接受中枢神经系统定向治疗的儿童癌症成年幸存者医疗服务利用的预测因素。
Predictors of health care utilization in adult survivors of childhood cancer exposed to central nervous system-directed therapy.
作者信息
Kimberg Cara I, Klosky James L, Zhang Nan, Brinkman Tara M, Ness Kirsten K, Srivastava Deo Kumar, Robison Leslie L, Hudson Melissa M, Krull Kevin R
机构信息
Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee.
出版信息
Cancer. 2015 Mar 1;121(5):774-82. doi: 10.1002/cncr.29121. Epub 2014 Nov 6.
BACKGROUND
Survivors of childhood cancer treated with central nervous system (CNS)-directed therapy may be at risk for poor health care utilization because of neurocognitive deficits. This study examined associations between neurocognitive function and adherence to routine and risk-based medical evaluations in adult survivors exposed to CNS-directed therapy.
METHODS
Neurocognitive function and health care utilization were assessed in 1304 adult survivors of childhood cancer enrolled in the St. Jude Lifetime Cohort Study. Adherence to recommended care was defined as meeting guidelines published by the Children's Oncology Group. Multivariate models were used to evaluate associations between neurocognitive function and health screenings. Established predictors of health care utilization were included as covariates. Odds ratios (ORs) or prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated for variables maintained in the final models.
RESULTS
Adherence to recommended medical care was higher for routine care (general physician care, 57.6%; dental care, 49.1%) versus specialized care (survivor-focused care, 21.9%; echocardiogram, 19.9%). Higher intelligence was predictive of general physician care (OR, 1.74; 95% CI, 1.41-2.15) and survivor-focused care (OR, 1.44; 95% CI, 1.13-1.83) in comparison with no care, whereas better executive function skills were associated with reduced dental care (PR, 0.94; 95% CI, 0.91-0.98). Echocardiogram monitoring was not associated with neurocognition. Possible late effects of cancer treatment (pain and reduced cardiorespiratory fitness) were associated with an increased likelihood of receiving specialized medical care.
CONCLUSIONS
Survivors with reduced global cognition are at risk for poor health care utilization. Educational practices regarding recommended health care should be personalized to ensure comprehension by survivors with neurocognitive impairment.
背景
接受中枢神经系统（CNS）定向治疗的儿童癌症幸存者，可能因神经认知缺陷而面临医疗保健利用率低的风险。本研究调查了接受CNS定向治疗的成年幸存者的神经认知功能与坚持常规和基于风险的医学评估之间的关联。
方法
对参加圣裘德终身队列研究的1304名儿童癌症成年幸存者进行神经认知功能和医疗保健利用率评估。坚持推荐治疗的定义为符合儿童肿瘤学组发布的指南。采用多变量模型评估神经认知功能与健康筛查之间的关联。将已确定的医疗保健利用率预测因素作为协变量纳入。对最终模型中保留的变量计算比值比（OR）或患病率比（PR）以及95%置信区间（CI）。
结果
与专科护理（以幸存者为重点的护理，21.9%；超声心动图检查，19.9%）相比，常规护理（普通内科医生护理，57.6%；牙科护理，49.1%）的推荐医疗护理依从性更高。与未接受护理相比，较高的智力可预测普通内科医生护理（OR，1.74；95%CI，1.41 - 2.15）和以幸存者为重点的护理（OR，1.44；95%CI，1.13 - 1.83），而更好的执行功能技能与牙科护理减少相关（PR，0.94；95%CI，0.91 - 0.98）。超声心动图监测与神经认知无关。癌症治疗可能的晚期效应（疼痛和心肺功能下降）与接受专科医疗护理的可能性增加相关。
结论
整体认知能力下降的幸存者存在医疗保健利用率低的风险。关于推荐医疗保健的教育实践应个性化，以确保神经认知受损的幸存者能够理解。
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