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Preston MA, Amoli MM, Chukmaitov AS, Krist AH, Dahman B. The impact of the affordable care act and Medicaid expansion on colorectal cancer screening: Evidence from the 5th year of Medicaid expansion. Cancer Med 2024; 13:e7054. [PMID: 38591114 PMCID: PMC11002632 DOI: 10.1002/cam4.7054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 02/05/2024] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Colorectal cancer screening rates remain suboptimal, particularly among low-income populations. Our objective was to evaluate the long-term effects of Medicaid expansion on colorectal cancer screening. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed data from 354,384 individuals aged 50-64 with an income below 400% of the federal poverty level (FPL), who participated in the Behavioral Risk Factors Surveillance System from 2010 to 2018. A difference-in-difference analysis was employed to estimate the effect of Medicaid expansion on colorectal cancer screening. Subgroup analyses were conducted for individuals with income up to 138% of the FPL and those with income between 139% and 400% of the FPL. The effect of Medicaid expansion on colorectal cancer screening was examined during the early, mid, and late expansion periods. MAIN OUTCOMES AND MEASURES The primary outcome was the likelihood of receiving colorectal cancer screening for low-income adults aged 50-64. RESULTS Medicaid expansion was associated with a significant 1.7 percentage point increase in colorectal cancer screening rates among adults aged 50-64 with income below 400% of the FPL (p < 0.05). A significant 2.9 percentage point increase in colorectal cancer screening was observed for those with income up to 138% the FPL (p < 0.05), while a 1.5 percentage point increase occurred for individuals with income between 139% and 400% of the FPL. The impact of Medicaid expansion on colorectal cancer screening varied based on income levels and displayed a time lag for newly eligible beneficiaries. CONCLUSIONS Medicaid expansion was found to be associated with increased colorectal cancer screening rates among low-income individuals aged 50-64. The observed variations in impact based on income levels and the time lag for newly eligible beneficiaries receiving colorectal cancer screening highlight the need for further research and precision public health strategies to maximize the benefits of Medicaid expansion on colorectal cancer screening rates.
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Affiliation(s)
- Michael A. Preston
- School of Population Health, Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
- Massey Cancer Center, Health Equity and Disparities ResearchVirginia Commonwealth UniversityRichmondVirginiaUSA
- Department of Pharmacy PracticePurdue UniversityWest LafayetteIndianaUSA
| | - Mahmoud Manouchehri Amoli
- School of Population Health, Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Askar S. Chukmaitov
- School of Population Health, Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Alex H. Krist
- Department of Family Medicine and Population HealthVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Bassam Dahman
- School of Population Health, Department of Health Behavior and PolicyVirginia Commonwealth UniversityRichmondVirginiaUSA
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Sun J, Frick KD, Liang H, Chow CM, Aronowitz S, Shi L. Examining cancer screening disparities by race/ethnicity and insurance groups: A comparison of 2008 and 2018 National Health Interview Survey (NHIS) data in the United States. PLoS One 2024; 19:e0290105. [PMID: 38416784 PMCID: PMC10901319 DOI: 10.1371/journal.pone.0290105] [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: 04/27/2023] [Accepted: 08/01/2023] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Pervasive differences in cancer screening among race/ethnicity and insurance groups presents a challenge to achieving equitable healthcare access and health outcomes. However, the change in the magnitude of cancer screening disparities over time has not been thoroughly examined using recent public health survey data. METHODS A retrospective cross-sectional analysis of the 2008 and 2018 National Health Interview Survey (NHIS) database focused on breast, cervical, and colorectal cancer screening rates among race/ethnicity and insurance groups. Multivariable logistic regression models were used to assess the relationship between cancer screening rates, race/ethnicity, and insurance coverage, and to quantify the changes in disparities in 2008 and 2018, adjusting for potential confounders. RESULTS Colorectal cancer screening rates increased for all groups, but cervical and mammogram rates remained stagnant for specific groups. Non-Hispanic Asians continued to report consistently lower odds of receiving cervical tests (OR: 0.42, 95% CI: 0.32-0.55, p<0.001) and colorectal cancer screening (OR: 0.55, 95% CI: 0.42-0.72, p<0.001) compared to non-Hispanic Whites in 2018, despite significant improvements since 2008. Non-Hispanic Blacks continued to report higher odds of recent cervical cancer screening (OR: 1.98, 95% CI: 1.47-2.68, p<0.001) and mammograms (OR: 1.32, 95% CI: 1.02-1.71, p<0.05) than non-Hispanic Whites in 2018, consistent with higher odds observed in 2008. Hispanic individuals reported improved colorectal cancer screening over time, with no significant difference compared to non-Hispanics Whites in 2018, despite reporting lower odds in 2008. The uninsured status was associated with significantly lower odds of cancer screening than private insurance for all three cancers in 2008 and 2018. CONCLUSION Despite an overall increase in breast and colorectal cancer screening rates between 2008 and 2018, persistent racial/ethnic and insurance disparities exist among race/ethnicity and insurance groups. These findings highlight the importance of addressing underlying factors contributing to disparities among underserved populations and developing corresponding interventions.
