WHO Occupied Palestinian Territory, Jerusalem, Israel.
Department of Translational Medicine and CRIMEDIM-Research Center in Emergency and Disaster Medicine, University of Eastern Piedmont, Novara, Italy.
PLoS One. 2021 Jun 2;16(6):e0251058. doi: 10.1371/journal.pone.0251058. eCollection 2021.
Gaza has been under land, sea, and aerial closure for 13 years, during which time Palestinian patients from Gaza have been required to obtain Israeli-issued permits to access health facilities in the West Bank (including east Jerusalem), as well as in Israel and Jordan. Specific groups, like cancer patients, have a high need for permits due to lack of services in Gaza. The approval rate for patient permits to exit Gaza dropped from 94% in 2012 to 54% in 2017. We aimed to assess the impact of access restrictions due to permit denials/delays on all-cause mortality for cancer patients from Gaza referred for chemotherapy and/or radiotherapy.
This study matched 17,072 permit applications for 3,816 cancer patients referred for chemotherapy and/or radiotherapy from 1 January 2008 to 31 December 2017 with referrals data for the same period and mortality data from 1 January 2008 to 30 June 2018. We carried out separate analyses by period of first application (2008-14; 2015-17), in light of varying access to Egypt during these times. Primary analysis compared survival of patients according to their first referral decision (approved versus denied/delayed) using Kaplan-Meier method and Cox regression.
Mortality in patients unsuccessful in permit applications from 2015-17 was significantly higher than mortality among successful patients, with a hazard ratio of 1·45 (95% CI: 1·19-1·78, p<0.001), after adjusting for age, sex, type of procedure, and type of cancer. There was no significant difference in mortality risk for the two groups in the 2008-2014 period.
Limitations to patient access due to unsuccessful applications for permits to exit the Gaza Strip had a significant impact on mortality for cancer patients applying for chemotherapy and/or radiotherapy in the period 2015-17. The substantially higher number of annual unsuccessful permit applications from 2015, combined with severely limited alternatives to access chemotherapy and radiotherapy during these years, may be important factors to explain the difference in the impact of permits delays/denials between the two study periods.
加沙地带已被陆地、海洋和空中封锁了 13 年，在此期间，加沙的巴勒斯坦患者需要获得以色列颁发的许可证，才能前往西岸（包括东耶路撒冷）以及以色列和约旦的卫生设施。由于加沙缺乏服务，癌症等特定群体对许可证的需求很高。2012 年，获准离开加沙的患者许可证批准率为 94%，到 2017 年降至 54%。我们旨在评估因拒绝/延迟发放许可证而对被转诊接受化疗和/或放疗的加沙癌症患者的全因死亡率的影响。
本研究将 2008 年 1 月 1 日至 2017 年 12 月 31 日期间为 3816 名接受化疗和/或放疗的癌症患者转诊申请的 17072 份申请与同期转诊数据和 2008 年 1 月 1 日至 2018 年 6 月 30 日的死亡率数据进行匹配。根据这两个时期进出埃及的情况，我们分别对第一份申请的时期（2008-14 年；2015-17 年）进行了分析。主要分析比较了首次转诊决定（批准与拒绝/延迟）后患者的生存情况，采用 Kaplan-Meier 方法和 Cox 回归。
2015-17 年未获得许可证的患者的死亡率明显高于获得许可证的患者，调整年龄、性别、手术类型和癌症类型后，危险比为 1.45（95%CI：1.19-1.78，p<0.001）。2008-2014 年期间，两组患者的死亡率风险无显著差异。
由于未能获得离开加沙地带的许可证，限制了患者的就诊机会，对 2015-17 年期间申请化疗和/或放疗的癌症患者的死亡率产生了重大影响。2015 年未获得许可证的年度申请数量大幅增加，再加上这些年接受化疗和放疗的选择受到严重限制，这可能是两个研究期间许可证延误/拒绝影响差异的重要因素。
