The Breast and Cervical Cancer Prevention and Treatment Act in Georgia: effects on time to Medicaid enrollment

An Investigation of Travel Distance and Timeliness of Breast Cancer Treatment Among a Diverse Cohort in the United States

Travel to and from distant cancer treatment facilities can place a significant burden on cancer patients, particularly rural and minority survivors. Thus, the purpose of our investigation was to examine the association between patient travel distance and delays in types of treatment for breast cancer (surgery, radiation, chemotherapy, and hormonal therapy) and treatment delays. Using a novel linkage between the state cancer registry and administrative data from Medicaid and a private insurance plan, 2155 BC patients were successfully linked to create the cohort. ArcGIS was used to geocode all case residences and treatment facility addresses and calculate network distance between the residence and each facility. Logistic regression models were used to calculate the adjusted odds of being delayed versus timely by street distance. Odds of late surgery were increased by 1% (95% CI: 1.00, 1.01) for each one-mile increase from the patient's residence to the treatment facility. In race-stratified models, the odds of late treatment for Black patients increased by 3% per mile (95% CI 1.01, 1.06) for radiation. Increased travel distance appears to significantly increase treatment delays for surgical, radiation, and chemotherapeutic treatments for women with BC, especially among Black women.

Impact of Healthcare Access Disparities on Initial Diagnosis of Breast Cancer in the Emergency Department

Breast cancer continues to be the second leading cause of cancer deaths in women in the United States. This is more noticeable in communities with pronounced healthcare disparities. The aim of this study was to investigate the different demographics that might play a role in the detection of breast cancer in a county hospital emergency department (ED).

A retrospective study was conducted of female patients diagnosed with breast cancer over a five-year period (1/1/2015 to 12/31/2018). Patients with breast cancer as the primary or secondary diagnosis were identified.

This study shows that 66 (73.3%) women diagnosed in the ED were Hispanic or African American. There was a significant delay (a median of 461 days) in the time between the diagnosis of suspected breast cancer in the ED to their follow-up visit with definitive diagnosis in a primary care clinic.

These findings suggest that women with a suspected breast cancer diagnosis who are seen in a safety net hospital and have Medicaid funding may have significant delays before final diagnosis is made. Patient demographics could have an impact on the patients' access to screening and regular healthcare visits, hindering an early breast cancer diagnosis by a primary care provider.

Redox Regulation of NOX Isoforms on FAK(Y397)/SRC(Y416) Phosphorylation Driven Epithelial-to-Mesenchymal Transition in Malignant Cervical Epithelial Cells

Epithelial-to-mesenchymal transition (EMT) promulgates epithelial cell associated disease-defining characteristics in tumorigenesis and organ fibrosis. Growth factors such as epidermal growth factor and fibroblast growth factor in addition to cytokines such as transforming growth factor-β1 (TGF-β1) is said to play a prominent role in remodeling related pathological events of cancer progression such as invasion, metastasis, apoptosis, EMT, etc. through redox related cellular secondary messengers, in particular the reactive oxygen species (ROS). However, the signaling cascade underlying the redox mechanism and thereby the progression of EMT remains largely unknown. In this study, upon TGF-β1 treatment, we observed an induction in NOX isoforms-NOX2 and NOX4-that have time (early and late) and cellular localization (nucleus and autophagosome co-localized) dependent effects in mediating EMT associated cell proliferation and migration through activation of the focal adhesion kinase (FAK)/SRC pathway in HeLa, human cervical cancer cells. Upon silencing NOX2/4 gene expression and using the SRC inhibitor (AZD0530), progression of TGF-β1 induced EMT related cellular remodeling, extra cellular matrix (ECM) production, cell migration and invasion, got significantly reverted. Together, these results indicate that NOX2 and NOX4 play important, albeit distinct, roles in the activation of cytokine mediated EMT and its associated processes via tyrosine phosphorylation of the FAK/SRC pathway.

