Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
Ann Surg Oncol. 2022 Sep;29(9):5759-5769. doi: 10.1245/s10434-022-11834-4. Epub 2022 May 24.
Delays between breast cancer diagnosis and surgery are associated with worsened survival. Delays are more common in urban-residing patients, although factors specific to surgical delays among rural and urban patients are not well understood.
We used a 100% sample of fee-for-service Medicare claims during 2007-2014 to identify 238,491 women diagnosed with early-stage breast cancer undergoing initial surgery and assessed whether they experienced biopsy-to-surgery intervals > 90 days. We employed multilevel regression to identify associations between delays and patient, regional, and surgeon characteristics, both in combined analyses and stratified by rurality of patient residence.
Delays were more prevalent among urban patients (2.5%) than rural patients (1.9%). Rural patients with medium- or high-volume surgeons had lower odds of delay than patients with low-volume surgeons (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.58-0.88; OR = 0.74, 95% CI = 0.61-0.90). Rural patients whose surgeon operated at ≥ 3 hospitals were more likely to experience delays (OR = 1.29, 95% CI = 1.01-1.64, Ref: 1 hospital). Patient driving times ≥ 1 h were associated with delays among urban patients only. Age, black race, Hispanic ethnicity, multimorbidity, and academic/specialty hospital status were associated with delays.
Sociodemographic, geographic, surgeon, and facility factors have distinct associations with > 90-day delays to initial breast cancer surgery. Interventions to improve timeliness of breast cancer surgery may have disparate impacts on vulnerable populations by rural-urban status.
乳腺癌诊断与手术之间的延迟与生存预后恶化相关。在城市居住的患者中，这种延迟更为常见，尽管农村和城市患者中导致手术延迟的具体因素尚不清楚。
我们使用了 2007 年至 2014 年期间 100%的医疗保险按服务收费样本，以确定 238491 名接受初始手术的早期乳腺癌诊断患者，并评估他们是否经历了活检至手术间隔超过 90 天的情况。我们采用多水平回归分析，以确定延迟与患者、地区和外科医生特征之间的关联，同时在综合分析和按患者居住地的农村/城市情况进行分层分析中均进行了评估。
与农村患者（1.9%）相比，城市患者中出现延迟的比例更高（2.5%）。中高容量外科医生的农村患者发生延迟的可能性低于低容量外科医生（比值比[OR] = 0.71，95%置信区间[CI] = 0.58-0.88；OR = 0.74，95%CI = 0.61-0.90）。手术医院≥3 家的农村患者更有可能出现延迟（OR = 1.29，95%CI = 1.01-1.64，参照：1 家医院）。仅在城市患者中，患者驾车时间≥1 小时与延迟相关。年龄、黑人种族、西班牙裔、多种合并症和学术/专科医院状态与延迟相关。
社会人口学、地理、外科医生和医疗机构因素与初始乳腺癌手术超过 90 天的延迟有不同的关联。改善乳腺癌手术及时性的干预措施可能会根据农村/城市的不同状态，对弱势群体产生不同的影响。
