Medicaid status and stage at diagnosis of cervical cancer

Survival disparities in non-Hispanic Black and White cervical cancer patients vary by histology and are largely explained by modifiable factors

PURPOSE

We investigated racial disparities in survival by histology in cervical cancer and examined the factors contributing to these disparities.

METHODS

Non-Hispanic Black and non-Hispanic White (hereafter known as Black and White) patients with stage I-IV cervical carcinoma diagnosed between 2004 and 2017 in the National Cancer Database were studied. Survival differences were compared using Cox modeling to estimate hazard ratio (HR) or adjusted HR (AHR) and 95% confidence interval (CI). The contribution of demographic, socioeconomic and clinical factors to the Black vs White differences in survival was estimated after applying propensity score weighting in patients with squamous cell carcinoma (SCC) or adenocarcinoma (AC).

RESULTS

This study included 10,111 Black and 43,252 White patients with cervical cancer. Black patients had worse survival than White cervical cancer patients (HR = 1.40, 95% CI = 1.35-1.45). Survival disparities between Black and White patients varied significantly by histology (HR = 1.20, 95% CI = 1.15-1.24 for SCC; HR = 2.32, 95% CI = 2.12-2.54 for AC, interaction p < 0.0001). After balancing the selected demographic, socioeconomic and clinical factors, survival in Black vs. White patients was no longer different in those with SCC (AHR = 1.01, 95% CI 0.97-1.06) or AC (AHR = 1.09, 95% CI = 0.96-1.24). In SCC, the largest contributors to survival disparities were neighborhood income and insurance. In AC, age was the most significant contributor followed by neighborhood income, insurance, and stage. Diagnosis of AC (but not SCC) at ≥65 years old was more common in Black vs. White patients (26% vs. 13%, respectively).

CONCLUSIONS

Histology matters in survival disparities and diagnosis at ≥65 years old between Black and White cervical cancer patients. These disparities were largely explained by modifiable factors.

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.

Mediation of Racial and Ethnic Inequities in the Diagnosis of Advanced-Stage Cervical Cancer by Insurance Status

Importance

Black and Hispanic or Latina women are more likely than White women to receive a diagnosis of and to die of cervical cancer. Health insurance coverage is associated with diagnosis at an earlier stage of cervical cancer.

Objective

To evaluate the extent to which racial and ethnic differences in the diagnosis of advanced-stage cervical cancer are mediated by insurance status.

Design, Setting, and Participants

This retrospective, cross-sectional population-based study used data from the Surveillance, Epidemiology, and End Results (SEER) program on an analytic cohort of 23 942 women aged 21 to 64 years who received a diagnosis of cervical cancer between January 1, 2007, and December 31, 2016. Statistical analysis was performed from February 24, 2022, to January 18, 2023.

Exposures

Health inusurance status (private or Medicare insurance vs Medicaid or uninsured).

Main Outcomes and Measures

The primary outcome was a diagnosis of advanced-stage cervical cancer (regional or distant stage). Mediation analyses were performed to assess the proportion of observed racial and ethnic differences in the stage at diagnosis that were mediated by health insurance status.

Results

A total of 23 942 women (median age at diagnosis, 45 years [IQR, 37-54 years]; 12.9% were Black, 24.5% were Hispanic or Latina, and 52.9% were White) were included in the study. A total of 59.4% of the cohort had private or Medicare insurance. Compared with White women, patients of all other racial and ethnic groups had a lower proportion with a diagnosis of early-stage cervical cancer (localized) (American Indian or Alaska Native, 48.7%; Asian or Pacific Islander, 49.9%; Black, 41.7%; Hispanic or Latina, 51.6%; and White, 53.3%). A larger proportion of women with private or Medicare insurance compared with women with Medicaid or uninsured received a diagnosis of an early-stage cancer (57.8% [8082 of 13 964] vs 41.1% [3916 of 9528]). In models adjusting for age, year of diagnosis, histologic type, area-level socioeconomic status, and insurance status, Black women had higher odds of receiving a diagnosis of advanced-stage cervical cancer compared with White women (odds ratio, 1.18 [95% CI, 1.08-1.29]). Health insurance was associated with mediation of more than half (ranging from 51.3% [95% CI, 51.0%-51.6%] for Black women to 55.1% [95% CI, 53.9%-56.3%] for Hispanic or Latina women) the racial and ethnic inequities in the diagnosis of advanced-stage cervical cancer across all racial and ethnic minority groups compared with White women.

Conclusions and Relevance

This cross-sectional study of SEER data suggests that insurance status was a substantial mediator of racial and ethnic inequities in advanced-stage cervical cancer diagnoses. Expanding access to care and improving the quality of services rendered for uninsured patients and those covered by Medicaid may mitigate the known inequities in cervical cancer diagnosis and related outcomes.

Health Insurance Coverage Disruptions and Access to Care and Affordability among Cancer Survivors in the United States

BACKGROUND

Lack of health insurance is associated with having problems with access to high-quality care. We estimated prevalence and evaluated associations of insurance coverage disruptions and access to health care and affordability among cancer survivors in the United States.

METHODS

Adult cancer survivors ages 18 to 64 years with current private or public health insurance were identified from the 2011 to 2018 National Health Interview Survey (n = 7,186). Health insurance coverage disruption was measured as self-reports of any time in the prior year without coverage. Outcomes included preventive services use, problems with care affordability, and cost-related medication nonadherence in the prior year. We used separate multivariable logistic models to evaluate associations between coverage disruptions and study outcomes by current insurance coverage.

