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Barnes JM, Johnson KJ, Osazuwa-Peters N, Spraker MB. The impact of individual-level income predicted from the BRFSS on the association between insurance status and overall survival among adults with cancer from the SEER program. Cancer Epidemiol 2024; 89:102541. [PMID: 38325026 DOI: 10.1016/j.canep.2024.102541] [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: 11/01/2023] [Revised: 01/06/2024] [Accepted: 01/22/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Among patients with cancer in the United States, Medicaid insurance is associated with worse outcomes than private insurance and with similar outcomes as being uninsured. However, prior studies have not addressed the impact of individual-level socioeconomic status, which determines Medicaid eligibility, on the associations of Medicaid status and cancer outcomes. Our objective was to determine whether differences in cancer outcomes by insurance status persist after accounting for individual-level income. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was queried for 18-64 year-old individuals with cancer from 2014-2016. Individual-level income was imputed using a model trained on Behavioral Risk Factors Surveillance Survey participants including covariates also present in SEER. The association of 1-year overall survival and insurance status was estimated with and without adjustment for estimated individual-level income and other covariates. RESULTS A total of 416,784 cases in SEER were analyzed. The 1-yr OS for patients with private insurance, Medicaid insurance, and no insurance was 88.7%, 76.1%, and 73.7%, respectively. After adjusting for all covariates except individual-level income, 1-year OS differences were worse with Medicaid (-6.0%, 95% CI = -6.3 to -5.6) and no insurance (-6.7%, 95% CI = -7.3 to -6.0) versus private insurance. After also adjusting for estimated individual-level income, the survival difference for Medicaid patients was similar to privately insured (-0.4%, 95% CI = -1.9 to 1.1) and better than uninsured individuals (2.1%, 95% CI = 0.7 to 3.4). CONCLUSIONS Income, rather than Medicaid status, may drive poor cancer outcomes in the low-income and Medicaid-insured population. Medicaid insurance coverage may improve cancer outcomes for low-income individuals.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, Saint Louis, MO, USA.
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Fenton D, Diaz A, Chen H, Armstrong M, Auger S, Bujnowski D, Pedroza A, Polster S, Das P, Horowitz P, Roxbury C. Determining the association of insurance coverage and survival outcomes in patients with olfactory neuroblastoma utilizing machine learning. Int Forum Allergy Rhinol 2023; 13:2082-2085. [PMID: 37132277 DOI: 10.1002/alr.23172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/04/2023]
Abstract
KEY POINTS We use machine learning to examine health insurance and mortality in olfactory neuroblastoma. Private insurance significantly improved survival even after adjusting for confounders. The regression model also found no statistical difference between Medicare and no insurance.
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Affiliation(s)
- David Fenton
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ashley Diaz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Haobin Chen
- Program in Quantitative Biomedical Sciences, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Mikhayla Armstrong
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Samuel Auger
- Department of Surgery, Section of Otolaryngology, University of Chicago, Chicago, Illinois, USA
| | - Daniel Bujnowski
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Alena Pedroza
- Univerisity of Chicago, Division of the Biological Sciences, Chicago, Illinois, USA
| | - Sean Polster
- Department of Surgery, Section of Neurological Surgery, University of Chicago, Chicago, Illinois, USA
| | - Paramita Das
- Department of Surgery, Section of Neurological Surgery, University of Chicago, Chicago, Illinois, USA
| | - Peleg Horowitz
- Department of Surgery, Section of Neurological Surgery, University of Chicago, Chicago, Illinois, USA
| | - Christopher Roxbury
- Department of Surgery, Section of Otolaryngology, University of Chicago, Chicago, Illinois, USA
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Awad M, Butterfield JT, Dhawan S, Tyler MA, Venteicher AS. Prognostic Factors and Treatment Impact on Overall Survival in Adult Craniopharyngioma. World Neurosurg 2023; 173:e132-e139. [PMID: 36773809 DOI: 10.1016/j.wneu.2023.02.020] [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: 12/13/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE To examine the demographics, tumor characteristics, treatments, and clinical outcomes of a large adult craniopharyngioma population. METHODS The 2004-2018 National Cancer Database was queried to investigate adult patients with craniopharyngioma. Univariable and multivariable Cox hazard ratio analysis was conducted to analyze the overall survival (OS) impact of demographic and clinical variables. RESULTS A total of 666 adult patients with craniopharyngioma were identified with a mean age of 51 years (standard deviation 16 years). On multivariable analysis, independent of demographic and clinical variables, increased age, uninsured status, Medicaid, Medicare, Charlson-Deyo Comorbidity Index of 2, and tumor size greater than 40 mm were independently associated with worse OS. There was no significant difference in survival between histologic subtypes. Gross total resection (GTR) (hazard ratio [HR] 0.602, 95% confidence interval [CI] 0.384-0.942, P = 0.026) and subtotal resection (STR) with adjuvant radiotherapy (HR 0.316, 95% CI 0.140-0.710, P = 0.005) were independently associated with improved OS. GTR with radiotherapy trended towards improved OS (HR 0.601, 95% CI 0.334-1.083, P =0.090), but STR alone and radiotherapy alone demonstrated no significant difference in survival compared with no treatment on multivariable analysis. Kaplan-Meier survival models demonstrated improved survival with GTR, GTR + radiation therapy, and STR + radiation therapy. Patients undergoing endoscopic resection had significantly lower GTR rates and greater rates of adjuvant radiotherapy compared with open approaches but no difference in OS. CONCLUSION Adult patients with craniopharyngioma who underwent GTR or STR with adjuvant radiotherapy had significantly improved overall survival. Endoscopic approaches had lower rates of GTR but no difference in OS.
