Association Between Medicaid Expansion and Diagnosis and Management of Colon Cancer

Association of Policy With Palliative Care Uptake in Patients With Head and Neck Cancer

BACKGROUND

Head and neck squamous cell carcinoma presents substantial symptom burdens in advanced stages, yet only a small fraction of patients receive palliative care (PC). Medicaid expansion and state-specific PC policies may influence PC uptake in this population.

OBJECTIVE

This study evaluates the impact of Medicaid expansion and state-level PC laws on PC utilization among patients with stage III and IV HNC across the United States.

METHODS

Using 2015-2020 National Cancer Database (NCDB) data, we identified deceased HNC patients with stage III or IV cancer and prognoses under 6 months. Using adjusted logistic regression, we analyzed the role of Medicaid expansion in PC utilization. Additionally, the Yale Palliative Care GPS was used to assess the distribution of state PC laws.

RESULTS

Of 10 305 eligible patients, 69.7% were from Medicaid expansion states. Medicaid expansion (aOR: 1.22, 95% CI: 1.01-1.49), higher Charles Comorbidity Index (CCI ≥ 3 vs. CCI = 1, aOR: 1.84, 95% CI: 1.16-2.81), and later years were associated with increased PC use. Geographic differences in PC law implementation were observed, with the West having the most enacted/passed laws while the Northeast had the highest PC utilization rate.

CONCLUSIONS

Medicaid expansion and specific state PC laws positively impact PC access for advanced HNC patients. These findings underscore the potential of policy interventions in enhancing PC accessibility and utilization among vulnerable cancer populations.

Impact of medicaid expansion on screenable versus non-screenable gastrointestinal cancers

BACKGROUND

Medicaid expansion afforded increased healthcare access to low-income Americans contributing to a positive impact on cancer outcomes. However, it is unclear if these benefits were mainly due to enhanced access to cancer screening and earlier diagnosis versus access to cancer treatment METHODS: The National Cancer Database (NCDB) was queried between 2010 and 2021 for Medicaid and uninsured patients with GI malignancies. Patients were stratified by screenable (SGI) and non-screenable (NGI) cancers and expansion state (ES) categories: early (EES) and late (LES) adopters, and non-expansion state (NES) cohorts. Statistical analyses, including difference-in-difference (DiD) and adjusted models, assessed the impact of Medicaid expansion on stage at diagnosis.

RESULTS

There were 230,159 pre-expansion and 539,028 post-expansion patients. There was an increase in Medicaid coverage (14.8 % vs. 11.1 %) and a concomitant decline in the uninsured population (5.3 % vs. 8.2 %) in the post-expansion era. For SGI cancers, Medicaid expansion was associated with significantly lower mean stage at diagnosis (DiD Coef. -0.12; p < 0.01). For NGI cancers, Medicaid expansion was associated with a lower mean stage at diagnosis but with much smaller coefficient (DiD Coef. -0.015; p < 0.01). Comparing EES and LES to NES, EES had more impact on lower mean stage at diagnosis (vs NES DiD Coef. -0.16; p < 0.01) compared to LES (vs NES DiD Coef. -0.02; p = 0.04) for SGI cancers. For NGI cancers, there was a modest reduction in mean stage at diagnosis only for EES (vs NES DiD Coef. -0.04; p < 0.01).

CONCLUSION

Medicaid expansion, particularly for SGI cancers and early adopters, had a profound impact in lowering the mean stage at diagnosis. This emphasizes that long-term advantages of providing access to preventive care and screening, and thus earlier treatment, may be one of the main mechanisms of Medicaid expansion on improving cancer outcomes for GI malignancies.

POLICY SUMMARY

To establish the benefits of Medicaid expansion under the Affordable Care Act 2010 for gastrointestinal cancer patients particularly in screening.

Disparities in Access, Quality, and Clinical Outcome for Latino Californians With Colon Cancer

OBJECTIVE

To compare access, quality, and clinical outcomes between Latino and non-Latino White Californians with colon cancer.

BACKGROUND

Racial and ethnic disparities in cancer care remain understudied, particularly among patients who identify as Latino. Exploring potential mechanisms, including differential utilization of high-volume hospitals, is an essential first step to designing evidence-based policy solutions.

METHODS

We identified all adults diagnosed with colon cancer between January 1, 2010 and December 31, 2020 from a statewide cancer registry linked to hospital administrative records. We compared survival, access (stage at diagnosis, receipt of surgical care, treatment at a high-volume hospital), and quality of care (receipt of adjuvant chemotherapy and adequacy of lymph node resection) between patients who identified as Latino and non-Latino White.

RESULTS

A total of 75,543 patients met inclusion criteria, including 16,071 patients who identified as Latino (21.3%). Latino patients were significantly less likely to undergo definitive surgical resection [marginal difference (MD): -0.72 percentage points, 95% CI: -1.19, -0.26], have an operation in a timely manner (MD: -3.24 percentage points, 95% CI: -4.16, -2.32), or have an adequate lymphadenectomy (MD: -2.85 percentage points, 95% CI: -3.59, -2.12) even after adjustment for clinical and sociodemographic factors. Latino patients treated at high-volume hospitals were significantly less likely to die and more likely to meet access and quality metrics.

CONCLUSIONS

Latino patients with colon cancer experienced delays, segregation, and lower receipt of recommended care. Hospital-level colectomy volume appears to be strongly associated with access, quality, and survival-especially for patients who identify as Latino-suggesting that directing at-risk patients with cancer to high-volume hospitals may improve health equity.

Medicaid Expansion Increases Treatment for Patients with Colon Cancer

INTRODUCTION

Medicaid expansion (ME) has positively impacted colon cancer screening. ME's effect on colon cancer treatment is less clear. This study analyses the effect of ME on patterns of colon cancer treatment.

METHODS

Patients with primary invasive colon cancer were identified using the Louisiana Tumor Registry. Patients diagnosed with colon cancer prior to ME (2014-2015) were compared to those diagnosed after (2017-2018). Coordinate variables were analyzed using Fisher's exact test. Treatment status was modeled with multivariable logistic regression and the results are reported as adjusted odds ratios.

RESULTS

The proportion of uninsured patients decreased following ME (5.5 versus 1.9, p < 0.001), with the greatest reductions among patients between 45 and 54 years old (13.5% to 3.5%, p < 0.0001), African Americans (8.9 to 2.1%, p < 0.0001), and those in high-poverty neighborhoods (7.1 to 2.1%, p < 0.0001). Following ME, all patients with Stage I-III disease were more likely to receive surgery (OR = 1.95; 95%: CI 1.21-3.14)-especially the extremely impoverished (OR = 2.39; 95% CI 1.41-4.02). Young patients with Stage IV colon cancer were more likely to receive chemotherapy (OR-1.6; 95% CI 1.03-2.4). Patients with Stage IV colon cancer were less likely to receive treatment within 30 days of diagnosis (OR = 0.7; 95% CI 0.5-0.9), but, on subset analysis, this was only observed in non-Medicaid patients.

CONCLUSION

ME is associated with increased treatment for patients with colon cancer, and it did not appear to affect time to treatment. However, it seems to affect different subsets of the population differently.

Closing the Gap: Approaches to Improving Colorectal Surgery Care for the Uninsured and Underinsured

Health insurance plays a critical role in access to and delivery of health care in the United States. As the only industrialized nation without universal health coverage, Americans without adequate insurance (i.e., uninsured or underinsured individuals) face numerous obstacles to obtaining necessary health care. In this article, we review the mechanisms by which inadequate insurance leads to worse clinical outcomes in patients with common benign and malignant colorectal pathologies. We then discuss several evidence-based solutions for improving access to optimal colorectal care for these patients. These include increasing access to and affordability of health insurance, mitigating disparities between differently insured populations, strengthening the health care safety net, and tailoring outreach and clinical decision-making for the uninsured and underinsured. By exploring the nuance and impact of inadequate insurance coverage, we ultimately seek to highlight critical opportunities for future research and advocacy within the realm of insurance design and policy.

The Impact of Medicaid Expansion on Stage at Diagnosis of Melanoma Patients: A Retrospective Study

BACKGROUND

This study addresses the lack of research on Medicaid expansion's impact on melanoma staging, treatment utilization, and outcomes by evaluating its effects under the Affordable Care Act (ACA), particularly focusing on staging at diagnosis, treatment use, and 3-year mortality outcomes. The objective is to determine whether Medicaid expansion led to earlier melanoma diagnosis and improved survival rates among non-elderly adults (ages 40-64) by analyzing data from the National Cancer Database (NCDB).

METHODS

A total of 12,667 patients, aged 40-64, diagnosed with melanoma from 2010 to 2020 were identified using the NCDB. Difference-in-difference (DID) analysis was performed to analyze tumor staging at presentation between Medicaid expansion states and non-Medicaid expansion states both prior to the expansion and after the expansion.

