Ihemelandu Chukwuemeka, Zheng Chaoyi, Hall Erin, Langan Russell C, Shara Nawar, Johnson Lynt, Al-Refaie Waddah
Department of General Surgery, MedStar Washington Hospital Center, 106 Irving St, NW, POB Suite 3900, Washington, DC, 20010, USA.
MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC, USA.
Am J Surg. 2016 Apr;211(4):697-702. doi: 10.1016/j.amjsurg.2015.09.017. Epub 2016 Feb 28.
The Institute of Medicine has recently prioritized access of quality cancer care to vulnerable persons including multimorbid patients. Despite promotional efforts to regionalize major surgical procedures to high-volume hospitals (HVHs), little is known about change in access to HVH over time among multimorbid patients in need of major cancer surgery. We performed a time-trend appraisal of access of multimorbid persons to HVH for major cancer surgery within a large nationally representative cohort.
We identified 168,934 patients who underwent 6 major cancer surgeries from the Nationwide Inpatient Sample (1998 to 2010). Comorbidities were identified using Elixhauser's method. HVHs were defined as hospitals of highest procedure volumes that treated 1/3 of all the patients. Logistic regression models and predictive margins were used to assess the adjusted effects of comorbidity on receiving major cancer surgeries at HVH.
Of all, 45.7% of the patients had 2 comorbidities or more. Multimorbidity predicted decreased access to HVH for esophagectomy, total gastrectomy, pancreatectomy, hepatectomy, and proctectomy, but not for distal gastrectomy, after controlling for covariates. A comorbidity level by year interaction analysis also showed that little disparity existed for receiving distal gastrectomy at an HVH, whereas the predicted difference in probability of receiving any of the other 5 major cancer procedures remained prominent between the years 1998 and 2010.
In this large 12-year time-trend study, multimorbid cancer patients have sustained low access to HVH for major cancer surgery across many oncologic resections. These results continue to reinforce and highlight the need for policy targeted research and intervention aimed at improving these access gaps.
医学研究所最近将为包括多病患者在内的弱势群体提供优质癌症护理作为优先事项。尽管为将主要外科手术集中到高容量医院（HVHs）做出了推广努力，但对于需要进行重大癌症手术的多病患者随时间推移获得HVH治疗的情况变化知之甚少。我们在一个具有全国代表性的大型队列中，对多病患者接受重大癌症手术获得HVH治疗的情况进行了时间趋势评估。
我们从全国住院患者样本（1998年至2010年）中识别出168,934例接受6种主要癌症手术的患者。使用埃利克斯豪泽方法识别合并症。HVHs被定义为治疗所有患者三分之一的手术量最高的医院。使用逻辑回归模型和预测边际来评估合并症对在HVH接受重大癌症手术的调整影响。
总体而言，45.7%的患者有2种或更多合并症。在控制协变量后，多病状况预示着接受食管切除术、全胃切除术、胰腺切除术、肝切除术和直肠切除术时获得HVH治疗的机会减少，但远端胃切除术并非如此。按年份进行的合并症水平交互分析还表明，在HVH接受远端胃切除术的差异很小，而在1998年至2010年期间，接受其他5种主要癌症手术之一的预测概率差异仍然显著。
在这项为期12年的大型时间趋势研究中，多病癌症患者在许多肿瘤切除术中接受重大癌症手术时获得HVH治疗的机会持续较低。这些结果继续强化并突出了针对政策的研究和干预的必要性，旨在缩小这些治疗机会差距。
