Centralization of Cancer Care: Implications for Access, Outcomes, and Disparities

项目摘要 近年来，癌症治疗已急剧转向集中式护理模式， 癌症患者可以选择性地在地区转诊中心接受综合治疗， 往往是三级癌症中心。集中化与改善成果有关， 由于各种原因在区域转诊中心接受治疗的患者，包括更好的 治疗大量患者的资源和人员。然而，更广泛的影响 在人口一级集中成果的情况仍然不明。特别令人关切的是， 没有在这些中心接受治疗，而是继续在非区域中心接受治疗的患者 转诊中心，通常治疗较低数量的患者。这些“留守”患者可能 由于获得高质量护理的机会减少，结果不佳。此外，在一定程度上， 患者代表传统上服务不足的患者（即，长期以来， 经历了健康差距，如种族和少数民族，低收入个人，和农村 居民），集中癌症护理的趋势可能会无意中扩大结果的差异， 为那些留下来的病人提供更好的护理。这个项目的总体目标是批判性地审视 癌症治疗集中在人群水平的影响，特别关注是否 集中化的趋势无意中扩大了癌症的社会人口差异， 结果。我们将使用混合方法以及一个创新的数据集连接癌症 两个大州（纽约和宾夕法尼亚）11年来的登记和管理数据 期我们将重点关注最常见的患者（即，膀胱，乳腺，结肠直肠，肺， 前列腺）和致死（即，脑癌、食道癌、肝癌、肺癌、胰腺癌）-这些癌症经常 需要复杂的治疗，并在区域转诊中心改善了结果。目标1： 将确定与不接受区域转诊护理相关的患者特征 中心在目标2中，我们将研究在区域转诊中心接受护理是否会介导 作为传统上服务不足的患者（种族/少数民族、低收入 个人、农村居民）和护理质量。在目标3中，我们将确定减少癌症的战略 通过与主要利益攸关方的访谈，了解集中化背景下的差异。本研究 重要的是，它将为医院，供应商和政策制定者提供可操作的新数据， 集中化可能既帮助又伤害患者的方式，导致新的策略， 最大限度地减少健康差距，影响到多个层面的干预措施和政策变化。

Project Summary In recent years, cancer treatment has dramatically shifted towards a centralized model of care, whereby patients with cancer selectively receive complex treatment at regional referral centers, which tend to be tertiary cancer centers. Centralization is associated with improved outcomes for the patients who receive care at regional referral centers for a variety of reasons, including better resources and personnel who treat high volumes of patients. However, the broader impact of centralization on outcomes at the population level remains unknown. Of specific concern are the patients who do not receive care at these centers, but instead continue to receive care at non-regional referral centers, which generally treat lower volumes of patients. These “left behind” patients may suffer poor outcomes due to decreased access to high-quality care. Moreover, to the degree these patients represent traditionally underserved patients (i.e., sociodemographic groups that have long experienced health disparities such as racial and ethnic minorities, low-income individuals, and rural residents), the trend towards centralized cancer care may inadvertently widen disparities in outcomes, worsening care for those patients left behind. The overall goal of this project is to critically examine the impact of cancer treatment centralization at the population level, with a specific focus on whether the trend toward centralization is inadvertently widening sociodemographic disparities in cancer outcomes. We will use a mixed-methods approach as well as an innovative dataset linking cancer registry and administrative data in two large states (New York and Pennsylvania) over an 11-year period. We will focus on patients with the most prevalent (i.e., bladder, breast, colorectal, lung, prostate) and lethal (i.e., brain, esophageal, liver, lung, pancreatic) cancers—these cancers frequently require complex treatments and have improved outcomes at regional referral centers. In Aim 1, we will determine the patient characteristics associated with not receiving care at a regional referral center. In Aim 2, we will examine whether receipt of care at a regional referral center mediates the relationship between being a traditionally underserved patient (racial/ethnic minority, low-income individual, rural resident) and quality of care. In Aim 3, we will identify strategies to minimize cancer disparities in the context of centralization through interviews with key stakeholders. This study is important because it will provide hospitals, providers, and policymakers with actionable new data on the ways centralization may be both helping and harming patients, leading to new strategies to minimize health disparities with implications for interventions and policy changes at multiple levels.