The effect of Medicaid expansion on prescriptions for breast cancer hormonal therapy medications

OBJECTIVE

To quantify the effects of the Affordable Care Act Medicaid expansion on prescriptions for effective breast cancer hormonal therapies (tamoxifen and aromatase inhibitors) among Medicaid enrollees.

DATA SOURCE/STUDY SETTING

Medicaid State Drug Utilization Database (SDUD) 2011-2018, comprising the universe of outpatient prescription medications covered under the Medicaid program.

STUDY DESIGN

Differences-in-differences and event-study linear models compare population rates of tamoxifen and aromatase inhibitor (anastrozole, exemestane, and letrozole) use in expansion and nonexpansion states, controlling for population characteristics, state, and time.

PRINCIPAL FINDINGS

Relative to nonexpansion states, Medicaid-financed hormonal therapy prescriptions increased by 27.2 per 100 000 nonelderly women in a state. This implies a 28.8 percent increase from the pre-expansion mean of 94.2 per 100 000 nonelderly women in expansion states. The event-study model reveals no evidence of differential pretrends in expansion and nonexpansion states and suggests use grew to 40 or more prescriptions per 100 000 nonelderly women 3-5 years postexpansion.

CONCLUSIONS

Medicaid expansion may have had a meaningful impact on the ability of lower-income women to access effective hormonal therapies used to treat breast cancer.

Having Medicaid insurance negatively impacts outcomes in patients with head and neck malignancies

BACKGROUND

Patients covered by Medicaid insurance appear to have poorer cancer outcomes. Herein, the authors sought to test whether Medicaid was associated with worse outcomes among patients with head and neck cancer (HNC).

METHODS

The records of 1698 patients with squamous cell HNC without distant metastatic disease were retrospectively reviewed from an institutional database between 1998 and 2011. At the time of diagnosis, insurance status was categorized as Medicaid, Medicare/other government insurance, or private insurance. Outcomes including locoregional control (LRC) and overall survival (OS) were estimated using the Kaplan-Meier method and Cox regression multivariate analysis (MVA).

RESULTS

The median follow-up for all patients was 35 months. Medicaid patients comprised 11% of the population; the remaining patients were privately insured (56%) or had Medicare/government insurance (34%). On MVA, Medicaid patients were younger, were current smokers, had higher tumor T and N classifications, and experienced a longer time from diagnosis to treatment initiation (all P<.005). Medicaid insurance status was associated with a deficit of 13% in LRC (69% vs 82%) and 26% in OS (46% vs 72%) at 3 years (all with P<.001). A time from diagnosis to treatment initiation of >45 days was found to be associated with worse 3-year LRC (77% vs 83%; P = .009) and OS (68% vs 71%; P = .008). On MVA, Medicaid remained associated with a deficit in LRC (P = .002) and OS (P<.001).

CONCLUSIONS

Patients with Medicaid insurance more often present with locally advanced HNC and experience a higher rate of treatment delays compared with non-Medicaid patients. Medicaid insurance status appears to be independently associated with deficits in LRC and OS. Improvements in the health care system, such as expediting treatment initiation, may improve the outcomes of patients with HNC. Cancer 2016;122:3529-3537. © 2016 American Cancer Society.

Health Reform, Medicaid Expansions, and Women's Cancer Screening

BACKGROUND

Health reform, including Medicaid expansion, is increasing insurance coverage and financial access to breast and cervical cancer screening for low-income women, although services for low-income uninsured women are still needed.

METHODS

American Community Survey and administrative data about Medicaid and health insurance enrollment are used to estimate the number of low-income women who will be uninsured in 2017, focusing on the age ranges 21 to 64, 40 to 64, and 50 to 64.

