Bouquet Benjamin, Barone-Adesi Francesco, Lafi Mohamed, Quanstrom Kathryn, Riccardi Federica, Doctor Henry V, Shehada Walaa, Nassar Juliana, Issawi Sali, Daher Mahmoud, Rockenschaub Gerald, Rashidian Arash
WHO, occupied Palestinian territory, Jerusalemxs.
Department of Translational Medicine and CRIMEDIM, Research Center in Emergency and Disaster Medicine, University of Eastern Piedmont, Novara, Italy.
Lancet. 2021 Jul;398 Suppl 1:S20. doi: 10.1016/S0140-6736(21)01506-3.
Gaza has been under land, sea, and aerial blockade for more than 13 years, during which time Israel has continued its permit regime to control access for Palestinian patients from Gaza to health facilities in the West Bank (including East Jerusalem), Israel, and Jordan. Specific groups, such as patients with cancer, have a high need for permits owing to a 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 effect of access restrictions due to permit denials or delays on all-cause mortality for patients with cancer from Gaza who were referred for chemotherapy, radiotherapy, or both.
This study matched 17 072 permit applications for 3816 patients referred for chemotherapy, radiotherapy, or both, from Jan 1, 2008, to Dec 31, 2017, with referral data for the same period and mortality data from Jan 1, 2008, to Jun 30, 2018. We stratified survival analysis 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 or delayed) using Kaplan-Meier methods and Cox regression. Consent for the study was granted by the Palestinian Ministry of Health, and ethical approval was granted by the Helsinki Committee of the Palestinian Ministry of Health.
Mortality was significantly higher among patients who were initially unsuccessful in permit applications from 2015 to 2017 (141 events over 493 person-years, corresponding to a rate of 286 per 100 person-years) than among patients who were initially successful in the same period (375 events over 1923 person-years, corresponding to a rate of 195 per 100 person-years) with a hazard ratio of 1·45 (95% CI 1·19-1·78, p=0.0009) after adjusting for age, sex, type of procedure, and type of cancer. There was no significant difference in mortality risk between the two groups in the 2008-14 period, with a hazard ratio of 0·84 (95% CI 0·69-1·01, p=0·071).
Barriers to patient access to health care through denied or delayed permit applications had a significant impact on mortality for patients with cancer who applied for chemotherapy, radiotherapy, or both, in the period 2015-17. Relative ease of access through Rafah from 2008 to 2014 may have mitigated the health effects of access restrictions.
WHO received funding from the Swiss Agency for Development and Cooperation.
加沙地带遭受陆地、海上和空中封锁已超过13年，在此期间，以色列继续实施其许可制度，以控制加沙的巴勒斯坦患者进入约旦河西岸（包括东耶路撒冷）、以色列和约旦的医疗机构。由于加沙缺乏相关服务，特定群体，如癌症患者，对许可证的需求很高。患者离开加沙的许可批准率从2012年的94%降至2017年的54%。我们旨在评估因许可证被拒或延误导致的就医限制对被转诊接受化疗、放疗或两者皆有的加沙癌症患者全因死亡率的影响。
本研究将2008年1月1日至2017年12月31日期间3816例被转诊接受化疗、放疗或两者皆有的患者的17072份许可申请，与同期的转诊数据以及2008年1月1日至2018年6月30日的死亡率数据进行匹配。根据首次申请的时间段（2008 - 2014年、2015 - 2017年）进行生存分析分层，鉴于这两个时期进入埃及的难易程度不同。初步分析使用Kaplan - Meier方法和Cox回归，根据患者的首次转诊决定（批准与被拒或延误）比较患者的生存率。本研究获得了巴勒斯坦卫生部的同意，并得到了巴勒斯坦卫生部赫尔辛基委员会的伦理批准。
2015年至2017年期间，最初许可证申请未成功的患者死亡率（493人年中有141例死亡，相当于每100人年286例）显著高于同期最初申请成功的患者（1923人年中有375例死亡，相当于每100人年195例），在调整年龄、性别、手术类型和癌症类型后，风险比为1.45（95%置信区间1.19 - 1.78，p = 0.0009）。在2008 - 2014年期间，两组的死亡风险没有显著差异，风险比为0.84（95%置信区间0.69 - 1.01，p = 0.071）。
2015 - 2017年期间，因许可证申请被拒或延误而导致患者获得医疗保健的障碍，对申请化疗、放疗或两者皆有的癌症患者死亡率产生了重大影响。2008年至2014年通过拉法相对容易进入可能减轻了就医限制对健康的影响。
世界卫生组织获得了瑞士发展与合作署的资金。
