School of Social Work, University of Windsor, Windsor, Ontario, Canada.
Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada.
BMJ Support Palliat Care. 2019 Sep;9(3):e24. doi: 10.1136/bmjspcare-2015-001035. Epub 2016 Aug 23.
Many Americans with metastasised colon cancer do not receive indicated palliative chemotherapy. We examined the effects of health insurance and physician supplies on such chemotherapy in California.
We analysed registry data for 1199 people with metastasised colon cancer diagnosed between 1996 and 2000 and followed for 1 year. We obtained data on health insurance, census tract-based socioeconomic status and county-level physician supplies. Poor neighbourhoods were oversampled and the criterion was receipt of chemotherapy. Effects were described with rate ratios (RR) and tested with logistic regression models.
Palliative chemotherapy was received by less than half of the participants (45%). Facilitating effects of primary care (RR=1.23) and health insurance (RR=1.14) as well as an impeding effect of specialised care (RR=0.86) were observed. Primary care physician (PCP) supply took precedence. Adjusting for poverty, PCP supply was the only significant and strong predictor of chemotherapy (OR=1.62, 95% CI 1.02 to 2.56). The threshold for this primary care advantage was realised in communities with 8.5 or more PCPs per 10 000 inhabitants. Only 10% of participants lived in such well-supplied communities.
This study's observations of facilitating effects of primary care and health insurance on palliative chemotherapy for metastasised colon cancer clearly suggested a way to maximise Affordable Care Act (ACA) protections. Strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realised. Such would go a long way towards facilitating access to palliative care.
许多患有转移性结肠癌的美国人并未接受既定的姑息化疗。我们研究了加利福尼亚州的医疗保险和医生供应对这种化疗的影响。
我们分析了 1996 年至 2000 年间诊断出患有转移性结肠癌的 1199 名患者的登记数据，并对其进行了为期 1 年的随访。我们获得了医疗保险、基于普查区的社会经济地位和县级医生供应的数据。贫困社区被过度抽样，标准是接受化疗。使用率比（RR）描述效果，并使用逻辑回归模型进行检验。
姑息化疗的接受率不到一半（45%）。观察到初级保健（RR=1.23）和医疗保险（RR=1.14）的促进作用，以及专业保健的阻碍作用（RR=0.86）。初级保健医生（PCP）的供应占主导地位。调整贫困因素后，PCP 的供应是化疗的唯一显著和重要预测因素（OR=1.62，95%CI 1.02 至 2.56）。在每 10000 名居民中有 8.5 名或更多 PCP 的社区中，实现了这种初级保健优势的门槛。只有 10%的参与者生活在这种供应充足的社区中。
本研究观察到初级保健和医疗保险对转移性结肠癌姑息化疗的促进作用，这清楚地表明了一种最大限度地发挥《平价医疗法案》（ACA）保护作用的方法。加强美国的初级保健体系可能是确保 ACA 充分发挥效益的最佳途径。这将在很大程度上促进姑息治疗的获得。