RESULTS

Assuming that 29 states expand Medicaid (as of June 2015), the national percentage of low-income women 21 to 64 who are uninsured will fall from 32.2% in 2013 to 14.6% by 2017. Among Medicaid-expanding states, the percentage of uninsured will decrease from 28.7% to 8.0%, whereas in non-expanding states, the level will decrease from 36.9% to 23.3%. About 5.7 million women 21 to 64 and 2.6 million women 40 to 64 will remain uninsured in 2017. The size of the uninsured low-income population will remain much larger than the 659,000 women who have previously received Pap tests and 548,000 obtaining mammograms under the National Breast and Cervical Cancer Early Detection Program in 2013.

DISCUSSION

Even before 2014, women living in states that are not expanding Medicaid were less likely to get mammograms and Pap tests than women in expanding states. Affordable Care Act-related insurance expansions will lower financial barriers to screening and should boost overall screening rates. But disparities in insurance coverage and cancer screening across Medicaid-expanding and non-expanding states could widen.

CONCLUSIONS

Programs to support cancer screening for low-income uninsured women will still be needed.

Comparing Breast Cancer Outcomes Between Medicaid and the Ohio Breast and Cervical Cancer Early Detection Program

PURPOSE

To compare outcomes between women enrolling in Medicaid after being diagnosed with breast cancer and those referred to Medicaid through the Ohio Breast and Cervical Cancer Early Detection Program (BCCEDP).

METHODS

Using linked data from the 2002 to 2008 Ohio Cancer Incidence Surveillance System, Medicaid, the BCCEDP database, and Ohio death certificates (through 2010), we identified women 40 to 64 years of age diagnosed with incident invasive breast cancer during the study years and enrolled in Medicaid 3 months before or after cancer diagnosis. We compared the following outcomes across BCCEDP one-time and repeat participants and nonparticipants: (1) cancer stage at diagnosis, (2) treatment delays, (3) receipt of standard treatment, and (4) survival. We conducted multivariable logistic regression and survival analysis to examine the association between BCCEDP participation and the outcomes of interest, controlling for potential confounders.

RESULTS

We identified 427 and 654 BCCEDP participants and nonparticipants, respectively; 28.5% of BCCEDP women were repeat participants. Compared with nonparticipants, BCCEDP one-time and repeat participants were significantly less likely to be diagnosed with advanced-stage cancer (one-time: adjusted odds ratio [AOR], 0.64; 95% CI, 0.49 to 0.85; repeat: AOR, 0.34; 95% CI, 0.23 to 0.52), or experience delays in treatment initiation (one-time: adjusted hazard ratio [AHR], 1.29; 95% CI, 1.09 to 1.51; repeat: AHR, 1.38; 95% CI, 1.11 to 1.72). In addition, although we observed no difference in receipt of standard cancer treatment, BCCEDP participants experienced cancer-specific and overall survival benefits.

CONCLUSION

Compared with nonparticipants, BCCEDP participants experienced earlier breast cancer stage at diagnosis, shorter time to treatment initiation, and survival benefits.

Lasting Effects of the Breast and Cervical Cancer Early Detection Program on Breast Cancer Detection and Outcomes, Ohio, 2000-2009

Introduction

The National Breast and Cervical Cancer Early Detection Program (BCCP) in Ohio provides screening and treatment services for uninsured low-income women aged 40 to 64. Because participation in the BCCP might engender greater self-efficacy for cancer screening, we hypothesized that breast cancer and survival outcomes would be better in BCCP participants who become age-eligible to transition to Medicare than in their low-income non-BCCP counterparts.

Methods

Linking data from the 2000 through 2009 Ohio Cancer Incidence Surveillance System with the BCCP database, Medicare files, Ohio death certificates (through 2010), and the US Census, we identified Medicare beneficiaries who were aged 66 to 74 and diagnosed with incident invasive breast cancer. We compared the following outcomes between BCCP women (n = 93) and low-income non-BCCP women (n = 420): receipt of screening mammography in previous year, advanced-stage disease at diagnosis, timely and standard care, all-cause survival, and cancer survival. We conducted multivariable logistic regression and survival analysis to examine the association between BCCP status and each of the outcomes, adjusting for patient covariates.

