种族/民族、持续性贫困与终末期胃肠道癌患者阿片类药物可及性的关联。
Association of Race/Ethnicity, Persistent Poverty, and Opioid Access Among Patients with Gastrointestinal Cancer Near the End of Life.
机构信息
Division of Surgical Oncology, Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
Division of Palliative Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
出版信息
Ann Surg Oncol. 2023 Dec;30(13):8548-8558. doi: 10.1245/s10434-023-14218-4. Epub 2023 Sep 4.
BACKGROUND
Social determinants of health (SDoH) can impact access to healthcare. We sought to assess the association between persistent poverty (PP), race/ethnicity, and opioid access among patients with gastrointestinal cancer near the end-of-life (EOL).
METHODS
SEER-Medicare patients with gastric, liver, pancreatic, biliary, colon, and rectal cancer were identified between 2008 and 2016 near EOL, defined as 30 days before death or hospice enrolment. Data were linked with county-level poverty from the American Community Survey and the US Department of Agriculture (2000-2015). Counties were categorized as never high-poverty (NHP), intermittent high-poverty (IHP) and persistent poverty (PP). Trends in opioid prescription fills and daily dosages (morphine milligram equivalents per day) were examined.
RESULTS
Among 48,631 Medicare beneficiaries (liver: n = 6551, 13.5%; pancreas: n = 13,559, 27.9%; gastric: n = 5486, 1.3%; colorectal: n = 23,035, 47.4%), there was a steady decrease in opioid prescriptions near EOL. Black, Asian, Hispanic, and other racial groups had markedly decreased odds of filling an opioid prescription near EOL (Black: OR 0.84, 95% CI 0.79-0.90; Asian: OR 0.86, 95% CI 0.79-0.94; Hispanic: OR 0.90, 95% CI 0.84-0.95; Other: OR 0.83, 95% CI 0.74-0.93; all p < 0.05). Even after filling an opioid prescription, this subset of patients received lower daily doses versus White patients (Black: -16.5 percentage points, 95% CI -21.2 to -11.6; Asian: -11.9 percentage points, 95% CI -18.5 to -4.9; Hispanic: -19.1 percentage points, 95%CI -23.5 to -14.6; all p < 0.05). The disparity in opioid access and average daily doses among was attenuated in IHP/PP areas for Asian, Hispanic, and other racial groups, yet exacerbated among Black patients.
CONCLUSIONS
Race/ethnicity-based disparities in EOL pain management persist with SDoH-based variations in EOL opioid use. In particular, PP impacted EOL opioid access and utilization.
背景
健康的社会决定因素（SDoH）会影响医疗保健的获取。我们旨在评估在接近生命末期（EOL）的胃肠道癌症患者中，持续性贫困（PP）、种族/民族与阿片类药物获取之间的关联。
方法
我们确定了 2008 年至 2016 年间 SEER-Medicare 接近 EOL 的胃癌、肝癌、胰腺癌、胆管癌、结肠癌和直肠癌患者，定义为死亡前 30 天或开始接受临终关怀。数据与县一级的贫困状况进行了关联，数据来自美国社区调查和美国农业部（2000-2015 年）。将县分为从未处于高贫困状态（NHP）、间歇性高贫困（IHP）和持续性贫困（PP）。检查了阿片类药物处方和每日剂量（每天吗啡毫克当量）的趋势。
结果
在 48631 名 Medicare 受益人中（肝脏：n = 6551，13.5%；胰腺：n = 13559，27.9%；胃：n = 5486，1.3%；结直肠：n = 23035，47.4%），接近 EOL 时阿片类药物的处方数量稳步下降。黑人、亚洲人、西班牙裔和其他种族群体在接近 EOL 时开阿片类药物处方的几率明显降低（黑人：OR 0.84，95%CI 0.79-0.90；亚洲人：OR 0.86，95%CI 0.79-0.94；西班牙裔：OR 0.90，95%CI 0.84-0.95；其他人：OR 0.83，95%CI 0.74-0.93；均 P < 0.05）。即使开了阿片类药物处方，这部分患者的每日剂量也低于白人患者（黑人：-16.5 个百分点，95%CI -21.2 至 -11.6；亚洲人：-11.9 个百分点，95%CI -18.5 至 -4.9；西班牙裔：-19.1 个百分点，95%CI -23.5 至 -14.6；均 P < 0.05）。然而，在 IHP/PP 地区，亚洲人、西班牙裔和其他种族群体的阿片类药物获取和平均每日剂量之间的差异有所缓解，而黑人患者的差异则加剧了。
结论
与社会决定因素导致的 EOL 阿片类药物使用变化相关的 EOL 疼痛管理中的种族/民族差异仍然存在。特别是，PP 影响了 EOL 阿片类药物的获取和使用。
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