联邦和州政策变化对乳房切除术后即刻乳房重建种族/族裔差异的影响。
Effect of federal and state policy changes on racial/ethnic variation in immediate postmastectomy breast reconstruction.
作者信息
Mahmoudi Elham, Giladi Aviram M, Wu Lizi, Chung Kevin C
机构信息
Ann Arbor, Mich. From the Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, and the University of Michigan Health System.
出版信息
Plast Reconstr Surg. 2015 May;135(5):1285-1294. doi: 10.1097/PRS.0000000000001149.
BACKGROUND
Breast reconstruction after mastectomy has been shown to provide substantial clinical and psychosocial benefits for many patients; however, disparities in the use of immediate postmastectomy breast reconstruction persist. Using the unique dataset from the New York State Inpatient Database, the following developments were studied: (1) trends in immediate postmastectomy breast reconstruction between 1998 and 2006 among white, African American, and Hispanic women; (2) factors associated with its use; and (3) changes in racial/ethnic variation in immediate postmastectomy breast reconstruction before and after implementation of the New York State Medicaid expansion in 2001.
METHODS
A step-in multivariable logistic regression model was used to assess the effect of race/ethnicity, age, mastectomy type, number of comorbidities, socioeconomic status, and insurance on the probability of undergoing immediate postmastectomy breast reconstruction. Then, adjusted immediate postmastectomy breast reconstruction rates for before and after Medicaid expansion were predicted, stratified by race/ethnicity.
RESULTS
The probability of undergoing immediate postmastectomy breast reconstruction increased (p < 0.001); however, even with Medicaid expansion occurring during the 8 years studied, gaps in use between white and African American women and between white and Hispanic women increased by 6 percent (95% CI, 0.07 to 0.05) and 5 percent (95% CI, 0.07 to 0.04), respectively. Being younger, having greater income and education, and having private health insurance are associated with a greater probability of immediate postmastectomy breast reconstruction.
CONCLUSION
These findings indicate that expanding safety-net policies such as Medicaid without providing support such as consultation or health literacy education might not be effective in reducing disparities in health care.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
背景
乳房切除术后乳房重建已被证明能为许多患者带来显著的临床和心理社会效益；然而，即刻乳房切除术后乳房重建的使用差异仍然存在。利用纽约州住院患者数据库的独特数据集，研究了以下情况：（1）1998年至2006年间白人、非裔美国人和西班牙裔女性即刻乳房切除术后乳房重建的趋势；（2）与其使用相关的因素；（3）2001年纽约州医疗补助扩大实施前后即刻乳房切除术后乳房重建的种族/民族差异变化。
方法
采用逐步多变量逻辑回归模型评估种族/民族、年龄、乳房切除类型、合并症数量、社会经济地位和保险对即刻乳房切除术后乳房重建概率的影响。然后，按种族/民族分层预测医疗补助扩大前后的调整后即刻乳房切除术后乳房重建率。
结果
即刻乳房切除术后乳房重建的概率增加（p<0.001）；然而，即使在研究的8年期间发生了医疗补助扩大，白人和非裔美国女性之间以及白人和西班牙裔女性之间的使用差距分别增加了6%（95%CI，0.07至0.05）和5%（95%CI，0.07至0.04）。年龄较小、收入和教育程度较高以及拥有私人健康保险与即刻乳房切除术后乳房重建的可能性较大相关。
结论
这些发现表明，扩大诸如医疗补助之类的安全网政策，而不提供诸如咨询或健康素养教育等支持，可能无法有效减少医疗保健方面的差异。
临床问题/证据水平：风险，III级
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