摘要：Objectives. We assessed cancer care disparities within the Veterans Affairs (VA) health care system and whether between-hospital differences explained disparities. Methods. We linked VA cancer registry data with VA and Medicare administrative data and examined 20 cancer-related quality measures among Black and White veterans diagnosed with colorectal (n = 12 897), lung (n = 25 608), or prostate (n = 38 202) cancer from 2001 to 2004. We used logistic regression to assess racial disparities for each measure and hospital fixed-effects models to determine whether disparities were attributable to between- or within-hospital differences. Results. Compared with Whites, Blacks had lower rates of early-stage colon cancer diagnosis (adjusted odds ratio [AOR] = 0.80; 95% confidence interval [CI] = 0.72, 0.90), curative surgery for stage I, II, or III rectal cancer (AOR = 0.57; 95% CI = 0.41, 0.78), 3-year survival for colon cancer (AOR = 0.75; 95% CI = 0.62, 0.89) and rectal cancer (AOR = 0.61; 95% CI = 0.42, 0.87), curative surgery for early-stage lung cancer (AOR = 0.50; 95% CI = 0.41, 0.60), 3-dimensional conformal or intensity-modulated radiation (3-D CRT/IMRT; AOR = 0.53; 95% CI = 0.47, 0.59), and potent antiemetics for highly emetogenic chemotherapy (AOR = 0.87; 95% CI = 0.78, 0.98). Adjustment for hospital fixed-effects minimally influenced racial gaps except for 3-D CRT/IMRT (AOR = 0.75; 95% CI = 0.65, 0.87) and potent antiemetics (AOR = 0.95; 95% CI = 0.82, 1.10). Conclusions. Disparities in VA cancer care were observed for 7 of 20 measures and were primarily attributable to within-hospital differences. Compared with all other racial/ethnic groups, Blacks in the United States experience the greatest burden of death from all of the most common cancer types. 1 Past research indicates that racial/ethnic disparities in care and outcomes exist for many conditions, but that these disparities are attenuated in the Veterans Affairs (VA) health care system, where financial barriers to care are substantially reduced for eligible veterans. 2–4 Recent work suggests that cancer care in the VA is comparable with or of better quality than care provided to insured individuals in the private sector 5–7 ; however, less is known about the extent of cancer-related disparities in the VA. Much of the research examining racial/ethnic disparities in the VA has focused on cardiovascular disease, mental health, or preventive and ambulatory care. 8 The few studies that have assessed cancer disparities have generated mixed findings, with some studies observing disparities in cancer care and others reporting equitable care for Black and White veterans. 2,3,9–12 However, these studies have typically focused on a few cancer types or quality measures, or have examined care in a limited number of VA hospitals. Moreover, these studies offer little insight into the factors that might account for any observed cancer care disparities within the entire VA. A variety of factors contribute to lower care quality and excess burden of death among Blacks in the United States, including differential access to health care, socioeconomic status, and racial differences in receipt of recommended care. 13–16 Differences in where Black and White cancer patients receive care may also contribute to disparities. US hospital care is highly concentrated for Black Americans, with facilities caring for a larger share of Black patients (minority-serving institutions) often providing lower quality care than hospitals that serve nonminorities. 17,18 In addition, racial differences in hospital site of care have been linked to disparities in receipt of recommended care and outcomes. 17,19,20 In this study, we assessed the extent of race-based cancer care disparities in the VA across a range of cancer types and measures. In addition, we examined whether racial differences in where cancer patients were treated explained any observed disparities in cancer care and outcomes, assessing whether racial disparities were mainly attributable to between- or within-hospital differences in the VA.
