INSURANCE STATUS HAS THE STRONGEST IMPACT ON DISPARITY OF GASTROINTESTINAL CANCER CARE
Omid Salehi*1,2, Eduardo A. Vega1,2, Christopher Lathan1,3, Olga Kozyreva1,3, Beth Herrick1, Daria M. James1, Claudius Conrad1,3
1St. Elizabeth's Medical Center, Boston, MA; 2Tufts University School of Medicine, Boston, MA; 3Dana-Farber Cancer Institute/ Harvard Medical School, Boston, MA
BACKGROUND: Socioeconomic status, patient demographics, and insurance play a significant role in access to and quality of healthcare. Moreover, the complexity of oncologic care needed for the optimal treatment of gastrointestinal malignancies may magnify access and quality of care issues in disadvantaged patient populations.
METHODS: A multi-institutional (5 community hospitals, 1 tertiary center) prospectively maintained cancer database was reviewed for gastrointestinal (GI) cancers (esophagus, stomach, liver, pancreas, colorectal, and hepatopancreatobiliary, including bile duct, ampulla, and gallbladder cancers) from 2007-2017. Patient characteristics included age, sex, race, insurance status, county-based per capita income, and geographic location; oncologic parameters included cancer stage, chemotherapy use, surgical management, and delay to treatment. Logistic regression was used to adjusted for cofounders. Overall survival (OS) was calculated as the time from diagnosis to last follow-up. Kaplan-Meier survival curves were compared using log-rank test. These metrics helped evaluate potential factors underlying healthcare discrepancy.
RESULTS: 1072 patients with GI malignancies were identified. Survival was improved in patients with private insurance compared to government-funded options such as Medicare or Medicaid [Median OS 57.8 vs. 21.2 months; p = <0.001]. Private insurance also correlated to earlier stages of cancer at diagnosis, higher rate of chemotherapy and surgical treatment, and longer follow-up. Advanced age (>65) was associated with less curative treatments, but no difference in palliative management compared to a younger cohort. Sex differences identified included higher degree of chemotherapy administration and more frequent use of palliative care in males. Treatments and outcomes were similar across races after adjustment by stage. Patients living further away (>30 miles) from the tertiary cancer center had higher stage malignancy at the time of diagnosis and poorer follow up. In 90-days delay to chemotherapy from initial diagnosis, no significance was found in those not receiving surgery across all patient parameters; this lack of significance was also true for 30-day surgical delay once controlled for no chemotherapy administration, except in those living close (<5 miles) from the tertiary cancer center.
CONCLUSION: While gender, race, age or distance from a tertiary center, have been correlated with healthcare disparity, insurance status (private vs. none vs. governmental) was found to have the strongest negative impact on access and quality of oncologic care in this multi-institutional hospital network in Massachusetts. Governmental programs to increase the rate of insured patients and recognition of insurance bias may not only improve parity of care but concretely overall survival for patients with GI malignancies.
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