Y. A. Zerhouni1,3, E. B. Schneider2, N. Melnitchouk1 1Brigham And Women’s Hospital,C,Boston, MA, USA 2Ohio State University,Columbus, OH, USA 3UCSF- East Bay,Surgery,Oakland, CA, USA
Introduction:
Disparities in referral to surgical intervention for cancer exist for Medicaid patients. Emergent surgical procedures, both curative and palliative, play a major part in the management of patients with colorectal cancer (CRC), and carry worse outcomes. We evaluated the disparity of procedures by insurance coverage in the management of CRC patients who present to the emergency department (ED) for care of CRC.
Methods:
We queried the 2008-2014 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS), a 20% stratified sample of United States ED visits, to identify all visits with a primary ICD-9-CM diagnosis of CRC. CRC patients who underwent a colon resection, ostomy creation, colon dilation, or colon stenting were identified (PROC). Comparisons were done between Medicaid and private insurance PROC patients and those who did not have a procedure (NOPROC). Using coarsened exact matching controlling for age, sex, cancer site, hospital region, zip-code median income, year of presentation, and discharge weight within the NEDS, a one-to-one match was made between Medicaid and private insurance patients. Descriptive analyses were done to compare the matched cohorts.
Results:
Medicaid and private insurance patients accounted for 12.7% and 20.1% respectively of an estimated 312,105 ED visits for a primary diagnosis of CRC. In the unmatched analysis, Medicaid patients were noted to be younger (mean age NOPROC 53.5 vs. 57.3 and PROC 54.9 vs. 57.9, p<0.001). Both Medicaid and private insurance patients were more likely to be male (NOPROC 55.8% vs 57.9%, p=0.092; PROC 55.0% vs 51.6%, p<0.001). Both groups of Medicaid patients were more likely to have more comorbidities than private patients, notably tobacco use, malnutrition, COPD, liver disease, and AIDS. Private NOPROC patients were significantly more likely to be obese, have a history of myocardial infarction, congestive heart failure, peripheral vascular disease, and chronic renal disease. Private PROC patients were more likely to be obese than Medicaid patients (14.0% vs. 10.0%, p<0.001). Medicaid patients were more likely to receive an ostomy only as their procedure (15.4% vs. 8.5%, p<0.001). 4,087 matched pairs were made. After matching, Medicaid patients were still less likely to have a procedure (p=0.021) and died at a higher rate after a procedure but this did not meet statistical significance (2.6% vs. 1.7%, p=0.055).
Conclusion:
After matching, Medicaid patients continue to be less likely to be treated with a surgical procedures. Medicaid patients presenting for emergent care of CRC have more co-morbidities and rectal disease than private patients. Medicaid patients were more likely to undergo ostomy creation as their sole procedure.
