{"title":"Explicit inference: A meta-replication of SEER cancer registry research evaluating the Affordable Care Act's Medicaid expansion.","authors":"Jason Semprini","doi":"10.1111/jep.14055","DOIUrl":null,"url":null,"abstract":"<p><strong>Objectives: </strong>Among the provisions within the Affordable Care Act (ACA), expanding Medicaid was arguably the greatest contributor to increasing access to care. For over a decade, researchers have investigated how Medicaid expansion impacted cancer outcomes. Over this same decade, statistical theory illuminated how state-based policy research could be compromised by invalid inference. After reviewing the literature to identify the inference strategies of state-based cancer registry Medicaid expansion research, this study aimed to assess how inference decisions could change the interpretation of Medicaid expansion's impact on staging, treatment, and mortality in cancer patients.</p><p><strong>Data sources: </strong>Cancer case data (2000-2019) was obtained from the Surveillance, Epidemiology, End Results (SEER) programme. Cases included all cancer sites combined, top 10 cancer sites combined, and three screening amenable cancers (colorectal, female breast, female cervical).</p><p><strong>Study design: </strong>A Difference-in-Differences design estimated the association between Medicaid expansion and four binary outcomes: distant stage, initiating treatment >1 month after diagnosis, no surgery recommendation, and death. Three inference techniques were compared: (1) traditional, (2) cluster, and (3) Wild Cluster Bootstrap.</p><p><strong>Data collection: </strong>Data was accessed via SEER*Stat.</p><p><strong>Principal findings: </strong>Estimating standard errors via traditional inference would suggest that Medicaid expansion was associated with delayed treatment initiation and surgery recommendations. Traditional and clustered inference also suggested that Medicaid expansion reduced mortality. Inference using Wild Cluster Bootstrap techniques never rejected the null hypotheses.</p><p><strong>Conclusions: </strong>This study reiterates the importance of explicit inference. Future state-based, cancer policy research can be improved by incorporating emerging techniques. These findings warrant caution when interpreting prior SEER research reporting significant effects of Medicaid expansion on cancer outcomes, especially studies that did not explicitly define their inference strategy.</p>","PeriodicalId":15997,"journal":{"name":"Journal of evaluation in clinical practice","volume":null,"pages":null},"PeriodicalIF":2.1000,"publicationDate":"2024-07-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of evaluation in clinical practice","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1111/jep.14055","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
引用次数: 0
Abstract
Objectives: Among the provisions within the Affordable Care Act (ACA), expanding Medicaid was arguably the greatest contributor to increasing access to care. For over a decade, researchers have investigated how Medicaid expansion impacted cancer outcomes. Over this same decade, statistical theory illuminated how state-based policy research could be compromised by invalid inference. After reviewing the literature to identify the inference strategies of state-based cancer registry Medicaid expansion research, this study aimed to assess how inference decisions could change the interpretation of Medicaid expansion's impact on staging, treatment, and mortality in cancer patients.
Data sources: Cancer case data (2000-2019) was obtained from the Surveillance, Epidemiology, End Results (SEER) programme. Cases included all cancer sites combined, top 10 cancer sites combined, and three screening amenable cancers (colorectal, female breast, female cervical).
Study design: A Difference-in-Differences design estimated the association between Medicaid expansion and four binary outcomes: distant stage, initiating treatment >1 month after diagnosis, no surgery recommendation, and death. Three inference techniques were compared: (1) traditional, (2) cluster, and (3) Wild Cluster Bootstrap.
Data collection: Data was accessed via SEER*Stat.
Principal findings: Estimating standard errors via traditional inference would suggest that Medicaid expansion was associated with delayed treatment initiation and surgery recommendations. Traditional and clustered inference also suggested that Medicaid expansion reduced mortality. Inference using Wild Cluster Bootstrap techniques never rejected the null hypotheses.
Conclusions: This study reiterates the importance of explicit inference. Future state-based, cancer policy research can be improved by incorporating emerging techniques. These findings warrant caution when interpreting prior SEER research reporting significant effects of Medicaid expansion on cancer outcomes, especially studies that did not explicitly define their inference strategy.
期刊介绍:
The Journal of Evaluation in Clinical Practice aims to promote the evaluation and development of clinical practice across medicine, nursing and the allied health professions. All aspects of health services research and public health policy analysis and debate are of interest to the Journal whether studied from a population-based or individual patient-centred perspective. Of particular interest to the Journal are submissions on all aspects of clinical effectiveness and efficiency including evidence-based medicine, clinical practice guidelines, clinical decision making, clinical services organisation, implementation and delivery, health economic evaluation, health process and outcome measurement and new or improved methods (conceptual and statistical) for systematic inquiry into clinical practice. Papers may take a classical quantitative or qualitative approach to investigation (or may utilise both techniques) or may take the form of learned essays, structured/systematic reviews and critiques.