RESULTS

Among currently insured survivors, 3.7% [95% confidence interval (95% CI), 3.0%-4.4%] with private, and 7.8% (95% CI, 6.5%-9.4%) with public insurance reported coverage disruptions in 2011 to 2018. We estimated that approximately 260,000 survivors ages 18 to 64 years had coverage disruptions in 2018. Among privately and publicly insured survivors, those with coverage disruptions were less likely to report all preventive services use (16.9% vs. 36.2%; 14.6% vs. 25.3%, respectively) and more likely to report any problems with care affordability (55.0% vs. 17.7%; 71.1% vs. 38.4%, respectively) and any cost-related medication nonadherence (39.4% vs. 10.1%; 36.5% vs. 16.3%, respectively) compared with those continuously insured (all P < 0.05).

CONCLUSIONS

Coverage disruptions in the prior year were associated with problems with health care access and affordability among currently insured survivors.

IMPACT

Reducing coverage disruptions may help improve access and affordability for survivors.

Health Insurance Coverage Disruptions and Cancer Care and Outcomes: Systematic Review of Published Research

BACKGROUND

Lack of health insurance coverage is associated with poor access and receipt of cancer care and survival in the United States. Disruptions in coverage are common among low-income populations, but little is known about associations of disruptions with cancer care, including prevention, screening, and treatment, as well as outcomes of stage at diagnosis and survival.

METHODS

We conducted a systematic review of studies of health insurance coverage disruptions and cancer care and outcomes published between 1980 and 2019. We used the PubMed, EMBASE, Scopus, and CINAHL databases and identified 29 observational studies. Study characteristics and key findings were abstracted and synthesized qualitatively.

RESULTS

Studies evaluated associations between coverage disruptions and prevention or screening (31.0%), treatment (13.8%), end-of-life care (10.3%), stage at diagnosis (44.8%), and survival (20.7%). Coverage disruptions ranged from 4.3% to 32.8% of patients age-eligible for breast, cervical, or colorectal cancer screening. Between 22.1% and 59.5% of patients with Medicaid gained coverage only at or after cancer diagnosis. Coverage disruptions were consistently statistically significantly associated with lower receipt of prevention, screening, and treatment. Among patients with cancer, those with Medicaid disruptions were statistically significantly more likely to have advanced stage (odds ratios = 1.2-3.8) and worse survival (hazard ratios = 1.28-2.43) than patients without disruptions.

CONCLUSIONS

Health insurance coverage disruptions are common and adversely associated with receipt of cancer care and survival. Improved data infrastructure and quasi-experimental study designs will be important for evaluating the associations of federal and state policies on coverage disruptions and care and outcomes.

Impact of Health Insurance on Stage at Cancer Diagnosis Among Adolescents and Young Adults

BACKGROUND

Uninsured adolescents and young adults (AYAs) and those with publicly funded health insurance are more likely to be diagnosed with cancer at later stages. However, prior population-based studies have not distinguished between AYAs who were continuously uninsured from those who gained Medicaid coverage at the time of cancer diagnosis.

METHODS

AYA patients (ages 15-39 years) with nine common cancers diagnosed from 2005 to 2014 were identified using California Cancer Registry data. This cohort was linked to California Medicaid enrollment files to determine continuous enrollment, discontinuous enrollment, or enrollment at diagnosis, with other types of insurance determined from registry data. Multivariable logistic regression was used to evaluate factors associated with later stages at diagnosis.

RESULTS

The majority of 52 774 AYA cancer patients had private or military insurance (67.6%), followed by continuous Medicaid (12.4%), Medicaid at diagnosis (8.5%), discontinuous Medicaid (3.9%), other public insurance (1.6%), no insurance (2.9%), or unknown insurance (3.1%). Of the 13 069 with Medicaid insurance, 50.1% were continuously enrolled. Compared to those who were privately insured, AYAs who enrolled in Medicaid at diagnosis were 2.2-2.5 times more likely to be diagnosed with later stage disease, whereas AYAs discontinuously enrolled were 1.7-1.9 times and AYAs continuously enrolled were 1.4-1.5 times more likely to be diagnosed with later stage disease. Males, those residing in lower socioeconomic neighborhoods, and AYAs of Hispanic or black race and ethnicity (vs non-Hispanic white) were more likely to be diagnosed at a later stage, independent of insurance.

CONCLUSIONS

Our findings suggest that access to continuous medical insurance is important for decreasing the likelihood of late stage cancer diagnosis.

Trends in guideline-adherent fertility-sparing surgery for early-stage cervical cancer before and after the Affordable Care Act

OBJECTIVE

To assess trends in guideline-adherent fertility-sparing surgery (GA-FSS) for early-stage cervical cancer relative to Patient Protection and Affordable Care Act (ACA) implementation.

METHODS

National Cancer Database patients treated for Stage IA1-IB1 cervical cancer from 2004 to 2016 were included. Multivariable logistic regression was used to determined trends in GA-FSS relative to the ACA and identify patient factors independently associated with GA-FSS.

