PO.PS01.10 · 人群科学
在全民可及的医疗系统中结直肠癌诊断后盆底治疗的利用情况
Utilization of pelvic floor therapy after a colorectal cancer diagnosis in a universal-access health system
作者与单位 Authors & Affiliations
摘要 Abstract
中文摘要
背景：约70-90%的结直肠癌患者在治疗后经历肠道功能下降。盆底治疗（PFT）可以改善肠道功能和生活质量，然而PFT的可及性仍然有限，且与其使用相关的因素研究不足。在美国军事医疗系统（一个全民医疗系统）内开展本研究，能够在最大限度减少可负担性和可及性对结果影响的同时，更清晰地评估与接受PFT相关的人口学、临床和系统层面因素。
方法：我们在MilCanEpi数据库中，对2001-2014年间诊断为I-III期结直肠癌且在诊断6个月内接受手术的成人（≥18岁）开展了一项巢式病例对照研究。PFT接受者（病例）和非接受者（对照）按诊断月/年以1:1比例匹配。排除了非TRICARE保险的患者（Medicare除外，因为它作为所有≥65岁患者TRICARE for Life覆盖的一部分）。采用逐步多变量logistic回归计算校正比值比（aOR）及95%置信区间（CI），并识别与PFT使用相关的因素。为评估性别可能的效应修饰，将整体校正模型的结果与仅男性分析进行了比较。
结果：PFT接受者（n=679）相较于非接受者（n=679）年龄更大（中位数[最小-最大]：60 [21-94] vs 55 [23-88]），更可能为男性（64% vs 58%）、未婚（24% vs 19%）、有≥1种合并症（43% vs 32%），以及在军事医疗机构（MTF）接受护理（37% vs 29%）。在完全校正的模型中，PFT的使用在年龄较大的患者（aOR=1.03，95% CI: 1.01, 1.04）、男性（aOR=1.34，95% CI: 1.02, 1.77）、≥3种合并症者（aOR=2.13，95% CI: 1.34, 3.38）、现役身份者（aOR=1.67，95% CI: 1.09, 2.55），以及相较于私营部门在MTF接受护理者（aOR=1.91，95% CI: 1.39, 2.61）中更可能发生。在男性中，年龄较大（aOR=1.04，95% CI: 1.02, 1.06）、全（相较于部分）结肠切除术和/或直肠切除术（aOR=4.97，95% CI: 1.52, 16.27）以及相较于私营部门在MTF接受护理（aOR=3.08，95% CI: 1.60, 5.91）与更高的PFT使用相关。
结论：在军事医疗系统（MHS）内，完全校正的分析显示，结直肠癌手术后PFT的利用在年龄较大的患者、男性、有≥3种合并症者、现役军人，以及相较于私营部门在MTF接受护理的患者中更高，凸显了人口学、临床和医疗系统因素对PFT使用的影响。在男性中，全（相较于部分）手术是唯一额外与更高PFT使用相关的因素。这些发现提示，可能需要有针对性的策略来提高MHS中使用可能性较低的患者群体（如青年患者和女性）的PFT利用。
查看英文原文 English abstract
Background: About 70-90% of patients with colorectal cancer experience declined bowel function after treatment. Pelvic floor therapy (PFT) can improve bowel function and quality of life, yet access to PFT remains limited and factors associated with its use are understudied. Conducting this research within the U.S. Military Health System, a universal healthcare system, allows a clearer assessment of demographic, clinical, and system-level factors associated with receiving PFT while minimizing the effects of affordability and access on the results.
Methods: We conducted a nested case-control study of adults (≥18 years) with stage I-III colorectal cancer who had surgery within 6 months of diagnosis (2001-2014) in the MilCanEpi database. PFT recipients (cases) and non-recipients (controls) were matched by diagnosis month/year with a 1:1 ratio. Patients with non-TRICARE insurance (except Medicare which is part of coverage for all patients aged ≥65 years with TRICRE for Life) were excluded. Stepwise multivariable logistic regression was used to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) and identify factors associated with PFT use. To assess potential effect modification by sex, results from the overall adjusted model were compared with a men-only analysis.
Results: PFT recipients (n=679) were older (median [min-max]: 60 [21-94] vs 55 [23-88]) and more likely to be male (64% vs 58%), unmarried (24% vs 19%), have ≥1 comorbidity (43% vs 32%), and receive care at a military treatment facility (MTF; 37% vs 29%) than non-recipients (n=679). In the fully adjusted model, the use of PFT was more likely among patients with increased age (aOR=1.03, 95% CI: 1.01, 1.04), males (aOR=1.34, 95% CI: 1.02, 1.77), ≥3 comorbidities (aOR=2.13, 95% CI: 1.34, 3.38), active-duty status (aOR=1.67, 95% CI: 1.09, 2.55), and among those receiving care at a MTF compared to the private-sector (aOR=1.91, 95% CI: 1.39, 2.61). Among men, older age (aOR=1.04, 95% CI: 1.02, 1.06), total (vs partial) colectomy and/or proctectomy (aOR=4.97, 95% CI: 1.52, 16.27) and receiving care at a MTF compared to the private-sector (aOR=3.08, 95% CI: 1.60, 5.91) were associated with higher PFT use.
Conclusion: Within the MHS, fully adjusted analyses showed that PFT utilization after colorectal cancer surgery was higher among older patients, males, those with ≥3 comorbidities, active-duty service members, and patients receiving care at a MTF compared to the private-sector, highlighting the influence of demographic, clinical, and healthcare system factors on PFT use. In men, total (vs partial) surgery was the only factor additionally associated with higher PFT use. These findings suggest that targeted strategies may be needed to increase PFT utilization among groups of patients with a lower likelihood of use in the MHS, such as among younger patients and females.
利益披露 Disclosure
K. R. Robins, None.