Essays on Health Care Quality and Access: Cancer Care Disparities, Composite Measure Development, and Geographic Variations in Electronic Health Record Adoption.

摘要

Racial/ethnic disparities in cancer care are well documented in the research literature; however, less is known about the extent and potential source of cancer care disparities in the Veterans Health Administration (VA). In my first paper, I use logistic regression and hospital fixed effects models to examine racial disparities in 20 cancer-related quality measures and the extent to which racial differences in site of care explain VA cancer care disparities. I found evidence of racial disparities in 7 out of 20 cancer-related quality measures. In general, these disparities were primarily driven by racial differences in care for black and white patients within the same VA hospital, rather than racial differences in site of care.;There has been limited use of composite measures for cancer care quality measurement. In my second paper, I employ and compare several grouping (i.e., empirical factor analysis vs. cancer-specific vs. care-modality-specific) and weighting (i.e., fixed- vs. opportunity-weighting) approaches for computing VA hospital-level composite measures of cancer care quality. I assess correlations among composites and estimate all-cause survival for colorectal and lung cancers as a function of composite scores. The empirically-derived care dimensions summarized relationships among care processes and reflected a combination of cancer-specific and care-modality-specific composites. Patterns in predicting patient survival were similar for composites with comparable measure compositions. In addition, opportunity-based composites were subject to variation reflecting differences in the case mix of eligible patients at each hospital rather than actual differences in quality.;In my third paper, I assess geographic variations in electronic health record (EHR) adoption among primary care providers (PCPs) enrolled in the Regional Extension Center (REC) program. I employ hierarchical models to examine associations between EHR adoption among REC-enrolled PCPs and several county-level measures. I found that community health center presence, Medicaid enrollment, and Medicare Advantage enrollment within the county were positively associated with EHR adoption. However, health professional shortage area status and minority concentration were negatively associated with EHR adoption. My findings suggest that federal efforts, such as the Medicare and Medicaid EHR incentive programs, may be encouraging EHR adoption. Still, some geographic disparities in EHR adoption remain a concern.