RESULTS

Odds of GA-FSS increased in the post- compared to pre-ACA cohort (aOR = 1.65; 95%CI: 1.34-2.03). Decreasing age, Asian/Pacific Islander race, higher education and income levels, more recent treatment year, and lower clinical stage were independently associated with increased odds of receiving GA-FSS. In the pre- and post-ACA samples, decreasing age (per 1 year age increase; pre-ACA aOR = 0.87, 95%CI:0.85-0.90; post-ACA aOR = 0.85, 95%CI:0.83-0.87), higher education level (top vs. lowest education quartile; pre-ACA aOR = 2.08, 95%CI:1.19-3.65; post-ACA aOR = 2.00, 95%CI:1.43-2.80), and lower clinical stage (stages IA2 [pre-ACA aOR = 0.19, 95%CI:0.09-0.41; post-ACA aOR = 0.29, 95%CI:0.19-0.45] and IB1 [pre-ACA aOR = 0.06, 95%CI:0.06-0.16; post-ACA aOR = 0.16, 95%CI: 0.12-0.20] relative to stage IA1) were independently associated with increased odds of GA-FSS receipt. After the ACA, Asian/Pacific Islander race (aOR = 2.81, 95%CI: 1.81-4.36) and more recent treatment year (Spearman's ρ = 0.0348, p-value = 0.008) were also independently associated with increased odds of GA-FSS receipt. When adjusted for the pre- vs. post-ACA treatment periods, Medicaid patients were less likely to undergo GA-FSS than privately-insured patients (aOR = 1.65; 95%CI:1.34-2.03).

CONCLUSIONS

Patients were more likely to receive GA-FSS post-ACA. Though the proportion of publicly-insured women increased after ACA implementation, women on Medicaid remained less likely to receive GA-FSS than women with private insurance.

Influence of Socioeconomic Status on Stage at Presentation of Laryngeal Cancer in the United States

Objective

Identify socioeconomic predictors of stage at diagnosis of laryngeal cancer in the United States.

Study Design

Retrospective analysis of the North American Association of Central Cancer Registries’ Incidence Data–Cancers in North America Deluxe Analytic File for expanded races.

Setting

All centers reporting to the US Centers for Disease Control and Prevention’s National Program of Cancer Registries.

Subjects and Methods

All cases of laryngeal cancer in adult patients from 2005 to 2013 were reviewed. Ordinal logistic regression models were used to evaluate odd ratios (ORs) for socioeconomic indicators potentially predictive of advancing American Joint Committee on Cancer stage at diagnosis.

Results

A total of 72,472 patients were identified and included. Analysis revealed significant correlation between advanced stage at diagnosis and: Medicaid insurance, lack of insurance, female sex, older age, black race, and certain states of residence. The strongest predictor of advanced stage was lack of insurance (OR, 2.212; P < .001; 95% CI, 2.035-2.406). The strongest protective factor was residing in the state of Utah (OR, 0.571; P < .001; 95% CI, 0.536-0.609). Once adjusted for regional price and wage disparities, relative income was not a significant predictor of stage at presentation across multiple analyses.

Conclusion

Multiple socioeconomic factors were predictive of severity of disease at presentation of laryngeal cancer in the United States. This study demonstrated that insurance type was strongly predictive, whereas relative income had surprisingly little influence.

Development of a goat model for evaluation of withaferin A: Cervical implants for the treatment of cervical intraepithelial neoplasia

Cervical cancer is caused by human papillomavirus (HPV). The disease develops over many years through a series of precancerous lesions. Cervical cancer can be prevented by HPV-vaccination, screening and treatment of precancer before development of cervical cancer. The treatment of high-grade cervical dysplasia (CIN ²⁺) has traditionally been by cervical conization. Surgical procedures are associated with increased risk of undesirable side effects including bleeding, infection, scarring (stenosis), infertility and complications in later pregnancies. An inexpensive, non-invasive method of delivering therapeutics locally will be favorable to treat precancerous cervical lesions without damaging healthy tissue. The feasibility and safety of a sustained, continuous drug-releasing cervical polymeric implant for use in clinical trials was studied using a large animal model. The goat (Capra hircus), non-pregnant adult female Boer goats, was chosen due to similarities in cervical dimensions to the human. Estrus was induced with progesterone CIDR® vaginal implants for 14days followed by the administration of chorionic gonadotropins 48h prior to removal of the progesterone implants to relax the cervix to allow for the placement of the cervical implant. Cervical implants, containing 2% and 4% withaferin A (WFA), with 8 coats of blank polymer, provided sustained release for a long duration and were used for the animal study. The 'mushroom'-shaped cervical polymeric implant, originally designed for women required redesigning to be accommodated within the goat cervix. The cervical implants were well tolerated by the animals with no obvious evidence of discomfort, systemic or local inflammation or toxicity. In addition, we developed a new method to analyze tissue WFA levels by solvent extractions and LS/MS-MS. WFA was found to be localized to the target and adjacent tissues with 12-16ng WFA/g tissue, with essentially no detectable WFA in distant tissues. This study suggests that the goat is a good large animal model for the future development and evaluation of therapeutic efficacy of continuous local drug delivery by cervical polymeric implants to treat precancerous cervical lesions.

Medical costs of treating breast cancer among younger Medicaid beneficiaries by stage at diagnosis

BACKGROUND

Younger women (aged 18-44 years) diagnosed with breast cancer often face more aggressive tumors, higher treatment intensity, and lower survival rates than older women. In this study, we estimated incident breast cancer costs by stage at diagnosis and by race for younger women enrolled in Medicaid.

