Tannenbaum Sara, Soulos Pamela R, Herrin Jeph, Mougalian Sarah, Long Jessica B, Wang Rong, Ma Xiaomei, Gross Cary P, Xu Xiao
*Yale School of Medicine†Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine‡Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University§Division of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT∥Health Research and Educational Trust, Chicago, IL¶Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine#Department of Chronic Disease Epidemiology, Yale School of Public Health**Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
Med Care. 2017 Dec;55(12):1030-1038. doi: 10.1097/MLR.0000000000000822.
Despite evidence on large variation in breast cancer expenditures across geographic regions, there is little understanding about the association between expenditures and patient outcomes.
To examine whether Medicare beneficiaries with nonmetastatic breast cancer living in regions with higher cancer-related expenditures had better survival.
A retrospective cohort study of women with localized breast cancer from the Surveillance, Epidemiology, and End Results-Medicare linked database. Hospital referral regions (HRR) were categorized into quintiles based on risk-standardized per patient Medicare expenditures on initial phase of breast cancer care. Hierarchical generalized linear models were estimated to examine the association between patients' HRR quintile and survival.
In total, 12,610 Medicare beneficiaries diagnosed with stage II-III breast cancer during 2005-2008 who underwent surgery.
Outcome measures for our analysis were 3- and 5-year overall survival.
Risk-standardized per patient Medicare expenditures on initial phase of breast cancer care ranged from $13,338 to $26,831 across the HRRs. Unadjusted 3- and 5-year survival varied from 66.7% to 92.2% and 50.0% to 84.0%, respectively, across the HRRs, but there was no significant association between HRR quintile and survival in bivariate analysis (P=0.08 and 0.28, respectively). After adjustment for sociodemographic and clinical characteristics, quintiles of regional cancer expenditures remained unassociated with patients' 3-year (P=0.35) and 5-year survival (P=0.20). Further analysis adjusting for treatment factors (surgery type and receipt of radiation and systemic therapy) and stratifying by cancer stage showed similar results.
For Medicare beneficiaries with nonmetastatic breast cancer, residence in regions with higher breast cancer-related expenditures was not associated with better survival. More attention to value in breast cancer care is warranted.
尽管有证据表明不同地理区域的乳腺癌支出差异很大，但对于支出与患者预后之间的关联却知之甚少。
研究患有非转移性乳腺癌的医疗保险受益人在癌症相关支出较高的地区是否有更好的生存率。
一项对来自监测、流行病学和最终结果-医疗保险链接数据库中患有局部乳腺癌女性的回顾性队列研究。医院转诊区域（HRR）根据乳腺癌护理初始阶段每位患者的风险标准化医疗保险支出分为五等份。采用分层广义线性模型来研究患者的HRR五分位数与生存率之间的关联。
共有12610名在2005 - 2008年期间被诊断为II - III期乳腺癌并接受手术的医疗保险受益人。
我们分析的结局指标为3年和5年总生存率。
各HRR地区乳腺癌护理初始阶段每位患者的风险标准化医疗保险支出从13338美元到26831美元不等。未经调整的3年和5年生存率在各HRR地区分别从66.7%到92.2%以及从50.0%到84.0%不等，但在双变量分析中，HRR五分位数与生存率之间无显著关联（分别为P = 0.08和0.28）。在对社会人口学和临床特征进行调整后，区域癌症支出五分位数与患者的3年生存率（P = 0.35）和5年生存率（P = 0.20）仍无关联。进一步调整治疗因素（手术类型以及是否接受放疗和全身治疗）并按癌症分期分层分析显示了类似结果。
对于患有非转移性乳腺癌的医疗保险受益人，居住在乳腺癌相关支出较高的地区与更好的生存率无关。乳腺癌护理中对价值的更多关注是必要的。
