Influence of insurance status and income in anaplastic astrocytoma: an analysis of 4325 patients

Demographic variations and time to initiation of adjunct treatment following surgical resection of anaplastic astrocytoma in the United States: a National Cancer Database analysis

BACKGROUND AND AIMS

The aim of this study was to analyze the trends, demographic differences in the type and time to initiation (TTI) of adjunct treatment AT following surgery for anaplastic astrocytoma (AA).

MATERIAL AND METHODS

The National Cancer Database (NCDB) was queried for patients diagnosed with AA from 2004 to 2016. Cox proportional hazards and modeling was used to determine factors influencing survival, including the impact of time to initiation (TTI) of adjuvant therapy.

RESULTS

Overall, 5890 patients were identified from the database. The use of combined RT + CT temporally increased from 66.3% (2004-2007) to 79% (2014-2016), p < 0001. Patients more likely to receive no treatment following surgical resection included elderly (> 60 years old), hispanic patients, those with either no or government insurance, those living > 20 miles from the cancer facility, those treated at low volume centers (< 2 cases/year). AT was received following surgical resection within 0-4 weeks, 4.1-8 weeks, and > 8 weeks in 41%, 48%, and 3%, respectively. Compared to patients who received RT + CT, patients were likely to receive RT only as AT either at 4-8 weeks or > 8 weeks after the surgical procedure. Patients who received AT within 0-4 weeks had the 3-year OS of 46% compared to 56.7% for patients who received treatment at 4.1-8 weeks.

CONCLUSION

We found significant variation in the type and timing of adjunct treatment following surgical resection of AA in the United States. A considerable number of patients (15%) received no AT following surgery.

The Influence of Household Income on Survival following Posterior Fossa Tumor Resection at a Large Academic Medical Center

Objectives  The present study examines the effect of median household income on mid- and long-term outcomes in a posterior fossa brain tumor resection population. Design  This is a retrospective regression analysis. Setting  The study conducted at a single, multihospital, urban academic medical center. Participants  A total of 283 consecutive posterior fossa brain tumor cases, excluding cerebellar pontine angle tumors, over a 6-year period (June 09, 2013-April 26, 2019) was included in this analysis. Main Outcome Measures  Outcomes studied included 90-day readmission, 90-day emergency department evaluation, 90-day return to surgery, reoperation within 90 days after index admission, reoperation throughout the entire follow-up period, mortality within 90 days, and mortality throughout the entire follow-up period. Univariate analysis was conducted for the whole population and between the lowest (Q1) and highest (Q4) socioeconomic quartiles. Stepwise regression was conducted to identify confounding variables. Results  Lower socioeconomic status was found to be correlated with increased mortality within 90 postoperative days and throughout the entire follow-up period. Similarly, analysis between the lowest and highest household income quartiles (Q1 vs. Q4) demonstrated Q4 to have significantly decreased mortality during total follow-up and a decreasing but not significant difference in 90-day mortality. No significant difference in morbidity was observed. Conclusion  This study suggests that lower household income is associated with increased mortality in both the 90-day window and total follow-up period. It is possible that there is an opportunity for health care providers to use socioeconomic status to proactively identify high-risk patients and provide additional resources in the postoperative setting.

Trends in Premature Deaths among Women Living with HIV/AIDS and Cervical Cancer

OBJECTIVES

There is a lack of updated information on premature death and years of potential life lost (YPLL) among human immunodeficiency (HIV)-positive women with cervical cancer. We hypothesize that increased access to preventive resources such as antiretroviral therapy, preexposure prophylaxis, and human papillomavirus vaccines has reduced premature mortality and YPLL in these women in the previous decades.

METHODS

We used data from the National Inpatient Sample database from 2003 to the third quarter of 2015, and restricted the analysis to HIV-positive women with or without cervical cancer. Joinpoint regression models were run to identify trends in the rates of HIV and cervical cancer. Overall and age-stratified YPLL were calculated for HIV-positive women with cervical cancer. Adjusted survey logistic regression models were built to determine the predictive factors of in-hospital mortality among women living with HIV.

RESULTS

Among hospitalized women, low-income, non-Hispanic Blacks, and patients aged 40 to 59 years experienced greater frequencies of HIV/cervical cancer comorbidity. The prevalence of HIV hospitalizations increased by an average annual percentage of 0.9% (95% confidence interval 0.3-1.6). YPLL decreased in HIV-positive women living with and without cervical cancer by 4.9% and 4.3%, respectively. The trajectory for YPLL was not uniform across age groups. YPLL decreased substantially in women aged 20 to 29 years with HIV/cervical cancer comorbidity. Cervical cancer remained a significant predictor of mortality among HIV-positive women when adjusted for age, race, and insurance coverage.