METHODS

We analyzed cancer registry data linked to Medicaid claims in North Carolina from 2003 to 2008. We used Surveillance, Epidemiology, and End Results (SEER) Summary 2000 definitions for cancer stage. We split breast cancer patients into two cohorts: a younger and older group aged 18-44 and 45-64 years, respectively. We conducted a many-to-one match between patients with and without breast cancer using age, county, race, and Charlson Comorbidity Index. We calculated mean excess total cost of care between breast cancer and non-breast cancer patients.

RESULTS

At diagnosis, younger women had a higher proportion of regional cancers than older women (49 vs. 42%) and lower proportions of localized cancers (44 vs. 50%) and distant cancers (7 vs. 9%). The excess costs of breast cancer (all stages) for younger and older women at 6 months after diagnosis were $37,114 [95% confidence interval (CI) = $35,769-38,459] and $28,026 (95% CI = $27,223-28,829), respectively. In the 6 months after diagnosis, the estimated excess cost was significantly higher to treat localized and regional cancer among younger women than among older women. There were no statistically significant differences in excess costs of breast cancer by race, but differences in treatment modality were present among younger Medicaid beneficiaries.

CONCLUSIONS

Younger breast cancer patients not only had a higher prevalence of late-stage cancer than older women, but also had higher within-stage excess costs.

Treatment Costs of Breast Cancer Among Younger Women Aged 19-44 Years Enrolled in Medicaid

INTRODUCTION

A few studies have examined the costs of breast cancer treatment in a Medicaid population at the state level. However, no study has estimated medical costs for breast cancer treatment at the national level for women aged 19-44 years enrolled in Medicaid.

METHODS

A sample of 5,542 younger women aged 19-44 years enrolled in fee-for-service Medicaid with diagnosis codes for breast cancer in 2007 were compared with 4.3 million women aged 19-44 years enrolled in fee-for-service Medicaid without breast cancer. Nonlinear regression methods estimated prevalent treatment costs for younger women with breast cancer compared with those without breast cancer. Individual medical costs were estimated by race/ethnicity and by type of services. Analyses were conducted in 2013 and all medical treatment costs were adjusted to 2012 U.S. dollars.

RESULTS

The estimated monthly direct medical costs for breast cancer treatment among younger women enrolled in Medicaid was $5,711 (95% CI=$5,039, $6,383) per woman. The estimated monthly cost for outpatient services was $4,058 (95% CI=$3,575, $4,541), for inpatient services was $1,003 (95% CI=$708, $1,298), and for prescription drugs was $539 (95% CI=$431, $647). By race/ethnicity, non-Hispanic white women had the highest monthly total medical costs, followed by Hispanic women and non-Hispanic women of other race.

CONCLUSIONS

Cost estimates demonstrate the substantial medical costs associated with breast cancer treatment for younger Medicaid beneficiaries. As the Medicaid program continues to evolve, the treatment cost estimates could serve as important inputs in decision making regarding planning for treatment of invasive breast cancer in this population.

Breast Cancer Stage and Treatment Among Ohio Medicaid Beneficiaries With and Without Mental Illness

PURPOSE

There is a dearth of studies on cancer outcomes in individuals with mental illness. We compared breast cancer outcomes in Medicaid beneficiaries with and without mental illness.

METHODS

Using records from the 1996 to 2005 Ohio Cancer Incidence Surveillance System (OCISS) and Medicaid files, we identified fee-for-service women age < 65 years diagnosed with incident invasive breast cancer who had enrolled in Medicaid ≥ 3 months before cancer diagnosis (n = 2,177). We retrieved cancer stage, patient demographics, and county of residence from the OCISS. From Medicaid claims data, we identified breast cancer treatment based on procedure codes and mental illness status based on diagnosis codes, prescription drugs dispensed, and service codes. We developed logistic regression models to examine the association between mental illness, cancer stage, and treatment for locoregional disease, adjusting for potential confounders.

RESULTS

Women with mental illness represented 60.2% of the study population. Adjusting for potential confounders, women with mental illness were less likely than those without mental illness to have unstaged or unknown-stage cancer (adjusted odds ratio [OR], 0.61; 95% CI, 0.44 to 0.86; P = .005) or to be diagnosed with distant-stage cancer (adjusted OR, 0.59; 95% CI, 0.40 to 0.85; P = .005). We observed no difference by mental illness status in receipt of definitive treatment (adjusted OR, 1.04; 95% CI, 0.84 to 1.29; P = .08).

CONCLUSION

Among Ohio Medicaid beneficiaries, women with mental illness did not experience disparities in breast cancer stage or treatment of locoregional disease. These findings may reflect the equalizing effects of Medicaid through vulnerable individuals' improved access to both physical and mental health care.

The impact of continuous Medicaid enrollment on diagnosis, treatment, and survival in six surgical cancers

OBJECTIVE

To examine the effect of Medicaid enrollment on the diagnosis, treatment, and survival of six surgically relevant cancers among poor and underserved Californians.

DATA SOURCES

California Cancer Registry (CCR), California's Patient Discharge Database (PDD), and state Medicaid enrollment files between 2002 and 2008.

STUDY DESIGN

We linked clinical and administrative records to differentiate patients continuously enrolled in Medicaid from those receiving coverage at the time of their cancer diagnosis. We developed multivariate logistic regression models to predict death within 1 year for each cancer after controlling for sociodemographic and clinical variables.

