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Demkowicz PC, Buck MB, Nie J, Marks VA, Wheeler SB, Dinan MA, Gross CP, Leapman MS. Changes in Facility Share of Medicaid-insured Patients With Urologic Cancers Following Implementation of the Patient Protection and Affordable Care Act. Urology 2024; 192:19-27. [PMID: 38901803 DOI: 10.1016/j.urology.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/19/2024] [Accepted: 06/04/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE To examine Medicaid-insurance acceptance at facilities treating urologic cancers following implementation of the Affordable Care Act (ACA). METHODS We conducted a retrospective, longitudinal study with a pre-post design. We accessed 2010-2017 data from the National Cancer Database, calculating the facility-level change in proportion of urologic cancer patients with Medicaid following implementation of the ACA. We used multivariable logistic regression to assess baseline clinical and demographic factors associated with changes in the proportion of patients at a facility insured through Medicaid. RESULTS We identified 630 facilities, including 287 in Medicaid expansion states and 343 in non-expansion states associated with 436,082 urologic cancer patients. The mean facility-level change in proportion of patients with Medicaid was + 5.8% (95% CI 5.0%-6.5%) in expansion states versus + 0.6% (95% CI 0.2%-0.9%) in non-expansion states. There were 179 facilities that experienced a decrease in the post-ACA period, representing 13.6% of facilities in expansion states and 40.8% in non-expansion states (P <.001). Factors associated with a decrease in proportion of urologic cancer patients insured by Medicaid included non-expansion state status (OR 8.9, 95% CI 5.3-15.6, P <.001), higher baseline proportion of patients with Medicaid (highest quartile vs lowest: OR 4.6, 95% CI 2.3-9.4, P <.001) and high-income zip code (highest vs lowest quartile: OR 3.1, 95% CI 1.5-6.6, P <.001). CONCLUSION Urologic cancer care for Medicaid-insured Americans remains unevenly distributed across cancer care centers, even in states that expanded coverage. Our findings suggest that this variation may reflect the effort of some facilities to reduce their financial exposure to increased numbers of Medicaid patients in the wake of ACA-supported state expansions.
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Affiliation(s)
| | - Matthew B Buck
- Department of Urology, Sidney Kimmel Medical College, Philadelphia, PA
| | - James Nie
- Department of Urology, University of California San Francisco, San Francisco, CA
| | | | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michaela A Dinan
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - Cary P Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - Michael S Leapman
- Department of Urology, Yale School of Medicine, New Haven, CT; Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT.
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Antar RM, Xu VE, Adesanya O, Drouaud A, Longton N, Gordon O, Youssef K, Kfouri J, Azari S, Tafuri S, Goddard B, Whalen MJ. Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer. Curr Oncol 2024; 31:2566-2581. [PMID: 38785473 PMCID: PMC11119047 DOI: 10.3390/curroncol31050192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 05/25/2024] Open
Abstract
Background: Muscle-invasive bladder cancer (MIBC) is a potentially fatal disease, especially in the setting of locally advanced or node-positive disease. Adverse outcomes have also primarily been associated with low-income status, as has been reported in other cancers. While the adoption of neoadjuvant cisplatin-based chemotherapy (NAC) followed by radical cystectomy (RC) and pelvic lymph node dissection (PLND) has improved outcomes, these standard-of-care treatments may be underutilized in lower-income patients. We sought to investigate the economic disparities in NAC and PLND receipt and survival outcomes in MIBC. Methods: Utilizing the National Cancer Database, a retrospective cohort analysis of cT2-4N0-3M0 BCa patients with urothelial histology who underwent RC was conducted. The impact of income level on overall survival (OS) and the likelihood of receiving NAC and PLND was evaluated. Results: A total of 25,823 patients were included. This study found that lower-income patients were less likely to receive NAC and adequate PLND (≥15 LNs). Moreover, lower-income patients exhibited worse OS (Median OS 55.9 months vs. 68.2 months, p < 0.001). Our findings also demonstrated that higher income, treatment at academic facilities, and recent years of diagnosis were associated with an increased likelihood of receiving standard-of-care modalities and improved survival. Conclusions: Even after controlling for clinicodemographic variables, income independently influenced the receipt of standard MIBC treatments and survival. Our findings identify an opportunity to improve the quality of care for lower-income MIBC patients through concerted efforts to regionalize multi-modal urologic oncology care.