RESULTS

Of the total patients, 2307 were from the pre-expansion time period residing in Medicaid expansion states (MES) and 1804 in non-Medicaid expansion states. In the post-expansion time period there were 5571 residing in the MES and 2985 in the non-MES. DID analysis revealed a decrease in stage IV melanoma at diagnosis (DID -0.222, p < 0.001) between MES and non-MES before and after Medicaid expansion. After expansion, in stage IV, the occurrence of primary surgery was 0.42 in non-MES and 0.44 (difference 0.02); DID analysis was not statistically significant. The use of immunotherapy in MES was significantly higher than in non-MES after expansion (p < 0.001), although DID analysis did not reveal a statistically significant difference. DID analysis showed a statistically significant decrease in 3-year mortality (DID -0.05, p = 0.001) between MES and non-MES before and after Medicaid expansion.

CONCLUSIONS

This study revealed the positive impact of the ACA's Medicaid expansion on melanoma stage at presentation, highlighting the importance of public health policies in reducing disparities in mortality rates and early-stage diagnoses. Future research should explore additional barriers to care and evaluate the long-term outcomes of Medicaid expansion to optimize cancer care for vulnerable populations.

The Association Between Medicaid Expansion and Disparities in Vestibular Schwannoma Incidence

OBJECTIVES

The effect of Medicaid expansion as a part of the Affordable Care Act on vestibular schwannoma (VS) incidence overall and in marginalized populations has not yet been elucidated. The goal of this study was to determine if Medicaid expansion was associated with increases in VS incidence overall, as well as in patients of non-white race or in counties of low socioeconomic status (SES).

METHODS

We performed a difference-in-difference (DiD) analysis from January 1st 2010-December 31st 2017 utilizing the Surveillance, Epidemiology, and End Results (SEER) database. Our DiD method compared the change in VS rate between counties that did and did not expand Medicaid among patients of white and non-white race, in low and high SES counties, before and after expansion.

RESULTS

The study included 17,312 cases across 1020 counties. Medicaid expansion was associated with a 15% increase (incidence rate ratio 95% CI: [11%, 19]) in VS incidence. White populations saw a 10% increase (CI: [1.06, 1.19]), Black populations saw a 20% increase (CI: [1.10, 1.29]), and patients of other races saw a 44% increase in incidence associated with expansion (CI: [1.21, 1.70]). Low SES counties saw an increase in incidence 1.12 times higher than that of high SES counties (CI:[1.04, 1.20]).

CONCLUSION

Medicaid expansion was associated with increases in VS incidence across populations. Furthermore, this increase was more evident in disadvantaged populations, such as patients of non-white race and those from low SES counties. These findings emphasize the impact of Medicaid expansion on healthcare utilization for VS diagnosis.

LEVEL OF EVIDENCE

3-Retrospective Cohort Study Laryngoscope, 134:4383-4388, 2024.

Association of Medicaid Expansion with Reduction in Racial Disparities in the Timely Delivery of Upfront Surgical Care for Patients With Early-Stage Breast Cancer

OBJECTIVE

We evaluated the association between Medicaid expansion and time to surgery among patients with early-stage breast cancer (BC).

BACKGROUND

Delays in surgery are associated with adverse outcomes. It is known that underrepresented minorities are more likely to experience treatment delays. Understanding the impact of Medicaid expansion on reducing racial and ethnic disparities in health care delivery is critical.

METHODS

This was a population-based study including women ages 40 to 64 with stage I-II BC who underwent upfront surgery identified in the National Cancer Database (2010-2017) residing in states that expanded Medicaid on January 1, 2014. Difference-in-difference analysis compared rates of delayed surgery (>90 d from pathological diagnosis) according to time period (preexpansion [2010-2013] and postexpansion [2014-2017]) and race/ethnicity (White vs. racial and ethnic minority), stratified by insurance type (private vs. Medicaid/uninsured). Secondary analyses included logistic and Cox proportional hazards (PH) regression. All analyses were conducted among a cohort of patients in the nonexpansion states as a falsification analysis. Finally, a triple-differences approach compared preexpansion with the postexpansion trend between expansion and nonexpansion states.

RESULTS

Among Medicaid expansion states, 104,569 patients were included (50,048 preexpansion and 54,521 postexpansion). In the Medicaid/uninsured subgroup, Medicaid expansion was associated with a -1.8% point (95% CI: -3.5% to -0.1, P =0.04) reduction of racial disparity in delayed surgery. Cox regression models demonstrated similar findings (adjusted difference-in-difference hazard ratio 1.12 [95% CI: 1.05 to 1.21]). The falsification analysis showed a significant racial disparity reduction among expansion states but not among nonexpansion states, resulting in a triple-difference estimate of -2.5% points (95% CI: -4.9% to -0.1%, P =0.04) in this subgroup.

CONCLUSIONS

As continued efforts are being made to increase access to health care, our study demonstrates a positive association between Medicaid expansion and a reduction in the delivery of upfront surgical care, reducing racial disparities among patients with early-stage BC.

Effect of Medicaid expansion on cancer treatment and survival among Medicaid beneficiaries and the uninsured

BACKGROUND

The Affordable Care Act expanded Medicaid coverage for people with low income in the United States. Expanded insurance coverage could promote more timely access to cancer treatment, which could improve overall survival (OS), yet the long-term effects of Medicaid expansion (ME) remain unknown. We evaluated whether ME was associated with improved timely treatment initiation (TTI) and 3-year OS among patients with breast, cervical, colon, and lung cancers who were affected by the policy.

METHODS

Medicaid-insured or uninsured patients aged 40-64 with stage I-III breast, cervical, colon, or non-small cell lung cancer within the National Cancer Database (NCDB). A difference-in-differences (DID) approach was used to compare changes in TTI (within 60 days) and 3-year OS between patients in ME states versus nonexpansion (NE) states before (2010-2013) and after (2015-2018) ME. Adjusted DID estimates for TTI and 3-year OS were calculated using multivariable linear regression and Cox proportional hazards regression models, respectively.

RESULTS

ME was associated with a relative increase in TTI within 60 days for breast (DID = 4.6; p < 0.001), cervical (DID = 5.0 p = 0.013), and colon (DID = 4.0, p = 0.008), but not lung cancer (p = 0.505). In Cox regression analysis, ME was associated with improved 3-year OS for breast (DID hazard ratio [HR] = 0.82, p = 0.009), cervical (DID-HR = 0.81, p = 0.048), and lung (DID-HR = 0.87, p = 0.003). Changes in 3-year OS for colon cancer were not statistically different between ME and NE states (DID-HR, 0.77; p = 0.075).

CONCLUSIONS

Findings suggest that expanded insurance coverage can improve treatment and survival outcomes among low income and uninsured patients with cancer. As the debate surrounding ME continues nationwide, our findings serve as valuable insights to inform the development of policies aimed at fostering accessible and affordable healthcare for all.

Utilization and Outcomes of Roux-en-Y Gastric Bypass Surgery Following the Affordable Care Act in the United States

BACKGROUND

The passage of the Affordable Care Act (ACA) in 2010 marked a pivotal moment in American health care policy, significantly expanding access to health care services. This study aims to explore the relationship between the ACA and the utilization and outcomes of Roux-en-Y Gastric Bypass (RYGB) surgery.

METHODS

Using data from the National Inpatient Sample (NIS) Database, this retrospective study compares the pre-ACA period (2007-2009) with the post-ACA period (2017-2019), encompassing patients who had RYGB. Multivariable logistic analysis was done accounting for patient's characteristics, comorbidities, and hospital type.

RESULTS

In the combined periods, there were 158 186 RYGB procedures performed, with 30.0% transpiring in pre-ACA and 70.0% in the post-ACA. Post-ACA, the proportion of uninsured patients decreased from 4.8% to 3.6% (P < .05), while Black patients increased from 12.5% to 18.5% (P < .05). Medicaid-insured patients increased from 6.8% to 18.1% (P < .05), and patients in the poorest income quartile increased from 20% to 26% (P < .05). Patients in the post-ACA period were less likely to have longer hospital stays (OR = .16: 95% CI .16-.17, P < .01), in-hospital mortality (OR = .29: 95% CI .18-.46, P < .01), surgical site infection (OR = .25: 95% CI .21-.29, P < .01), postop hemorrhage (OR = .24: 95% CI .21-.28, P < .01), and anastomotic leak (OR = .14: 95% CI .10-.18, P < .01) than those in the pre-ACA period.

DISCUSSION

Following the implementation of the ACA, utilization of bariatric surgery significantly increased, especially among Black patients, Medicaid beneficiaries, and low-income patients. Moreover, despite the inclusion of more high-risk surgical patients in the post-ACA period, there were better outcomes after surgery.

Impact of Medicaid Expansion on Surgical Care and Outcomes for Hepatobiliary Malignancies

BACKGROUND

As part of the Patient Protection and Affordable Care Act, some states expanded Medicaid eligibility to adults with incomes below 138% of the federal poverty line. While this resulted in an increased proportion of insured residents, its impact on the diagnosis and treatment of hepatopancreaticobiliary (HPB) cancers has not been studied.

STUDY DESIGN

The National Cancer Database (NCDB) from 2010 to 2017 was used. Patients diagnosed with HPB malignancies in states which expanded in 2014 were compared to patients in non-expansion states. Subset analyses of patients who underwent surgery and those in high-risk socioeconomic groups were performed. Outcomes studied included initiation of treatment within 30 days of diagnosis, stage at diagnosis, care at high volume or academic center, perioperative outcomes, and overall survival. Adjusted difference-in-differences analysis was performed.