Results

Women who participated in the BCCP were nearly twice as likely as low-income non-BCCP women to have undergone screening mammography in the previous year (adjusted odds ratio, 1.77; 95% confidence interval, 1.01–3.09). No significant differences were detected in any other outcomes.

Conclusion

With the exception of screening mammography, the differences in outcomes were not significant, possibly because of the small size of the study population. Future analysis should be directed toward identifying the factors that explain these findings.

Explaining variation across grantees in breast and cervical cancer screening proportions in the NBCCEDP

PURPOSE

There is substantial variation across the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) grantees in terms of the proportion of the eligible population served by the grantees each year (hereafter referred to as the screening proportion). In this paper, we assess program- and state-level factors to better understand the reason for this variation in breast and cervical cancer screening proportions across the NBCCEDP grantees.

METHODS

We constructed a longitudinal data set, consisting of data from NBCCEDP grantees for each of the three study years (program-years 2006-2007, 2008-2009, and 2009-2010). We performed multivariate analysis to explain the variation in breast and cervical cancer screening proportions across the grantees. The program-level factors studied were the total federal funds received, average cost of screening women by grantee, and the overall organizational structure. The state-level variables included were urban versus rural mix, access to care, and the size of the eligible population.

RESULTS

Of the 48 grantees included in the study, those that serve larger populations, as measured by the size of the population and the percentage of women eligible for services, had lower screening proportions. Higher average cost of service delivery was also associated with lower screening proportions. In addition, grantees whose populations were more concentrated in urban areas had lower screening proportions.

CONCLUSIONS

Overall, the average cost of screening, the overall size of the population eligible, and the concentration of population in urban areas all had a negative relationship to the proportion of eligible women screened by NBCCEDP grantees.

Enhancing screening and early detection among women transitioning to Medicare from the NBCCEDP in Georgia

PURPOSE

The National Breast and Cervical Cancer Early Detection Program through each state's administration serves millions of low-income and uninsured women aged 40-64. Our purpose was to assess whether cases screened through Georgia's Breast and Cervical Cancer Program (BCCP) were diagnosed at an earlier stage of disease and whether those who used the state's program regularly continued to obtain age-appropriate screens as they aged out of BCCP into Medicare between 2000 and 2005.

METHODS

We used BCCP screening data to identify women with more than one screen and an interval of 18 months or less between screens as "regular" users of BCCP. Using the linked BCCP and Medicare enrollment/claims data, we tested whether women with any BCCP use (n = 3,134) or "regular" users (n = 1,590) were more likely than women not using BCCP (n = 10,086) to exhibit regular screening under Medicare. We used linked BCCP and Georgia Cancer Registry data to examine breast cancer incidence and stage at diagnosis of BCCP women compared to the Georgia population.

RESULTS

Under Medicare, almost 63 % of women with any BCCP use were re-screened versus 51 % of non-BCCP users. The probability of being screened within 18 months of Medicare enrollment was 3.5 % points higher for any BCCP user and 17.7 points higher for "regular" BCCP users, compared to nonusers. Among Black non-Hispanics, the difference for any BCCP user was 13.7 % points and for regular users, 22.4 % points. A larger percentage of BCCP users were diagnosed at in situ or localized disease stage than overall.

CONCLUSIONS

The majority of women aging out of the GA BCCP 2000-2005 had used the program to obtain regular mammography. Regular users of GA BCCP continued to be screened within appropriate intervals once enrolled in Medicare due perhaps to educational and support components of BCCP.

