Insurance Status and Hospital Payer Mix Are Linked With Variation in Metastatic Site Resection in Patients With Advanced Colorectal Cancers.
Insurance Status and Hospital Payer Mix Are Linked With Variation in Metastatic Site Resection in Patients With Advanced Colorectal Cancers.
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DOI：
10.1097/dcr.0000000000000684
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发表时间：
2016-11
影响因子：
3.9
通讯作者：
Suwanabol PA
中科院分区：
文献类型：
--
作者：
Healy MA;Pradarelli JC;Krell RW;Regenbogen SE;Suwanabol PA
尽管结直肠癌转移部位切除术大大提高了生存率，但某些患者对侵袭性手术方法的接受率仍然很低。目前尚不清楚医疗的财务决定因素，如保险状况，是否在这种治疗差距中发挥作用。我们试图评估保险状况对晚期结直肠癌患者行直肠切除术的影响。使用国家癌症数据库参与者用户文件，确定了2010 - 2013年诊断为转移至肺和/或肝的结直肠癌事件病例。控制患者、肿瘤和医院特征，使用分层回归来检查医院支付者组合与转移部位切除之间的关联。我们在队列中确定了42，300例患者，平均年龄为64岁。转移部位切除发生在所有患者的12.3%。调整患者和医院的固定效应后，我们发现，没有保险或接受医疗补助的患者接受膀胱切除术的可能性降低了38%（OR，0.62; 95%CI，0.56 - 0.66）。在医院治疗高比例的无保险或医疗补助患者的患者不太可能接受膀胱切除术，即使在控制了个别患者的保险状况后。这项研究受到其回顾性设计和国家癌症数据库的粒度和准确性的限制。在转移到肺和/或肝的结直肠癌患者中，保险状态和医院支付者组合的差异与转移部位切除率的差异相关。对于没有保险或有医疗补助保险的个体患者，以及在治疗大部分没有保险或医疗补助患者的医院寻求护理的所有患者，需要改善转移部位切除术的可及性。对个别病人的补救措施可能包括通过就业或个人计划改善获得私人保险的机会，或改善医疗补助对这一程序的报销。对低绩效医院的患者的策略包括选择性地转诊到适当时更频繁地进行乳房切除术的中心。
Despite substantially improved survival with metastatic site resection in colorectal cancers, uptake of aggressive surgical approaches remains low among certain patients. It is unknown whether financial determinants of care, such as insurance status, play a role in this treatment gap. We sought to evaluate the effect of insurance status on metastasectomy in patients with advanced colorectal cancers. Using the National Cancer Data Base Participant User File, incident cases of colorectal cancer metastatic to the lung and/or liver with diagnosis from 2010 – 2013, were identified. Controlling for patient, tumor, and hospital characteristics, hierarchical regression was used to examine associations between hospital payer mix and metastatic site resection. We identified 42,300 patients in our cohort with mean age 64 years. Metastatic site resection occurred in 12.3% of all patients. Adjusting for patient and hospital fixed effects, we found that patients who were uninsured or on Medicaid were 38% less likely to undergo metastasectomy (OR, 0.62; 95% CI, 0.56 – 0.66). Patients in hospitals treating a high percentage of uninsured or Medicaid patients were less likely to undergo metastasectomy, even after controlling for individual patient insurance status. The study was limited by its retrospective design and the granularity and accuracy of the National Cancer Data Base. Differences in insurance status and hospital payer mix are associated with differences in rates of metastatic site resection in patients with colorectal cancer that is metastatic to the lung and/or liver. There is a need for improved access to metastatic site resection for individual patients who are uninsured or who have Medicaid insurance, and for all patients who seek care at hospitals treating a large proportion of uninsured or Medicaid patients. Remedies for individual patients could include improved access to private insurance through employment or individual plans or improved reimbursement from Medicaid for this procedure. Strategies for patients at low-performing hospitals include selective referral to centers that perform mestastectomy more frequently when appropriate.