RESULTS

A total of 345,684 patients were included, of whom 55% resided in non-expansion states and 54% were diagnosed with pancreatic cancer. Overall survival was higher in states with Medicaid expansion (HR .90, 95% CI [.88-.92], P < .01). There were also better postoperative outcomes including 30-day mortality (.67 [.57-.80], P < .01) and 30-day readmissions (.87 [.78-.97], P = .02) as well as increased likelihood of having surgery in a high-volume center (1.42 [1.32-1.53], P < .01). However, there were lower odds of initiating care within 30 days of diagnosis (.77 [.75-.80], P < .01) and higher likelihood of diagnosis with stage IV disease (1.09 [1.06-1.12], P < .01) in expansion states.

CONCLUSION

While operative outcomes and overall survival from HPB cancers were better in states with Medicaid expansion, there was no improvement in timeliness of initiating care or stage at diagnosis.

The impact of the affordable care act and Medicaid expansion on colorectal cancer screening: Evidence from the 5th year of Medicaid expansion

BACKGROUND

Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods.

MAIN OUTCOMES AND MEASURES

The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64.

RESULTS

Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries.

CONCLUSIONS

Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.

Medicaid expansion and palliative care for advanced-stage liver cancer

BACKGROUND

Medicaid expansion (ME) has contributed to transforming the United States healthcare system. However, its effect on palliative care of primary liver cancers remains unknown. This study aimed to evaluate the association between ME and the receipt of palliative treatment in advanced-stage liver cancer.

METHODS

Patients diagnosed with stage IV hepatocellular carcinoma or intrahepatic cholangiocarcinoma were identified from the National Cancer Database and divided into pre-expansion (2010-2013) and postexpansion (2015-2019) cohorts. Logistic regression identified predictors of palliative treatment. Difference-in-difference (DID) analysis assessed changes in palliative care use between patients living in ME states and patients living in non-ME states.

RESULTS

Among 12,516 patients, 4582 (36.6%) were diagnosed before expansion, and 7934 (63.6%) were diagnosed after expansion. Overall, rates of palliative treatment increased after ME (18.1% [pre-expansion] vs 22.3% [postexpansion]; P < .001) and are more pronounced among ME states. Before expansion, only cancer type and education attainment were associated with the receipt of palliative treatment. Conversely, after expansion, race, insurance, location, cancer type, and ME status (odds ratio [OR], 1.23; 95% CI, 1.06-1.44; P = .018) were all associated with palliative care. Interestingly, the odds were higher if treatment involved receipt of pain management (OR, 2.05; 95% CI, 1.23-2.43; P = .006). Adjusted DID analysis confirmed increased rates of palliative treatment among patients living in ME states relative to non-ME states (DID, 4.4%; 95% CI, 1.2-7.7; P = .008); however, racial disparities persist (White, 5.6; 95% CI, 1.4-9.8; P = .009; minority, 2.6; 95% CI, -2.5 to 7.6; P = .333).

CONCLUSION

The implementation of ME contributed to increased rates of palliative treatment for patients residing in ME states after expansion. However, racial disparities persist even after ME, resulting in inequitable access to palliative care.

Prevalence and predictors of colorectal cancer screening in the United States: evidence from the HINTS database 2018 to 2020

BACKGROUND

The incidence of colorectal cancer (CRC) and CRC-related mortality among young adults (< 50 years) has been on the rise. The American Cancer Society (ACS) reduced the CRC screening age to 45 in 2018. Few studies have examined the barriers to CRC screening among young adults.

METHODS

Analyses were conducted using data from 7,505 adults aged 45-75 years who completed the 2018 to 2020 Health Information National Trends Survey. We examined the sociodemographic characteristics associated with CRC screening overall and by age group using separate multivariable logistic regression models.

RESULTS

76% of eligible adults had received screening for CRC. Increasing age, Black racial group [OR 1.45; 95% CI (1.07, 1.97)], having some college experience, a college degree or higher [OR 1.69; 95% CI (1.24, 2.29)], health insurance coverage [OR 4.48; 95% CI (2.96, 6.76)], primary care provider access [OR 2.48; 95% CI (1.91, 3.22)] and presence of a comorbid illness [OR 1.39; 95% CI (1.12, 1.73)] were independent predictors of CRC screening. Current smokers were less likely to undergo CRC screening [OR 0.59; 95% CI (0.40, 0.87)]. Among adults aged 50-64 years, being of Hispanic origin [OR 0.60; 95% CI (0.39, 0.92)] was associated with a lower likelihood of CRC screening.

CONCLUSION

CRC screening rates among adults 45-49 years are low but are increasing steadily. Odds of CRC screening among Blacks is high which is encouraging while the odds among current smokers is low and concerning given their increased risk of developing CRC.

Impact of Medicaid expansion on the multimodal treatment of biliary tract cancer

INTRODUCTION

The impact of Medicaid expansion (ME) on the treatment of patients with cancer remains controversial, especially individuals requiring complex multidisciplinary care. We sought to evaluate the impact of Medicaid expansion (ME) on receipt of multimodal care, including surgical resection, for Stage I-III biliary tract cancer (BTC).

METHODS

Patients diagnosed with BTC between 40 and 65 years of age were identified from the National Cancer Database and divided into pre- (2008-2012) and post- (2015-2018) ME cohorts. Difference-in-difference (DID) analysis was used to determine the impact of ME on the utilization of surgery and multimodal chemotherapy and/or radiotherapy treatment for BTC.

RESULTS

Among 12,415 patients with BTC (extrahepatic, n = 5622, 45.3%; intrahepatic, n = 4352, 35.1%; gallbladder, n = 1944, 15.7%; overlapping, n = 497, 4.0%), 5835 (47.0%) and 6580 (53.0%) patients were diagnosed before versus after ME, respectively. Overall utilization of surgery (OR 1.13, 95% CI 1.02-1.26) and multimodality therapy (OR 1.13, 95% CI 1.01-1.27) increased in states that adopted ME. Utilization of surgery among uninsured/Medicaid patients in ME states increased relative to patients living in non-ME states (∆+10.1%, p = 0.01). Similarly, the use of multimodal treatment increased among uninsured/Medicaid patients living in ME versus non-ME states (∆+6.4%, p = 0.04); in contrast, there were no difference among patients with other insurance statuses (overall: ∆+1.5%, private: ∆-2.0%, other: ∆+3.9%, all p > 0.5). Uninsured/Medicaid patients with BTC who lived in a ME state had a lower risk of long-term death in the post-ME era (HR 0.81, 95% CI 0.67-0.98; p = 0.03).

CONCLUSIONS

Implementation of ME positively impacted survival among patients who underwent surgical and multimodal treatment for Stage I-III BTC.

Association Between Racial and Socioeconomic Disparities and Hospital Performance in Treatment and Outcomes for Patients with Colon Cancer

BACKGROUND

Disparities in colon cancer care and outcomes by race/ethnicity, socioeconomic status (SES), and insurance are well recognized; however, the extent to which inequalities are driven by patient factors versus variation in hospital performance remains unclear. We sought to compare disparities in care delivery and outcomes at low- and high-performing hospitals.

METHODS

We identified patients with stage I-III colon adenocarcinoma from the 2012-2017 National Cancer Database. Adequate lymphadenectomy and timely adjuvant chemotherapy administration defined hospital performance. Multilevel regression models evaluated disparities by race/ethnicity, SES, and insurance at the lowest- and highest-performance quartile hospitals.

RESULTS

Of 92,573 patients from 704 hospitals, 45,982 (49.7%) were treated at 404 low-performing hospitals and 46,591 (50.3%) were treated at 300 high-performing hospitals. Low-performing hospitals treated more non-Hispanic (NH) Black, Hispanic, low SES, and Medicaid patients (all p < 0.01). Among low-performing hospitals, patients with low versus high SES (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.82-0.92), and Medicare (OR 0.90, 95% CI 0.85-0.96) and Medicaid (OR 0.88, 95% CI 0.80-0.96) versus private insurance, had decreased odds of receiving high-quality care. At high-performing hospitals, NH Black versus NH White patients (OR 0.83, 95% CI 0.72-0.95) had decreased odds of receiving high-quality care. Low SES, Medicare, Medicaid, and uninsured patients had worse overall survival at low- and high-performing hospitals (all p < 0.01).

CONCLUSION

Disparities in receipt of high-quality colon cancer care occurred by SES and insurance at low-performing hospitals, and by race at high-performing hospitals. However, survival disparities by SES and insurance exist irrespective of hospital performance. Future steps include improving low-performing hospitals and identifying mechanisms affecting survival disparities.

Accounting for Medicaid expansion and regional policy and programs to advance equity in cancer prevention in the United States

BACKGROUND

Many studies compare state-level outcomes to estimate changes attributable to Medicaid expansion. However, it is imperative to conduct more granular, demographic-level analyses to inform current efforts on cancer prevention among low-income adults. Therefore, the authors compared the volume of patients with cancer and disease stage at diagnosis in Ohio, which expanded its Medicaid coverage in 2014, with those in Georgia, a nonexpansion state, by cancer site and health insurance status.

