Scodari Bruno T, Schaefer Andrew P, Kapadia Nirav S, O'Malley A James, Moen Erika L
Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA.
Cancer Med. 2024 Dec;13(23):e70489. doi: 10.1002/cam4.70489.
Oncology outreach is a common strategy for addressing cancer workforce shortages, where traveling oncologists commute across clinical settings to extend their services. Despite its known benefits specifically for rural patients, oncology outreach reallocates physician resources to satellite clinics and may negatively impact the coordination of cancer care.
In this retrospective study, we identified patients with incident breast, colorectal, and lung cancers from 2016-2019 nationwide Medicare claims and linked them to oncologists using Part B. We considered encounters occurring outside the physician's primary hospital service area as "outreach visits" and calculated the proportion of outreach visits by oncology specialty for contiguous US hospital referral regions (HRRs) using 2016-2017 claims. We constructed a nationwide physician patient-sharing network from 2018-2019 claims and computed median care density-a measure of physician team familiarity-and local transitivity-a measure of physician cohesion/clustering-for each HRR as proxies for care coordination. Generalized linear models were used to explore the associations between oncology outreach and care coordination measures at the HRR level.
We found that HRRs with high medical oncology outreach were associated with 16% decreases in care density (95% CI: 5-25) and 4% decreases in local transitivity (95% CI: 1-8) compared to HRRs with low medical oncology outreach. HRRs with high radiation and surgical oncology outreach were not associated with network-based measures of care coordination.
While medical oncology outreach increases access for underserved patient populations, it potentially fragments care delivery across clinical settings. Health systems may consider this trade-off to inform decisions concerning the implementation of outreach programs or policies aimed at hedging against fragmentation in markets with active outreach arrangements.
肿瘤外展服务是解决癌症医疗人力短缺问题的常见策略，即肿瘤医生穿梭于不同临床机构提供服务。尽管肿瘤外展服务对农村患者有显著益处，但它将医生资源重新分配到卫星诊所，可能对癌症护理的协调产生负面影响。
在这项回顾性研究中，我们从2016年至2019年全国医疗保险索赔中识别出乳腺癌、结直肠癌和肺癌患者，并通过B部分将他们与肿瘤医生关联起来。我们将发生在医生主要医院服务区之外的诊疗视为“外展诊疗”，并利用2016 - 2017年的索赔数据计算美国相邻医院转诊区域（HRR）按肿瘤专科划分的外展诊疗比例。我们根据2018 - 2019年的索赔数据构建了全国医生患者共享网络，并计算每个HRR的护理密度中位数（衡量医生团队熟悉程度的指标）和局部传递性（衡量医生凝聚力/聚类程度的指标），作为护理协调的代理指标。使用广义线性模型来探索HRR层面肿瘤外展服务与护理协调措施之间的关联。
我们发现，与低肿瘤内科外展服务的HRR相比，高肿瘤内科外展服务的HRR护理密度降低了16%（95%置信区间：5 - 25），局部传递性降低了4%（95%置信区间：1 - 8）。高放射肿瘤学和外科肿瘤学外展服务的HRR与基于网络的护理协调措施无关。
虽然肿瘤内科外展服务增加了服务不足患者群体的就医机会，但它可能会使临床机构之间的护理提供碎片化。卫生系统在考虑实施外展项目或政策以避免在活跃的外展安排市场中出现碎片化时，可能需要权衡这一点。
