Geographic disparities among U.S. counties are considerable. Health care disparities between rural and
urban Americans, in particular, is worsening. Cancer outcomes are no exception. Progress toward ameliorating
disparities has been hindered by a lack of data on the actionable items that lead to improved outcomes. We
propose to link the Colorado Central Cancer Registry (CCR) with the statewide All Payer Claims Database
(APCD). We supplement these data with the Area Resource File and other public use data to enhance the
existing infrastructure. The resulting dataset will contain information at the person, treatment, county, and
policy and health care delivery levels for the years 2009-2018. We focus on common adult cancers: breast,
cervical, prostate, colorectal, melanoma, and lung. Our aims are:
Aim 1: Evaluate the completeness of the linked CCR and APCD in terms of rural/urban residency,
race/ethnicity, age, gender, and insurance type (Medicare, Medicaid, private, uninsured). This aim is critical for
dissemination and implementation efforts in other states. It serves two purposes: 1) informs the registry about
the utility of the APCD in case ascertainment and treatment data and 2) informs the research community about
the benefits and pitfalls of using linked registry-APCD data.
Aim 2. Measure the relationship between rural residence and the following outcomes: stage, treatment
(time to treatment, guideline concordant care, use of newly approved agents), spending, and mortality.
H1: Rural residence will be positively associated with adverse outcomes.
H2: Hispanics and American Indians residing in rural areas will disproportionately experience poor outcomes
relative to their white counterparts in rural areas and their Hispanic counterparts in urban areas.
Aim 3: Evaluate the impact of Medicaid's Accountable Care Collaborative (ACC) on cancer outcomes.
H1: Enrollment in ACCs improved cancer outcomes for rural residents through enhanced care coordination and
The proposed study will generate new data to inform whether linkages between central cancer
registries and All Payer Claims Databases yield valuable data for understanding and addressing disparities,
particularly in rural populations. We test hypotheses regarding distance to health care resources and the
type of resources available (primary and specialty care) and the policies that govern them. These
assessments will inform policy debates about the type of health care investments needed to close the gap
between cancer treatment and mortality in rural and urban areas.
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