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癌症筛查可有效提高早期癌症检出率并延长生存。不过，虽然平价医疗法案取消了癌症筛查的大部分费用分摊，但是仅不到70%的美国成年人接受推荐筛查了两种最常见癌症：乳腺癌和结直肠癌。工作压力、时间限制和工资损失等障碍通常被认为是癌症筛查等预防医疗服务利用率不足的主要因素，这促使研究人员假设提供覆盖癌症筛查的带薪病假可以提高对癌症筛查指南的依从性。 美国是没有联邦授权保证工人获得带薪病假的两个发达国家之一。2004年健康家庭法案是联邦带薪病假立法的首次尝试，虽然此后多次提出，但是该法案仍未成为法律。因此，全国近30%的劳动力缺少带薪病假，低收入工人、女性以及服务不足的种族和民族带薪病假覆盖率较低。在没有联邦政策的情况下，华盛顿特区等17个州、4个县和18个城市已经强制要求向符合条件的工人提供带薪病假。因此，截至2022年底，将近2000万工人可享受带薪病假。可是，有18个州先发制人通过法律禁止市政当局强制执行带薪病假，该事实凸显当前带薪病假政策的争议。 虽然缺少带薪病假可能阻碍获得预防医疗服务，但是现有证据不足以得出其与癌症筛查关联有意义的结论。为数不多分析该关联的研究通常报告了积极的关联。然而，这些研究通常将有带薪病假工人与无带薪病假工人进行比较，因此可能由于选择偏倚而混淆。例如，特别注重健康的员工更有可能依从筛查指南，也更可能从事提供带薪病假的工作。在这种情况下，带薪病假与癌症筛查之间的关联将被夸大，因为其既包括带薪病假对筛查率的因果影响，也包括有健康意识者接受筛查的意愿更强烈。 2023年3月2日，全球四大医学期刊之首、美国麻省医学会《新英格兰医学杂志》在线发表杜兰大学公共卫生与热带医学院、墨菲政治经济学研究所、乔治亚州立大学安德鲁·杨政策研究学院、旧金山加利福尼亚大学医学院的研究报告，在政策合理改变带薪病假覆盖范围，强制雇主授权允许雇员带薪缺勤接受预防医疗服务以后，通过准实验研究设计克服了选择偏倚问题。该研究由国家癌症研究所提供资助。 该研究利用2012年至2019年大约200万私营企业雇员行政医疗保险索赔数据，对居住于受到与未受带薪病假政策影响影响的大都市统计区工人12个月和24个月结直肠癌筛查率和乳腺钼靶筛查率变化进行比较，分析带薪病假政策与乳腺癌和结直肠癌筛查的关联。 结果，该研究期间美国有61个大都市统计区（16%）受到带薪病假政策影响。在政策通过之前，大都市统计区的筛查率相似。 对其他影响因素进行校正后，居住于受到与未受带薪病假政策影响影响的大都市统计区工人相比： 12个月结直肠癌筛查率高1.31个百分点（95%置信区间：0.28～2.34） 24个月结直肠癌筛查率高1.56个百分点（95%置信区间：0.33～2.79） 12个月乳腺钼靶筛查率高1.22个百分点（95%置信区间：-0.20～2.64） 24个月乳腺钼靶筛查率高2.07个百分点（95%置信区间：0.15～3.99）
因此，该研究结果表明，对于美国私营企业工人，居住于实施与未实施带薪病假政策的大都市统计区工人相比，癌症筛查率显著较高。缺少带薪病假是癌症筛查的障碍之一。 N Engl J Med. 2023 Mar 2;388(9):824-832. IF: 176.079Cancer Screening after the Adoption of Paid-Sick-Leave Mandates.Callison K, Pesko MF, Phillips S, Sosa JA.School of Public Health and Tropical Medicine, Murphy Institute of Political Economy, Tulane University, New Orleans; Andrew Young School of Policy Studies, Georgia State University, Atlanta; School of Medicine, University of California at San Francisco, San Francisco.BACKGROUND: By the end of 2022, nearly 20 million workers in the United States have gained paid-sick-leave coverage from mandates that require employers to provide benefits to qualified workers, including paid time off for the use of preventive services. Although the lack of paid-sick-leave coverage may hinder access to preventive care, current evidence is insufficient to draw meaningful conclusions about its relationship to cancer screening.METHODS: We examined the association between paid-sick-leave mandates and screening for breast and colorectal cancers by comparing changes in 12- and 24-month rates of colorectal-cancer screening and mammography between workers residing in metropolitan statistical areas (MSAs) that have been affected by paid-sick-leave mandates (exposed MSAs) and workers residing in unexposed MSAs. The comparisons were conducted with the use of administrative medical-claims data for approximately 2 million private-sector employees from 2012 through 2019.RESULTS: Paid-sick-leave mandates were present in 61 MSAs in our sample. Screening rates were similar in the exposed and unexposed MSAs before mandate adoption. In the adjusted analysis, cancer-screening rates were higher among workers residing in exposed MSAs than among those in unexposed MSAs by 1.31 percentage points (95% confidence interval [CI], 0.28 to 2.34) for 12-month colorectal cancer screening, 1.56 percentage points (95% CI, 0.33 to 2.79) for 24-month colorectal cancer screening, 1.22 percentage points (95% CI, -0.20 to 2.64) for 12-month mammography, and 2.07 percentage points (95% CI, 0.15 to 3.99) for 24-month mammography.CONCLUSIONS: In a sample of private-sector workers in the United States, cancer-screening rates were higher among those residing in MSAs exposed to paid-sick-leave mandates than among those residing in unexposed MSAs. Our results suggest that a lack of paid-sick-leave coverage presents a barrier to cancer screening.GRANT SUPPORT: R01CA237888/National Cancer InstituteDOI: 10.1056/NEJMsa2209197
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