DATA COLLECTION/EXTRACTION METHODS

All incident cases of six cancers (colon, esophageal, lung, pancreas, stomach, and ovarian) were identified from CCR. CCR records were linked to hospitalizations (PDD) and monthly Medicaid enrollment.

PRINCIPAL FINDINGS

Continuous enrollment in Medicaid for at least 6 months prior to diagnosis improves survival in three surgically relevant cancers. Discontinuous Medicaid patients have higher stage tumors, undergo fewer definitive operations, and are more likely to die even after risk adjustment.

CONCLUSIONS

Expansion of continuous insurance coverage under the Affordable Care Act is likely to improve both access and clinical outcomes for cancer patients in California.

Impact of state-specific Medicaid reimbursement and eligibility policies on receipt of cancer screening

BACKGROUND

Although state Medicaid programs cover cancer screening, Medicaid beneficiaries are less likely to be screened for cancer and are more likely to present with tumors of an advanced stage than are those with other insurance. The current study was performed to determine whether state Medicaid eligibility and reimbursement policies affect the receipt of breast, cervical, and colon cancer screening among Medicaid beneficiaries.

METHODS

Cross-sectional regression analyses of 2007 Medicaid data from 46 states and the District of Columbia were performed to examine associations between state-specific Medicaid reimbursement/eligibility policies and receipt of cancer screening. The study sample included individuals aged 21 years to 64 years who were enrolled in fee-for-service Medicaid for at least 4 months. Subsamples eligible for each screening test were: Papanicolaou test among 2,136,511 patients, mammography among 792,470 patients, colonoscopy among 769,729 patients, and fecal occult blood test among 753,868 patients. State-specific Medicaid variables included median screening test reimbursement, income/financial asset eligibility requirements, physician copayments, and frequency of eligibility renewal.

RESULTS

Increases in screening test reimbursement demonstrated mixed associations (positive and negative) with the likelihood of receiving screening tests among Medicaid beneficiaries. In contrast, increased reimbursements for office visits were found to be positively associated with the odds of receiving all screening tests examined, including colonoscopy (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 1.06-1.08), fecal occult blood test (OR, 1.09; 95% CI, 1.08-1.10), Papanicolaou test (OR, 1.02; 95% CI, 1.02-1.03), and mammography (OR, 1.02; 95% CI, 1.02-1.03). Effects of other state-specific Medicaid policies varied across the screening tests examined.

CONCLUSIONS

Increased reimbursement for office visits was consistently associated with an increased likelihood of being screened for cancer, and may be an important policy tool for increasing screening among this vulnerable population.

Human papillomavirus vaccine administration among Medicaid providers who consistently recommended vaccination

We examined factors potentially related to providers' self-reported human papillomavirus vaccine administration to female Medicaid enrollees among providers who consistently recommended vaccination. Some pronounced variability was observed in characteristics among providers who consistently administered vaccination, including provider age, race, and Vaccines for Children enrollment; patient/parent vaccine refusal; patient race/ethnicity; and patient volume.

Effect of health care disparities on screening

Significant declines in the incidence and mortality rates of cervical cancer have occurred in the United States since the introduction of the Papanicolaou (Pap) test. Unfortunately, a reduction in the burden of cervical cancer is not equal across all ethnic and racial groups; significant disparities exist. Disparities are reflected not only in mortality and incidence rates, but also in screening rates. We review barriers to screening and effective approaches towards overcoming them. As minority populations increase over the next few decades, it becomes ever more urgent to employ interventions that will reduce the burden of cervical cancer among diverse groups.

Provider factors associated with disparities in human papillomavirus vaccination among low-income 9- to 17-year-old girls

BACKGROUND

Many women who develop cervical cancer are eligible for or are participants of Medicaid. Providing human papillomavirus (HPV) vaccination to girls enrolled in Medicaid may reduce cervical cancer disparities in low-income and minority women. This study evaluated provider characteristics associated with HPV vaccination among 9- to 17-year-old female Medicaid enrollees.

METHODS

A random sample of 800 providers from the Florida Medicaid Master Provider File was mailed a survey in October 2009 that evaluated demographic and practice characteristics, HPV information and knowledge, barriers to HPV vaccination, vaccine practices, and vaccine recommendation practices. To measure HPV vaccination, Medicaid claims data were used to calculate the proportion of eligible patients who received at least 1 dose of the vaccine from participating providers within the study period. Provider factors associated with vaccination at the bivariate level were evaluated in a multiple linear regression model.

RESULTS

The response rate was 68.3% (N = 485). After excluding ineligible respondents, the current analysis included 433 providers. HPV vaccination prevalence ranged from 0% to 61.9% (M = 20.4, standard deviation = 14.5). HPV vaccination rates were higher among providers who were pediatricians, had a private practice, practiced in a single specialty setting, were providers under the Vaccines for Children program, saw primarily non-Hispanic white patients, used 2 or more strategies for vaccine series completion, and did not refer out for HPV vaccination.

CONCLUSIONS

Despite financial coverage for Medicaid-eligible girls, HPV vaccination rates are low. Study findings can be used to target health services interventions to providers least likely to administer HPV vaccine to female Medicaid enrollees.

