Society for Surgery of the Alimentary Tract
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Henrique Araujo Lima*, Yutaka Endo, Laura Alaimo, Zorays Moazzam, Mary Dillhoff, Aslam Ejaz, Jordan Cloyd, Timothy M. Pawlik
Surgery, The Ohio State Wexner Medical Center, Columbus, OH

Introduction: The impact of Medicaid Expansion (ME) on complex gastrointestinal cancers such as hepatocellular carcinoma (HCC) remains controversial. Despite improving overall health insurance coverage, the heterogeneous impact of ME on access to cancer care may be related to sociodemographic factors. We sought to evaluate the association between ME and receipt of surgical treatment among patients with early-stage HCC.

Methods: Patients diagnosed with early-stage HCC between the ages of 40 and 64 were identified from the National Cancer Database; patients were divided into pre- (2004-2012) versus post- (2015-2017) ME cohorts. Multivariable logistic regression was performed to assess predictors of receipt of surgical treatment. A Difference-in-Difference (DID) analysis was used to evaluate changes in surgical treatment among patients living in ME versus non-ME states.

Results: Among 19,745 patients, 12,220 (61.9%) individuals were diagnosed before the implementation of ME and 7,525 (38.1%) after. Although overall rates of receipt of surgical treatment decreased in the post-expansion era among ME and non-ME states (ME state, pre-ME era: 62.2% vs post-ME era: 51.6%; non-ME state, pre-ME era: 62.1% vs post-ME era: 50.8%; both p<0.001), this trend varied relative to insurance status. Of note, among uninsured/Medicaid patients living in ME states (n=2,249, 47.7%), receipt of surgical treatment was more likely to occur in the post-ME era (pre-ME era: 48.1%; post-ME era: 52.3%, p<0.001). Moreover, among these patients, treatment at an academic (OR 1.35, 95%CI 1.10-1.65) or high-volume facility (HVF) (OR 1.45, 95%CI 1.18-1.78) was associated with an increased likelihood of undergoing surgical treatment in the pre-expansion period (both p<0.01). In contrast, in the post-expansion era, treatment at an academic facility (OR 1.83, 95%CI 1.47-2.30) and living in an ME state at the time of diagnosis (OR 1.28, 95%CI 1.07-1.54) were predictors of receipt of surgical treatment (both p<0.01). DID analysis demonstrated that uninsured/Medicaid patients living in ME states had increased utilization of surgical treatment relative to individuals in non-ME states (uninsured/Medicaid: 6.4%, p<0.05), although no differences were noted relative to other insurance types (private: -2.0%, other government: 0.3%, overall: 0.7%, all p>0.05)(Figure).

Conclusion: While the implementation of ME did not homogeneously impact receipt of surgery, uninsured/Medicaid patients with early-stage HCC residing in ME states had an increased utilization of surgical treatment after expansion. The data demontrate that ME had a beneficial effect on surgical utilization among the most vulnerable patient populations with HCC.

Figure: (a) Map depicting medicaid expansion by States that were included in analysis, (b) Difference-in-difference analysis showing receipt of surgical treatment by Medicaid exapansion and non-Medicaid expansion states and (c) proportion of patients living in Medicaid expansion states by receipt of surgical treatment, in the pre-expansion (2004–2012) and post-expansion (2015–2017)

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