Facilitators and barriers to cervical cancer screening, diagnosis, and enrollment in Medicaid: experiences of Georgia's Women's Health Medicaid Program enrollees

Although cervical cancer incidence and mortality rates have declined in the USA, African American women have a higher incidence rate of cervical cancer and a higher percentage of late-stage diagnosis than white women. Previous analyses by the authors showed that, even after adjusting for age, provider location, and availability, African American women were almost half as likely as white women to be diagnosed or enter Medicaid while at an early stage of their cervical cancer. To understand why these differences exist, we undertook a qualitative examination of the cervical cancer experiences of women enrolled in Georgia's Women's Health Medicaid Program (WHMP). Life history interviews were conducted with 24 WHMP enrollees to understand what factors shaped their cervical cancer experiences, from screening through enrollment in Medicaid. We also examined whether these factors differed by race in order to identify opportunities for increasing awareness of cervical cancer screening among underserved women. Results suggest that many women, especially African Americans, lacked understanding and recognition of early symptoms of cervical cancer, which prevented them from receiving a timely diagnosis. Additionally, participants responded positively to provider support and good communication but wished that their doctors explained their diagnosis more clearly. Finally, women were able to enroll in Medicaid without difficulty due largely to the assistance of clinical staff. These findings support the need to strengthen provider education and public health efforts to reach low-income and minority communities for screening and early detection of cervical cancer.

Variations in Guideline-Concordant Breast Cancer Adjuvant Therapy in Rural Georgia

OBJECTIVE

To examine factors associated with guideline-concordant adjuvant therapy among breast cancer patients in a rural region of the United States and to present an advancement in quality-of-care assessment in the context of multiple treatments.

DATA SOURCES

Chart abstraction on initial therapy received by 868 women diagnosed with primary, invasive, early-stage breast cancer in a largely rural region of southwest Georgia.

STUDY DESIGN

Using multivariable logistic regression, we examined predictors of adjuvant chemo-, radiation, and hormonal therapy regimens defined as guideline-concordant according to the 2000 National Institutes of Health Consensus Development Conference Statement.

PRINCIPAL FINDINGS

Overall, 35.2 percent of women received guideline-concordant care for all three adjuvant therapies. Higher socioeconomic status was associated with receiving guideline-concordant care for all three adjuvant therapies jointly, and for chemotherapy. Compared with private insurance, having Medicaid was associated with guideline-concordant chemotherapy. Unmarried women were more likely to be nonconcordant for chemotherapy and radiation therapy. Increased age predicted nonconcordance for adjuvant therapies jointly, for chemotherapy, and for hormonal therapy.

CONCLUSIONS

A number of factors were independently associated with receiving guideline-concordant adjuvant therapy. Identifying and addressing factors that lead to nonconcordance may reduce disparities in treatment and survival.

Breast cancer treatment experiences by race and location in Georgia's Women's Health Medicaid Program

BACKGROUND

This study seeks to understand the breast cancer treatment patterns and experiences of women enrolled in Georgia's Breast and Cervical Cancer Prevention and Treatment Act program, the Women's Health Medicaid Program (WHMP), and whether these experiences vary by race or location.

METHODS

We conducted a mixed-methods analysis of WHMP breast cancer enrollees by race and urban/rural location. Quantitative analysis used a hazard rate model approach to identify differences in the timing of diagnosis, enrollment into Medicaid, and various modalities of treatment for 810 enrollees. Qualitative analysis used a systematic retrieval and review of coded data from 34 in-depth disease life history interview transcripts to a complete, focused analysis of enrollees' cancer treatment experiences.

FINDINGS

African-American women began treatment, on average, 6 days later after diagnosis than White women, driven by delays of one month among African-American women with late-stage cancers. This time delay for African-American women was not significant on multivariate analysis of time from enrollment to treatment. Once enrolled in WHMP, women reported gaining access to equitable breast cancer treatment regardless of race or location, with the exception of breast reconstruction, for which some women in our sample reported barriers to care.

CONCLUSIONS

The equitable access to cancer treatment and other health services provided by WHMP to low-income, uninsured women in Georgia with breast cancer makes it a critical health care safety net program in Georgia, the need for which will continue through the implementation of the Affordable Care Act.

