Nadpara Pramit, Madhavan S Suresh, Tworek Cindy
Virginia Commonwealth University, School of Pharmacy, Department of Pharmacotherapy & Outcomes Science, Richmond, VA 23298-0533, USA.
West Virginia University, School of Pharmacy, Department of Pharmaceutical Systems & Policy, Morgantown, WV 26506-9500, USA.
Cancer Epidemiol. 2015 Dec;39(6):1136-44. doi: 10.1016/j.canep.2015.06.005. Epub 2015 Jun 29.
Elderly carry a disproportionate burden of lung cancer in the US. Therefore, its important to ensure that these patients receive quality cancer care. Timeliness of care is an important dimension of cancer care quality but its impact on prognosis remains to be explored. This study evaluates the variations in guideline-concordant timely lung cancer care and prognosis among elderly in the US.
Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2002-2007), we identified elderly patients with lung cancer (n=48,850) and determined time to diagnosis and treatment. We categorized patients by receipt of timely care using guidelines from the British Thoracic Society and the RAND Corporation. Hierarchical generalized logistic model was constructed to identify variables associated with receipt of timely care. Kaplan-Meier analysis and Log Rank test was used for estimation and comparison of the three-year survival. Multivariable Cox proportional hazards model was constructed to estimate lung cancer mortality risk associated with receipt of delayed care.
Time to diagnosis and treatment varied significantly among the elderly. However, majority of them (77.5%) received guideline-concordant timely lung cancer care. The likelihood of receiving timely care significantly decreased with NSCLC disease, early stage diagnosis, increasing age, non-white race, higher comorbidity score, and lower income. Paradoxically, survival outcomes were significantly worse among patients receiving timely care. Adjusted lung cancer mortality risk was also significantly lower among patients receiving delayed care, relative to those receiving timely care (Hazard ratio (HR)=0.68, 95% Confidence interval (CI)=(0.66-0.71); p ≤ 0.05).
This study highlights the critical need to address disparities in receipt of guideline-concordant timely lung cancer care among elderly. Although timely care was not associated with better prognosis in this study, any delays in diagnosis and treatment should be avoided, as it may increase the risk of disease progression and psychological stress in patients. Furthermore, given that lung cancer diagnostic and management services are covered under the Medicare program, observed delays in care among Medicare beneficiaries is also a cause for concern.
在美国，老年人患肺癌的负担 disproportionately 过重。因此，确保这些患者获得高质量的癌症护理非常重要。护理及时性是癌症护理质量的一个重要方面，但其对预后的影响仍有待探索。本研究评估了美国老年人中符合指南的及时肺癌护理和预后的差异。
利用监测、流行病学和最终结果（SEER）-医疗保险数据库（2002 - 2007 年），我们确定了老年肺癌患者（n = 48,850），并确定了诊断和治疗时间。我们根据英国胸科学会和兰德公司的指南，按是否接受及时护理对患者进行分类。构建分层广义逻辑模型以识别与接受及时护理相关的变量。采用 Kaplan-Meier 分析和 Log Rank 检验进行三年生存率的估计和比较。构建多变量 Cox 比例风险模型以估计与接受延迟护理相关的肺癌死亡风险。
老年人的诊断和治疗时间差异显著。然而，他们中的大多数（77.5%）接受了符合指南的及时肺癌护理。随着非小细胞肺癌疾病、早期诊断、年龄增加、非白人种族、更高的合并症评分和更低的收入，接受及时护理的可能性显著降低。矛盾的是，接受及时护理的患者的生存结果明显更差。与接受及时护理的患者相比，接受延迟护理的患者调整后的肺癌死亡风险也显著更低（风险比（HR）= 0.68，95%置信区间（CI）=（0.66 - 0.71）；p≤0.05）。
本研究强调迫切需要解决老年人中接受符合指南的及时肺癌护理方面的差异。尽管在本研究中及时护理与更好的预后无关，但应避免诊断和治疗的任何延迟，因为这可能会增加患者疾病进展和心理压力的风险。此外，鉴于医疗保险计划涵盖肺癌诊断和管理服务，医疗保险受益人中观察到的护理延迟也是一个令人担忧的问题。