CONCLUSIONS

Within a large, national sample from 2003 to 2015, we found an overall declining trend in YPLL in women living with HIV/cervical cancer comorbidity. In-hospital mortality among HIV-positive women was associated with cervical cancer, age, race, and insurance coverage. We recommend further investigation into the quality of HIV and cervical cancer treatment and prevention services for the sociodemographic groups described.

Demographics of Astrocytoma in Central Texas: The Interaction Between Race, Histology, and Primary Tumor Site

Introduction The epidemiological factors surrounding astrocytoma and gliomas have been studied with little avail. Even limited conclusions have not been reached in spite of significant past research efforts. Ionizing radiation is currently one of the only factors consistently associated with glioma formation. Studies in an attempt to link environmental and occupational exposures with brain neoplasms have continued to produce inconsistent results. This study aims to explore the distribution and epidemiology of astrocytomas within a Central Texas patient population in order to elucidate any possible differences in epidemiologic and prognostic factors based on race, histology, and primary tumor site. Methods Eight hundred forty-five clinical cases with the diagnosis of astrocytoma were retrospectively obtained from the tumor registry of the Scott & White Integrated Healthcare System from 1976 to 2014. We investigated the effects of gender, race, tumor histology, tumor site, treatment methods, and mortality of this cohort of patients in Central Texas. Results Prevalence data echoes that of the national epidemiology in that among our sample, White individuals had the highest prevalence (n=666, 78.8%), followed by Hispanics (n=94, 11.1%) and Black individuals (n=78, 9.2%). White patients had higher rates of parietal lobe (6.6% vs. 0.6%, p<0.01), brain overlapping (6.8% vs. 0.0%, p<0.01), and brainstem (5.9% vs. 1.7%, p=0.02) tumors. Black patients had higher rates of tumors located in brain (not otherwise specified) (35.9% vs. 15.7%, p<0.01) and cerebellum (33.3% vs. 5.6%, p<0.01). Hispanic patients had higher rates of tumor located in the temporal lobe (31.9% vs. 22.8%, p<0.05) and brain (not otherwise specified) (28.7% vs. 16.1%, p<0.01). Hispanics had the largest proportion of deaths (72.3% vs. 38.0%, p<0.01) when compared to the remainder of the sample, followed by White individuals (39.6% vs. 49.7%, p=0.02) and Black individuals (21.8% vs. 43.8%, p<0.01). Conclusions Discrepancies in mortality rates amongst various racial groups may be due to a number of factors. Primary tumor site and histology seem to indeed play a role in mortality and may present variably between ethnic groups. Mortality is also influenced by race, genetic predisposition, environmental and occupational exposure, and access to healthcare.

Community economic factors influence outcomes for patients with primary malignant glioma

Background

Community economics and other social health determinants influence outcomes in oncologic patient populations. We sought to explore their impact on presentation, treatment, and survival in glioma patients.

Methods

A retrospective cohort of patients with glioma (World Health Organization grades III-IV) diagnosed between 1999 and 2017 was assembled with data abstracted from medical record review. Patient factors included race, primary care provider (PCP) identified, marital status, insurance status, and employment status. Median household income based on zip code was used to classify patients as residing in high-income communities (HICs; ie, above the median state income) or low-income communities (LICs; ie, below the median state income). The Kaplan-Meier method was used to assess overall survival (OS); Cox proportional hazards regression was used to explore associations with OS.

Results

Included were 312 patients, 73% from LICs. Survivors residing in LICs and HICs did not differ by age, sex, race, tumor grade, having a PCP, employment status, insurance, time to presentation, or baseline performance status. Median OS was 4.1 months shorter for LIC patients (19.7 vs 15.6 mo; hazard ratio [HR], 0.75; 95% CI: 0.56-0.98, P = 0.04); this difference persisted with 1-year survival of 66% for HICs versus 61% for LICs at 1 year, 34% versus 24% at 3 years, and 29% versus 17% at 5 years. Multivariable analysis controlling for age, grade, and chemotherapy treatment showed a 25% lower risk of death for HIC patients (HR, 0.75; 95% CI: 0.57-0.99, P < 0.05).

Conclusions

The economic status of a glioma patient's community may influence survival. Future efforts should investigate potential mechanisms such as health care access, stress, treatment adherence, and social support.

Oncologic Services Through Project Access and Other Safety Net Care Coordination Programs

PURPOSE

Little is known about the provision of oncologic services by Project Access safety net care coordination programs.