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Affiliation(s)
- Ryan M. Antar
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | - Vincent E. Xu
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | | | - Arthur Drouaud
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | - Noah Longton
- College of Medicine, Drexel University, Philadelphia, PA 19104, USA;
| | - Olivia Gordon
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | - Kirolos Youssef
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | - Jad Kfouri
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | - Sarah Azari
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | - Sean Tafuri
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | - Briana Goddard
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
| | - Michael J. Whalen
- Department of Urology, School of Medicine, George Washington University, Washington, DC 20052, USA; (V.E.X.); (A.D.); (K.Y.); (J.K.); (S.A.); (S.T.); (B.G.); (M.J.W.)
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Jiang C, Perimbeti S, Deng L, Xing J, Chatta GS, Han X, Gopalakrishnan D. Medicaid expansion and racial disparity in timely multidisciplinary treatment in muscle invasive bladder cancer. J Natl Cancer Inst 2023; 115:1188-1193. [PMID: 37314971 DOI: 10.1093/jnci/djad112] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/03/2023] [Accepted: 06/04/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Multidisciplinary cancer care (neoadjuvant chemotherapy followed by radical cystectomy or trimodality therapy) is crucial for outcome of muscle-invasive bladder cancer (MIBC), a potentially curable illness. Medicaid expansion through Affordable Care Act (ACA) increased insurance coverage especially among patients of racial minorities. This study aims to investigate the association between Medicaid expansion and racial disparity in timely treatment in MIBC. METHODS This quasi-experimental study analyzed Black and White individuals aged 18-64 years with stage II and III bladder cancer treated with neoadjuvant chemotherapy followed by radical cystectomy or trimodality therapy from National Cancer Database 2008-2018. Primary outcome was timely treatment started within 45 days following cancer diagnosis. Racial disparity is the percentage-point difference between Black and White patients. Patients in expansion and nonexpansion states were compared using difference-in-differences and difference-in-difference-in-differences analyses, controlling for age, sex, area-level income, clinical stage, comorbidity, metropolitan status, treatment type, and year of diagnosis. RESULTS The study included 4991 (92.3% White, n = 4605; 7.7% Black, n = 386) patients. Percentage of Black patients who received timely care increased following the ACA in Medicaid expansion states (54.5% pre-ACA vs 57.4% post-ACA) but decreased in nonexpansion states (69.9% pre-ACA vs 53.7% post-ACA). After adjusting covariates, Medicaid expansion was associated with a net 13.7 percentage-point reduction of Black-White patient disparity in timely receipt of MIBC treatment (95% confidence interval = 0.5% to 26.8%; P < .01). CONCLUSIONS Medicaid expansion was associated with statically significant reduction in racial disparity between Black and White patients in timely multidisciplinary treatment for MIBC.
