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罹患乳腺癌的贫困女性与富裕女性相比，生存结局较差，并且大多在小型医疗机构进行手术。2009年，纽约州采取一项政策干预，将每年乳腺癌手术少于30次的医疗机构列入纽约州联邦医疗补助受益者乳腺癌手术费用拒付名单，以鼓励乳腺癌患者前往乳腺癌手术较多的医疗机构进行治疗。2010年，40个县64家医疗机构被列入黑名单；到2019年，35个县84家医疗机构“上榜”。 2023年1月5日，美国临床肿瘤学会《临床肿瘤学杂志》在线发表威斯康星医学院、西奈山伊坎医学院、纽约州卫生署的研究报告，对贫困乳腺癌患者治疗集中化政策干预的效果进行了分析。 该研究首先根据纽约州癌症登记中心数据确定2004～2008年或2010～2013年纽约州罹患I～III期乳腺癌女性共计3万7822例，并将其与纽约州出院数据进行关联。随后，通过多因素双重差分法将纽约州联邦医疗补助保险患者死亡率与未受政策影响的商业保险或未保险患者死亡率进行比较。 结果发现，政策干预几年后接受治疗与政策干预前接受治疗的女性相比，5年总死亡率略低。联邦医疗补助患者生存率显著提高（P=0.018）。 参加联邦医疗补助计划的女性与其他女性相比，乳腺癌所致死亡率显著较低（P=0.005），而其他原因所致死亡率降低不显著（P=0.503）。 政策实施后，享受联邦医疗补助的女性校正后乳腺癌死亡率由6.6%降至4.5%，而其他女性的乳腺癌死亡率由3.9%仅降至3.8%。 同年接受治疗的新泽西州联邦医疗补助乳腺癌患者（不受该政策约束）未见类似效果。 因此，该研究结果表明，全州集中化政策不鼓励每年乳腺癌手术少于30次的医疗机构对乳腺癌进行初始治疗，与联邦医疗补助目标人群的生存结局较好有显著相关性。由于这些令人印象深刻的结果和既往研究结果，其他决策者应该考虑采用类似政策改善乳腺癌患者结局。J Clin Oncol. 2023 Jan 5. IF: 50.717Centralization of Initial Care and Improved Survival of Poor Patients With Breast Cancer.Nattinger AB, Bickell NA, Schymura MJ, Laud P, McGinley EL, Fergestrom N, Pezzin LE.Medical College of Wisconsin, Milwaukee, WI; Icahn School of Medicine at Mount Sinai, New York, NY; New York State Department of Health, Albany, NY.PURPOSE: Poor women with breast cancer have worse survival than others, and are more likely to undergo surgery in low-volume facilities. We leveraged a natural experiment to study the effectiveness of a policy intervention undertaken by New York (NY) state in 2009 that precluded payment for breast cancer surgery for NY Medicaid beneficiaries treated in facilities performing fewer than 30 breast cancer surgeries annually.METHODS: We identified 37,822 women with stage I-III breast cancer during 2004-2008 or 2010-2013 and linked them to NY hospital discharge data. A multivariable difference-in-differences approach compared mortality of Medicaid insured patients with that of commercially or otherwise insured patients unaffected by the policy.RESULTS: Women treated during the postpolicy years had slightly lower 5-year overall mortality than those treated prepolicy; the survival gain was significantly larger for Medicaid patients (P = .018). Women enrolled in Medicaid had a greater reduction than others in breast cancer-specific mortality (P = .005), but no greater reduction in other causes of death (P = .50). Adjusted breast cancer mortality among women covered by Medicaid declined from 6.6% to 4.5% postpolicy, while breast cancer mortality among other women fell from 3.9% to 3.8%. A similar effect was not observed among New Jersey Medicaid patients with breast cancer treated during the same years.CONCLUSION: A statewide centralization policy discouraging initial care for breast cancer in low-volume facilities was associated with better survival for the Medicaid population targeted. Given these impressive results and those from prior research, other policymakers should consider adopting comparable policies to improve breast cancer outcomes.KEY OBJECTIVE: Was a New York (NY) state policy that discouraged initial surgery for NY Medicaid patients with breast cancer in low-volume facilities effective in improving survival of the Medicaid population targeted?KNOWLEDGE GENERATED: In a difference-in-differences analysis of NY State Cancer Registry data linked to hospital information, Medicaid patients with breast cancer operated upon after policy implementation had significantly better gains in 5-year overall survival and breast cancer-specific survival than did women with other or no insurance. A similar effect was not seen in New Jersey Medicaid patients (who were not subject to the policy).RELEVANCE: In 2009, NY state implemented a law that denied payments to low-volume facilities for breast cancer surgery among Medicaid beneficiaries (fewer than 30 breast cancer surgeries annually). Following implementation, Medicaid enrollees with breast cancer had greater improvements in survival than similar women who had other forms of insurance. The analysis supports efforts to consolidate breast cancer surgery to higher volume centers.DOI: 10.1200/JCO.22.02012
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