整个筛查过程中的护理差异在多大程度上累积造成了差异。我们 将全面评估整个筛选连续体，从使用的测试和筛选质量到 在每年约380万人的队列中接受后续护理和符合指南的治疗 在近20年的时间里，在北加州凯撒永久(KPNC)和凯撒永久 南加州(KPSC)。我们将使用由卫生公平框架提供信息的混合方法来 检查：1)结直肠癌筛查的接收情况和质量，包括异常时的跟踪；2)筛查后 治疗和疾病结果，包括间隔CRCs、5年生存率和年龄标准化发病率和 总体死亡率和按地点分列的死亡率；3)质量差异的原因，并使用定性的 访谈；以及4)筛查连续体上的差异对 死亡率通过使用微观模拟建模。我们将在45-85岁的动态队列中进行研究 2003-2019年期间KPNC/KPSC的男性和女性。KPNC和KPSC的成员反映了 在社会因素方面，加州各地所服务地区的人的特征。完整的 对所有筛查步骤和不同的、定义明确的人群的捕获使整个战略研究成为可能 在社会群体中筛选连续体。我们的分析将比较种族和民族群体和 在近20年的时间里，按种族对每一种结果进行分层。我们将采访患者-临床医生二人组 阐明质量、随访和结果不同的原因。我们还将使用MISCAN-冒号 检验死亡率差异在多大程度上可归因于所发现的差异的微观模拟模型 在筛选连续体中的每一步。这项拟议的研究很有可能为 确定促进弱势种族和少数族裔群体健康公平的优先战略 从而推进国家公共卫生优先事项。我们团队15年来的高影响力合作， 我们的应用程序的设置和严谨支持了该领域的可行性和高影响力。

PROJECT SUMMARY/ABSTRACT: Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States and although the overall CRC mortality rate has been decreasing, disparities have persisted, particularly for Black and Native American people. CRC screening is highly effective and there is a welcome national attention on improving access to screening for groups that are socially disadvantaged. However, the benefits of screening depend on receiving both high-quality testing and timely follow-up care when abnormal. Thus, disparities may persist even when rates of participation in screening are similar across populations. Recently, the US Preventive Services Task Force highlighted a gap in the understanding of CRC disparities and the relative lack of interventions that have been shown to eliminate disparities by race and ethnicity. The goal of this application is to inform feasible and effective strategies for advancing health equity by elucidating the extent to which differences in care along the entire screening process cumulatively contribute to disparities. We will comprehensively evaluate the entire screening continuum from the tests used and screening quality to receipt of follow-up care and guideline-concordant treatment in a cohort of about 3.8 million people per year over a nearly 2-decade period in Kaiser Permanente Northern California (KPNC) and Kaiser Permanente Southern California (KPSC). We will use a mixed methods approach informed by health equity frameworks to examine: 1) the receipt and quality of screening for CRC, including follow-up when abnormal; 2) post-screening treatment and disease outcomes, including interval CRCs, 5-year survival, and age-standardized incidence and mortality, overall and by location; 3) the reasons for variations in quality and timely follow-up using qualitative interviews; and 4) the relative contributions of differences along the screening continuum to disparities in mortality by using microsimulation modeling. We will conduct our studies in a dynamic cohort of 45-85-year-old men and women in KPNC/KPSC during the 2003-2019 period. The members of KPNC and KPSC mirror the characteristics, in terms of social factors, of people in the regions served across California. The complete capture of all screening steps and diverse, well-defined populations enable studies of strategies across the screening continuum among social groups. Our analyses will compare the racial and ethnic groups and stratifications by race for each outcome over a nearly 2-decade period. We will interview patient-clinician dyads to elucidate reasons for variations in quality, follow-up, and outcome. We will also use the MISCAN-Colon microsimulation model to examine the extent to which disparities in mortality are attributable to differences found across each step in the screening continuum. The proposed research has a high potential to inform the prioritization of strategies for advancing health equity across disadvantaged racial and ethnic minority groups and thus advance a national public health priority. The 1½ decades of high-impact collaboration in our team, and the setting and rigor of our application support the feasibility and high potential for impact in the field.