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Affiliation(s)
- Changchuan Jiang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Stuthi Perimbeti
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Lei Deng
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jiazhang Xing
- Department of Medicine, Peking Union Medical College, Beijing, China
| | - Gurkamal S Chatta
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Xuesong Han
- Surveillance and Health Equity Science, American Cancer Society, Atlanta, GA, USA
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Unger JM, Xiao H, Vaidya R, LeBlanc M, Hershman DL. Medicaid Expansion of the Patient Protection and Affordable Care Act and Participation of Patients With Medicaid in Cancer Clinical Trials. JAMA Oncol 2023; 9:1371-1379. [PMID: 37590003 PMCID: PMC10436183 DOI: 10.1001/jamaoncol.2023.2800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/12/2023] [Indexed: 08/18/2023]
Abstract
Importance The Patient Protection and Affordable Care Act (ACA) Medicaid expansion resulted in increased use of Medicaid insurance nationwide. However, the association between Medicaid expansion and access to clinical trials has not been examined to date. Objective To examine whether the implementation of ACA Medicaid expansion was associated with increased participation of patients with Medicaid insurance in cancer clinical trials. Design, Setting, and Participants Data for this cohort study of 51 751 patients were from the SWOG Cancer Research Network. All patients aged 18 to 64 years and enrolled in treatment trials with Medicaid or private insurance between April 1, 1992, and February 29, 2020, were included. Interrupted time-series analysis with segmented logistic regression was used. The monthly unemployment rate and presidential administration were adjusted to reflect potential differences in Medicaid use associated with economic conditions and national administrative policies, respectively. Data analysis was conducted between June 22, 2021, and August 5, 2022. Exposure Implementation of Medicaid expansion on January 1, 2014, was the independent exposure variable. Main Outcomes and Measures The number and proportion of patients by insurance type enrolled in cancer clinical trials over time were analyzed. Results Overall, data for 51 751 patients were analyzed. Mean (SD) age was 50.6 (9.8) years, 67.3% of patients were female, 41.1% were younger than 50 years, and 9.1% used Medicaid. A 19% annual increase (odds ratio [OR], 1.19; 95% CI, 1.11-1.28; P < .001) was identified in the odds of patients using Medicaid after the ACA Medicaid expansion, resulting in a 52% increase (OR, 1.52; 95% CI, 1.29-1.78; P < .001) compared with what was expected in the number of Medicaid patients enrolled over time. The association was greater in states that adopted Medicaid expansion in 2014 to 2015 (OR, 1.26; 95% CI, 1.15-1.38; P < .001) compared with other states (OR, 1.08; 95% CI, 0.96-1.21; P = .20; P = .04 for interaction). By February 2020, the proportion of patients with Medicaid insurance was 17.8% (95% CI, 15.0%-20.8%; P < .001), whereas the expected proportion had ACA Medicaid expansion not occurred was 6.9% (95% CI, 4.4%-10.3%; P < .001). Conclusions and Relevance Findings suggest that implementation of ACA Medicaid expansion was associated with increased participation of patients using Medicaid in cancer clinical trials. Improved participation in clinical trials for Medicaid-insured patients is critical for socioeconomically vulnerable patients seeking access to the newest treatments available in trials and for improving confidence that trial findings apply to patients of all backgrounds.
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Affiliation(s)
- Joseph M. Unger
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Hong Xiao
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Riha Vaidya
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Michael LeBlanc
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Dawn L. Hershman
- Columbia University Irving Medical Center, Columbia University, New York, New York
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Fu R, Sun K, Wang X, Liu B, Wang T, Morze J, Nawrocki S, An L, Zhang S, Li L, Wang S, Chen R, Sun K, Han B, Lin H, Wang H, Liu D, Wang Y, Li Y, Zhang Q, Mu H, Geng Q, Sun F, Zhao H, Zhang X, Lu L, Mei D, Zeng H, Wei W. Survival differences between the USA and an urban population from China for all cancer types and 20 individual cancers: a population-based study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 37:100799. [PMID: 37693879 PMCID: PMC10485681 DOI: 10.1016/j.lanwpc.2023.100799] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/13/2023] [Accepted: 05/07/2023] [Indexed: 09/12/2023]
Abstract
Background The systematic comparison of cancer survival between China and the USA is rare. Here we aimed to assess the magnitude of survival disparities and disentangle the impact of the stage at diagnosis between a Chinese metropolitan city and the USA on cancer survival. Methods We included 11,046 newly diagnosed cancer patients in Dalian Cancer Registry, China, 2015, with the follow-up data for vital status until December 2020. We estimated age-standardised 5-year relative survival and quantified the excess hazard ratio (EHR) of death using generalised linear models for all cancers and 20 individual cancers. We compared these estimates with 17 cancer registries' data from the USA, using the Surveillance, Epidemiology, and End Results database. We further estimated the stage-specific survival for five major cancers by region. Findings Age-standardised 5-year relative survival for all patients in Dalian was lower than that in the USA (49.9% vs 67.9%). By cancer types, twelve cancers with poorer prognosis were observed in Dalian compared to the USA, with the largest gap seen in prostate cancer (Dalian: 55.8% vs USA: 96.0%). However, Dalian had a better survival for lung cancer, cervical cancer, and bladder cancer. Dalian patients had a lower percentage of stage Ⅰ colorectal cancer (Dalian: 17.9% vs USA: 24.2%) and female breast cancer (Dalian: 40.9% vs USA: 48.9%). However, we observed better stage-specific survival among stage Ⅰ-Ⅱ lung cancer patients in Dalian than in the USA. Interpretation This study suggests that although the overall prognosis for patients was better in the USA than in Dalian, China, survival deficits existed in both countries. Improvement in cancer early detection and cancer care are needed in both countries. Funding National Key R&D Program (2021YFC2501900, 2022YFC3600805), Major State Basic Innovation Program of the Chinese Academy of Medical Sciences (2021-I2M-1-010, 2021-I2M-1-046), and Talent Incentive Program of Cancer Hospital of Chinese Academy of Medical Sciences.
