Insurance Status and Hospital Payer Mix Are Linked With Variation in Metastatic Site Resection in Patients With Advanced Colorectal Cancers

Abstract

Background Despite substantially improved survival with metastatic site resection in colorectal cancers, uptake of aggressive surgical approaches remains low among certain patients. It is unknown whether financial determinants of care, such as insurance status, play a role in this treatment gap. Objective We sought to evaluate the effect of insurance status on metastasectomy in patients with advanced colorectal cancers. Methods Using the National Cancer Data Base Participant User File, incident cases of colorectal cancer metastatic to the lung and/or liver with diagnosis from 2010 – 2013, were identified. Controlling for patient, tumor, and hospital characteristics, hierarchical regression was used to examine associations between hospital payer mix and metastatic site resection. Results We identified 42,300 patients in our cohort with mean age 64 years. Metastatic site resection occurred in 12.3% of all patients. Adjusting for patient and hospital fixed effects, we found that patients who were uninsured or on Medicaid were 38% less likely to undergo metastasectomy (OR, 0.62; 95% CI, 0.56 – 0.66). Patients in hospitals treating a high percentage of uninsured or Medicaid patients were less likely to undergo metastasectomy, even after controlling for individual patient insurance status. Limitations The study was limited by its retrospective design and the granularity and accuracy of the National Cancer Data Base. Conclusion Differences in insurance status and hospital payer mix are associated with differences in rates of metastatic site resection in patients with colorectal cancer that is metastatic to the lung and/or liver. There is a need for improved access to metastatic site resection for individual patients who are uninsured or who have Medicaid insurance, and for all patients who seek care at hospitals treating a large proportion of uninsured or Medicaid patients. Remedies for individual patients could include improved access to private insurance through employment or individual plans or improved reimbursement from Medicaid for this procedure. Strategies for patients at low-performing hospitals include selective referral to centers that perform mestastectomy more frequently when appropriate.

Prolonged overall survival following metastasectomy in stage IV melanoma

“…Patients with private insurance were more likely to undergo the surgery. This finding is in concordance with a similar study on metastatic colorectal cancer, which called for improved access to or compensation for metastatic resection for patients who are uninsured or who have government insurance—stating that the relatively low reimbursements from insurances such as Medicaid likely contributed to this finding . Unsurprisingly, patients with M1a metastasis showed independently higher rates of metastasectomy likely due to the less invasive nature of the procedure.…”

Surgical Treatment for Early Small Cell Lung Cancer: Variability in Practice and Impact on Survival

“…We did find some demographic differences among high-use and low-use hospitals; for example, patients at high-use hospitals tended to be wealthier, were less likely to be Hispanic, and were more likely to be privately insured. These findings are consistent with prior work examining disparities in access to advanced surgical care for minorities and the poor [23][24][25]. However the differences we observed persisted despite control for these factors.…”

Distribution of Genomic Testing Resources by Oncology Practice and Rurality: A Nationally Representative Study

“…Multivariate logistic regression models were conducted to examine differences in each genomic testing resource by practice type and rurality while adjusting for known practice-level confounders (ie, patient volume and payer mix). [23][24][25] Adjusted odds ratios (aORs) and 95% CIs for the survey weighted population estimates are presented, and statistical significance for all analyses was determined at the P , .05 level (two-sided). Analyses were weighted to account for the probability sampling approach and survey nonresponse.…”