Columbia University, New York, New York.
SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, Washington.
JAMA Netw Open. 2024 Mar 4;7(3):e244008. doi: 10.1001/jamanetworkopen.2024.4008.
Reducing acute care use is an important strategy for improving value. Patients with cancer are at risk for unplanned emergency department (ED) visits and hospital stays (HS). Clinical trial patients have homogeneous treatment; despite this, structural barriers to care may independently impact acute care use.
To examine whether ED visits and HS within 12 months of trial enrollment are more common among Medicare enrollees who live in areas of socioeconomic deprivation or have Medicaid insurance.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study included patients with cancer who were 65 years or older and treated in SWOG Cancer Research Network trials from 1999 to 2018 using data linked to Medicare claims. Data were collected from 1999 to 2019 and analyzed from 2022 to 2024.
Outcomes were ED visits, HS, and costs in the first year following enrollment. Neighborhood socioeconomic deprivation was measured using patients' zip code linked to the Area Deprivation Index (ADI), measured on a 0 to 100 scale for increasing deprivation and categorized into tertiles (T1 to T3). Type of insurance was classified as Medicare with or without commercial insurance vs dual Medicare and Medicaid. Demographic, clinical, and prognostic factors were captured from trial records. Multivariable regression was used, and the association of ADI and insurance with each outcome was considered separately.
In total, 3027 trial participants were analyzed. The median (range) age was 71 (65-98) years, 1280 (32.3%) were female, 221 (7.3%) were Black patients, 2717 (89.8%) were White patients, 90 (3.0%) had Medicare and Medicaid insurance, and 660 (22.3%) were in the areas of highest deprivation (ADI-T3). In all, 1094 patients (36.1%) had an ED visit and 983 patients (32.4%) had an HS. In multivariable generalized estimating equation, patients living in areas categorized as ADI-T3 were more likely to have an ED visit (OR, 1.34; 95% CI, 1.10-1.62; P = .004). A similar but nonsignificant pattern was observed for HS (OR, 1.36; 95% CI, 0.96-1.93; P = .08). Patients from areas with the highest deprivation had a 62% increase in risk of either an ED visit or HS (OR, 1.62; 95% CI, 1.25-2.09; P < .001). Patients with Medicare and Medicaid were 96% more likely to have an ED visit (OR, 1.96; 95% CI, 1.56-2.46; P < .001).
In this cohort of older patients enrolled in clinical trials, neighborhood deprivation and economic disadvantage were associated with an increase in ED visits and HS. Efforts are needed to ensure adequate resources to prevent unplanned use of acute care in socioeconomically vulnerable populations.
降低急性护理的使用是提高价值的一个重要策略。癌症患者有计划外急诊（ED）就诊和住院（HS）的风险。临床试验患者接受同质的治疗；尽管如此，护理的结构性障碍可能会独立影响急性护理的使用。
检查医疗保险患者在试验登记后 12 个月内 ED 就诊和 HS 是否更常见，这些患者居住在社会经济贫困地区或拥有医疗补助保险。
设计、设置和参与者：本队列研究纳入了 1999 年至 2018 年期间在 SWOG 癌症研究网络试验中接受治疗的 65 岁及以上的癌症患者，使用与医疗保险索赔相关的数据进行分析。数据收集于 1999 年至 2019 年，并于 2022 年至 2024 年进行分析。
结果是登记后第一年的 ED 就诊、HS 和费用。使用患者与区域剥夺指数（ADI）相关联的邮政编码衡量邻里社会经济剥夺程度，ADI 以 0 到 100 的分数衡量，分数越高表示剥夺程度越高，并分为三分位数（T1 到 T3）。保险类型分为有或没有商业保险的医疗保险与双重医疗保险和医疗补助。从试验记录中捕获了人口统计学、临床和预后因素。使用多变量回归，分别考虑 ADI 和保险与每个结果的关联。
总共分析了 3027 名试验参与者。中位（范围）年龄为 71（65-98）岁，1280 名（32.3%）为女性，221 名（7.3%）为黑人患者，2717 名（89.8%）为白人患者，90 名（3.0%）拥有医疗保险和医疗补助保险，660 名（22.3%）处于剥夺程度最高的地区（ADI-T3）。共有 1094 名患者（36.1%）有 ED 就诊，983 名患者（32.4%）有 HS。在多变量广义估计方程中，居住在被归类为 ADI-T3 的地区的患者更有可能进行 ED 就诊（OR，1.34；95%CI，1.10-1.62；P=0.004）。对于 HS 也观察到类似但不显著的模式（OR，1.36；95%CI，0.96-1.93；P=0.08）。来自贫困程度最高地区的患者有 62%的风险增加 ED 就诊或 HS（OR，1.62；95%CI，1.25-2.09；P<0.001）。拥有医疗保险和医疗补助的患者进行 ED 就诊的可能性增加 96%（OR，1.96；95%CI，1.56-2.46；P<0.001）。
在这项纳入临床试验的老年患者队列研究中，邻里贫困和经济劣势与 ED 就诊和 HS 增加有关。需要努力确保为社会经济弱势群体提供足够的资源，以预防急性护理的无计划使用。
