S. M. Stokes1, E. Wakeam2, D. S. Swords1, J. R. Stringham3, T. K. Varghese3 1University Of Utah,Division Of General Surgery,Salt Lake City, UT, USA 2University Of Toronto,Division Of Thoracic Surgery,Toronto, ON, Canada 3University Of Utah,Division Of Cardiothoracic Surgery,Salt Lake City, UT, USA
Introduction: Insurance coverage by government funded programs has been a topic of debate, but the impact on outcomes in the modern era of evidence-based guidelines and increasing specialization remains unclear. Previous work have suggested that outcomes for Medicaid patients are inferior to those of privately insured patients. We sought to examine differences in receipt of cancer therapy and outcomes for early stage non-small lung cancer (NSCLC) patients according to their insurance coverage.
Methods: Clinical, T1-3, N0-1 NSCLC cases were identified in the 2004-2014 National Cancer Database. Patients were compared across four insurance groups: Private, Medicare, Medicaid, and Uninsured. Patients with unknown or other insurance status were excluded. A multivariable, linear regression model was used to examine the effects of insurance status on time to definitive surgical therapy by adjusting for patient and facility characteristics. Receipt of surgery, radiation, and chemotherapy were examined with multivariable logistic regression. Survival analysis was conducted with Cox regression to delineate the impact of insurance status on post-treatment survival.
Results: There were 291,732 patients presenting with early NSCLC (76,908 Private, 196,740 Medicare, 12,896 Medicaid, and 5,188 Uninsured). After adjusting for patient and facility characteristics, Medicaid and uninsured patients received definitive surgical therapy significantly later than privately insured patients (9.4 days and 7.5 days respectively, p < 0.001) and were significantly less likely to receive surgery (OR 0.50, 95% CI 0.48-0.53 and OR 0.48, 95% CI 0.45-0.52). Among all patients, 6.14% did not receive any form of treatment. Uninsured patients were more likely to receive no treatment (OR 2.26, 95% CI 2.02-2.53), followed by Medicaid patients (OR 1.75, 95% CI 1.61-1.90). Thirty and 90-day mortality were worse in Medicare, Medicaid, and uninsured populations. Overall survival was significantly worse in the Medicaid and uninsured populations (HR 1.44, 95% CI 1.39-1.48 and HR 1.37, 95% CI 1.31-1.43).
Conclusion: Even in the modern era, uninsured and Medicaid patients with early stage NSCLC have decreased odds of definitive treatment and poor outcomes after treatment compared to privately insured patients. This may relate to inferior access and underuse of cancer therapy in this population. Given significant state and federal expenditures on the Medicaid program, strategies for improving the optimal treatment and outcomes of Medicaid patients with lung cancer are needed.