Patterns of cervical cancer screening, diagnosis, and follow-up treatment in a state Medicaid fee-for-service population

Despite being a screening-amenable cancer, cervical cancer is the third most common genital cancer among white women and the most common among African American women. The study objective was to use administrative claims data for CC disease surveillance among recipients enrolled in a state Medicaid fee-for-service (FFS) program. West Virginia (WV) Medicaid FFS administrative claims data for female recipients aged 21-64 years from 2003 to 2008 were used for this study. All medical and prescription claims were aggregated to reflect each recipient's medical care and prescription drug utilization. The yearly prevalence of Pap smear testing declined from 23.9% in 2003 to 15.8% in 2008 in the Medicaid FFS population. During the 6-year study period, persistence with Pap smear testing was low; 41.8% of recipients received no Pap smear testing. Only 73.1% of recipients received Pap smear testing during the year prior to their CC or precancerous cervical lesions (PCL) diagnosis. The likelihood of a CC diagnosis increased with a decrease in Pap smear testing persistence. Only 10.1% of recipients received appropriate follow-up care following a diagnosis of high-grade PCL; only 31.5% of the recipients received appropriate follow-up care for low-grade PCL diagnosis. Although CC preventive services such as screening and PCL follow-up care are covered under Medicaid programs, underutilization of these services by recipients in the Medicaid FFS population is a concern. Results of this study emphasize the need to address disparities in screening and appropriate PCL follow-up care among recipients in the Medicaid FFS population.

Cancer stage comparison between dual Medicare-Medicaid eligibles using Medicaid as a supplemental health insurance program and low-income nonduals

BACKGROUND

Dual-eligibility status for both Medicare and Medicaid is associated with unfavorable cancer stage outcomes. However, given the reduced financial barriers, duals enrolled in Medicaid prior to cancer diagnosis-or those using Medicaid as a supplemental health insurance program (Dual/SHIP)-may have improved access to preventive services compared with low-income nonduals (LI/nondual), therefore, be more likely to be diagnosed at earlier stages of cancers amenable to screening.

OBJECTIVES

To compare breast, prostate, and colorectal cancer stage at diagnosis between Duals/SHIP and LI/nonduals, adjusting for sociodemographic variables, comorbidities, and nursing home status.

RESEARCH DESIGN

Cross-sectional study using a database developed by linking records from the Ohio Cancer Incidence Surveillance System with Medicare and Medicaid files, as well as US census data.

SUBJECTS

Fee-for-service, Ohio residents aged 65 years or older, and diagnosed with incident breast, prostate, or colorectal cancer in 1997-2001.

MEASURES

(1) Unknown stage/unstaged cancer and (2) distant-stage cancer at diagnosis.

RESULTS

Duals/SHIP were more likely than LI/nonduals to have unknown stage/unstaged breast cancer (adjusted odds ratio: 1.43, 95% Confidence Interval (CI): 1.02-2.0; P = .035). However, this difference was not seen in prostate or colorectal cancer. In prostate cancer patients, but not in breast or colorectal cancer patients, Dual/SHIP status was associated with distant-stage disease (adjusted odds ratio: 1.74, 95% CI: 1.12-2.70; P = .014). In colorectal cancer patients, dual status was not associated with cancer stage.

CONCLUSION

The findings show no benefit associated with Medicaid as SHIP. Rather, they indicate that for the most part, cancer stage is comparable between Duals/SHIP and LI/nonduals.

Survival disparities by Medicaid status: an analysis of 8 cancers

BACKGROUND

A study was undertaken to compare survival and 5-year mortality by Medicaid status in adults diagnosed with 8 select cancers.

METHODS

Linking records from the Ohio Cancer Incidence Surveillance System (OCISS) with Ohio Medicaid enrollment data, the authors identified Medicaid and non-Medicaid patients aged 15 to 54 years and diagnosed with the following incident cancers in the years 1996-2002: cancer of the testis; Hodgkin and non-Hodgkin lymphoma; early stage melanoma, colon, lung, and bladder cancer; and pediatric malignancies (n = 12,703). Medicaid beneficiaries were placed in the pre-diagnosis group if they were enrolled in Medicaid at least 3 months before cancer diagnosis, and in the peri/post-diagnosis group if they enrolled in Medicaid upon or after being diagnosed with cancer. The authors also linked the OCISS with death certificates and data from the US Census. By using Cox and logistic regression analysis, they examined the association between Medicaid status and survival and 5-year mortality, respectively, after adjusting for patient covariates.

RESULTS

Nearly 11% of the study population were Medicaid beneficiaries. Of those, 45% were classified in the peri/post-diagnosis group. Consistent with higher mortality, findings from the Cox regression model indicated that compared with non-Medicaid, patients in the Medicaid pre-diagnosis and peri/post-diagnosis groups experienced unfavorable survival outcomes (adjusted hazard ratio [AHR], 1.52; 95% confidence interval [CI], 1.27-1.82 and AHR, 2.01; 95% CI, 1.70-2.38, respectively).

CONCLUSIONS

Medicaid status was associated with unfavorable survival, even after adjusting for confounders. The findings reflect the vulnerability of Medicaid beneficiaries and possible inadequacies in the process of care.

Impact of payer status on treatment of cervical cancer at a tertiary referral center

OBJECTIVES

The study aims to determine the impact of payer status on the likelihood of receiving definitive treatment for invasive cervical cancer at a tertiary medical center.