Treatment patterns among medicaid-eligible women with breast cancer in georgia: are patterns different under the breast and cervical cancer prevention and treatment act?

PURPOSE

To investigate breast cancer treatment of patients enrolled under traditional Medicaid categories versus those in the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) in Georgia.

METHODS

Georgia Comprehensive Cancer Registry linked to Medicaid enrollment files were used to identify 2,048 enrollees with a primary cancer of the breast, of whom 1,046 were enrolled in BCCPTA, 674 were disabled, and 328 were in other Medicaid eligibility groups. Logistic regressions were used to estimate factors associated with the odds of receiving lumpectomy, mastectomy, or other surgery in addition to any drug regimen (hormonal or chemotherapy) and radiation.

RESULTS

Women in BCCPTA were more likely to receive any treatment (odds ratio [OR] = 4.71; 95% CI, 2.48 to 8.96), any drug regimen (OR = 3.58; 95% CI, 2.32 to 5.51), any radiation (OR = 1.61; 95% CI, 1.15to 2.24), and any definitive surgery (OR = 2.52; 95% CI, 1.74 to 3.66) than the "other" eligibility group after controlling for covariates. There were no significant differences by eligibility group in the receipt of a lumpectomy versus a mastectomy. However, women in BCCPTA were more likely to receive more adjuvant follow-up after a mastectomy.

CONCLUSION

The BCCPTA program in Georgia appears to create a quicker pathway for low-income, previously uninsured women with breast cancer to access services and, in turn, receive more treatment than women enrolled in the other, more traditional Medicaid eligibility groups. Yet the overall rate of adjuvant therapy, whether radiation, hormonal, or chemotherapy, appears to fall short of national criteria. This deserves attention in Georgia and, most likely, Medicaid programs in other states as well.

Medicaid enrollment at early stage of disease: the Breast and Cervical Cancer Prevention and Treatment Act in Georgia

This study linked data from the Georgia Comprehensive Cancer Registry to Medicaid enrollment and claims to test whether the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA), which provided a new and quicker pathway to Medicaid eligibility for low-income breast cancer patients, led to more patients enrolling at an early stage of disease. Results based on difference-in-differences analysis indicated that Georgia's BCCPTA increased by 11 percentage points the probability of breast cancer patients enrolling in Medicaid at an early stage (p = .024). This effect could mean more treatment options and higher survival rates for these patients.

Black-white differences in receipt and completion of adjuvant chemotherapy among breast cancer patients in a rural region of the US

Recent breast cancer treatment studies conducted in large urban settings have reported racial disparities in the appropriate use of adjuvant chemotherapy. This article presents the first focused evaluation of black-white differences in receipt and completion of chemotherapy for breast cancer in a primarily rural region of the United States. We performed chart abstraction on initial therapy received by 868 women diagnosed with Stages I, IIA, IIB, or IIIA breast cancer in 2001-2003 in southwest Georgia (SWGA). For chemotherapy, information collected included treatment plan, dates of delivery, concordance between therapy planned and received, and date and reasons for end of treatment. The patient's age at diagnosis, race, marital status, insurance coverage, hormone receptor status, comorbidities, socioeconomic status, urban/rural status, treatment site, and distance to the site were also collected. Following univariate analyses, we used multivariable logistic regression modeling to examine the impact of race on the likelihood of (1) receiving chemotherapy and (2) completing planned chemotherapy. For patients terminating chemotherapy prematurely, the reasons were documented. The results showed that the unadjusted black-white difference in receipt of chemotherapy (48.3 vs. 36.0%) was significant, but in the multivariable analysis the black-white odds ratio (OR = 1.18) was not. While the unadjusted black-white difference (92.0 vs. 87.8%) in completing chemotherapy was not significant, in multivariable models black race was positively associated with completing care (p ranging from 0.032 to 0.087 and OR, correspondingly, from 2.16 to 2.64). The impact of race on completing chemotherapy was influenced by marital status, with a significant black-white difference for patients not married (OR = 4.67), but no difference for those married (OR = 1.06). We find compelling racial differences in this largely rural region-with black breast cancer patients receiving or completing chemotherapy at rates that equal or exceed white patients. Further investigation is warranted, both in SWGA and in other rural regions.

