Division of Urology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Cancer. 2021 Feb 15;127(4):577-585. doi: 10.1002/cncr.33237. Epub 2020 Oct 21.
Underinsured patients face significant barriers in accessing high-quality care. Evidence of whether access to high-volume surgical care is mediated by disparities in health insurance coverage remains wanting.
The authors used the National Cancer Data Base to identify all adult patients who had a confirmed diagnosis of breast, prostate, lung, or colorectal cancer during 2004 through 2016. The odds of receiving surgical care at a high-volume hospital were estimated according to the type of insurance using multivariable logistic regression analyses for each malignancy. Then, the interactions between study period and insurance status were assessed.
In total, 1,279,738 patients were included in the study. Of these, patients with breast cancer who were insured by Medicare (odds ratio [OR], 0.75; P < .001), Medicaid (OR, 0.55; P < .001), or uninsured (OR, 0.50; P < .001); patients with prostate cancer who were insured by Medicare (OR, 0.87; P = .003), Medicaid (OR, 0.58; P = .001), or uninsured (OR, 0.36; P < .001); and patients with lung cancer who were insured by Medicare (OR, 0.84; P = .020), Medicaid (OR, 0.74; P = .001), or uninsured (OR, 0.48; P < .001) were less likely to receive surgical care at high-volume hospitals compared with patients who had private insurance. For patients with colorectal cancer, the effect of insurance differed by study period, and improved since 2011. For those on Medicaid, the odds of receiving care at a high-volume hospital were 0.51 during 2004 through 2007 and 0.99 during 2014 through 2016 (P for interaction = .001); for uninsured patients, the odds were 0.45 during 2004 through 2007 and 1.19 during 2014 through 2016 (P for interaction < .001) compared with patients who had private insurance.
Uninsured, Medicare-insured, and Medicaid-insured patients are less likely to receive surgical care at high-volume hospitals. For uninsured and Medicaid-insured patients with colorectal cancer, the odds of receiving care at high-volume hospitals have improved since implementation of the Patient Protection and Affordable Care Act of 2010.
保险不足的患者在获得高质量医疗服务方面面临重大障碍。关于获得高容量手术护理的机会是否受到健康保险覆盖范围差异的影响，目前仍缺乏证据。
作者使用国家癌症数据库（National Cancer Data Base），确定了 2004 年至 2016 年间所有被确诊患有乳腺癌、前列腺癌、肺癌或结直肠癌的成年患者。使用多变量逻辑回归分析，根据保险类型估计每一种癌症患者在高容量医院接受手术护理的可能性。然后，评估了研究期间和保险状况之间的相互作用。
共有 1279738 名患者纳入研究。在这些患者中，接受乳腺癌手术治疗的医疗保险（Medicare）（比值比[OR]，0.75；P <.001）、医疗补助（Medicaid）（OR，0.55；P <.001）或无保险（OR，0.50；P <.001）患者；接受前列腺癌手术治疗的医疗保险（Medicare）（OR，0.87；P =.003）、医疗补助（Medicaid）（OR，0.58；P =.001）或无保险（OR，0.36；P <.001）患者；接受肺癌手术治疗的医疗保险（Medicare）（OR，0.84；P =.020）、医疗补助（Medicaid）（OR，0.74；P =.001）或无保险（OR，0.48；P <.001）患者与拥有私人保险的患者相比，在高容量医院接受手术治疗的可能性较低。对于结直肠癌患者，保险的影响因研究期间而异，自 2011 年以来有所改善。对于医疗补助患者，2004 年至 2007 年在高容量医院接受治疗的几率为 0.51，2014 年至 2016 年为 0.99（P 交互=.001）；对于无保险患者，2004 年至 2007 年为 0.45，2014 年至 2016 年为 1.19（P 交互<.001），而拥有私人保险的患者。
无保险、医疗保险和医疗补助保险的患者在高容量医院接受手术治疗的可能性较低。对于 2010 年《患者保护与平价医疗法案》（Patient Protection and Affordable Care Act）实施以来接受结直肠癌治疗的无保险和医疗补助保险患者，在高容量医院接受治疗的几率有所提高。
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