METHODS

All consecutive patients presenting to Johns Hopkins Hospital with a diagnosis of invasive cervical cancer between 1/1/95-12/31/08 were retrospectively identified from the tumor registry. Demographic and clinical information were abstracted from the medical record. Payer status was categorized as private, public, no insurance, or unknown. Treatment was defined as surgery, chemo-radiation, chemotherapy, radiation, or no definitive therapy. The likelihood of receiving no definitive therapy was analyzed using Pearson chi-square analysis, univariate and multivariate models.

RESULTS

A total of 306 patients were identified. Median age was 47 and 60% of patients had early stage disease at diagnosis (stages IA-IIA). Fifty-six percent of the cohort had private insurance, 34% had public insurance, and 6% had no insurance. Having no insurance was the single most significant risk factor associated with receiving no standard therapy. While 7% of privately insured and 4% of publicly insured patients did not receive definitive therapy, 16% of uninsured patients did not receive definitive treatment. In multivariate analysis controlling for age, race, stage, histology, and comorbidities, uninsured payer status was a significant and independent predictor of receiving no definitive treatment (OR 8.01, CI 1.265-50.694, p=0.027) than patients with public insurance.

CONCLUSIONS

In this study, uninsured payer status was significantly associated with a higher likelihood of not receiving standard therapy for cervical cancer. Additional studies are warranted to characterize specific barriers to care for this at-risk population.

Impact of insurance type on survivor-focused and general preventive health care utilization in adult survivors of childhood cancer: the Childhood Cancer Survivor Study (CCSS)

BACKGROUND

Lack of health insurance is a key barrier to accessing care for chronic conditions and cancer screening. The influence of insurance type (private, public, none) on survivor-focused and general preventive health care in adult survivors of childhood cancer was examined.

METHODS

The Childhood Cancer Survivor Study is a retrospective cohort study of childhood cancer survivors diagnosed between 1970 and 1986. Among 8425 adult survivors, the relative risk (RR) and 95% confidence interval (CI) of receiving survivor-focused and general preventive health care were estimated for uninsured (n = 1390) and publicly insured (n = 640), compared with for the privately insured (n = 6395)

RESULTS

Uninsured survivors were less likely than those privately insured to report a cancer-related visit (adjusted RR, 0.83; 95% CI, 0.75-0.91) or a cancer center visit (adjusted RR, 0.83; 95% CI, 0.71-0.98). Uninsured survivors had lower levels of utilization in all measures of care in comparison with privately insured. In contrast, publicly insured survivors were more likely to report a cancer-related visit (adjusted RR, 1.22; 95% CI, 1.11-1.35) or a cancer center visit (adjusted RR, 1.41; 95% CI, 1.18-1.70) than were privately insured survivors. Although publicly insured survivors had similar utilization of general health examinations, they were less likely to report a Papanicolaou test or a dental examinations

CONCLUSIONS

Among this large, socioeconomically diverse cohort, publicly insured survivors utilize survivor-focused health care at rates at least as high as survivors with private insurance. Uninsured survivors have lower utilization of both survivor-focused and general preventive health care.

Disparities in human papillomavirus vaccine series initiation among adolescent girls enrolled in Florida Medicaid programs, 2006-2008

PURPOSE

To better understand the human papillomavirus (HPV) vaccine series initiation among 9-17-year-old female Medicaid beneficiaries in Florida programs between June 2006 and December 2008 (n = 237,015).

METHODS

Among the Florida Medicaid enrollees with itemized claims collected (non-managed care organization enrollees), we assessed the association between HPV vaccine series initiation (≥1 vaccine claim) and important demographic characteristics (age, race/ethnicity, program enrollment, area of residence, and length of enrollment).

RESULTS

Among 11-17-year-olds, vaccine initiation increased over time from <1% by December 2006 to nearly 19% by December 2008. By December 2008, HPV vaccine initiation increased with respect to age from 9 (1.6%) to 13 years (22.9%), remained relatively stable from ages 13 to 15 years (between 21% and 22%), and decreased among 16- (18.6%) and 17-year-olds (15.7%). Compared with girls in Pilot or Fee for Service programs, the girls in MediPass or Children's Medical Service Network programs were more likely to have initiated the vaccine series. Within three of the four programs, Hispanics were more likely than non-Hispanic white and black girls to have initiated the vaccine series.

CONCLUSIONS

This study expands the understanding of HPV vaccine initiation to low-income adolescents eligible for free vaccine through the Federal Vaccine for Children program. Increased understanding of reasons for the observed differences, especially by program and race/ethnicity, will aid in developing interventions to improve HPV vaccine initiation.

The utility of the state buy-in variable in the Medicare denominator file to identify dually eligible Medicare-Medicaid beneficiaries: a validation study

OBJECTIVE

To compare the adequacy of the state buy-in variable (SBI) in the Medicare denominator file to identify dually eligible patients. DATA SOURCE/STUDY SETTINGS: We used linked Medicare and Medicaid data from Michigan and Ohio for elders diagnosed with incident breast, prostate, or colorectal cancer between 1996 and 2001.

STUDY DESIGN

Using the Medicaid enrollment file as the "gold standard," we assessed the number of duals from Medicare files in cross-sectional and longitudinal analyses.

DATA COLLECTION/EXTRACTION METHODS

Data for the study population were linked with Medicare and Medicaid files using patient identifiers.