Health care reform and women's insurance coverage for breast and cervical cancer screening

INTRODUCTION

The Patient Protection and Affordable Care Act of 2010 (ACA) will increase insurance coverage for US citizens and for breast and cervical cancer screening through insurance expansions and regulatory changes. The primary objective of this study was to estimate the number of low-income women who would gain health insurance after implementation of the ACA and thus be able to obtain cancer screening. A secondary objective was to estimate the size and characteristics of the uninsured low-income population and the number of women who would still need National Breast and Cervical Cancer Early Detection Program (NBCCEDP) services.

METHODS

We used the nationally representative 2009 American Community Survey to estimate the determinants of insurance status for women in Massachusetts, assuming full implementation of the ACA. We extrapolated findings to simulate the effects of the ACA on each state. We used individual-level predicted probabilities of being uninsured to generate estimates of the number of women who would gain health insurance after implementation of the ACA and to predict demand for NBCCEDP services.

RESULTS

Approximately 6.8 million low-income women would gain health insurance, potentially increasing the annual demand for NBCCEDP cancer screenings initially by about 500,000 mammograms and 1.3 million Papanicolaou tests. Despite a 60% decrease in the number of low-income uninsured women, the NBCCEDP would still serve fewer than one-third of the estimated number of women eligible for services. The NBCCEDP-eligible population would comprise a larger number of women with language and literacy-related barriers to care.

CONCLUSION

Implementation of the ACA would increase insurance coverage and access to cancer screening for millions of women, but the NBCCEDP will remain essential for the millions who will remain uninsured.

The effect of insurance status on mortality and procedural use in critically ill patients

RATIONALE

Lack of health insurance maybe an independent risk factor for mortality and differential treatment in critical illness.

OBJECTIVES

To determine whether uninsured critically ill patients had differences in 30-day mortality and critical care service use compared with those with private insurance and to determine if outcome variability could be attributed to patient-level or hospital-level effects.

METHODS

Retrospective cohort study using Pennsylvania hospital discharge data with detailed clinical risk adjustment, from fiscal years 2005 and 2006, consisting of 167 general acute care hospitals, with 138,720 critically ill adult patients 64 years of age or younger.

MEASUREMENTS AND MAIN RESULTS

Measurements were 30-day mortality and receipt of five critical care procedures. Uninsured patients had an absolute 30-day mortality of 5.7%, compared with 4.6% for those with private insurance and 6.4% for those with Medicaid. Increased 30-day mortality among uninsured patients persisted after adjustment for patient characteristics (odds ratio [OR], 1.25 for uninsured vs. insured; 95% confidence interval [CI], 1.04–1.50) and hospital-level effects (OR, 1.26; 95% CI, 1.05–1.51). Compared with insured patients, uninsured patients had decreased risk-adjusted odds of receiving a central venous catheter (OR, 0.84; 95% CI,0.72–0.97), acute hemodialysis (OR, 0.59; 95% CI, 0.39–0.91), and tracheostomy (OR, 0.43; 95% CI, 0.29–0.64).

CONCLUSIONS

Lack of health insurance is associated with increased 30-day mortality and decreased use of common procedures for the critically ill in Pennsylvania. Differences were not attributable to hospital-level effects, suggesting that the uninsured have a higher mortality and receive fewer procedures when compared with privately insured patients treated at the same hospitals.

