ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery

Mishra, Ankit; DeLia, Derek; Zeymo, Alexander; Aminpour, Nathan; McDermott, James; Desale, Sameer; Al‐Refaie, Waddah B.

doi:10.1016/j.surg.2021.05.033

Cited by 5 publications

(4 citation statements)

References 28 publications

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“…That distance to nearest HVC is independently associated with lower odds of HVC referral is both unsurprising and troubling and echoes findings from a recent population-level study of intrahepatic cholangiocarcinoma . One solution may be to expand the use of telehealth for these and other patients with cancer, an option facilitated by the COVID-19 pandemic’s effect on the prevalence of telemedicine capabilities .…”

Section: Discussionmentioning

confidence: 87%

“…Importantly, the referral of patients to HVCs is a crucial aspect of PDAC care, particularly for patients with potentially resectable disease. While the expansion of Medicaid led to greater use of HVCs, less than half of patients with PDAC were referred to an HVC prior to the expansion with those referred more likely to be White (81.7% vs 73.6%; P < .001) and younger (mean age 61.9 years vs 63.2 years; P < .001) . Additionally, while prior studies have investigated socioeconomic and ethno-racial disparities in PDAC care and outcomes, none have simultaneously investigated selection bias in patients referred to HVCs and how this may propagate disparities through the lens of geographic and socioeconomic determinants …”

Section: Introductionmentioning

confidence: 99%

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Socioeconomic and Geographic Disparities in the Referral and Treatment of Pancreatic Cancer at High-Volume Centers

et al. 2023

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ImportanceTreatment at high-volume centers (HVCs) has been associated with improved overall survival (OS) in patients with pancreatic ductal adenocarcinoma (PDAC); however, it is unclear how patterns of referral affect these findings.ObjectiveTo understand the relative contributions of treatment site and selection bias in driving differences in outcomes in patients with PDAC and to characterize socioeconomic factors associated with referral to HVCs.Design, Setting, ParticipantsA population-based retrospective review of the Oregon State Cancer Registry was performed from 1997 to 2019 with a median 4.3 months of follow-up. Study participants were all patients diagnosed with PDAC in Oregon from 1997 to 2018 (n = 8026).ExposuresThe primary exposures studied were diagnosis and treatment at HVCs (20 or more pancreatectomies for PDAC per year), low-volume centers ([LVCs] less than 20 per year), or both.Main Outcomes and MeasuresOS and treatment patterns (eg, receipt of chemotherapy and primary site surgery) were evaluated with Kaplan-Meier analysis and logistic regression, respectively.ResultsEight thousand twenty-six patients (male, 4142 [52%]; mean age, 71 years) were identified (n = 3419 locoregional, n = 4607 metastatic). Patients receiving first-course treatment at a combination of HVCs and LVCs demonstrated improved median OS for locoregional and metastatic disease (16.6 [95% CI, 15.3-17.9] and 6.1 [95% CI, 4.9-7.3] months, respectively) vs patients receiving HVC only (11.5 [95% CI, 10.7-12.3] and 3.9 [95% CI, 3.5-4.3] months, respectively) or LVC-only treatment (8.2 [95% CI, 7.7-8.7] and 2.1 [95% CI, 1.9-2.3] months, respectively; all P &lt; .001). No differences existed in disease burden by volume status of diagnosing institution. When stratifying by site of diagnosis, HVC-associated improvements in median OS were smaller (locoregional: 10.4 [95% CI, 9.5-11.2] vs 9.9 [95% CI, 9.4-10.4] months; P = .03; metastatic: 3.6 vs 2.7 months, P &lt; .001) than when stratifying by the volume status of treating centers, indicating selection bias during referral. A total of 94% (n = 1103) of patients diagnosed at an HVC received HVC treatment vs 18% (n = 985) of LVC diagnoses. Among patients diagnosed at LVCs, later year of diagnosis and higher estimated income were independently associated with higher odds of subsequent HVC treatment, while older age, metastatic disease, and farther distance from HVC were independently associated with lower odds.Conclusions and RelevanceLVC-to-HVC referrals for PDAC experienced improved OS vs HVC- or LVC-only care. While disease-related features prompting referral may partially account for this finding, socioeconomic and geographic disparities in referral worsen OS for disadvantaged patients. Measures to improve access to HVCs are encouraged.

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Section: Discussionmentioning

confidence: 87%

Section: Introductionmentioning

confidence: 99%

Socioeconomic and Geographic Disparities in the Referral and Treatment of Pancreatic Cancer at High-Volume Centers

et al. 2023

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“…21 With the expansion of Medicaid, uninsured rates have decreased in these marginalized populations, 22,23 and access to care has shown promising signs of improvement. 24,25 However, the effect of Medicaid expansion on orofacial cleft care remains unexamined. To assess the impact of Medicaid expansion on orofacial cleft patients, we conducted a quasi-experimental, difference-in-differences design on a representative national database.…”

mentioning

confidence: 99%

“…With the expansion of Medicaid, uninsured rates have decreased in these marginalized populations, 22,23 and access to care has shown promising signs of improvement 24,25 . However, the effect of Medicaid expansion on orofacial cleft care remains unexamined.…”

mentioning

confidence: 99%

Associations Between Medicaid Expansion and Timely Repair of Cleft Lip and Palate

Barrero

Kavanagh

Pontell

et al. 2023

Journal of Craniofacial Surgery

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The expansion of Medicaid under the Affordable Care Act (ACA) increased access to health care for many low-income children. However, the impact of this expansion on the timing of primary cleft lip and palate repair remains unclear. This study aimed to evaluate whether Medicaid expansion improved access to timely cleft lip and palate repair and whether it reduced preexisting ethnoracial disparities. Using a quasi-experimental design, the study analyzed data from 44 pediatric surgical centers across the United States. The results showed that Medicaid expansion was associated with a 9.0 percentage-point increase in delayed cleft lip repairs, resulting in an average delay of 16 days. Non-White patients were disproportionately affected by this delay, experiencing a 14.8 percentage-point increase compared with a 4.9 percentage-point increase for White patients. In contrast, Medicaid expansion had no significant effect on the timing of palate repair or on ethnoracial disparities in palate repair. The study underscores the importance of monitoring unintended consequences of large-scale health system changes, especially those affecting disadvantaged populations. Delayed cleft lip repair can lead to worse outcomes for patients, and the disproportionate impact on non-White patients is concerning. Further research is needed to identify the reasons for this delay and to mitigate its effects. Overall, the study highlights the need for ongoing vigilance to ensure that health care policies and interventions do not inadvertently worsen health disparities.

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

Salehi,

Chandani,

Sammartino

et al. 2025

Journal of Cancer Policy

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ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery

Cited by 5 publications

References 28 publications

Socioeconomic and Geographic Disparities in the Referral and Treatment of Pancreatic Cancer at High-Volume Centers

Socioeconomic and Geographic Disparities in the Referral and Treatment of Pancreatic Cancer at High-Volume Centers

Associations Between Medicaid Expansion and Timely Repair of Cleft Lip and Palate

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

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