Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis
Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis
复制标题
DOI：
10.1016/s1470-2045(08)70032-9
复制
发表时间：
2008-03-01
期刊：
影响因子：
51.1
通讯作者：
Chen, Amy Y.
中科院分区：
文献类型：
--
作者：
Halpern, Michael T.;Ward, Elizabeth M.;Chen, Amy Y.
背景在美国，没有私人医疗保险的人比那些有私人医疗保险的人更不可能获得医疗保健或参与癌症筛查计划。美国较小的地区性研究表明，未参保和医疗补助参保的个人比私人参保的患者更有可能罹患晚期癌症；然而，这一发现尚未使用当代的全国性数据进行评估。此外，与非西班牙裔白人相比，少数民族癌症患者更有可能没有保险或医疗补助保险。很难区分这两种类型的患者特征对诊断时癌症分期的影响。方法使用美国国家癌症数据库对1998至2004年间诊断的美国癌症患者进行识别，该数据库基于医院，包含来自约1430家机构的患者信息。在控制患者特征的同时，估计了12个癌症部位(乳腺癌[女性]、结直肠、肾、肺、黑色素瘤、非霍奇金淋巴瘤、卵巢、胰腺、前列腺、膀胱、子宫和甲状腺)诊断时保险状况(医疗补助、医疗保险(65-99岁)、医疗保险(18-岁)、私人或未参保)和种族(白人、西班牙裔、黑人或其他)在疾病阶段上的优势比和95%CI。结果发现3742407名患者进入分析；患者特征与未纳入分析的相应美国人群相似。与私人参保的患者相比，未参保和医疗补助参保的患者患晚期癌症的可能性明显更大。这一发现在那些有可能通过筛查或症状评估早期发现癌症的患者中最为突出(例如，乳腺癌、结直肠癌、肺癌以及黑色素瘤)。例如，与私人参保的患者相比，未参保或医疗补助参保的结直肠癌患者确诊时晚期疾病(III或IV期)的优势比分别为2.0(95%可信区间1.9-2.1)和1.6(95%可信区间1.5-1.7)。对于晚期黑色素瘤，与私人保险患者相比，未参保患者的优势比为2.3(2.1-2.5)，医疗补助保险患者的优势比为3.3(3.0-3.6)。与白人患者相比，黑人和西班牙裔患者在确诊时患晚期疾病(III期或IV期)的风险更高，无论保险状态如何。在这项基于美国的分析中，解释说，没有保险和医疗补助保险的患者，以及那些来自少数民族的患者，在诊断时出现晚期癌症的风险显著增加。虽然保险状况以外的许多因素也影响所接受的护理质量，但适当的保险是获得适当的癌症筛查和及时获得医疗护理的关键因素。
Background Individuals in the USA without private medical insurance are less likely to have access to medical care or participate in cancer screening programmes than those with private medical insurance. Smaller regional studies in the USA suggest that uninsured and Medicaid-insured individuals are more likely to present with advanced-stage cancer than privately insured patients; however, this finding has not been assessed using contemporary, national-level data. Furthermore, patients with cancer from ethnic minorities are more likely to be uninsured or Medicaid-insured than non-Hispanic white people. Separating the effects on stage of cancer at diagnosis associated with these two types of patient characteristics can be difficult.Methods Patients with cancer in the USA, diagnosed between 1998 and 2004, were identified using the US National Cancer Database a hospital-based registry that contains patient information from about 1430 facilities. Odds ratios and 95% CIs for the effect of insurance status (Medicaid, Medicare (65-99 years), Medicare (18-64 years), private, or uninsured) and ethnicity (white, Hispanic, black, or other) on disease stage at diagnosis for 12 cancer sites (breast [female], colorectal, kidney, lung, melanoma, non-Hodgkin lymphoma, ovary, pancreas, prostate, urinary bladder, uterus, and thyroid) were estimated, while controlling for patient characteristics.Findings 3742407 patients were included in the analysis; patient characteristics were similar to those of the corresponding US population not included in the analysis. Uninsured and Medicaid-insured patients were significantly more likely to present with advanced-stage cancer compared with privately insured patients. This finding was most prominent for patients who had cancers that can potentially be detected early by screening or symptom assessment (eg, breast, colorectal, and lung cancer, as well as melanoma). For example, the odds ratios for advanced-stage disease (stage III or IV) at diagnosis for uninsured or Medicaid-insured patients with colorectal cancer were 2.0 (95% CI 1.9-2.1) and 1.6 (95% CI 1.5-1.7), respectively, compared with privately-insured patients. For advanced-stage melanoma, the odds ratios were 2.3 (2.1-2.5) for uninsured patients and 3.3 (3.0-3.6) for Medicaid-insured patients compared with privately insured patients. Black and Hispanic patients were noted to have an increased risk of advanced-stage disease (stage III or IV) at diagnosis, irrespective of insurance status, compared with White patients.Interpretation In this US-based analysis, uninsured and Medicaid-insured patients, and those from ethnic minorities, had substantially increased risks of presenting with advanced-stage cancers at diagnosis. Although many factors other than insurance status also affect the quality of care received, adequate insurance is a crucial factor for receiving appropriate cancer screening and timely access to medical care.