METHODS

The authors used state cancer registries from 2010 to 2017 to identify adults younger than 64 years who had incident female breast cancer, cervical cancer, or colorectal cancer. Multivariable Poisson regression was conducted by cancer type, health insurance, and state to examine the risk of late-stage disease, adjusting for individual-level and area-level covariates. A difference-in-differences framework was then used to estimate the differences in risks of late-stage diagnosis in Ohio versus Georgia.

RESULTS

In Ohio, the largest increase in all three cancer types was observed in the Medicaid group after Medicaid expansion. In addition, significantly reduced risks of late-stage disease were observed among patients with breast cancer on Medicaid in Ohio by approximately 7% and among patients with colorectal cancer on Medicaid in Ohio and Georgia after expansion by approximately 6%. Notably, the authors observed significantly reduced risks of late-stage diagnosis among all patients with colorectal cancer in Georgia after expansion.

CONCLUSIONS

More early stage cancers in the Medicaid-insured and/or uninsured groups after expansion suggest that the reduced cancer burden in these vulnerable population subgroups may be attributed to Medicaid expansion. Heterogeneous risks of late-stage disease by cancer type highlight the need for comprehensive evaluation frameworks, including local cancer prevention efforts and federal health policy reforms.

PLAIN LANGUAGE SUMMARY

This study looked at how Medicaid expansion affected cancer diagnosis and treatment in two states, Ohio and Georgia. The researchers found that, after Ohio expanded their Medicaid program, there were more patients with cancer among low-income adults on Medicaid. The study also found that, among people on Medicaid, there were lower rates of advanced cancer at the time of diagnosis for breast cancer and colon cancer in Ohio and for colon cancer in Georgia. These findings suggest that Medicaid expansion may be effective in reducing the cancer burden among low-income adults.

A national evaluation of adjuvant chemotherapy in pT4N0M0 colon cancer from the National Cancer Database

BACKGROUND

T stage is a prognostic biomarker for overall survival in colon cancer and pathologic T4 disease is a high-risk characteristic. Adjuvant chemotherapy is recommended to improve overall survival in pT4N0M0, but compliance with guidelines is unknown. We aimed to evaluate adjuvant chemotherapy use and impact on overall survival in pT4N0M0 colon cancer.

METHODS

The National Cancer Database was reviewed for pT4N0M0 colon adenocarcinomas undergoing curative surgical resection (2010-2017). Cases were stratified into no adjuvant chemotherapy and adjuvant chemotherapy cohorts. Moderated multiple regression assessed factors associated with no AC. Kaplan-Meier and Cox regression assessed overall survival in propensity-score matched cohorts. The main outcome measures were adjuvant chemotherapy use, factors associated with adjuvant chemotherapy, and impact on overall survival.

RESULTS

Of 11 847 cases, 62.4% (n = 7391) received no adjuvant chemotherapy. With private insurance, comorbidities or income do not affect adjuvant chemotherapy use. Medicare cases with a Charlson-Deyo comorbidity index of 0 (odds ratio [OR] = 0.861, 95% confidence interval [CI] = 0.760 to 0.975; P = .019) and Medicare payors with high income (OR = 0.813, 95% CI = 0.690 to 0.959; P = .014) were associated with adjuvant chemotherapy. Medicaid Charlson-Deyo comorbidity index 0 (OR = 1.374, 95% CI = 1.125 to 1.679; P = .002) and uninsured Charlson-Deyo comorbidity index 0 (OR = 1.351, 95% CI = 1.120 to 1.629; P = .002) were associated with no adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved 5-year overall survival (71.7% vs 56.4%; P < .001; adjusted hazard ratio = 0.543, 95% CI = 0.499 to 0.590; P < .001).

CONCLUSION

Although adjuvant chemotherapy is associated with improved overall survival, compliance is low. There is a complex relationship between payor, income, comorbidity, and adjuvant chemotherapy receipt. Medicare patients with no comorbidities or higher income have better adjuvant chemotherapy use. With private insurance, adjuvant chemotherapy compliance is not affected by comorbidities or income, whereas Medicaid and uninsured patients with no comorbidities have poor compliance. Future work could target these disparities for equitable care.

Impact of Medicaid Expansion on Stage at Diagnosis for US Adults with Pancreatic Cancer: a Population-Based Study

INTRODUCTION

We evaluated whether Medicaid expansion is associated with earlier stage at diagnosis for pancreatic cancer taking into account key demographic, clinical, and geographic factors.

METHODS

We obtained Surveillance, Epidemiology, and End-Results (SEER-18) data on individuals diagnosed with pancreatic cancer from 2007 to 2016 (< 65 years of age). We defined non-metastatic as either local or regional disease (vs. metastatic disease). To estimate the association of Medicaid expansion with pancreatic cancer stage at diagnosis, we used a difference-in-differences model, at the individual level, comparing those from early-adopting states in 2014 to non-early-adopting states. We utilized cluster-robust standard errors and explored the role of demographic factors (race, sex, insurance at diagnosis), clinical indicator (disease in the head of the pancreas), and county characteristics (Urban Influence Code, Social Deprivation Index).

RESULTS

In the univariable setting, the probability of non-metastatic disease at diagnosis increased by 3.9 percentage points (ppt) for those from Medicaid expansion states post-expansion (n = 36,609). After adjustment for covariates, the ppt was attenuated to 2.7. Of particular note, we observed evidence of interactions with sex and race. The beneficial effect was less pronounced for men (increase in the probability of non-metastatic stage at diagnosis by 2.1ppt) than women (3.6ppt) and non-existent for blacks (- 3.1ppt) compared to whites (4.9ppt) and other races (4.8ppt).

CONCLUSION

Medicaid expansion is associated with increased probability of non-metastatic stage at diagnosis for pancreatic cancer; however, this beneficial effect is not uniform across sex and race. This underscores the need to investigate the impact of policy and implementation strategies on pancreatic cancer survival disparities.

Association of Medicaid expansion with 2-year survival and time to treatment initiation in gastrointestinal cancer patients: A National Cancer Database study

INTRODUCTION

We evaluated whether Medicaid expansion (ME) was associated with improved 2-year survival and time to treatment initiation (TTI) among patients with gastrointestinal (GI) cancer.

METHODS

GI cancer patients diagnosed 40-64 years were queried from the National Cancer Database. Those diagnosed from 2010 to 2012 were considered pre-expansion; those diagnosed from 2014 to 2016 were considered post-expansion. Cox models estimated hazard ratios and 95% confidence intervals (CIs) for 2-year overall survival. Generalized estimating equations (GEE) estimated odds ratios (OR) and 95% CI of TTI within 30- and 90 days. Multivariable Difference-in-Difference models were used to compare expansion/nonexpansion cohorts pre-/post-expansion, adjusting for patient, clinical, and hospital factors.

RESULTS

377,063 patients were included. No significant difference in 2-year survival was demonstrated across ME and non-ME states overall or in site-based subgroup analysis. In stage-based subgroup analysis, 2-year survival significantly improved among stage II cancer, with an 8% decreased hazard of death at 2 years (0.92; 0.87-0.97). Those with stage IV had a 4% increased hazard of death at 2 years (1.04; 1.01-1.07). Multivariable GEE models showed increased TTI within 30 days (1.12; 1.09-1.16) and 90 days (1.22; 1.17-1.27). Site-based subgroup analyses indicated increased likelihood of TTI within 30 and 90 days among colon, liver, pancreas, rectum, and stomach cancers, by 30 days for small intestinal cancer, and by 90 days for esophageal cancer. In subgroup analyses, all stages experienced improved odds of TTI within 30 and 90 days.

CONCLUSION

ME was not associated with significant improvement in 2-year survival for those with GI cancer. Although TTI increased after ME for both cohorts, the 30- and 90-day odds of TTI was higher for those from ME compared with non-ME states. Our findings add to growing evidence of associations with ME for those diagnosed with GI cancer.

Impact of Medicaid Expansion on Abdominal Surgery Morbidity, Mortality, and Hospital Readmission

INTRODUCTION

Medicaid expansion's (ME) impact on postoperative outcomes after abdominal surgery remains poorly defined. We aimed to evaluate ME's effect on surgical morbidity, mortality, and readmissions in a state that expanded Medicaid (Virginia) compared to a state that did not (Tennessee) over the same time period.

METHODS

Virginia Surgical Quality Collaborative (VSQC) American College of Surgeons National Surgical Quality Improvement Program data for Medicaid, uninsured, and private insurance patients undergoing abdominal procedures before Virginia's ME (3/22/18-12/31/18) were compared with post-ME (1/1/19-12/31/19), as were corresponding non-ME state Tennessee Surgical Quality Collaborative (TSQC) data for the same 2018 and 2019 time periods. Postexpansion odds ratios for 30-d morbidity, 30-d mortality, and 30-d unplanned readmission were estimated using propensity score-adjusted logistic regression models.

