Adamson Adewole S, Zhou Lei, Baggett Christopher D, Thomas Nancy E, Meyer Anne-Marie
Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill.
Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill.
JAMA Dermatol. 2017 Nov 1;153(11):1106-1113. doi: 10.1001/jamadermatol.2017.3338.
Timely receipt of treatment for cancer is an important aspect of health care quality. It is unknown how delays of surgery for melanoma vary by insurance type.
To analyze factors associated with delays between diagnosis and surgery for melanoma in patients with Medicare, Medicaid, or private insurance.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of patients who received a diagnosis of melanoma between 2004 and 2011 in North Carolina using data from the North Carolina Cancer Registry linked to administrative claims from Medicare, Medicaid, and private insurance. Inclusion criteria were incident patients with a diagnosis of melanoma stage 0 to III and with continuous insurance enrollment from at least 1 month prior to the month of diagnosis to 12 months after diagnosis of melanoma.
Surgical delay, defined as definitive surgical excision occurring more than 6 weeks after melanoma diagnosis. Generalized linear models with log link, Poisson distributions, and robust standard errors were used to estimate adjusted risk ratios (RRs) to model risk of delay in definitive surgery.
A total of 7629 patients were included (4210 [55%] female; mean [SD] age, 64 [15] years), 48% (n = 3631) Medicare, 48% (n = 3667) privately insured, and 4% (n = 331) Medicaid patients. Privately insured patients were least likely to experience a delay in definitive surgery, followed by Medicare and Medicaid patients (519 [14%], 609 [17%], and 79 [24%], respectively; P < .001). After demographic adjustment, the risk of surgical delay was significantly increased in patients with Medicaid compared with private insurance (RR, 1.36; 95% CI, 1.09-1.70). Delays were more likely in nonwhite patients (RR, 1.38; 95% CI, 1.02-1.87). Surgical delays were less likely if the physician performing the surgery (RR, 0.82; 95% CI, 0.72-0.93) or the diagnosing clinician (RR, 0.81; 95% CI, 0.71-0.93) was a dermatologist as compared with a nondermatologist.
Surgical treatment delays were common but were less prevalent in patients diagnosed or surgically treated by a dermatologist. Medicaid patients experienced the most surgical delays. A reduction in delays in melanoma surgery could be achieved through better access to specialty care and cross-disciplinary coordination.
及时接受癌症治疗是医疗质量的一个重要方面。目前尚不清楚黑色素瘤手术延迟在不同保险类型之间如何变化。
分析医疗保险、医疗补助或私人保险患者中黑色素瘤诊断与手术之间延迟的相关因素。
设计、设置和参与者：对2004年至2011年在北卡罗来纳州被诊断为黑色素瘤的患者进行回顾性队列研究，使用北卡罗来纳州癌症登记处的数据，并与医疗保险、医疗补助和私人保险的行政索赔数据相链接。纳入标准为确诊为0至III期黑色素瘤且从诊断前至少1个月至黑色素瘤诊断后12个月持续参保的新发患者。
手术延迟，定义为在黑色素瘤诊断后超过6周进行确定性手术切除。使用对数链接、泊松分布和稳健标准误的广义线性模型来估计调整后的风险比（RR），以模拟确定性手术延迟的风险。
共纳入7629例患者（4210例[55%]为女性；平均[标准差]年龄为64[15]岁），48%（n = 3631）为医疗保险患者，48%（n = 3667）为私人保险患者，4%（n = 331）为医疗补助患者。私人保险患者进行确定性手术延迟的可能性最小，其次是医疗保险和医疗补助患者（分别为519例[14%]、609例[17%]和79例[24%]；P < 0.001）。经过人口统计学调整后，与私人保险患者相比，医疗补助患者手术延迟的风险显著增加（RR，1.36；95%置信区间，1.09 - 1.70）。非白人患者更易出现延迟（RR，1.38；95%置信区间：1.02 - 1.87）。与非皮肤科医生相比，如果进行手术的医生（RR，0.82；95%置信区间，0.72 - 0.93）或诊断临床医生（RR，0.81；95%置信区间，0.71 - 0.93）是皮肤科医生，则手术延迟的可能性较小。
手术治疗延迟很常见，但在由皮肤科医生诊断或手术治疗的患者中不太普遍。医疗补助患者经历的手术延迟最多。通过更好地获得专科护理和跨学科协调，可以减少黑色素瘤手术的延迟。
