Determinants of Variation in the Use of Adjuvant Chemotherapy for Stage III Colon Cancer in England
Determinants of Variation in the Use of Adjuvant Chemotherapy for Stage III Colon Cancer in England
复制标题
DOI：
10.1016/j.clon.2019.12.008
复制
发表时间：
2020-05-01
影响因子：
3.4
通讯作者：
Braun, M. S.
中科院分区：
文献类型：
--
作者：
Boyle, J. M.;Kuryba, A.;Braun, M. S.
目的：III 期结肠癌的辅助化疗 (ACT) 已成熟。本研究旨在探讨英国国家医疗服务体系 (NHS) 内 ACT 使用的决定因素以及医院间差异。材料和方法：从国家肠癌审计中确定了英国 NHS 中总共 11 932 名患有病理性 III 期结肠癌的患者（2014-2017 年诊断）。记录与系统抗癌治疗和医院发作统计数据库相关联。进行多级逻辑回归分析来估计 ACT 使用的独立因素，包括年龄、性别、剥夺、合并症、体能状态、美国麻醉师协会 (ASA) 等级、手术紧急程度、手术途径、TNM 分期、再入院和医院层面因素（大学教学医院、现场化疗和大容量中心）。对每家英国 NHS 医院 (n = 142) 进行了随机拦截建模。使用漏斗图方法探讨了医院之间的差异。在年轻（= 70 岁）患者中单独拟合完全调整的随机截取模型，并估计组内相关系数。结果：60.7% 的患者接受了 ACT。年龄是最强的决定因素。与年龄 = 80 岁的患者（aOR 0.05，95% 置信区间 0.04-0.06）相比，接受 ACT 的可能性明显较低。调整其他因素后，ACT 在社会经济地位较高、合并症较少、体能状态较好、ASA 分级较低、晚期疾病、选择性切除、腹腔镜手术且无计划外再入院的患者中更有可能使用。医院层面的因素并不显着。观察到的年轻人和老年人接受 ACT 治疗的比例分别为 46-100%（80% 医院为 74-90%）和 10-81%（80% 医院为 33-65%）。风险调整并没有减少医院之间的差异。尽管进行了调整，年龄占老年人医院间差异的 9.9% (7.2-13.4%)，而年轻患者的这一比例为 2.7% (1.2-5.7%)。 结论：对于 III 期结肠癌，尤其是老年患者，ACT 的使用存在显着的医院间差异。仅高龄似乎就成为一些医院使用 ACT 的更大障碍。 (C) 2020 年皇家放射科医生学院。由爱思唯尔有限公司出版。保留所有权利。
Aims: Adjuvant chemotherapy (ACT) for stage III colon cancer is well-established. This study aimed to explore the determinants of ACT use and between-hospital variation within the English National Health Service (NHS).Materials and methods: In total, 11 932 patients (diagnosed 2014-2017) with pathological stage III colon cancer in the English NHS were identified from the National Bowel Cancer Audit. Records were linked to Systemic Anti-Cancer Therapy and Hospital Episode Statistics databases. Multi-level logistic regression analyses were carried out to estimate independent factors for ACT use, including age, sex, deprivation, comorbidities, performance status, American Society of Anaesthesiologists (ASA) grade, surgical urgency, surgical access, TNM staging, readmission and hospital-level factors (university teaching hospital, on-site chemotherapy and high-volume centre). A random intercept was modelled for each English NHS hospital (n = 142). Between-hospital variation was explored using funnel plot methodology. Fully adjusted random-intercept models were fitted separately in young (= 70 years) patients and intra-class correlation coefficients estimated.Results: 60.7% of patients received ACT. Age was the strongest determinant. Compared with patients aged = 80 years (aOR 0.05, 95% confidence interval 0.04-0.06) were significantly less likely to receive ACT. With adjustment for other factors, ACT use was more likely in patients with higher socioeconomic status, fewer comorbidities, better performance status, lower ASA grade, advanced disease, elective resections, laparoscopic procedures and no unplanned readmissions. Hospital-level factors were non-significant. The observed proportions of ACT administration in the young and elderly were 46-100% (80% of hospitals 74-90%) and 10-81% (80% of hospitals 33-65%), respectively. Risk adjustment did not reduce between-hospital variation. Despite adjustment, age accounted for 9.9% (7.2-13.4%) of between-hospital variation in the elderly compared with 2.7% (1.2-5.7%) in the young.Conclusions: There is significant between-hospital variation in ACT use for stage III colon cancer, especially for older patients. Advanced age alone seems to be a greater barrier to ACT use in some hospitals. (C) 2020 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.