Factors Associated with High Quality Care for Patients with Lung Cancer

Significance: Non-small cell lung cancer (NSCLC), the leading cause of death from cancer in the U.S., is plagued by racial disparities across the spectrum of care, particularly between Black and White patients. Despite the fact that these differences in the care of Black and White patients are long-standing and well-described, fundamental knowledge gaps remain. First, the degree to which differences in NSCLC care and outcomes vary across geographic regions has not been thoroughly explored. Second, little is known about how community factors contribute to disparities in care and outcomes at the regional level. Historically, health services research has focused on the healthcare system as the primary driver of disparities, with a limited exploration of community factors such as area-level socioeconomic status and access to health care. Further, it is unclear how key stakeholders within the healthcare and community settings address and overcome barriers to providing high-quality NSCLC care. Objective: We will address these critical knowledge gaps, with the overarching goal of mitigating disparities between Black and White patients with NSCLC in diagnosis, treatment, and outcomes, by identifying modifiable health system and intermediary factors and strategies that influence quality in lung cancer care. We intend to conduct an explanatory sequential mixed methods study, combining novel retrospective, population-based studies of disparities in lung cancer care with a positive deviance analysis. Through qualitative interviews with key stakeholders in regions with high versus low quality of lung cancer care, we will reveal strategies and processes that influence quality in lung cancer care and outcomes. Our hypothesis is that the magnitude of Black-White disparities in quality varies substantially across counties, and there are specific factors, such as health system factors, that exacerbate these differences. Specific Aims: We propose an explanatory sequential mixed methods study of Medicare beneficiaries diagnosed with NSCLC from 2013 through 2017: (1) To assess variation in racial differences in NSCLC care (non-Hispanic Black vs. non- Hispanic White) across counties within SEER regions. (2) To assess foundational factors associated with these differences in NSCLC care. (3) To assess health system/intermediary determinants (e.g. hospital characteristics and competition, patient access) of these differences in NSCLC care. (4) To identify stakeholder strategies associated with ensuring high quality NSCLC care, regardless of county socioeconomic characteristics. The proposed mixed methods study will have a high impact, using a combination of innovative methods to identify modifiable foundational, socioeconomic, and social factors that contribute to lung cancer differences. Furthermore, we will elucidate strategies that stakeholders have used to decrease care disparities, identifying approaches that can be adopted more broadly to improve quality of care for patients with NSCLC.