Health care delivery system contributions to management of newly diagnosed prostate cancer.
Health care delivery system contributions to management of newly diagnosed prostate cancer.
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尽管临床指南提倡在前列腺癌男性患者的特定临床方案中使用保守治疗，但对它的理解仍然存在巨大的差异。这种变异可能会在存在相互竞争的健康风险的男性中放大，对他们来说，治疗决定并不直接。卫生保健提供系统的特点在多大程度上解释了这种差异仍不清楚。使用国家医疗保险数据，2014年至2019年新诊断为前列腺癌的男性被识别出来。采用分层Logistic回归模型来评估治疗使用与医疗保健提供系统决定因素之间的关系，这些决定因素包括财务激励措施(即辐射性金库所有权)、执业组织(即单一专科与多专科组)和医疗保健市场(即竞争)。对方差进行划分，以估计患者特征和实践特征对非癌症死亡风险组各层内治疗使用差异的相对影响。在62,507名新诊断为前列腺癌的男性中，非癌症死亡率高风险和极高风险的男性在不同治疗方法之间的使用差异最大(实践水平的治疗率范围：高：57%-71%，极高：41%-61%)。在实践水平上测量的卫生保健提供系统决定因素的增加分别解释了在10 年中非癌症死亡的低风险和中等风险男性中使用治疗的差异的13%和15%。相反，这些特征解释了非癌症死亡率高风险和极高风险男性(分别为26%和40%)在治疗使用上的差异所占比例更大。对于具有高风险和非常高风险的非癌症死亡率的男性，使用治疗的泌尿外科实践的差异最大。实践特征解释了这种差异的很大一部分原因。尽管前列腺癌男性患者越来越多地采用保守治疗，但在接受治疗方面仍存在巨大差异。这种差异可能会因输送系统的特点而放大，特别是在具有竞争性健康风险的男性中，他们的治疗决定对他们来说是具有挑战性的。在这项研究中，我们发现，对于具有高风险和非常高风险的非癌症死亡率的男性，使用治疗的差异性最高。在实践层面上衡量的交付系统的特点解释了这种差异的很大一部分原因。
Despite clinical guidelines advocating for use of conservative management in specific clinical scenarios for men with prostate cancer, there continues to be tremendous variation in its uptake. This variation may be amplified among men with competing health risks, for whom treatment decisions are not straightforward. The degree to which characteristics of the health care delivery system explain this variation remains unclear. Using national Medicare data, men with newly diagnosed prostate cancer between 2014 and 2019 were identified. Hierarchical logistic regression models were used to assess the association between use of treatment and health care delivery system determinants operating at the practice level, which included measures of financial incentives (i.e., radiation vault ownership), practice organization (i.e., single specialty vs. multispecialty groups), and the health care market (i.e., competition). Variance was partitioned to estimate the relative influence of patient and practice characteristics on the variation in use of treatment within strata of noncancer mortality risk groups. Among 62,507 men with newly diagnosed prostate cancer, the largest variation in the use of treatment between practices was observed for men with high and very high‐risk of noncancer mortality (range of practice‐level rates of treatment for high: 57%–71% and very high: 41%–61%). Addition of health care delivery system determinants measured at the practice level explained 13% and 15% of the variation in use of treatment among men with low and intermediate risk of noncancer mortality in 10 years, respectively. Conversely, these characteristics explained a larger share of the variation in use of treatment among men with high and very high‐risk of noncancer mortality (26% and 40%, respectively). Variation among urology practices in use of treatment was highest for men with high and very high‐risk noncancer mortality. Practice characteristics explained a large share of this variation. Despite increasing use of conservative management for men with prostate cancer, there is tremendous variation in its uptake. This variation may be amplified by features of the delivery system, particularly among men with competing health risks, for whom treatment decisions are challenging. In this study, we find that variation in use of treatment was highest for men with high and very high‐risk noncancer mortality. Characteristics of the delivery system, measured at the level of the practice explained a large share of this variation.
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影响因子：
120.7
作者：
Albertsen, PC;Hanley, JA;Barry, MJ
通讯作者：
Barry, MJ
影响因子：
2.1
作者：
Daskivich, Timothy J.;Lai, Julie;Saigal, Christopher
通讯作者：
Saigal, Christopher
DOI：
10.1056/nejmoa1311593
发表时间：
2014-03-06
期刊：
The New England journal of medicine
影响因子：
--
作者：
Bill-Axelson A;Holmberg L;Garmo H;Rider JR;Taari K;Busch C;Nordling S;Häggman M;Andersson SO;Spångberg A;Andrén O;Palmgren J;Steineck G;Adami HO;Johansson JE
通讯作者：
Johansson JE
影响因子：
3.4
作者：
Dimick, Justin B.;Staiger, Douglas O.;Birkmeyer, John D.
通讯作者：
Birkmeyer, John D.
影响因子：
7.2
作者：
Klabunde, CN;Potosky, AL;Warren, JL
通讯作者：
Warren, JL