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Affiliation(s)
- Ruiying Fu
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Ke Sun
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Xiaofeng Wang
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Bingsheng Liu
- School of Public Policy and Administration, Chongqing University, No.174 Shazhengjie, Shapingba District, Chongqing, 400044, China
| | - Tao Wang
- School of Public Policy and Administration, Chongqing University, No.174 Shazhengjie, Shapingba District, Chongqing, 400044, China
| | - Jakub Morze
- College of Medical Sciences, SGMK University, Olsztyn, Poland
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Sergiusz Nawrocki
- Department of Oncology, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-228, Olsztyn, Poland
| | - Lan An
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Siwei Zhang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Li Li
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shaoming Wang
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Ru Chen
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Kexin Sun
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Bingfeng Han
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hong Lin
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Huinan Wang
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Dan Liu
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Yang Wang
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Youwei Li
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Qian Zhang
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Huijuan Mu
- Liaoning Provincial Center for Disease Control and Prevention, Shenyang, 110005, China
| | - Qiushuo Geng
- School of Medical Device, Shenyang Pharmaceutical University, Benxi, 117004, China
| | - Feng Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Haitao Zhao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100021, China
| | - Xuehong Zhang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Lingeng Lu
- Department of Chronic Disease Epidemiology, Yale School of Public Health, Yale Cancer Center, Yale University, New Haven, CT, 06520, USA
- Yale Cancer Center and Center for Biomedical Data Science, Yale University, 60 College Street, New Haven, CT, 06520, USA
| | - Dan Mei
- Dalian Center for Disease Control and Prevention, Liaoning, 116035, China
| | - Hongmei Zeng
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Wenqiang Wei
- National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
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Hotca A, Bloom JR, Runnels J, Salgado LR, Cherry DR, Hsieh K, Sindhu KK. The Impact of Medicaid Expansion on Patients with Cancer in the United States: A Review. Curr Oncol 2023; 30:6362-6373. [PMID: 37504329 PMCID: PMC10378187 DOI: 10.3390/curroncol30070469] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023] Open
Abstract
Since 2014, American states have had the option to expand their Medicaid programs as part of the Affordable Care Act (ACA), which was signed into law by former President Barack H. Obama in 2010. Emerging research has found that Medicaid expansion has had a significant impact on patients with cancer, who often face significant financial barriers to receiving the care they need. In this review, we aim to provide a comprehensive examination of the research conducted thus far on the impact of Medicaid expansion on patients with cancer. We begin with a discussion of the history of Medicaid expansion and the key features of the ACA that facilitated it. We then review the literature, analyzing studies that have investigated the impact of Medicaid expansion on cancer patients in terms of access to care, quality of care, and health outcomes. Our findings suggest that Medicaid expansion has had a positive impact on patients with cancer in a number of ways. Patients in expansion states are more likely to receive timely cancer screening and diagnoses, and are more likely to receive appropriate cancer-directed treatment. Additionally, Medicaid expansion has been associated with improvements in cancer-related health outcomes, including improved survival rates. However, limitations and gaps in the current research on the impact of Medicaid expansion on patients with cancer exist, including a lack of long-term data on health outcomes. Additionally, further research is needed to better understand the mechanisms through which Medicaid expansion impacts cancer care.