PRINCIPAL FINDINGS

Sensitivity was low (74.2 percent, 95 percent confidence interval [CI]: 72.7, 75.6 and 80.8 percent, 79.7, 81.9, in Michigan and Ohio, respectively). PPV was above 95 percent in Michigan and 88.8 percent in Ohio. Both sensitivity and PPV varied between and within the states. Both in Michigan and in Ohio, we observed limited agreement on the length of enrollment in Medicaid between the two data sources.

CONCLUSIONS

Except to examine disparities by dual status at a very broad level, the SBI variable alone may be inadequate to identify duals. The findings call for improvements in Medicare and Medicaid information management systems and for uniformity in database linking strategies.

Age and comorbidities are effect modifiers of gender disparities in renal transplantation

Women have less access to kidney transplantation than men, but the contributions of age and comorbidity to this disparity are largely unknown. We conducted a national cohort study of 563,197 patients with first-onset ESRD between 2000 and 2005. We used multivariate generalized linear models to evaluate both access to transplantation (ATT), defined as either registration for the deceased-donor waiting list or receiving a live-donor transplant, and survival benefit from transplantation, defined as the relative rate of survival after transplantation compared with the rate of survival on dialysis. We compared relative risks (RRs) between women and men, stratified by age categories and the presence of common comorbidities. Overall, women had 11% less ATT than men. When the model was stratified by age, 18- to 45-yr-old women had equivalent ATT to men (RR 1.01), but with increasing age, ATT for women declined dramatically, reaching a RR of 0.41 for those who were older than 75 yr, despite equivalent survival benefits from transplantation between men and women in all age subgroups. Furthermore, ATT for women with comorbidities was lower than that for men with the same comorbidities, again despite similar survival benefits from transplantation. This study suggests that there is no disparity in ATT for women in general but rather a marked disparity in ATT for older women and women with comorbidities. These disparities exist despite similar survival benefits from transplantation for men and women regardless of age or comorbidities.

A matter of race: early-versus late-stage cancer diagnosis

We compared the stage at which cancer is diagnosed and survival rates between African Americans and whites, for thirty-four solid tumors, using the population-based Surveillance Epidemiology and End Results (SEER) database. Whites were diagnosed at earlier stages than African Americans for thirty-one of the thirty-four tumor sites. Whites were significantly more likely than blacks to survive five years for twenty-six tumor sites; no cancer site had significantly superior survival among African Americans. These differences cannot be explained by screening behavior or risk factors; they point instead to the need for broad-based strategies to remedy racial inequality in cancer survival.

California Medicaid enrollment and melanoma stage at diagnosis: a population-based study

BACKGROUND

Insurance status and SES are associated with the stage of melanoma at diagnosis. However, the influence of Medicaid enrollment on melanoma stage has not been studied in detail. This study examined the effect of Medicaid enrollment status and duration on melanoma stage at diagnosis in a large, multi-ethnic California population.

METHODS

California Cancer Registry records were linked with statewide Medicaid enrollment files to identify 4558 men and women diagnosed with invasive cutaneous and metastatic melanoma during 1998-1999. Multivariate logistic regression was used to evaluate the association between prediagnosis Medicaid enrollment status and late-stage diagnosis and tumor depth at diagnosis.

RESULTS

Late-stage disease was diagnosed in 27% of Medicaid and 9% of non-Medicaid melanoma patients. Those enrolled in Medicaid at diagnosis and those enrolled intermittently during the year prior to diagnosis had significantly greater covariate-adjusted odds of late-stage cancer than those not enrolled in Medicaid (OR 13.64, 95% CI=4.43, 41.98, and OR 2.77, 95% CI=1.28, 5.99, respectively). Participants continuously enrolled during the previous year were not at increased odds for late-stage disease. An increased likelihood of late-stage melanoma was also associated with low SES (p<0.05) and non-Hispanic black race/ethnicity (p<0.10) after covariate adjustment.

CONCLUSIONS

Men and women intermittently enrolled in Medicaid or not enrolled until the month of diagnosis had a significantly increased likelihood of late-stage melanoma. Greater education and outreach, particularly in low-SES areas, are needed to improve melanoma awareness and access to screening.

Social factors affecting treatment of cervical cancer: ethical issues and policy implications

Health care in the United States has become a privilege rather than a right. Patients who have the greatest need are the ones most likely to be denied this privilege. Despite recent advances in disease detection and treatment, many patients do not receive even the bare minimum of care. The high complexity of the health care system in the setting of patients with low levels of health literacy significantly affects the ability to seek and receive treatment in a timely fashion. In addition, lack of insurance, transportation, and social support further complicate access to care. To truly provide a standard of care to all patients, regardless of resources, our health care system must evolve to address the needs of the population. In this paper, we report a tragic case where social factors affected the outcome of a single mother with advanced cervical cancer.

Exploring older women's approaches to cervical cancer screening

The purpose of this qualitative study (N = 98, 11 focus groups) is to investigate how low-income, African American and Hispanic older women make decisions about cervical cancer screening. Using the health belief model to guide content analysis of transcripts, we found that primary barriers to screening were; embarrassment with, fear of, and pain from the test, difficulty in accessing screening, stigma associated with Medicaid coverage, and prior negative experiences with cancer detection. Women experienced cues to screening from their own bodies, in symptoms, and relied on spiritual beliefs to support them in coping with their health problems. Enhanced understanding of these factors could increase uptake of cervical cancer screening among the unscreened and underscreened.