RESULTS

In Virginia, 4753 abdominal procedures, 2097 pre-ME were compared to 2656 post-ME. In Tennessee, 5956 procedures, 2484 in 2018 were compared to 3472 in 2019. VSQC's proportion of Medicaid population increased following ME (8.9% versus 18.8%, P < 0.001) while uninsured patients decreased (20.4% versus 6.4%, P < 0.001). Post-ME VSQC had fewer 30-d readmissions (12.2% versus 6.0%, P = 0.013). Post-ME VSQC Medicaid patients had significantly lower probability of morbidity (-8.18, 95% confidence interval: -15.52 ∼ -0.84, P = 0.029) and readmission (-6.92, 95% confidence interval: -12.56 ∼ -1.27, P = 0.016) compared to pre-ME. There were no differences in probability of morbidity or readmission in the TSQC Medicaid population between study periods (both P > 0.05); there were no differences in mortality between study periods in VSQC and TSQC patient populations (both P > 0.05).

CONCLUSIONS

ME was associated with decreased 30-d morbidity and unplanned readmissions in the VSQC. Data-driven policies accounting for ME benefits should be considered.

The Impact of Medicaid Expansion on Early-Stage Pancreatic Adenocarcinoma at High- Versus Low-Volume Facilities

INTRODUCTION

While Medicaid Expansion (ME) has improved healthcare access, disparities in outcomes after volume-dependent surgical care persist. We sought to characterize the impact of ME on postoperative outcomes among patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) at high-volume (HVF) versus low-volume (LVF) facilities.

METHODS

Patients who underwent resection for PDAC were identified from the National Cancer Database (NCDB; 2011-2018). HVF was defined as ≥20 resections/year. Patients were divided into pre- and post-ME cohorts, and the primary outcome was textbook oncologic outcomes (TOO). Difference-in-difference (DID) analysis was used to assess changes in TOO achievement among patients living in ME versus non-ME states.

RESULTS

Among 33,764 patients who underwent resection of PDAC, 19.1% (n = 6461) were treated at HVF. Rates of TOO achievement were higher at HVF (HVF: 45.7% vs. LVF: 32.8%; p < 0.001). On multivariable analysis, undergoing surgery at HVF was associated with higher odds of achieving TOO (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.49-1.72) and improved overall survival (OS) [hazard ratio (HR) 0.96, 95% CI 0.92-0.99]. Compared with patients living in non-ME states, individuals living in ME states were more likely to achieve TOO on adjusted DID analysis (5.4%, p = 0.041). Although rates of TOO achievement did not improve after ME at HVF (3.7%, p = 0.574), ME contributed to markedly higher rates of TOO among patients treated at LVF (6.7%, p = 0.022).

CONCLUSIONS

Although outcomes for PDAC remain volume-dependent, ME has contributed to significant improvement in TOO achievement among patients treated at LVF. These data highlight the impact of ME on reducing disparities in surgical outcomes relative to site of care.

Disparities in Time to Diagnosis Among Patients With Multiple Myeloma

BACKGROUND

Multiple myeloma (MM) is one of the most diagnosed hematologic malignancies in the United States. Despite improvements in therapy, health disparities persist among patients with MM. Here, we aim to determine whether there are disparities in time to diagnosis (TTD) among MM patients with regard to income, race/ethnicity, and gender.

PATIENTS

Patients with a monoclonal protein detected in the serum and/or urine and a subsequent bone marrow biopsy confirmed diagnosis of MM were included in the study.

METHODS

We extracted data on patients with MM and assessed whether the predictor variables were associated with the primary outcome of TTD, which we define as the time between detection of a monoclonal protein in the serum or urine and bone marrow biopsy diagnosis of MM.

RESULTS

Compared to patients with commercial insurance, patients receiving Medicaid (HR: 0.408, 95% CI: 0.206-0.808; P = .010) and patients without insurance (HR: 0.428, 95% CI: 0.207-0.885; P = .022) were significantly more likely to have delayed TTD. TTD was also prolonged if the provider who ordered the testing for the detection of a monoclonal protein was not a hematologist (HR: 0.435, 95% CI: 0.284-0.668; P < .0001). No disparities were found with regard to race/ethnicity or gender.

CONCLUSION

This study suggests there may be socioeconomic disparities in TTD among patients with MM. Interventions such as patient navigation may be useful to reduce TTD among socioeconomically disadvantaged patient populations. Further studies need to be conducted to elucidate reasons for delays.

[Socioeconomic status and cecal adenocarcinoma mortality risk: an American population-based analysis]

OBJECTIVE

To explore the relationship between socioeconomic status (SES) and disease mortality in patients with cecal adenocarcinoma in America through the Surveillance, Epidemiology, and End results (SEER) database.

METHODS

The SEER database was queried for patients with cecal adenocarcinoma in America diagnosed from 2011 to 2015. Factor analysis, cluster analysis, and univariate and multivariate Cox proportional hazard models were used for data analysis. Five social security factors were identified: factor 1, economic and educational disadvantage; factor 2, characteristics related to immigration (language isolation and foreign birth); factor 3, high relocation rate in the county; factor 4, high intra-state relocation rate; and factor 5, high domestic relocation rate. Five clusters defined by SES were identified.

RESULTS

The number of all-cause deaths among 17 185 patients was 5948, and the number of survivors was 11, 237. In the multivariate Cox regression analysis, with cluster 1 (low poverty rate and high education level) as the reference, the hazard ratio (HR) of cluster 3 (high intra-county mobility rate) was 1.13 (95% CI: 1.04-1.21, P < 0.05), and the risk was 13% higher than that of cluster 1. The HR of cluster 4 (low language isolation, foreign birth, housing overcrowding, and intra-country mobility rates) was 1.15 (95% CI: 1.07- 1.24, P < 0.001) with a 15% higher risk than cluster 1. The HR of cluster 5 (economic and educational disadvantages, immigration-related characteristics, and low intra-country mobility) was 1.11 (95% CI: 1.03-1.20, P < 0.01) with a 11% higher risk. The factors related to SES indicators were based on the mortality of patients with cecal adenocarcinoma, indicating that low economic and education levels are risk factors for cecal adenocarcinoma.

CONCLUSION

Low socioeconomic status is associated with an increased risk of death in patients with cecal adenocarcinoma in the United States and show different distribution patterns based on population. Improving health insurance policies and strengthening psychotherapy can provide guidance for improving prognosis f cecal adenocarcinoma patients.

The Impact of Medicaid Expansion on Early-Stage Hepatocellular Carcinoma Care

INTRODUCTION

The impact of Medicaid expansion (ME) on hepatocellular carcinoma (HCC) remains controversial, and heterogeneous effects on care processes may relate to sociodemographic factors. We sought to evaluate the association between ME and receipt of surgery in early-stage HCC.

METHODS

Patients diagnosed with early-stage HCC between 40 and 64 years of age were identified from the National Cancer Database and divided into pre- (2004-2012) and post- (2015-2017) expansion cohorts. Logistic regression was used to identify predictors of surgical treatment. Difference-in-difference (DID) analysis assessed changes in surgical treatment between patients living in ME and non-ME states.

RESULTS

Among 19,745 patients, 12,220 (61.9%) were diagnosed before ME and 7525 (38.1%) after. Although overall utilization of surgery decreased after expansion (ME, pre-expansion: 62.2% versus post-expansion: 51.6%; non-ME, pre-expansion: 62.1% versus post-expansion: 50.8%, p < 0.001), this trend varied relative to insurance status. Notably, receipt of surgery increased among uninsured/Medicaid patients living in ME states after expansion (pre-expansion: 48.1%, post-expansion: 52.3%, p < 0.001). Moreover, treatment at academic or high-volume facilities increased the likelihood of undergoing surgery before expansion. After expansion, treatment at an academic facility and living in an ME state (OR 1.28, 95% CI 1.07-1.54, p < 0.01) were predictors of surgical treatment. DID analysis demonstrated increased utilization of surgery for uninsured/Medicaid patients living in ME states relative to non-ME states (uninsured/Medicaid: 6.4%, p < 0.05), although no differences were noted among patients with other insurance statuses (overall: 0.7%, private: -2.0%, other: 0.3%, all p > 0.05).

CONCLUSIONS

Implementation of ME heterogeneously impacted utilization of care in early-stage HCC. Notably, uninsured/Medicaid patients residing in ME states demonstrated increased utilization of surgical treatment after expansion.

Medicaid Expansion Associated With Increase In Palliative Care For People With Advanced-Stage Cancers

Clinical guidelines have endorsed early palliative care for patients with advanced malignancies, but receipt remains low in the US. This study examined the association between Medicaid expansion under the Affordable Care Act and receipt of palliative care among patients newly diagnosed with advanced-stage cancers. Using the National Cancer Database, we found that the percentage of eligible patients who received palliative care as part of first-course treatment increased from 17.0 percent preexpansion to 18.9 percent postexpansion in Medicaid expansion states and from 15.7 percent to 16.7 percent, respectively, in nonexpansion states, resulting in a net increase of 1.3 percentage points in expansion states in adjusted analyses. Increases in receipt of palliative care associated with Medicaid expansion were largest for patients with advanced pancreatic, colorectal, lung, and oral cavity and pharynx cancers and non-Hodgkin lymphoma. Our findings suggest that increasing Medicaid coverage facilitates access to guideline-based palliative care for advanced cancer, and they provide additional evidence of benefit in cancer care from states' expansion of income eligibility for Medicaid.