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Affiliation(s)
- Alexandra Hotca
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Julie R Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Juliana Runnels
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Lucas Resende Salgado
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daniel R Cherry
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kristin Hsieh
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Kunal K Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Siapno AED, Gaither TW, Tandel MD, Kwan L, Meng YY, Connor SE, Maliski SL, Fink A, George S, Litwin MS. Impact of Comprehensive Health Insurance on Quality of Life in Low-Income Hispanic Men with Prostate Cancer. Urology 2023; 172:89-96. [PMID: 36400270 DOI: 10.1016/j.urology.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/24/2022] [Accepted: 11/02/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the effect of the transition from IMPACT, a disease-focused treatment program, to comprehensive health insurance under Medicaid through the Affordable Care Act (ACA) on general and prostate cancer-specific quality of life (QoL) on a cohort of previously uninsured low-income men. We hypothesize that general QoL would improve and prostate cancer-specific QoL would remain the same after the transition to comprehensive health insurance. METHODS We assessed and compared general QoL using the RAND SF-12v2™ (12-Item Short Form Survey, version 2) and prostate cancer-specific QoL using the UCLA PCI (Prostate Cancer Index) one year before, at, and one year after the transition between 30 men who transitioned to comprehensive insurance (newly insured/Medicaid group) and 54 men who remained in the prostate cancer program (uninsured/IMPACT group). We assessed the independent effects of Medicaid coverage on QoL outcomes using repeated-measures regression. RESULTS Our cohort was composed primarily of Hispanic men (82%). At transition, patient demographics and clinical characteristics were similar between the groups. General and prostate cancer-specific QoL did not differ between the groups and remained stable over time, Radical prostatectomy as primary treatment and shorter time since treatment were associated with worse urinary and sexual function across both groups and over all three time points. CONCLUSION Those who transitioned to full-scope insurance and those who remained in the free prostate cancer-focused treatment program had stable general and prostate cancer-specific QoL. High-touch navigation aspects of a disease-focused program may have contributed to stability in outcomes.
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Affiliation(s)
- Allen Enrique D Siapno
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA.
| | - Thomas W Gaither
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Megha D Tandel
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, CA
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Ying-Ying Meng
- Center for Health Policy Research, University of California, Los Angeles, CA
| | - Sarah E Connor
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA
| | | | - Arlene Fink
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA; Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA
| | - Sheba George
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA; Department of Preventive and Social Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA
| | - Mark S Litwin
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles, CA; Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, CA
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8
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Nemirovsky DR, Klose C, Wynne M, McSweeney B, Luu J, Chen J, Atienza M, Waddell B, Taber B, Haji-Momenian S, Whalen MJ. Role of Race and Insurance Status in Prostate Cancer Diagnosis-to-Treatment Interval. Clin Genitourin Cancer 2022; 21:e198-e203. [PMID: 36653224 DOI: 10.1016/j.clgc.2022.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/24/2022] [Accepted: 12/28/2022] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Numerous studies have shown that both race and insurance status may affect prostate cancer (PCa) workup and treatment. Preliminary investigations have shown that these factors may be associated with treatment delays, which may indicate inequitable care and increase risk of tumor progression. This investigation aimed to assess whether race and insurance impacted the interval between multiparametric MRI (mpMRI)-to-biopsy, and biopsy-to-prostatectomy. MATERIALS AND METHODS A single-institution analysis of 261 patients with recorded race and insurance data was performed using an Institutional Review Board-compliant database with information spanning from 2016 to 2022. Race was self-reported during intake, and insurance status was retrieved from the electronic medical record. Insurance was sub-divided into private, Medicare, and Medicaid. Diagnostic or treatment latency was defined as time between mpMRI-to-biopsy, or biopsy-to-surgery. RESULTS Stratified by race, there was no difference in either latency period when comparing African American (AA) and white patients. Stratified by insurance status, there was no difference in time from mpMRI-to-biopsy (P = .50), but there was a significantly longer interval from biopsy-to-prostatectomy for patients with Medicaid insurance (P = .02). Patients with Medicaid waited on average 168 days to receive surgery, in contrast to 92 days for private and 87 for Medicare. Notably, 82% of Medicaid patients were AA. CONCLUSION Insurance status, which is inherently linked to race and social determinants of health, portended a significantly increased interval between biopsy and surgery. Physicians should be aware of the relationship between insurance status and treatment delay, as well as its potential downstream consequences.