MATERIALS AND METHODS

Information on safety net care coordination program locations, health services, and patient eligibility was obtained via program Web sites and calls. For programs not offering oncologic care, program directors were interviewed to identify oncologic care barriers.

RESULTS

Web sites of 29 safety net care coordination programs in 22 states were identified; 62% (n = 18) offered oncologic services. Programs were in 65% (n = 11) of states that did not expand Medicaid. Of those offering oncologic services, 83% (n = 15) offered free chemotherapy, and 93% (n = 27) of all programs offered oncologic imaging. Program director interviews revealed costs, longitudinal care, and multiple-physician buy-in as barriers limiting oncologic care.

CONCLUSION

Third-party care coordination centers provide a novel and potentially unrecognized approach to increasing oncology service access. Further research should identify strategies to overcome the relative lack of oncologic care offerings.

Disparities in health care determine prognosis in newly diagnosed glioblastoma

OBJECTIVE Glioblastoma (GBM) is an aggressive brain malignancy with a short overall patient survival, yet there remains significant heterogeneity in outcomes. Although access to health care has previously been linked to impact on prognosis in several malignancies, this question remains incompletely answered in GBM. METHODS This study was a retrospective analysis of 354 newly diagnosed patients with GBM who underwent first resection at the authors' institution (2007-2015). RESULTS Of the 354 patients (median age 61 years, and 37.6% were females), 32 (9.0%) had no insurance, whereas 322 (91.0%) had insurance, of whom 131 (40.7%) had Medicare, 45 (14%) had Medicaid, and 146 (45.3%) had private insurance. On average, insured patients survived almost 2-fold longer (p < 0.0001) than those who were uninsured, whereas differences between specific insurance types did not influence survival. The adjusted hazard ratio (HR) for death was higher in uninsured patients (HR 2.27 [95% CI 1.49-3.33], p = 0.0003). Age, mean household income, tumor size at diagnosis, and extent of resection did not differ between insured and uninsured patients, but there was a disparity in primary care physician (PCP) status-none of the uninsured patients had PCPs, whereas 72% of insured patients had PCPs. Postoperative adjuvant treatment rates with temozolomide (TMZ) and radiation therapy (XRT) were significantly less in uninsured (TMZ in 56.3%, XRT in 56.3%) than in insured (TMZ in 75.2%, XRT in 79.2%; p = 0.02 and p = 0.003) patients. Insured patients receiving both agents had better prognosis than uninsured patients receiving the same treatment (9.1 vs 16.34 months; p = 0.025), suggesting that the survival effect in insured patients could only partly be explained by higher treatment rates. Moreover, having a PCP increased survival among the insured cohort (10.7 vs 16.1 months, HR 1.65 [95% CI 1.27-2.15]; p = 0.0001), which could be explained by significant differences in tumor diameter at initial diagnosis between patients with and without PCPs (4.3 vs 4.8 cm, p = 0.003), and a higher rate of clinical trial enrollment, suggesting a critical role of PCPs for a timelier diagnosis of GBM and proactive cancer care management. CONCLUSIONS Access to health care is a strong determinant of prognosis in newly diagnosed patients with GBM. Any type of insurance coverage and having a PCP improved prognosis in this patient cohort. Higher rates of treatment with TMZ plus XRT, clinical trial enrollment, fewer comorbidities, and early diagnosis may explain survival disparities. Lack of health insurance or a PCP are major challenges within the health care system, which, if improved upon, could favorably impact the prognosis of patients with GBM.

Effects of the Affordable Care Act on Payer Mix and Physician Reimbursement in Hand Surgery

PURPOSE

To evaluate the effect of the Affordable Care Act (ACA) on the payer distribution and reimbursement rate for hand surgery at our institution.

METHODS

We reviewed records of 4,257 patients who underwent hand surgery at our institution between January 2008 and June 2016; 2,601 patients underwent surgery before the implementation of the ACA, and 1,656 patients after. Type of procedure, insurance status, amount of money billed, and amount collected were recorded.

RESULTS

After the implementation of the ACA, we performed fewer metacarpal fracture repairs, distal radius fracture repairs, and abscess incision and drainage procedures. We performed more endoscopic carpal tunnel releases. The proportion of uninsured patients decreased significantly (15% to 6.4%), and the proportion of patients on Medicare (15.4% to 20.3%) and Medicaid (9.5% to 17.8%) increased significantly. The overall reimbursement rate did not change significantly (32.3% to 30.3%) between the 2 time periods.

CONCLUSIONS

After the implementation of the ACA, we observed a significant reduction in the number of uninsured patients and an increase in Medicaid and Medicare patients. However, this led to no significant change in reimbursement rates.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and design analysis II.