Social Determinants of Health and Impact in Perioperative Space

The Centers for Disease Control and Prevention (CDC) defines the social determinants of health (SDOH) as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a range of health, functioning, and quality-of-life outcomes and risks," which includes economic stability, access to quality health care, and physical environment. There is increasing evidence that SDOH have an impact in shaping a patient's access and recovery from surgery. This review evaluates the role surgeons play in reducing these disparities.

Understanding Factors Leading to Surgical Attrition for "Resectable" Gastric Cancer

OBJECTIVES

We used a novel combined analysis to evaluate various factors associated with failure to surgical resection in non-metastatic gastric cancer.

METHODS

We identified factors associated with the receipt of surgery in publicly available clinical trial data for gastric cancer and in the National Cancer Database (NCDB) for patients with stages I-III gastric adenocarcinoma. Next, we evaluated variable importance in predicting the receipt of surgery in the NCDB.

RESULTS

In published clinical trial data, 10% of patients in surgery-first arms did not undergo surgery, mostly due to disease progression and 15% of patients in neoadjuvant therapy arms failed to reach surgery. Effects related to neoadjuvant administration explained the increased attrition (5%). In the NCDB, 61.7% of patients underwent definitive surgery. In a subset of NCDB patients resembling those enrolled in clinical trials (younger, healthier, and privately insured patients treated at high-volume and academic centers) the rate of surgery was 79.2%. Decreased likelihood of surgery was associated with advanced age (OR 0.97, p < 0.01), Charlson-Deyo score of 2+ (OR 0.90, p < 0.01), T4 tumors (OR 0.39, p < 0.01), N+ disease (OR 0.84, p < 0.01), low socioeconomic status (OR 0.86, p = 0.01), uninsured or on Medicaid (OR 0.58 and 0.69, respectively, p < 0.01), low facility volume (OR 0.64, p < 0.01), and non-academic cancer programs (OR 0.79, p < 0.01).

CONCLUSION

Review of clinical trials shows attrition due to unavoidable tumor and treatment factors (~ 15%). The NCDB indicates non-medical patient and provider characteristics (i.e., age, insurance status, facility volume) associated with attrition. This combined analysis highlights specific opportunities for improving potentially curative surgery rates.

Specialist access and leg amputations among Texas Medicaid patients

Medicaid coverage among patients with peripheral artery disease (PAD) has been associated with higher rates of primary amputations. We sought to determine the relative contributions of clinical, demographic, and hospital factors to leg amputations among Texas Medicaid patients. Patient-level data were used to identify patients who underwent treatment for PAD-related foot complications in Texas. Patients were categorized into groups by insurance provider (Medicaid, Medicare, dual-enrollee, commercial, and provider network). Individual- and area-level multivariate analyses were used to find associations with primary amputation. Of 21,592 patients identified, 8.8% were covered by Medicaid, 35.3% by Medicare, 27.8% by Medicare and Medicaid, 7.3% by commercial insurance, and 20.7% by a provider network. Compared with commercially insured patients, Medicaid patients more often underwent amputation (33% v 49%), were categorized as Black or Hispanic (45% v 64%), presented with gangrene (61% v 71%), were admitted through an emergency department (61% v 73%), and were admitted to a safety net hospital (3% v 16%). They had lower relative rates of outpatient evaluation (1.33 v 0.55) and their hospitalizations were less centralized (Gini coefficient 0.43 v 0.39) (P < .001 for all). Amputations among Medicaid patients were associated with infection and gangrene, care at safety net hospitals, rate of outpatient visits, and Black and Hispanic race, even after risk-adjustment (P < .001). Leg amputations among Medicaid patients were associated with race, disease severity, hospital characteristics, and outpatient evaluation rates, but not with provider density and location. Focusing efforts on preventative care and early outpatient referrals could help address this disparity.

Medicaid expansion and surgery for HPB/GI cancers: NCDB difference-in-difference analysis

BACKGROUND

It is unclear if Medicaid expansion improved access to surgical resection for hepatopancreatobiliary (HPB) and gastrointestinal (GI) cancers.

METHODS

This was a quasi-experimental, cohort study using difference-in-difference analysis to evaluate differences in surgical resection for HPB/GI cancers in the post-Medicaid expansion era compared to the pre-Medicaid expansion era among patients residing in states that had Medicaid expansion versus not.

RESULTS

During the pre- (2011-2013) and post-Medicaid expansion (2015-2017) eras, there were 49,954 patients between the ages of 40-64 who had liver cancer (n = 19,384; 38.8%), pancreatic cancer (n = 14,351; 28.7%), colorectal liver metastasis (n = 7566; 15.1%), or gastric cancer (n = 8653; 17.3%). 43.2% resided in expansion states (n = 21,577). There were no significant differences in the overall rates of surgical resection between expansion and non-expansion states before and after Medicaid expansion.

CONCLUSIONS

Medicaid expansion did not impact surgical resection for HPB/GI cancers.

Palliative Therapies in Metastatic Pancreatic Cancer: Does Medicaid Expansion Make a Difference?

BACKGROUND

The aim of this study was to evaluate the impact of medicaid expansion (ME) on receipt of palliative therapies in metastatic pancreatic cancer patients.

PATIENTS AND METHODS

A difference-in-differences (DID) approach was used to analyze patients with metastatic pancreatic cancer identified from the National Cancer Database diagnosed during two time periods: pre-expansion (2010-2012) and post-expansion (2014-2016). Patients diagnosed while residing in ME states were compared with those in non-ME states. Multivariable logistic regression was used to identify predictors of receipt of palliative therapies.

RESULTS

Of 87,738 patients overall, 7483(18.1%) received palliative therapies in the pre-expansion, while 10,211(21.5%) received palliative therapies in the post-expansion period. In the pre-expansion period, treatment at a high-volume facility (HVF) (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.02-1.18) and non-west geographic location were predictive of increased palliative therapies. In the post-expansion period, treatment at an HVF (OR 1.09, 95% CI 1.02-1.16), geographic location, and living in an ME state at the time of diagnosis (OR 1.14, 95% CI 1.06-1.22) were predictive of increased palliative therapies. Older age, highest quartile median income (zip-code based), and treatment at a nonacademic facility were independently associated with decreased palliative therapies in both periods. DID analysis demonstrated that patients with metastatic pancreatic cancer living in ME states had increased receipt of palliative therapies relative to those in non-ME states (DID = 2.68, p < 0.001).

CONCLUSIONS

The overall utilization of palliative therapies in metastatic pancreatic cancer is low. Multiple sociodemographic disparities exist in the receipt of palliative therapies. ME is associated with increased receipt of palliative therapies in patients with metastatic pancreatic cancer.

Post-Affordable Care Act Improvements in Cancer Stage Among Ohio Medicaid Beneficiaries Resulted From an Increase in Stable Coverage

BACKGROUND

The mechanisms underlying improvements in early-stage cancer at diagnosis following Medicaid expansion remain unknown. We hypothesized that Medicaid expansion allowed for low-income adults to enroll in Medicaid before cancer diagnosis, thus increasing the number of stably-enrolled relative to those who enroll in Medicaid only after diagnosis (emergently-enrolled).

METHODS

Using data from the 2011-2017 Ohio Cancer Incidence Surveillance System and Medicaid enrollment files, we identified individuals diagnosed with incident invasive breast (n=4850), cervical (n=1023), and colorectal (n=3363) cancer. We conducted causal mediation analysis to estimate the direct effect of pre- (vs. post-) expansion on being diagnosed with early-stage (-vs. regional-stage and distant-stage) disease, and indirect (mediation) effect through being in the stably- (vs. emergently-) enrolled group, controlling for individual-level and area-level characteristics.

RESULTS

The percentage of stably-enrolled patients increased from 63.3% to 73.9% post-expansion, while that of the emergently-enrolled decreased from 36.7% to 26.1%. The percentage of patients with early-stage diagnosis remained 1.3-2.9 times higher among the stably-than the emergently-enrolled group, both pre-expansion and post-expansion. Results from the causal mediation analysis showed that there was an indirect effect of Medicaid expansion through being in the stably- (vs. emergently-) enrolled group [risk ratios with 95% confidence interval: 1.018 (1.010-1.027) for breast cancer, 1.115 (1.064-1.167) for cervical cancer, and 1.090 (1.062-1.118) for colorectal cancer.

CONCLUSION

We provide the first evidence that post-expansion improvements in cancer stage were caused by an increased reliance on Medicaid as a source of stable insurance coverage.

Application of RNA processing factors for predicting clinical outcomes in colon cancer

Background: Colon cancer is the fifth most common cause of cancer-related death worldwide, and despite significant advances in related treatment, the prognosis of colon cancer patients remains poor.

Objective: This study performs systematic bioinformatics analysis of prognostic-associated RNA processing factor genes in colon cancer using the Cancer Related Genome Atlas database to explore their role in colon carcinogenesis and prognosis and excavate potential therapeutic targets.

Methods: Data sets of colon cancer patients were obtained from GEO and TCGA databases. Univariate cox analysis was performed on the GSE39582 training set to identify prognosis-associated RNA processing factor genes and constructed a muticox model. The predictive performance of the model was validated by Correlation curve analysis. Similar results were obtained for the test dataset. Functional analyses were performed to explore the underlying mechanisms of colon carcinogenesis and prognosis.

