编者按：随着民主党人奥巴马的离任、共和党人特朗普的上任，一直存在争议的奥巴马医改法案，已在共和党人占优势的众议院被投票废除。这时，德克萨斯（保守的共和党人大票仓）却在《美国医学会杂志肿瘤学分册》亮出了有利于奥巴马医改法案的乳腺癌医疗质量证据，为参议院的投票增加了悬念。
乳腺癌医疗质量与医疗保险交易所覆盖的相关性
保乳手术后放疗使用分析
2017年6月1日，《美国医学会杂志肿瘤学分册》在线发表德克萨斯大学MD安德森癌症中心（MDACC）的研究报告，通过分析乳腺癌患者在医疗保险市场投保与否的放疗模式，评定了乳腺癌的医疗质量。
既往按医疗保险类型对癌症医疗质量进行比较的研究得出结论：癌症患者无保险或仅有低水平公费医疗补助，与私营（商业）医疗保险相比，所获医疗质量较差【1,2】。奥巴马政府《平价医疗法案》创建了一种新的保险类型，可从医疗保险市场（又称为交易所）购买保险。本研究通过检查保乳手术后的放疗模式（乳腺癌的重要医疗指标【3】）对《平价医疗法案》的癌症医疗质量进行了实证调查。
医疗保险交易所：2009年奥巴马政府推出新医改方案的措施之一，可使医疗保险公司提供更吸引人的价格和服务，同时开发新的医疗保险市场。医疗保险交易所可在现有体系内，展示如何才能实现更高质低价的医疗服务。医疗保险交易所有利有弊，将使美国人失去五大自由（选择医疗保险项目的自由、身体健康而少交保费的自由、选择省钱医疗保险方案的自由、继续投保原有医疗保险的自由、选择医院医生的自由），故毁誉参半。
本研究采用了2014年医疗费用研究所（HCCI）去除个人信息后的数据，该商业索赔数据库覆盖每年5000万被保险个人。UT-MDACC伦理审查委员会批准本研究采用去除个人信息后的数据。2016年11月，HCCI发布了2014年数据的新变量，能够识别通过交易所购买保险的个人，创造了前所未有的机会，以了解该组人群接受的医疗质量。本研究队列为通过交易所或其他私营保险获得保险且在保乳手术后6个月内未行乳房切除手术的乳腺癌保乳手术患者，并根据年龄组和居住州按1∶2匹配建立病例对照队列。为了确定患者在保乳手术后6个月内是否获得放疗，保乳手术后需要至少连续入组6个月以确保信息完整。分别采用χ²和对数秩检验，比较交易组和非交易组之间的放疗使用率和放疗启动时间分布。分布采用逻辑回归和Cox比例风险回归模型，分析匹配数据结构，以确定放疗使用和放疗启动时间的相关因素。采用1∶3匹配队列进行敏感性分析。
结果，研究队列入组乳腺癌患者279例，其中交易组93例。大约60%的患者年龄≥55岁，72.4%为基本保险人。交易与非交易组的未校正放疗率相似（64.5%比66.1%，P=0.79）。逻辑回归分析显示，通过交易获得保险与否的放疗率相似（比值比：0.89，95%置信区间：0.49～1.63）。交易组与非交易组相比，放疗启动时间分布的单变量分析（中位63比74天，P=0.98）和多变量分析（风险比：1.17，95%置信区间：0.78～1.75）未见统计学显著差异。放疗启动时间的唯一显著预测因素为化疗（风险比：0.30，95%置信区间：0.15～0.54）。敏感性分析结果相似。
本分析显示，交易组与非交易组的乳腺癌患者医疗质量（放疗率和放疗启动时间）相似。这两组保乳手术后患者之间应该有可比性，因为按交易与否对手术类型进行的比较显示保乳手术率相似。该发现意味着《平价医疗法案》已经发挥预期效果，对于未通过交易所购买保险的未被保险或者保险不足的乳腺癌患者，并未降低医疗质量。这里报道的较低放疗率，可能反映了用于确定放疗的较短时间窗和相对较年轻的研究队列，因为有研究显示年轻女性的放疗率较低【4】。重要的数据局限性为缺乏关于种族或民族的信息，已知与放疗使用有关【5】。将来取代《平价医疗法案》的政策应该确保任何转型计划不会有损医疗的获得、延续和质量，并能进一步扩大仍无保险或保额不足患者的医疗覆盖。
JAMA Oncol. 2017 Jun 1. [Epub ahead of print]
Association Between Quality of Care for Breast Cancer and Health Insurance Exchange Coverage: An Analysis of Use of Radiation Therapy After Breast-Conserving Surgery.