State-level cancer quality assessment and research: building and sustaining the data infrastructure

Over a decade ago, the Institute of Medicine called for a national cancer data system in the United States to support quality-of-care assessment and improvement, including research on effective interventions. Although considerable progress has been achieved in cancer quality measurement and effectiveness research, the nation still lacks a population-based data infrastructure for accurately identifying cancer patients and tracking services and outcomes over time. For compelling reasons, the most effective pathway forward may be the development of state-level cancer data systems, in which central registry data are linked to multiple public and private secondary sources. These would include administrative/claims files from Medicare, Medicaid, and private insurers. Moreover, such a state-level system would promote rapid learning by encouraging adoption of near-real-time reporting and feedback systems, such as the Commission on Cancer's new Rapid Quality Reporting System. The groundwork for such a system is being laid in the state of Georgia, and similar work is advancing in other states. The pace of progress depends on the successful resolution of issues related to the application of information technology, financing, and governance.

Treating cervical cancer: Breast and Cervical Cancer Prevention and Treatment Act patients

OBJECTIVE

To investigate cervical cancer treatment of patients enrolled under the Breast and Cervical Cancer Prevention and Treatment Act in Georgia.

STUDY DESIGN

Georgia Comprehensive Cancer Registry and Medicaid enrollment/claims were used to identify enrollees with preinvasive disease (n = 1149) and invasive cervical cancer (n = 444). Logistic regressions were used to estimate factors associated with the odds of receiving: (1) cancer workup, (2) precancerous procedure, (3) surgery, (4) radiation, and (5) chemotherapy.

RESULTS

Preinvasive disease cases with cervical intraepithelial neoplasia 3, in situ, a comorbidity or without a Commission on Cancer approved hospital nearby were more likely to receive surgery. Among invasive cases, later stage was associated with higher odds of receiving radiation or chemotherapy. Black patients were less likely to have surgery than white patients regardless of preinvasive (P < .01) or invasive status (P = .05).

CONCLUSION

Treatment patterns among Georgia Medicaid cases appear appropriate to stage but 18% with invasive cervical cancer received no cancer treatment, although Medicaid enrolled.

The effect of the Breast and Cervical Cancer Prevention and Treatment Act on Medicaid disenrollment

BACKGROUND

The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) of 2000 created a new Medicaid option that allowed states to expand coverage to previously uninsured low-income women screened by certain public providers and found in need of treatment for those cancers. States also had the flexibility to allow any provider to screen for this new eligibility category and BCCPTA women were made eligible for all Medicaid services for the duration of their treatment. We have assessed the effect of this new program on the disenrollment patterns of women with breast/cervical cancer versus those with control cancers pre- and post-BCCPTA in Georgia. The post-BCCPTA period analyzed here was one in which Georgia BCCPTA women could self-report that they were in active treatment and, hence, still eligible.

METHODS

The Georgia Comprehensive Cancer Registry (1999-2004) was linked to Medicaid enrollment files (1998-2005) to identify female Medicaid enrollees aged under 65 and enrolled in Medicaid at or after being diagnosed with breast (n = 2,265), cervical (n = 439) or one of five control cancers (n = 700). The rate of disenrollment (per 100 person-months) was computed for each cancer group pre- versus post-BCCPTA. We employed difference-in-differences analysis to adjust for any temporal changes other than BCCPTA that could affected the disenrollment rate of women with both the treatment (breast/cervical) and control cancers. We used a parametric hazard model with a Weibull distribution to analyze the odds of disenrollment.

RESULTS

The unadjusted disenrollment rate declined 50% for women with breast and cervical cancers, whereas it increased over 30% for those with control cancers, pre- versus post-BCCPTA. The direction and magnitude of these results held after adjusting for socio-demographics and area characteristics that could affect disenrollment rates.

CONCLUSION

Georgia BCCPTA has the potential to improve continuity of care for women with breast and cervical cancers because they experience more stable coverage and simpler recertification process under this new eligibility category.