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Affiliation(s)
- Daniel R Nemirovsky
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC.
| | - Charles Klose
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC; The Brody School of Medicine at East Carolina University, Greenville, NC
| | - Michael Wynne
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
| | - Benjamin McSweeney
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
| | - Jennica Luu
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
| | - Joyce Chen
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
| | - Matthew Atienza
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
| | - Brandon Waddell
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
| | - Benjamin Taber
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
| | - Shawn Haji-Momenian
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
| | - Michael J Whalen
- The George Washington University School of Medicine and Health Sciences, Washington, DC; The George Washington University Medical Faculty Associates, Washington, DC
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9
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Cioffi G, Waite KA, Edelson JL, Kruchko C, Ostrom QT, Barnholtz-Sloan JS. Changes in survival over time for primary brain and other CNS tumors in the United States, 2004-2017. J Neurooncol 2022; 160:209-219. [PMID: 36198894 PMCID: PMC9622549 DOI: 10.1007/s11060-022-04138-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 09/17/2022] [Indexed: 12/05/2022]
Abstract
Purpose Despite advances in cancer diagnosis and clinical care, survival for many primary brain and other central nervous system (CNS) tumors remain poor. This study performs a comprehensive survival analysis on these tumors. Methods Survival differences were determined utilizing the National Program of Cancer Registries Survival Analytic file for primary brain and CNS tumors. Overall survival and survival of the 5 most common histopathologies, within specific age groups, were determined. Overall survival was compared for three time periods: 2004–2007, 2008–2012, and 2013–2017. Survival differences were evaluated using Kaplan–Meier and multivariable Cox proportional hazards models. Models were adjusted for sex, race/ethnicity, and treatment. Malignant and non-malignant brain tumors were assessed separately. Results Among malignant brain and CNS tumor patients overall, there were notable differences in survival by time period among all age groups. Similar differences were noted in non-malignant brain and CNS tumor patients, except for adults (aged 40–64 years), where no survival changes were observed. Survival differences varied within specific histopathologies across age groups. There were improvements in survival in 2008–2012 and 2013–2017, when compared to 2004–2007, in children, AYA, and older adults with malignant tumors, and among older adults with non-malignant tumors. Conclusion Overall survival for malignant brain and other CNS tumors improved slightly in 2013–2017 for all age groups as compared to 2004–2007. Significant changes were observed for non-malignant brain and other CNS tumors among older adults. Information regarding survival over time can be utilized to identify population level effects of diagnostic and treatment improvements. Supplementary Information The online version contains supplementary material available at 10.1007/s11060-022-04138-w.
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Affiliation(s)
- Gino Cioffi
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.,Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Kristin A Waite
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.,Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Jacob L Edelson
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Quinn T Ostrom
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA.,Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA.,The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, NC, USA.,Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Jill S Barnholtz-Sloan
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA. .,Central Brain Tumor Registry of the United States, Hinsdale, IL, USA. .,Center for Biomedical Informatics & Information Technology, National Cancer Institute, Bethesda, MD, USA. .,National Cancer Institute, Shady Grove Campus 9609 Medical Center Dr, Rockville, MD, 20850, USA.
