Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis.
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
JAMA Oncol. 2023 Mar 1;9(3):324-333. doi: 10.1001/jamaoncol.2022.6296.
Immunotherapies reflect an important breakthrough in cancer treatment, substantially improving outcomes for patients with a variety of cancer types, yet little is known about which practices have adopted this novel therapy or the pace of adoption.
To assess adoption of immunotherapies across US oncology practices and examine variation in adoption by practice type.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from Medicare fee-for-service beneficiaries undergoing 6-month chemotherapy episodes between 2010 and 2017. Data were analyzed January 19, 2021, to September 28, 2022, for patients with cancer types for which immunotherapy was approved by the US Food and Drug Administration (FDA) during the study period: melanoma, kidney cancer, lung cancer, and head and neck cancer.
Oncology practice location (rural vs urban), affiliation type (academic system, nonacademic system, independent), and size (1 to 5 physicians vs 6 or more physicians).
The primary outcome was whether a practice adopted immunotherapy. Adoption rates for each practice type were estimated using multivariate linear models that adjusted for patient characteristics (age, sex, race and ethnicity, cancer type, Charlson Comorbidity Index, and median household income).
Data included 71 659 episodes at 1732 oncology practices. Of these, 264 practices (15%) were rural, 900 (52%) were independent, and 492 (28%) had 1 to 5 physicians. Most practices adopted immunotherapy within 2 years of FDA approval, but there was substantial variation in adoption rates across practice types. After FDA approval, adoption of immunotherapy was 11 (95% CI, -16 to -6) percentage points lower at rural practices than urban practices and 27 (95% CI, -32 to -22) percentage points lower at practices with 1 to 5 physicians than practices with 6 or more physicians. Adoption rates were similar at independent practices and nonacademic systems; however, both practice types had lower adoption than academic systems (independent practice difference, -6 [95% CI, -9 to -3] percentage points; nonacademic systems difference, -9 [95% CI, -11 to -6] percentage points).
In this cohort study of Medicare claims, practice characteristics, especially practice size and rural location, were associated with adoption of immunotherapy. These findings suggest that there may be geographic disparities in access to important innovations for treating patients with cancer.
免疫疗法是癌症治疗的一个重要突破，极大地改善了多种癌症类型患者的预后，但人们对哪些实践采用了这种新疗法以及采用的速度知之甚少。
评估美国肿瘤学实践中免疫疗法的应用情况，并研究不同实践类型的应用差异。
设计、设置和参与者：本队列研究使用了 2010 年至 2017 年期间接受 6 个月化疗的医疗保险费用服务受益人的数据。数据于 2021 年 1 月 19 日进行分析，至 2022 年 9 月 28 日，用于分析研究期间美国食品和药物管理局（FDA）批准的免疫疗法治疗的癌症类型：黑色素瘤、肾癌、肺癌和头颈部癌。
肿瘤学实践地点（农村与城市）、附属类型（学术系统、非学术系统、独立）和规模（1 至 5 名医生与 6 名或更多医生）。
主要结果是实践是否采用免疫疗法。使用调整了患者特征（年龄、性别、种族和民族、癌症类型、Charlson 合并症指数和中位数家庭收入）的多变量线性模型来估计每种实践类型的采用率。
数据包括 1732 个肿瘤学实践中的 71659 个病例。其中，264 个实践（15%）位于农村，900 个（52%）为独立实践，492 个（28%）有 1 至 5 名医生。大多数实践在 FDA 批准后 2 年内采用了免疫疗法，但不同实践类型的采用率存在很大差异。在 FDA 批准后，农村实践的免疫疗法采用率比城市实践低 11 个百分点（95%CI，-16 至-6），1 至 5 名医生的实践比 6 名或更多医生的实践低 27 个百分点（95%CI，-32 至-22）。独立实践和非学术系统的采用率相似；然而，这两种实践类型的采用率均低于学术系统（独立实践差异，-6[95%CI，-9 至-3]个百分点；非学术系统差异，-9[95%CI，-11 至-6]个百分点）。
在这项针对医疗保险索赔的队列研究中，实践特征，尤其是实践规模和农村位置，与免疫疗法的采用有关。这些发现表明，在为癌症患者提供重要创新治疗方面，可能存在地理差异。
