McLeod A
MRC Social and Public Health Sciences Unit, Glasgow.
J Epidemiol Community Health. 1999 Dec;53(12):775-81. doi: 10.1136/jech.53.12.775.
To quantify the impact of patient, area and hospital characteristics on variations in the provision of chemotherapy for colorectal cancer.
Incident cases of colorectal cancer (ICD 153-154), aged under 75 years and resident in Scotland, derived from linked hospital discharge records and death records for the period January 1990 to June 1994. The final analysis was carried out on 7852 patients resident in 823 areas and first admitted to one of 59 hospitals.
Whether a patient received chemotherapy (OPCS4 procedure code X35.2) during any hospital episode in the six months after their first admission.
Multilevel logistic regression to separate effects of patients, areas and hospitals.
During the study period, 8% (n = 626) of the study population received chemotherapy within six months of their first admission. Adjusting for comorbidities and emergency admissions, both age and deprivation were significantly associated with the treatment. The odds ratios (OR) of chemotherapy relative to patients aged 65-74 were 2.13 and 4.50 for patients aged 55-64 and under 55 respectively. Relative to patients resident in the most affluent areas, the OR of chemotherapy for patients resident in the most deprived areas was 0.73. Area level availability of the treatment was not significantly associated with a patient's odds of receiving the treatment while on site provision of chemotherapy at the hospital of first admission was (OR = 4.32). There was significant unexplained variation between hospitals of first admission but not between areas of residence; between hospital variation decreased by 22% during the study period.
Differences according to age may reflect both clinical and patient decisions regarding the benefits of the treatment relative to its toxicity. Lower treatment rates in deprived areas may indicate inequitable access to services. Hospital differences may reflect consultant effects and it would be expected that these should decrease now that the efficacy of the treatment has been recognised and guidelines have been issued.
量化患者、地区和医院特征对结直肠癌化疗服务差异的影响。
1990年1月至1994年6月期间，从苏格兰医院出院记录和死亡记录中提取的年龄在75岁以下、居住在苏格兰的结直肠癌（国际疾病分类153 - 154）新发病例。最终分析纳入了居住在823个地区、首次入住59家医院之一的7852名患者。
患者首次入院后六个月内的任何一次住院期间是否接受化疗（OPCS4手术编码X35.2）。
采用多水平逻辑回归分析患者、地区和医院的影响因素。
在研究期间，8%（n = 626）的研究人群在首次入院后六个月内接受了化疗。在调整合并症和急诊入院因素后，年龄和贫困程度均与治疗显著相关。相对于65 - 74岁的患者，55 - 64岁和55岁以下患者接受化疗的比值比（OR）分别为2.13和4.50。相对于居住在最富裕地区的患者，居住在最贫困地区的患者接受化疗的OR为0.73。地区层面的化疗服务可及性与患者接受治疗的几率无显著关联，而首次入院医院的现场化疗服务则与之相关（OR = 4.32）。首次入院医院之间存在显著的无法解释的差异，但居住地区之间无差异；研究期间医院间差异下降了22%。
年龄差异可能反映了临床和患者对治疗益处与其毒性的权衡决策。贫困地区较低的治疗率可能表明服务获取不公平。医院差异可能反映了会诊医生的影响，鉴于该治疗的疗效已得到认可且已发布指南，预计这些差异将会减少。
