The association of health insurance and race with treatment and survival in patients with metastatic colorectal cancer

Abstract

Background Black patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC. Materials and methods Patients diagnosed with metastatic CRC within NCDB from 2006–2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively. Results 128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy. Conclusion Black patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships between Race/Ethnicity, Insurance Type and Neighborhood Deprivation

“…Patients identified as Black were associated with less desirable/worse outcomes in this and other studies 42,44,56 . Consistent with prior studies, patients with non-private insurances were associated with less desirable/worse outcomes 41,43 .…”

“…Including potentially modifiable clinical variables in the lowest-/highest-risk scenarios showed stark differences in DOOR and TO probabilities, demonstrating how presentation acuity might result in care disparities. Other studies typically limit social risk factors to a single variable 11,41,42 or lack important variables such as neighborhood deprivation, 43,44 which underestimates the risk in vulnerable populations. Relationships between race/ethnicity, insurance type and neighborhood deprivation are complex, interdependent, and confounded.…”

Patterns of venous thromboembolism risk, treatment, and outcomes among patients with cancer from uninsured and vulnerable populations

“…4 Studies have shown that uninsured or underinsured patients are less likely to receive appropriate cancer treatment and more likely to have increased morbidity and mortality. [5][6][7] Many existing CAT epidemiology studies have been conducted in Caucasian European countries with universal healthcare systems. [8][9][10] Within the US, CAT studies have either relied on cancer registry-linked discharge claim databases without outpatient follow-up or private insurance claims databases without mortality data.…”

“…Recent US Census Data have shown that approximately 1 in 10 remains uninsured 4 . Studies have shown that uninsured or under‐insured patients are less likely to receive appropriate cancer treatment and more likely to have increased morbidity and mortality 5–7 . Many existing CAT epidemiology studies have been conducted in Caucasian European countries with universal healthcare systems 8–10 .…”

Receipt of Targeted Therapy and Survival Outcomes in Patients With Metastatic Colorectal Cancer

“…As well, this reflects a more judicious choice of therapy in patients who may draw limited benefits, given how costly these treatments are and the uncertainties surrounding the cost-effectiveness of these therapies . Second, while we anticipated that, compared with White patients, historically marginalized patient populations would have lower odds of receiving targeted therapies, especially in light of extensive prior documentation of higher mortality among Black patients with mCRC, our findings unexpectedly showed that Black patients had higher odds of receiving such treatment. We note, however, that because of absent data on tumor sidedness, we were unable to determine the appropriateness of the treatment received with respect to EGFR inhibitors.…”