Results: A constructed muticox model consisting of βi and prognosis-related RNA processing factor gene expression levels (Expi) was established to evaluate the risk score of each patient. The subgroup with a higher risk score had lower overall survival (OS), higher risk factor, and mortality. We found that the risk score, age, gender, and TNM Stage were strongly associated with OS, and the 13-gene signature as an independent prognostic factor for colon cancer. The model has good accuracy in predicting patient survival and is superior to traditional pathological staging.

Conclusion: This study proposes 13 RNA processing factor genes as a prognostic factor for colon cancer patients, which can independently predict the clinical outcome by risk score. The gene expression profile in this model is closely related to the immune status and prognosis of colon cancer patients. The interaction of the 13 RNA processing factor genes with the immune system during colon carcinogenesis provides new ideas for the molecular mechanisms and targeted therapies for colon cancer.

Sociodemographic factors associated with Wilms tumor treatment and survival: a population-based study

INTRODUCTION

Though Wilms tumor (WT) is one of the most common malignancies in children, there is a paucity of epidemiologic studies exploring sociodemographic disparities in treatment and survival. Here, we leveraged a national cancer registry to examine sociodemographic factors associated with receipt of adjuvant therapy, either chemotherapy or radiation, as well as overall survival among pediatric patients with WT.

MATERIALS AND METHODS

Within the Surveillance Epidemiology and End Results database (2000-2016), we identified 2043 patients (≤ 20 years of age) with unilateral WT. Multivariable logistic regression and Cox proportional hazard models were constructed to examine the association of sociodemographic factors with, respectively, adjuvant chemotherapy/radiotherapy and overall survival (OS).

RESULTS

Patients in the lowest SES quintile (OR 0.56, 95% CI 0.33-0.93, p = 0.03) were less likely to receive chemotherapy as compared to those in the highest SES quintile, though this association did not persist in sensitivity analyses including only patients at least 2 years of age and patients with regional/distant disease. In addition, female patients were more likely to receive chemotherapy (OR 1.46, 95% CI 1.08-1.97, p = 0.02) than male patients. Age, race, year of diagnosis, insurance status, and tumor laterality were not associated with receipt of chemotherapy. No sociodemographic variables were associated with receipt of radiotherapy. Lastly, as compared to Non-Hispanic-White patients, Hispanic patients had worse OS (HR 1.59, 95% CI 1.08-2.35, p = 0.02); no other sociodemographic variables were associated with OS.

CONCLUSIONS

This study suggests multilevel sociodemographic disparities involving ethnicity and SES in WT treatment and survival.

Medicaid expansion is associated with a higher likelihood of early diagnosis, resection, transplantation, and overall survival in patients with hepatocellular carcinoma

BACKGROUND

We examined the association between Medicaid expansion (ME) and the diagnosis, treatment, and survival of patients with hepatocellular carcinoma (HCC).

METHODS

We identified patients with HCC <65yrs with Medicaid or without insurance within the National Cancer Database before (2010-2013) or after (2015-2017) ME with early (cT1) or intermediate/advanced (cT2-T4 or M1) disease.

RESULTS

We identified 4848 patients with HCC before and 4526 after ME. Prior to ME, there was no association between future ME status and diagnosis of early HCC (34.5% vs. 32.9%). There was no association between future ME status and treating early HCC with ablation, resection, or transplantation. Patients with early HCC in future ME states were less likely to die (HR = 0.81, 95% CI: 0.67-0.98). After ME, patients in ME states were more likely to be diagnosed with early HCC (39.2% vs. 32.1%). Patients with early disease in ME states were more likely to undergo resection (OR=1.78, 95% CI: 1.16-2.75) or transplantation (OR=3.20, 95% CI: 1.40-7.33). There was a further associated decrease in the hazard of death (HR=0.68, 95% CI: 0.54-0.86).

CONCLUSION

ME was associated with early diagnosis of HCC. For early HCC, ME was associated with increased utilization of resection and transplantation and improvement in survival.

Impact of Medicaid Expansion Under the Affordable Care Act on Receipt of Surgery for Breast Cancer

To determine whether Medicaid expansion under the 2010 Affordable Care Act affected rates of breast cancer surgery.

Impact of the affordable care act's medicaid expansion on presentation stage and perioperative outcomes of colorectal cancer

BACKGROUND AND OBJECTIVES

Medicaid expansion has improved healthcare coverage and preventive health service use. To what extent this has resulted in earlier stage colorectal cancer diagnoses and impacted perioperative outcomes is unclear.

METHODS

This was a retrospective difference-in-difference study using the National Cancer Database on adults (40-64) with Medicaid or no insurance, diagnosed with colorectal adenocarcinomas before (2010-2013) and after (2015-2018) expansion. The primary outcome was early-stage (American Joint Committee on Cancer Stage 0-1) diagnosis. The secondary outcomes were rate of local excision, emergency surgery, postoperative length of stay, rates of minimally invasive surgery, postoperative mortality, and overall survival (OS).

RESULTS

Medicaid expansion was associated with an increase in early-stage diagnoses for patients with colorectal cancers (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.15-1.43), an increase in local excision (OR: 1.39, 95% CI: 1.13-1.69), and a decreased rate of emergent surgery (OR: 0.85, 95% CI: 0.75-0.97) and 90-day mortality (OR: 0.75, 95% CI: 0.59-0.97). Additionally, patients in expansion states postexpansion had an improved 5-year OS (hazard ratio: 0.88, 95% CI: 0.83-0.94).

CONCLUSIONS

Insurance coverage expansion may be particularly important for optimizing stage of diagnosis, subsequent survival, and perioperative outcomes for socioeconomically vulnerable patients.

Acceptance of Simulated Adult Patients With Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis

IMPORTANCE

Although there have been significant increases in the number of US residents insured through Medicaid, the ability of patients with Medicaid to access cancer care services is less well known.

OBJECTIVE

To assess facility-level acceptance of Medicaid insurance among patients diagnosed with common cancers.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional secret shopper study was conducted in 2020 in a random sample of Commission on Cancer-accredited facilities in the United States using a simulated cohort of Medicaid-insured adult patients with colorectal, breast, kidney, and melanoma skin cancer.

EXPOSURES

Telephone call requesting an appointment for a patient with Medicaid with a new cancer diagnosis.

MAIN OUTCOMES AND MEASURES

Acceptance of Medicaid insurance for cancer care. Descriptive statistics, χ2 tests, and multivariable logistic regression models were used to examine factors associated with Medicaid acceptance for colorectal, breast, kidney, and skin cancer. High access hospitals were defined as those offering care across all 4 cancer types surveyed. Explanatory measures included facility-level factors from the 2016 American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services General Information database.

RESULTS

A nationally representative sample of 334 facilities was created, of which 226 (67.7%) provided high access to patients with Medicaid seeking cancer care. Medicaid acceptance differed by cancer site, with 319 facilities (95.5%) accepting Medicaid insurance for breast cancer care; 302 (90.4%), colorectal; 290 (86.8%), kidney; and 266 (79.6%), skin. Comprehensive community cancer programs (OR, 0.4; 95% CI, 0.2-0.7; P = .007) were significantly less likely to provide high access to care for patients with Medicaid. Facilities with nongovernment, nonprofit (vs for-profit: OR, 3.5; 95% CI, 1.1-10.8; P = .03) and government (vs for-profit: OR, 6.6; 95% CI, 1.6-27.2; P = .01) ownership, integrated salary models (OR, 2.6; 95% CI, 1.5-4.5; P = .001), and average (vs above-average: OR, 6.4; 95% CI, 1.4-29.6; P = .02) or below-average (vs above-average: OR, 8.4; 95% CI, 1.5-47.5; P = .02) effectiveness of care were associated with high access to Medicaid. State Medicaid expansion status was not significantly associated with high access.

CONCLUSIONS AND RELEVANCE

This study identified access disparities for patients with Medicaid insurance at centers designated for high-quality care. These findings highlight gaps in cancer care for the expanding population of patients receiving Medicaid.

Medicaid Expansions: Probing Medicaid's Filling of the Cancer Genetic Testing and Screening Space

Cancer is the third largest source of spending for Medicaid in the United States. A working group of the American Public Health Association Genomics Forum Policy Committee reviewed 133/149 pieces of literature addressing the impact of Medicaid expansion on cancer screening and genetic testing in underserved groups and the general population. Breast and colorectal cancer screening rates improved during very early Medicaid expansion but displayed mixed improvement thereafter. Breast cancer screening rates have remained steady for Latina Medicaid enrollees; colorectal cancer screening rates have improved for African Americans. Urban areas have benefited more than rural. State programs increasingly cover BRCA1/2 and Lynch syndrome genetic testing, though testing remains underutilized in racial and ethnic groups. While increased federal matching could incentivize more states to engage in Medicaid expansion, steps need to be taken to ensure that they have an adequate distribution of resources to increase screening and testing utilization.

Is Medicaid Expansion Associated with Improved Nonmetastatic Colon Cancer Survival? An Analysis of the National Cancer Database

METHODS

This retrospective study of 86 413 patients (40-64 years old) undergoing surgical resection for a new diagnosis of invasive, nonmetastatic colon cancer included in the National Cancer Database (NCDB) from 2010 to 2015 compared overall survival (OS) in MES to NES. Cox proportional hazard models, fit for OS, and propensity score-matching (PSM) analysis were performed.