Ya-Chen Tina Shih; Ying Xu; Mariana Chavez-MacGregor; B. Ashleigh Guadagnolo; Benjamin D. Smith; Sharon H. Giordano.
University of Texas MD Anderson Cancer Center, Houston, Texas.
This analysis of patients with breast cancer insured through the health insurance marketplace assesses their quality of care by examining patterns of radiation therapy.
Research comparing quality of cancer care by insurance categories concluded that cancer patients without insurance or with Medicaid experienced inferior quality of care compared with those with private insurance.[1,2] A new insurance category created from the Affordable Care Act (ACA) is insurance purchased from the Health Insurance Marketplace (also known as the exchange). The present study provides empirical investigations of the quality of cancer care under the ACA by examining patterns of radiation therapy (RT) following breast-conserving surgery (BCS), an important quality of care indicator for breast cancer.[3]
METHODS
We used 2014 Health Care Cost Institute (HCCI) (www.healthcostinstitute.org) deidentified data, a commercial claims database covering 50 million insured individuals per year. The study was exempt for approval by the institutional review board at The University of Texas MD Anderson Cancer Center for the use of deidentified data. In November 2016, the HCCI released a new variable for 2014 data that allowed identification of individuals insured through an exchange, creating an unprecedented opportunity to understand quality of care received by this group. We identified our study cohort as breast cancer patients who received BCS after obtaining insurance through an exchange or other private insurance and had no mastectomy within 6 months of BCS, and constructed 1-to-2 case-control cohort (matched by age group and state of residence). To determine whether a patient received RT within 6 months of BCS, a minimum of 6 months of continuous enrollment since BCS was required to ensure complete information. We compared rate of RT and distribution of time to RT initiation (TTI) between the exchange and nonexchange groups using χ2 and log-rank test, respectively. We employed logistic regression and Cox proportional hazards regression model that accounted for paired data structure to determine factors (covariates see Table) associated with RT use and TTI, respectively. We performed sensitivity analyses on a 1-to-3 matched cohort.
RESULTS
The study cohort included 279 breast cancer patients (93 in the exchange group). Approximately 60% of patients were≥age 55 and the primary insurance holder (72.4%). The unadjusted rate of RT was similar between the exchange and nonexchange groups (64.5% vs 66.1%, P=.79) (Table). Logistic regression showed that the likelihood of receiving RT did not differ by whether the insurance was obtained through the exchange (odds ratio=0.89, 95% CI, 0.49-1.63). No statistically significant difference in distribution of TTI was found between the exchange and nonexchange groups both in the univariate (median TTI 63 vs 74 days, P=.98) and multivariable analysis (hazard ratio [HR]: 1.17, 95% CI, 0.78-1.75) (Figure). The only significant predictor of TTI was chemotherapy (HR 0.30; 95% CI, 0.15-0.54). Sensitivity analysis showed similar patterns.
DISCUSSION
Our analysis showed breast cancer patients in the exchange group had quality of care similar to those in the nonexchange group, as indicated by similar rate of RT and TTI between the two groups. BCS patients should be comparable between these two groups as comparisons of surgery type by exchange status showed similar rate of BCS. Our finding implies that the ACA has exerted its intended effect to improve the quality of care for breast cancer patients who would otherwise be uninsured or underinsured without purchasing insurance acquired through the exchange. The lower rate of RT reported here likely reflected a shorter time window employed to identify RT and a relatively younger study cohort as research has shown a lower RT rate among younger women.[4] An important data limitation is the lack of information on race/ethnicity, which is known to be associated with RT use.[5] Future policies to replace the ACA should ensure that any transitioning plans will not jeopardize the access, continuity, and quality of care and will further expand accessibility to patients who remain uninsured or underinsured.
REFERENCES
Churilla TM, Egleston B, Bleicher R, Dong Y, Meyer J, Anderson P. Disparities in the local management of breast cancer in the US according to health insurance status. Breast J. 2017;23(2):169-176.
Freedman RA, Virgo KS, He Y, et al. The association of race/ethnicity, insurance status, and socioeconomic factors with breast cancer care. Cancer. 2011;117(1):180-189.
Desch CE, McNiff KK, Schneider EC, et al. American Society of Clinical Oncology/National Comprehensive Cancer Network Quality Measures. J Clin Oncol. 2008;26(21):3631-3637.
Freedman RA, Virgo KS, Labadie J, He Y, Partridge AH, Keating NL. Receipt of locoregional therapy among young women with breast cancer. Breast Cancer Res Treat. 2012;135(3):893-906.
Martinez SR, Beal SH, Chen SL, et al. Disparities in the use of radiation therapy in patients with local-regionally advanced breast cancer. Int J Radiat Oncol Biol Phys. 2010;78(3):787-792.
DOI: 10.1001/jamaoncol.2017.1287
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