Insurance status and racial differences in uterine cancer survival: A study of patients in the National Cancer Database
ABSTRACT To examine the impact of race and insurance on survival among a large cohort of uterine cancer patients from the National Cancer Database (NCDB).
Women diagnosed with stages I-III uterine cancer between 2000 and 2001 were selected from the NCDB. Kaplan-Meier (KM) and multivariate Cox proportional hazards were used to estimate 4 year survival rates and hazard ratios (HR) and 95% confidence intervals (CIs), respectively.
Among the 39,510 evaluable patients, African Americans had a higher risk of death compared to whites (HR=1.43 95% CI 1.31-1.56) after adjusting for age, clinical and facility factors and zip code level education. After additional adjustment for treatment, the risk death decreased among African Americans (HR=1.33 95%CI 1.21-1.46) and subsequent adjustment for insurance further reduced the hazard of death (HR=1.28 95% CI 1.17-1.40). Patients with insurance other than private had an increased risk of death (uninsured HR=1.44 95% CI 1.20-1.72, Medicaid HR=1.70, 95% CI 1.46-1.99, Medicare among patients aged 18-64 HR=2.49, 95% CI 2.10-2.95, Medicare among patients aged 65-99 HR=1.22, 95% 1.11-1.34).
The largest contributors to African American/white survival disparities in this study were clinical factors, including stage at diagnosis, grade and histopathology. Patients without private health insurance had worse uterine cancer survival that may be improved through future health care reform aimed at improving access to preventive services and adequate treatment.
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ABSTRACT: Study Design. The Spine End Results Registry (2003-2004) is a registry of prospectively collected data of all patients undergoing spinal surgery at the University of XXX Medical Center and XXX Medical Center. Insurance data was prospectively collected and used in multivariate analysis to determine risk of perioperative complications.Objective. Given the negative financial impact of surgical site infections and the higher overall complication rates of patients with a Medicaid payer status, we hypothesized that a Medicaid payer status would have a significantly higher surgical site infection rate.Summary of Background Data. The medical literature demonstrates lesser outcomes and increased complication rates in patients that have public insurance as compared to private insurance. No one has shown that patients with a Medicaid payer status as compared to Medicare and privately insured patients have a significantly increased surgical site infection rate for spine surgery.Methods. The prospectively collected Spine End Results Registry provided data for analysis. Surgical site infection was defined as treatment requiring operative debridement. Demographic, social, medical, and the surgical severity index risk factors were assesses against the exposure of payer status for the surgical procedure.Results. The population included Medicare (N = 354), Medicaid (N = 334), the Veterans' Administration (N = 39), private insurers (N = 603), and self-pay (N = 42). Those patients whose insurer was Medicaid had a 2.06 odds (95% CI: 1.19, 3.58, p = 0.01) of having a surgical site infection when compared to the privately insured.Conclusion. The study highlights the increased cost of spine surgeries for Medicaid patients with the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA). The PPACA provisions could cause a reduction in re-imbursement to the hospital for taking care of patients with Medicaid insurance due to their higher complication rates and higher costs. This very issue could inadvertently lead to access limitations.Spine 06/2014; 39(20). DOI:10.1097/BRS.0000000000000496 · 2.45 Impact Factor
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ABSTRACT: BACKGROUND: In the general US population, blacks and whites have been shown to undergo colon cancer treatment at disproportionate rates. Accessibility to medical care may be the most important factor influencing differences in colon cancer treatment rates among whites and blacks. OBJECTIVE: We assessed whether racial disparities in colon cancer surgery and chemotherapy existed in an equal-access health care system. In addition, we sought to examine whether racial differences varied according to demographic and tumor characteristics. DESIGN AND SETTING: Database research using the Department of Defense Military Health System. PATIENTS: Patients included 2560 non-Hispanic whites (NHW) and non-Hispanic blacks (NHB) with colon cancer diagnosed from 1998 to 2007. MAIN OUTCOME MEASURES: Logistic regression was used to assess the associations between race and the receipt of colon cancer surgery or chemotherapy while controlling for available potential confounders, both overall and stratified by age at diagnosis, sex, and tumor stage. RESULTS: After multivariate adjustment, the odds of receiving colon cancer surgery or chemotherapy for NHBs versus NHWs were similar (OR, 0.75 [95% CI, 0.37-1.53]; OR, 0.79 [95% CI, 0.59-1.04]). In addition, no effect modifications by age at diagnosis, sex, and tumor stage were observed. LIMITATIONS: Treatment data might not be complete for beneficiaries who also had non-Department of Defense health insurance. CONCLUSIONS: When access to medical care is equal, racial disparities in the provision of colon cancer surgery and chemotherapy were not apparent. Thus, it is possible that the inequalities in access to care play a major role in the racial disparities seen in colon cancer treatment in the general population.Diseases of the Colon & Rectum 09/2014; 57(9):1059-1065. DOI:10.1097/DCR.0000000000000177 · 3.20 Impact Factor
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ABSTRACT: Purpose The purpose of this study was to determine the association of insurance status with disease stage at presentation, treatment, and survival among the top 10 most deadly cancers using the SEER database. Patients and Methods A total of 473,722 patients age 18 to 64 years who were diagnosed with one of the 10 most deadly cancers in the SEER database from 2007 to 2010 were analyzed. A Cox proportional hazards model was used for multivariable analyses to assess the effect of patient and tumor characteristics on cause-specific death. Results Overall, patients with non-Medicaid insurance were less likely to present with distant disease (16.9%) than those with Medicaid coverage (29.1%) or without insurance coverage (34.7%; P < .001). Patients with non-Medicaid insurance were more likely to receive cancer-directed surgery and/or radiation therapy (79.6%) compared with those with Medicaid coverage (67.9%) or without insurance coverage (62.1%; P < .001). In a Cox regression that adjusted for age, race, sex, marital status, residence, percent of county below federal poverty level, site, stage, and receipt of cancer-directed surgery and/or radiation therapy, patients were more likely to die as a result of their disease if they had Medicaid coverage (hazard ratio [HR], 1.44; 95% CI, 1.41 to 1.47; P < .001) or no insurance (HR, 1.47; 95% CI, 1.42 to 1.51; P < .001) compared with non-Medicaid insurance. Conclusion Among patients with the 10 most deadly cancers, those with Medicaid coverage or without insurance were more likely to present with advanced disease, were less likely to receive cancer-directed surgery and/or radiation therapy, and experienced worse survival. (C) 2014 by American Society of Clinical OncologyJournal of Clinical Oncology 08/2014; 32(28). DOI:10.1200/JCO.2014.55.6258 · 17.88 Impact Factor