Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
Division of Transplant Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, MSB 2006C, Cincinnati, OH, 45267-0558, USA.
J Gastrointest Surg. 2018 Jan;22(1):98-106. doi: 10.1007/s11605-017-3549-0. Epub 2017 Aug 28.
Due to disparities in access to care, patients with Medicaid or no health insurance are at risk of not receiving appropriate adjuvant treatment following resection of pancreatic cancer. We have previously shown inferior short-term outcomes following surgery at safety-net hospitals. Subsequently, we hypothesized that safety-net hospitals caring for these vulnerable populations utilize less adjuvant chemoradiation, resulting in inferior long-term outcomes.
The American College of Surgeons National Cancer Data Base was queried for patients diagnosed with pancreatic adenocarcinoma (n = 32,296) from 1998 to 2010. Hospitals were grouped according to safety-net burden, defined as the proportion of patients with Medicaid or no insurance. The highest quartile, representing safety-net hospitals, was compared to lower-burden hospitals with regard to patient demographics, disease characteristics, surgical management, delivery of multimodal systemic therapy, and survival.
Patients at safety-net hospitals were less often white, had lower income, and were less educated. Safety-net hospital patients were just as likely to undergo surgical resection (OR 1.03, p = 0.73), achieving similar rates of negative surgical margins when compared to patients at medium and low burden hospitals (70% vs. 73% vs. 66%). Thirty-day mortality rates were 5.6% for high burden hospitals, 5.2% for medium burden hospitals, and 4.3% for low burden hospitals. No clinically significant differences were noted in the proportion of surgical patients receiving either chemotherapy (48% vs. 52% vs. 52%) or radiation therapy (26% vs. 30% vs. 29%) or the time between diagnosis and start of systemic therapy (58 days vs. 61 days vs. 53 days). Across safety-net burden groups, no difference was noted in stage-specific median survival (all p > 0.05) or receipt of adjuvant as opposed to neoadjuvant systemic therapy (82% vs. 85% vs. 85%). Multivariate analysis adjusting for cancer stage revealed no difference in survival for safety-net hospital patients who had surgery and survived > 30 days (HR 1.02, p = 0.63).
For patients surviving the perioperative setting following pancreatic cancer surgery, safety-net hospitals achieve equivalent long-term survival outcomes potentially due to equivalent delivery of multimodal therapy at non-safety-net hospitals. Safety-net hospitals are a crucial resource that provides quality long-term cancer treatment for vulnerable populations.
由于获得医疗保健的机会存在差异，拥有医疗补助或没有医疗保险的患者在接受胰腺癌切除术后可能无法接受适当的辅助治疗。我们之前曾发现在医疗保障不足的医院手术后短期结果较差。随后，我们假设这些弱势群体的医疗保障不足的医院使用的辅助放化疗较少，从而导致长期结果较差。
从 1998 年至 2010 年，美国外科医师学会国家癌症数据库中查询了 32296 名被诊断为胰腺腺癌的患者。根据医疗保障负担将医院分组，定义为拥有医疗补助或没有保险的患者比例。代表医疗保障不足的医院的最高四分位数与负担较低的医院进行比较，比较内容包括患者人口统计学特征、疾病特征、手术管理、多模式系统治疗的提供情况和生存情况。
医疗保障不足的医院的患者白人较少、收入较低且受教育程度较低。与中低负担医院相比，医疗保障不足的医院的患者同样有可能接受手术切除（比值比 1.03，p=0.73），且达到了相似的阴性手术切缘率（70%比 73%比 66%）。高负担医院的 30 天死亡率为 5.6%，中负担医院为 5.2%，低负担医院为 4.3%。接受化疗的手术患者比例（48%比 52%比 52%）、接受放疗的患者比例（26%比 30%比 29%）或诊断后开始系统治疗的时间（58 天比 61 天比 53 天）没有明显差异。在各医疗保障负担组中，特定阶段的中位生存时间无差异（均 p>0.05），或接受辅助治疗而不是新辅助治疗的患者比例也无差异（82%比 85%比 85%）。对癌症分期进行多变量调整后，术后存活 30 天以上的医疗保障不足的医院手术患者的生存情况没有差异（风险比 1.02，p=0.63）。
对于接受胰腺癌手术后围手术期治疗的患者，医疗保障不足的医院实现了等效的长期生存结果，这可能是由于非医疗保障不足的医院等效地提供了多模式治疗。医疗保障不足的医院是为弱势群体提供优质长期癌症治疗的重要资源。