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Affiliation(s)
- Jingjing Sun
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kevin D Frick
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Carey Business School, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Hailun Liang
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- School of Administration and Policy, Renmin University of China, Beijing, China
| | - Clifton M Chow
- Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts, United States of America
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sofia Aronowitz
- Independent Researcher, Albany, New York, United States of America
| | - Leiyu Shi
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
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He Y, Xu T, Fang J, Tong L, Gao W, Zhang Y, Wang Y, Xu Y, Shi S, Liu S, Jin L. Trends in colorectal cancer screening in the United States, 2012 to 2020. J Med Screen 2023; 30:125-133. [PMID: 37157812 DOI: 10.1177/09691413231174163] [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] [Indexed: 05/10/2023]
Abstract
OBJECTIVES Despite recommendations to increase the uptake of colorectal cancer (CRC) screening, trends in CRC screening vary with sociodemographic status. We aimed to evaluate trends in CRC screening in the US population and subpopulations. METHODS A total of 1,082,924 participants aged 50 to 75 from five cycles (2012, 2014, 2016, 2018, and 2020) of the Behavioral Risk Factor Surveillance System were involved. Multivariable logistic regression models were performed to evaluate linear trends in CRC screening utilization from 2012 to 2018. Rao-Scott chi-square tests were used to assess the differences in CRC screening utilization between 2018 and 2020. RESULTS The estimated percentage reporting up-to-date with CRC screening increased significantly (P for trend <0.001), from 62.8% (95% CI, 62.4%-63.2%) in 2012 to 66.7% (95% CI, 66.3%-67.2%) in 2018 and 70.4% (95% CI, 69.8%-71.0%) in 2020, in accordance with 2008 US Preventive Services Task Force recommendations. Trends followed similar patterns in most subgroups, although with different magnitudes in several subgroups, primarily those underweight showed a stable percentage over time (P for trend = 0.170). In 2020, 72.4% of participants reported they were up to date with CRC screening, including the utilization of stool DNA tests and virtual colonoscopy. Colonoscopy was the most commonly used test in 2020 (64.5%), followed by FOBT (12.6%), stool DNA test (5.8%), sigmoidoscopy (3.8%), and virtual colonoscopy (2.7%). CONCLUSIONS In this nationally representative survey of the US population from 2012 through 2020, the percentage reporting up to date with CRC screening has increased, but not equally among all subgroups.
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Affiliation(s)
- Yue He
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Tong Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Jiaxin Fang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Li Tong
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Wenhui Gao
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yuan Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yanfang Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yan Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Shunyao Shi
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Siyu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Lina Jin
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
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Eslami MH, Semaan DB. Increased Medicaid eligibility of Affordable Care Act: Evidence of improved outcomes for patients with peripheral artery disease. Semin Vasc Surg 2023; 36:58-63. [PMID: 36958898 DOI: 10.1053/j.semvascsurg.2023.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023]
Abstract
Peripheral artery disease (PAD) is a debilitating disease that disproportionately affects people of low socioeconomic status and racial minority individuals. These groups also tend to have lower rates of revascularization and worse outcomes, including higher rates of major amputation. In 2010, the Affordable Care Act (ACA) was signed into law, providing better opportunities for health care access to millions of uninsured Americans, although the implementation of different components started at a later date. Political issues led to uneven adaptation by states of the different ACA components. In states that adopted Medicaid expansion under the ACA, similar to that under the Massachusetts Health Care Reform Law of 2006, patients of low socioeconomic status and racial minority patients gained better access to health care. This review article will examine the disparities that exist in peripheral artery disease outcomes, as well as the effects of the ACA and Medicaid expansion on revascularization, limb salvage, and major amputation rates.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular Surgery, UPMC, Heart and Vascular Institute, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213.