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10
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Bivins VM, Durkin M, Khilfeh I, Rossi C, Kinkead F, Waters D, Lefebvre P, Pilon D, Ellis L. Early prostate-specific antigen response among Black and non-Black patients with advanced prostate cancer treated with apalutamide. Future Oncol 2022; 18:3595-3607. [PMID: 36196743 DOI: 10.2217/fon-2022-0791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aim: To assess reduction in prostate-specific antigen (PSA) levels among Black and non-Black patients treated with apalutamide for non-metastatic castration-resistant prostate cancer (nmCRPC) or metastatic castration-sensitive prostate cancer (mCSPC). Patients & methods: Patients were identified from electronic medical data. PSA reduction (≥50%, ≥90% or below 0.2 ng/ml) after apalutamide initiation was assessed. Results: A total of 313 patients with nmCRPC and 260 patients with mCSPC were identified. The majority of patients treated with apalutamide achieved a 90% reduction in PSA regardless of indication or race. The proportion of patients achieving a PSA reduction at any level was similar among Black and non-Black patients and was consistent with apalutamide phase III trials. Conclusion: In routine clinical practice, apalutamide consistently produced reduction in PSA levels in Black and non-Black men with nmCRPC or mCSPC.
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Affiliation(s)
| | - Mike Durkin
- Former employee of Janssen Scientific Affairs, LLC, Horsham, PA 19044, USA
| | | | | | | | - Dexter Waters
- Janssen Scientific Affairs, LLC, Horsham, PA 19044, USA
| | | | | | - Lorie Ellis
- Janssen Scientific Affairs, LLC, Horsham, PA 19044, USA
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11
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Nie J, Hsiang W, Marks V, Laditi F, Varghese A, Umer W, Haleem A, Mothy D, Wang H, Patel R, Pan W, Shah R, Khan S, Singh R, Golla V, Cavallo J, Breyer BN, Leapman MS. Access to Urological Care for Medicaid-Insured Patients at Urology Practices Acquired by Private Equity Firms. Urology 2022; 164:112-117. [PMID: 35276202 DOI: 10.1016/j.urology.2022.01.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/29/2021] [Accepted: 01/02/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize appointment access for Medicaid-insured patients seeking care at urology practices affiliated with private equity firms in light of the recent national trends in practice consolidation. METHODS We identified 214 urology offices affiliated with private equity firms that were geographically matched with 231 non-private equity affiliated urology offices. Using a standardized script, researchers posed as an adult patient with either Medicaid or commercial insurance in the clinical setting of new onset, painless hematuria. The primary outcome was whether the patient's insurance was accepted for an appointment. The secondary outcome was appointment wait time. RESULTS We conducted 815 appointment inquiry calls to 214 PE and 231 non-PE-affiliated urology offices across 12 states. Appointment availability was higher for commercially-insured patients (99.0%; 95% CI: 98.1%-99.9%) versus Medicaid-insured patients (59.8%; 95% CI: 55.0%-64.6%) (p<0.0001). Medicaid acceptance was higher at non-PE affiliated (66.8%; CI 60.4%-73.2%) than PE-affiliated practices (52.1%; 95% CI 45.0%-59.2%) (p=0.003). On multivariable logistic regression analysis, state Medicaid expansion status (OR 2.20; CI 1.14-4.28; p=0.020) was independently associated with Medicaid appointment availability, whereas PE-affiliation (OR 0.55; CI 0.37-0.83; p=0.004) was independently associated with lower Medicaid access. Appointment wait times did not differ significantly for commercially-insured versus Medicaid patients (19.2 vs 20.1 days; p=0.59), but PE-affiliated practices offered shorter mean wait times than non-PE offices (17.5 vs 21.4 days; p=0.017). CONCLUSIONS Access disparities for urologic evaluation in patients with Medicaid insurance at urology practices and were more pronounced at private equity acquired practices.
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Affiliation(s)
- James Nie
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA
| | - Walter Hsiang
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Victoria Marks
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA
| | - Folawiyo Laditi
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA
| | - Adarsh Varghese
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Waez Umer
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Afash Haleem
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - David Mothy
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Hannah Wang
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Riya Patel
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - William Pan
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Rishi Shah
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Sophia Khan
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Rohan Singh
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jaime Cavallo
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Michael S Leapman
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA.
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