RESULTS

In this sample, 51 297 cases (59.2%) lived in MES and 35 116 (40.8%) in NES. Medicaid expansion states had earlier pathological stage compared to NES (stage I 25.38% vs 24.17%, stage II 32.93 vs 33.4%, and stage III 41.69 vs 42.43%; P < .001). 5-year OS in MES was higher than NES (79.1% vs 77.3%; P < .001); however, on both multivariable analysis (MVA) and PSM analysis, MES did not have significantly different OS from NES (hazard ratio (HR), .99, 95% confidence interval (CI), .95-1.03; P = .570; HR, .99, 95% CI, .95-1.03; P = .68).

CONCLUSION

Among NCDB patients with invasive, nonmetastatic colon cancer residing in MES at time of diagnosis was associated with earlier pathological stage. However, on both MVA and PSM analysis, OS was not significantly different in MES vs NES. Research on patient outcomes, such as receipt of guideline concordant care, can further inform the impact of insurance coverage expansion efforts on cancer outcomes.

Impact of Medicaid Expansion on the Diagnosis, Treatment, and Outcomes of Stage II and III Rectal Cancer Patients

BACKGROUND

Insurance status has been associated with disparities in stage at cancer diagnosis. We examined how Medicaid expansion (ME) impacted diagnoses, surgical treatment, use of neoadjuvant therapies (NCRT), and outcomes for Stage II and III rectal cancer.

STUDY DESIGN

We used 2010-2017 American College of Surgeons National Cancer Database (NCDB) to identify patients ages 18-65, with Medicaid as primary form of payment, and were diagnosed with Stage II or III rectal cancer. Patients were stratified based on Census bureau division's ME adoption rates of High, Medium, Low. Overall trends were examined, and patient characteristics and outcomes were compared before and after ME date of 1/1/2014.

RESULTS

Over 8 years of NCDB data examined, there was an increasing trend of Stage II and III rectal cancer diagnoses, surgical resection, and use of NCRT for Medicaid patients. We observed an increase in age, proportion of White Medicaid patients in Low ME divisions, and proportion of fourth income quartile patients in High ME divisions. Univariate analysis showed decreased use of open surgery for all 3 categories after ME, but adjusted odds ratios (aOR) were not significant based on multivariate analysis. NCRT utilization increased after ME for all 3 ME adoption categories and aOR significantly increased for Low and High ME divisions. ME significantly decreased 90-day mortality.

CONCLUSIONS

Medicaid expansion had important impacts on increasing Stage II and III rectal cancer diagnoses, use of NCRT, and decreased 90-day mortality for patients with Medicaid. Our study supports increasing health insurance coverage to improve Medicaid patient outcomes in rectal cancer care.

Impact of Medicaid Expansion on Pancreatic Cancer: An Examination of Sociodemographic Disparity in 1-Year Survival

BACKGROUND

This study examined the effect of Medicaid expansion on 1-year survival of pancreatic cancer for nonelderly adults. We further evaluated whether sociodemographic and county characteristics alter the association of Medicaid expansion and 1-year survival.

STUDY DESIGN

We obtained data from the Surveillance Epidemiology and End-Results dataset on individuals diagnosed with pancreatic cancer from 2007 to 2015. A Difference-in-Differences model compared those from early-adopting states to non-early-adopting states, before and after adoption (2014), while taking into consideration sociodemographic and county characteristics to estimate the effect of Medicaid expansion on 1-year survival.

RESULTS

In the univariable Difference-in-Differences model, the probability of 1-year survival for pancreatic cancer increased by 4.8 percentage points (ppt) for those from Medicaid expansion states postexpansion (n = 35,347). After adjustment for covariates, the probability of 1-year survival was reduced to 0.8 ppt. Interestingly, after multivariable adjustment the effect of living in an expansion state on 1-year survival was similar for men and women (0.6 ppt for men vs 1.2 ppt for women), was also similar for Whites (2.6 ppt), and was higher in those of other races (5.9 ppt) but decreased for Blacks (-2.0 ppt). Those who were insured (-0.1 ppt) or uninsured (-2.2 ppt) experienced a decrease in the probability of 1-year survival; however, those who were covered by Medicaid at diagnosis experienced an increase in the probability of 1-year survival (7.4 ppt).

CONCLUSIONS

Medicaid expansion during or after 2014 is associated with an increase in the probability of 1-year survival for pancreatic cancer; however, this effect is attenuated after adjustment for sociodemographic characteristics. Of note, the positive association was more pronounced in certain categories of key covariates suggesting further inquiry focused on these subgroups.

Association of State Medicaid Expansion Status With Hypertensive Disorders of Pregnancy in a Singleton First Live Birth

BACKGROUND

Incidence of hypertensive disorders of pregnancy is increasing in the United States. Early detection is important to prevent adverse maternal and offspring outcomes. This ecological study evaluated changes in rates of hypertensive disorders of pregnancy among states that expanded Medicaid compared with states that did not expand Medicaid.

METHODS

A quasi-experimental analysis using difference-in-differences models compared changes in rates of hypertensive disorders of pregnancy in Medicaid expansion states relative to non-Medicaid expansion states from 2012 to 2019. Maternal data from singleton first live births to individuals aged 20 to 39 years were obtained from the National Center for Health Statistics. Outcomes of interest included age-adjusted rates of de novo hypertension in pregnancy (gestational hypertension or preeclampsia) and prepregnancy hypertension.

RESULTS

Data from 7 764 965 individuals with a singleton first live birth were analyzed from 17 states and Washington, DC that expanded Medicaid and 15 states that did not. Rates of de novo hypertension in pregnancy increased over the study period in both expansion (54.34 [95% CI, 48.25-60.43] to 74.87 [95% CI, 71.20-78.55] per 1000 births) and nonexpansion states (68.32 [95% CI, 61.02-75.62] to 84.79 [95% CI, 80.67-88.91] per 1000 births). In adjusted difference-in-differences analyses, expansion status was associated with a greater increase in rates of de novo hypertension in pregnancy (difference-in-differences coefficient, +8.18 [95% CI, 4.00-12.36] per 1000 live births) but a decline in rates of de novo hypertension in pregnancy complicated by low birth weight (-7.20 [95% CI, -13.71 to -0.70] per 1000 births with hypertensive disorders of pregnancy). In adjusted difference-in-differences analyses, there were no significant changes in rates of prepregnancy hypertension in expansion relative to nonexpansion states (+1.13 [95% CI, -0.09 to +2.35] per 1000 live births).

CONCLUSIONS

Between 2012 and 2019, states that expanded Medicaid had a significantly greater increase in rates of de novo hypertension, with some evidence of better outcomes among those with de novo hypertension diagnosed in pregnancy.

Medicaid expansion and the management of pancreatic cancer

BACKGROUND

Medicaid expansion under the Affordable Care Act has improved access to screening and treatment for certain cancers. It is unclear how this policy has affected the diagnosis and management of pancreatic cancer.

METHODS

Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during two time periods: pre-expansion (2011-2012) and postexpansion (2015-2016). We investigated changes in cancer staging, treatment decisions, and surgical outcomes.

RESULTS

In this national cohort, pancreatic cancer patients in expansion states had increased Medicaid coverage relative to those in nonexpansion states (DID = 17.49, p < 0.01). Medicaid expansion also led to an increase in early-stage diagnoses (Stage I/II, DID = 4.71, p = 0.03), higher comorbidity scores among surgical patients (Charlson/Deyo score 0: DID = -13.69, p = 0.02), a trend toward more neoadjuvant radiation (DID = 6.15, p = 0.06), and more positive margins (DID = 11.69, p = 0.02). There were no differences in rates of surgery, postoperative outcomes, or overall survival.

CONCLUSION

Medicaid expansion was associated with improved insurance coverage and earlier stage diagnoses for Medicaid and uninsured pancreatic cancer patients, but similar surgical outcomes and overall survival. These findings highlight both the benefits of Medicaid expansion and the potential limitations of policy change to improve outcomes for such an aggressive malignancy.

Is Medicaid expansion associated with increases in palliative treatments for metastatic cancer?

Background: Medicaid expansion following the 2010 Affordable Care Act has an unknown impact on palliative treatments. Materials & methods: This registry-based study of individuals with metastatic cancer from 2010 to 2016 identified men and women with metastatic cancer in expansion and non-expansion states who received palliative treatments. A mixed effects logistic regression compared trends in expansion and non-expansion states and generated risk-adjusted probabilities or receiving palliative treatments each year. Results: Despite lower baseline use of palliative treatments, the rate of change was more rapid in expansion states (odds ratio [OR]: 1.02; 95% CI: 1.01-1.03; p < 0.001). The adjusted probability of receiving palliative treatments rose from 21.3 to 26.0% in non-expansion states, and from 19.7 to 26.9% in expansion states. Conclusion: Use of palliative treatments among metastatic cancer patients increased from 2010 to 2016 with a significantly greater increase in Medicaid expansion states, even when adjusting for demographic differences between states.