Bradley Cathy J, Clement Jan P, Lin Chunchieh
Department of Health Administration and Massey Cancer Center, Virginia Commonwealth University, Grant House, 1008 Clay Street, PO Box 980203, Richmond, VA 23298-0203, USA.
J Natl Cancer Inst. 2008 Jan 2;100(1):21-31. doi: 10.1093/jnci/djm271. Epub 2007 Dec 25.
Little is known about the effect cancer has on the lives of nursing home patients and the quality of care, including palliative care, delivered to them.
Using a statewide population-based dataset assembled from the Michigan Tumor Registry and Medicare records, we identified 1907 elderly Medicaid-insured nursing home residents who were diagnosed with cancer between 1997 and 2000. Logistic regression models were used to estimate odds ratios (ORs) and relative risks (RRs) according to age, race, sex, income, comorbidity, and cancer site for late or unstaged cancer at diagnosis, death within 3 months of diagnosis, receipt of hospice care, and--for patients diagnosed with early-stage breast, colorectal, lung, or prostate cancer--the likelihood of cancer-directed surgery. All statistical tests were two-sided.
Nursing home residents diagnosed with cancer had a preponderance of late or unstaged disease (62%), high mortality within 3 months of diagnosis (48%), and low hospice use if they had distant-stage cancer (28%). Only 22% received cancer-directed surgery, 61% of which was confined to breast cancer patients, and only 6% of patients received chemotherapy and/or radiation. Older age was positively associated with late or unstaged cancer and with death within 3 months of diagnosis. Patients aged 71-75 years were more likely to have cancer-directed surgery than patients aged 86 years and older (OR = 2.83, 95% confidence interval [CI] = 1.26 to 6.32; RR = 1.37, 95% CI = 1.08 to 1.75). African American patients were less likely to receive surgery (OR = 0.51, 95% CI = 0.26 to 0.99; RR = 0.80, 95% CI = 0.62 to 1.03) than white patients. Other demographic characteristics and comorbid conditions had little predictive value with regard to cancer treatment or hospice use in nursing home patients.
Very few cancer services are provided to Medicaid-insured nursing home patients, despite the fact that many of these patients likely experienced cancer-related symptoms and marked physical decline before diagnosis and death. A middle ground between what would be considered guideline treatment practices and the apparent absence of diagnosis and treatment is needed.
癌症对疗养院患者生活的影响以及提供给他们的护理质量，包括姑息治疗，目前所知甚少。
利用从密歇根肿瘤登记处和医疗保险记录中收集的全州基于人群的数据集，我们确定了1907名1997年至2000年间被诊断患有癌症的老年医疗补助保险的疗养院居民。使用逻辑回归模型根据年龄、种族、性别、收入、合并症和癌症部位来估计诊断时晚期或未分期癌症、诊断后3个月内死亡、接受临终关怀的比值比（OR）和相对风险（RR），以及——对于被诊断患有早期乳腺癌、结直肠癌、肺癌或前列腺癌的患者——进行癌症定向手术的可能性。所有统计检验均为双侧检验。
被诊断患有癌症的疗养院居民中晚期或未分期疾病占多数（62%），诊断后3个月内死亡率高（48%），如果患有远处期癌症，临终关怀使用率低（28%）。只有22%的患者接受了癌症定向手术，其中61%仅限于乳腺癌患者，只有6%的患者接受了化疗和/或放疗。年龄较大与晚期或未分期癌症以及诊断后3个月内死亡呈正相关。71 - 75岁的患者比86岁及以上的患者更有可能接受癌症定向手术（OR = 2.83，95%置信区间[CI] = 1.26至6.32；RR = 1.37，95% CI = 1.08至1.75）。非裔美国患者比白人患者接受手术的可能性更小（OR = 0.51，95% CI = 0.26至0.99；RR = 0.80，95% CI = 0.62至1.03）。其他人口统计学特征和合并症对于疗养院患者的癌症治疗或临终关怀使用几乎没有预测价值。
尽管许多医疗补助保险的疗养院患者在诊断和死亡前可能经历了与癌症相关的症状和明显的身体衰退，但提供给他们的癌症服务却非常少。需要在被认为是指南治疗实践与明显缺乏诊断和治疗之间找到一个中间立场。
