接近专科护理对胆管癌结局的影响：一项基于人群的回顾性队列研究。
Effect of proximity to specialty care on outcomes for biliary cancers: a population-based retrospective cohort study.
作者信息
Xu Yuan, Steckle Sue, Lui Arthur, Dixon Elijah, Ball Chad G, Sutherland Francis R, Spratlin Jennifer, Bathe Oliver F
机构信息
Beijing You-An Hospital (Xu), Capital Medical University, Beijing, China; Departments of Community Health Sciences (Xu, Dixon) and Surgery (Xu, Dixon, Ball, Sutherland, Bathe), University of Calgary; Innervative Strategies (Steckle), Calgary, Alta.; Department of Oncology (Lui, Spratlin), University of Alberta, Edmonton, Alta.; Department of Oncology (Dixon, Ball, Sutherland, Bathe), University of Calgary, Calgary, Alta.
出版信息
CMAJ Open. 2019 Feb 28;7(1):E131-E139. doi: 10.9778/cmajo.20180082. Print 2019 Jan-Mar.
BACKGROUND
The management of biliary cancers is complex and requires a multidisciplinary approach. Because it is unknown how access to specialty care affects resource use and survival in patients with biliary cancer, we conducted a population-based study to understand the needs of these patients and the relation of geography to care delivery and clinical outcomes for biliary cancer in Alberta.
METHODS
All patients with biliary cancer diagnosed in Alberta from Sept. 1, 2001, to Dec. 31, 2015 were included in this population-based retrospective cohort study. Data were extracted from administrative databases and the 2011 Canadian census. Driving time and types of medical services were tracked throughout the patients' clinical course. We categorized proximity to specialty care according to driving time to the nearest specialist. The primary outcome was overall survival. We conducted Cox proportional hazard regression to evaluate the effects of driving time on overall survival and multivariate logistic regression to evaluate the effect of driving time on treatment types and stage at diagnosis.
RESULTS
We identified 1610 patients with biliary cancer; they accounted for 117 381 medical encounters. Patients living 120 minutes or more from the nearest hepatobiliary surgeon and from the nearest cancer centre had significantly decreased survival (hazard ratio [and 95% confidence interval (CI)] 1.27 [1.17-1.37]) and 1.27 [1.14-1.41], respectively). Location of residence was not associated with advanced stage or probability of undergoing surgery or a biliary drainage procedure. Patients who lived 120 minutes or more from a cancer centre were less likely than those who lived less than 120 minutes away to receive chemotherapy (odds ratio 0.51, 95% CI 0.29-0.88). Subgroup analysis showed that the effect of travel time was especially pronounced among those who received only best supportive care and those who had biliary drains.
INTERPRETATION
Geography and accessibility to specialty care affected survival in patients with biliary cancer. Further study is required to understand how patients with biliary drains and those receiving best supportive care are affected by proximity to specialty care. This will aid in the identification of strategies to provide improved care for this subgroup who are particularly affected by geography.
背景
胆管癌的管理复杂，需要多学科方法。由于尚不清楚获得专科护理如何影响胆管癌患者的资源使用和生存情况，我们开展了一项基于人群的研究，以了解这些患者的需求，以及地理位置与艾伯塔省胆管癌护理提供和临床结局之间的关系。
方法
本基于人群的回顾性队列研究纳入了2001年9月1日至2015年12月31日在艾伯塔省诊断出的所有胆管癌患者。数据从行政数据库和2011年加拿大人口普查中提取。在患者的整个临床过程中跟踪驾驶时间和医疗服务类型。我们根据到最近专科医生的驾驶时间对接近专科护理的程度进行分类。主要结局是总生存期。我们进行Cox比例风险回归以评估驾驶时间对总生存期的影响，并进行多变量逻辑回归以评估驾驶时间对诊断时治疗类型和分期的影响。
结果
我们识别出1610例胆管癌患者；他们有117381次医疗接触。居住在距离最近的肝胆外科医生和最近的癌症中心120分钟或更长时间路程的患者，其生存期显著缩短（风险比[及95%置信区间（CI）]分别为1.27[1.17 - 1.37]和1.27[1.14 - 1.41]）。居住地点与晚期阶段或接受手术或胆管引流手术的概率无关。居住在距离癌症中心120分钟或更长时间路程的患者比居住在距离癌症中心不到120分钟路程的患者接受化疗的可能性更小（比值比0.51，95%CI 0.29 - 0.88）。亚组分析表明，旅行时间的影响在仅接受最佳支持治疗的患者和有胆管引流的患者中尤为明显。
解读
地理位置和获得专科护理的机会影响胆管癌患者的生存。需要进一步研究以了解有胆管引流的患者和接受最佳支持治疗的患者如何受到接近专科护理的影响。这将有助于确定为这一特别受地理位置影响的亚组提供改善护理的策略。
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