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Affiliation(s)
- Matthew Awad
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA; Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - John T Butterfield
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA; Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA; Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Matthew A Tyler
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, USA; Department of Otolaryngology- Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew S Venteicher
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA; Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, Minnesota, USA.
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Brosius DJ, Chaturvedi R, Andreae MH, White RS, Witkin LR, Nair S, Shaparin N. Social determinants of health: modeling and targeting patient propensity to attend pain clinic appointments. Pain Manag 2023; 13:151-159. [PMID: 36718774 DOI: 10.2217/pmt-2022-0059] [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: 02/01/2023] Open
Abstract
Aim: We sought to investigate the impact of social determinants of health on pain clinic attendance. Materials & methods: Retrospective data were collected from the Pain Center at Montefiore Medical Center from 2016 to 2020 and analyzed with multivariable logistic regression. Results: African-Americans were less likely to attend appointments compared with White patients (odds ratio [OR]: 0.73; 95% CI: 0.70-0.77; p < 0.001). Males had decreased attendance compared with females (OR: 0.89; 95% CI: 0.87-0.92; p < 0.001). Compared with Commercial, those with Medicaid (OR: 0.69; 95% CI: 0.66-0.72; p < 0.001) and Medicare (OR: 0.76; 95% CI: 0.73-0.80; p < 0.001) insurance had decreased attendance. Conclusion: Significant disparities exist in pain clinic attendance based upon social determinants of health including race, gender and insurance type.
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Affiliation(s)
- Daniel J Brosius
- Department of Anesthesiology, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA 17033, USA
| | - Rahul Chaturvedi
- Department of Anesthesiology, Cornell Medical Center, New York, NY 10065, USA
| | - Michael H Andreae
- Department of Anesthesiology, University of Utah, Salk Lake City, UT 84132, USA
| | - Robert S White
- Department of Anesthesiology, Cornell Medical Center, New York, NY 10065, USA
| | - Lisa R Witkin
- Department of Anesthesiology, Cornell Medical Center, New York, NY 10065, USA
| | - Singh Nair
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | - Naum Shaparin
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA
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Irace AL, Sharma RK, Smith TL, Stewart MG, Gudis DA. Impact of Medicaid Expansion on Rhinologic Cancer Presentation, Treatment, and Outcomes. Laryngoscope 2023; 133:43-50. [PMID: 35147223 DOI: 10.1002/lary.30049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/11/2022] [Accepted: 01/22/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The United States Patient Protection and Affordable Care Act allocated funds for states to expand Medicaid coverage. However, several states declined expansion. We aim to determine whether Medicaid expansion is associated with healthcare coverage, cancer stage at diagnosis, treatment, and survival among patients with rhinologic cancer. Rhinologic cancer was defined to include cancer of the nasal cavity, paranasal sinus, nasopharynx, or olfactory nerve. STUDY DESIGN Cohort study. METHODS Patients diagnosed with primary rhinologic malignancies between 2007 to 2016 were extracted from the National Cancer Institute Surveillance, Epidemiology, End Results (SEER) registry. Patients were grouped by diagnosis before and after 2014 (when Medicaid expansion became effective) and whether their state had expanded Medicaid. Multivariable logistic regression controlling for age, sex, race, ethnicity, and income/education was utilized to examine associations between Medicaid expansion/insurance status and stage at diagnosis, treatment, and survival. Overall and disease-specific survival were examined using Kaplan-Meier analysis. RESULTS Analysis included 10,164 patients. The proportion of uninsured patients decreased after 2014 (2.4%) compared to before 2014 (4.8%, P < .001). After 2014, patients in nonexpanded states were more likely to be diagnosed with advanced stage disease compared to patients in expanded states (N = 2,364; OR = 1.27, 95% CI 1.01-1.60). Being uninsured in any state was associated with advanced stage disease at diagnosis (OR = 1.75, 95% CI 1.41-2.22) and increased risk of disease-specific death (HR = 1.54, 95% CI 1.32-1.82). Survival measures were not associated with diagnosis before versus after 2014 or Medicaid expansion. CONCLUSIONS Patients lacking insurance or residing in nonexpanded states may be more likely to present with advanced stage rhinologic cancer. Longitudinal studies should validate these findings. LEVEL OF EVIDENCE 3 Laryngoscope, 133:43-50, 2023.
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Affiliation(s)
- Alexandria L Irace
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Rahul K Sharma
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
| | - Timothy L Smith
- Department of Otolaryngology-Head and Neck Surgery, Oregon Sinus Center, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Michael G Stewart
- Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, New York, U.S.A
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian/Columbia University Irving Medical Center, New York, New York, U.S.A
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Abiri A, Roman KM, Latif K, Goshtasbi K, Torabi SJ, Lehrich BM, Mohyeldin A, Hsu FPK, Kuan EC. Endoscopic versus Nonendoscopic Surgery for Resection of Craniopharyngiomas. World Neurosurg 2022; 167:e629-e638. [PMID: 36041722 DOI: 10.1016/j.wneu.2022.08.068] [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: 05/02/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE While surgery is a critical treatment option for craniopharyngiomas, the optimal surgical approach remains under debate. Herein, we studied a large cohort of craniopharyngioma patients to identify predictors of endoscopic surgery (ES) and to compare survival outcomes between patients undergoing ES versus nonendoscopic surgery (NES). METHODS The National Cancer Database was queried for patients receiving definitive surgical treatment in 2010-2016. Cox proportional hazards and propensity score-adjusted Kaplan-Meier analyses assessed mortality risk and overall survival, respectively. Predictors of surgical approach were evaluated via logistic regression. RESULTS Of 1721 patients, 508 (29.5%) underwent ES, 877 (50.9%) were female, and the average age was 41.8 ± 21.3 years. Matched ES and NES cohorts exhibited 5-year overall survival rates of 88.0% and 79.8%, respectively (P = 0.004). ES was associated with reduced mortality (Hazard Ratio = 0.634; 95% confidence interval [CI], 0.439-0.914; P = 0.015). Patients treated at academic facilities (Odds Ratio [OR] = 2.095; 95% CI, 1.529-2.904; P < 0.001) or diagnosed recently (OR = 1.132; 95% CI, 1.058-1.211; P < 0.001) were more likely to undergo ES, while those with tumor sizes >3 cm (OR = 0.604; 95% CI, 0.451-0.804; P < 0.001) or receiving adjuvant radiotherapy (OR = 0.641; 95% CI, 0.454-0.894; P = 0.010) were more likely to receive NES. Surgical inpatient stays were significantly shorter with ES compared to NES (8.0 vs. 10.5 days, P < 0.001). On linear regression, ES usage increased by 82.4% and NES usage decreased by 23.4% between 2010 and 2016 (R2 = 0.575, P = 0.031). CONCLUSIONS ES of craniopharyngioma was associated with reduced mortality and shorter inpatient stays compared to NES. Factors including tumor size, extent of resection, facility type, and year of diagnosis may predict receiving ES. There is a trend towards increased usage of ES for surgical management of craniopharyngiomas.
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Affiliation(s)
- Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Kelsey M Roman
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Kareem Latif
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Sina J Torabi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Brandon M Lehrich
- Medical Scientist Training Program, University of Pittsburgh and Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Ahmed Mohyeldin
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, Orange, California, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA; Department of Neurological Surgery, University of California, Irvine, Orange, California, USA.
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Megwalu UC, Raol NP, Bergmark R, Osazuwa-Peters N, Brenner MJ. Evidence-Based Medicine in Otolaryngology, Part XIII: Health Disparities Research and Advancing Health Equity. Otolaryngol Head Neck Surg 2022; 166:1249-1261. [PMID: 35316118 DOI: 10.1177/01945998221087138] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To provide a contemporary resource for clinicians and researchers on health equity research and implementation strategies to mitigate or eliminate disparities in health care. DATA SOURCES Published studies and literature on health disparities, applicable research methodologies, and social determinants of health in otolaryngology. REVIEW METHODS Literature through October 2021 was reviewed, including consensus statements, guidelines, and scientific publications related to health care equity research. This research focus provides insights into existing disparities, why they occur, and the outcomes of interventions designed to resolve them. Progress toward equity requires intentionality in implementing quality improvement initiatives, tracking data, and fostering culturally competent care. Priority areas include improving access, removing barriers to care, and ensuring appropriate and effective treatment. Although research into health care disparities has advanced significantly in recent years, persistent knowledge gaps remain. Applying the lens of equity to data science can promote evidence-based practices and optimal strategies to reduce health inequities. CONCLUSIONS Health disparities research has a critical role in advancing equity in otolaryngology-head and neck surgery. The phases of disparities research include detection, understanding, and reduction of disparities. A multilevel approach is necessary for understanding disparities, and health equity extensions can improve the rigor of evidence-based data synthesis. Finally, applying an equity lens is essential when designing and evaluating health care interventions, to minimize bias. IMPLICATIONS FOR PRACTICE Understanding the data and practices related to disparities research may help promote an evidence-based approach to care of individual patients and populations, with the potential to eventually surmount the negative effects of health care disparities.
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Affiliation(s)
- Uchechukwu C Megwalu
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Stanford University, Stanford, California, USA
| | - Nikhila P Raol
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Regan Bergmark
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA.,Duke Cancer Institute, Durham, North Carolina, USA
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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