| | - Dana B Semaan
- Division of Vascular Surgery, UPMC, Heart and Vascular Institute, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213
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Impact of the Affordable Care Act on Presentation, Treatment, and Outcomes of Intrahepatic Cholangiocarcinoma. J Gastrointest Surg 2023; 27:262-272. [PMID: 36400904 DOI: 10.1007/s11605-022-05496-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/20/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) transformed the US healthcare system, expanding healthcare insurance coverage. However, its impact on rare malignancies that lack an established screening strategy such as intrahepatic cholangiocarcinoma (ICC) remains ill-defined. METHODS Patients diagnosed with ICC were identified from the National Cancer Database and divided relative to ACA implementation. Multivariate logistic regression analyses were performed to evaluate association with stage at diagnosis, receipt of surgical and multimodal treatments, and survival. RESULTS Among the 9095 patients, 5636 (62.0%) were diagnosed before and 3459 (38.0%) after the implementation of the ACA. Across US regions, rates of early-stage diagnosis increased in the post-ACA era (Northeast, 62.9% vs. 85.2%; South, 63.7% vs. 78.5%; Midwest, 62.1% vs. 83.4%; West, 55.5% vs. 75.4%; p < 0.001). On multivariate analyses, the post-ACA era was associated with increased early-stage diagnosis (OR = 2.19; 95% CI 1.79-2.69), and receipt of surgical treatment (OR = 1.19, 95% CI 1.03-1.38) (both p < 0.01). Furthermore, the ACA's Medicaid expansion (ME) was also associated with improved overall survival (HR = 0.89, 95% CI 0.80-0.99, p = 0.038). Of note, although the odds of receiving surgical treatment increased after ACA for non-Hispanic White patients (OR = 1.34; 95% CI 1.20-1.49; p < 0.001), no such effect was observed in non-Hispanic Black (OR = 1.01, 95% CI 0.71-1.45), Hispanic (OR = 1.44, 95% CI 0.99-2.09), or others (OR = 1.43, 95% CI 0.98-2.10) (all p > 0.05). CONCLUSIONS The implementation of the ACA increased rates of early diagnosis and receipt of surgical treatment. Additionally, ME improved short- and long-term outcomes. However, racial and socioeconomic disparities persist, resulting in inequitable access to care and outcomes for patients with ICC.
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Qian Z, Chen X, Pucheril D, Al Khatib K, Lucas M, Nguyen DD, McNabb-Baltar J, Lipsitz SR, Melnitchouk N, Cole AP, Trinh QD. Long-Term Impact of Medicaid Expansion on Colorectal Cancer Screening in Its Targeted Population. Dig Dis Sci 2023; 68:1780-1790. [PMID: 36600118 PMCID: PMC9812352 DOI: 10.1007/s10620-022-07797-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Colorectal cancer screening continuously decreased its mortality and incidence. In 2010, the Affordable Care Act extended Medicaid eligibility to low-income and childless adults. Some states elected to adopt Medicaid at different times while others chose not to. Past studies on the effects of Medicaid expansion on colorectal cancer screening showed equivocal results based on short-term data following expansion. AIMS To examine the long-term impact of Medicaid expansion on colorectal cancer screening among its targeted population at its decade mark. METHODS Behavioral Risk Factor Surveillance System data were extracted for childless adults below 138% federal poverty level in states with different Medicaid expansion statuses from 2012 to 2020. States were stratified into very early expansion states, early expansion states, late expansion states, and non-expansion states. Colorectal cancer screening prevalence was determined for eligible respondents. Difference-in-differences analyses were used to examine the effect of Medicaid expansion on colorectal cancer screening in states with different expansion statuses. RESULTS Colorectal cancer screening prevalence in very early, early, late, and non-expansion states all increased during the study period (40.45% vs. 48.14%, 47.52% vs 61.06%, 46.06% vs 58.92%, and 43.44% vs 56.70%). Difference-in-differences analysis showed significantly increased CRC screening prevalence in very early expansion states during 2016 compared to non-expansion states (Crude difference-in-differences + 16.45%, p = 0.02, Adjusted difference-in-differences + 15.9%, p = 0.03). No statistical significance was observed among other years and groups. CONCLUSIONS Colorectal cancer screening increased between 2012 and 2020 in all states regardless of expansion status. However, Medicaid expansion is not associated with long-term increased colorectal cancer screening prevalence.
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Affiliation(s)
- Zhiyu Qian
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Xi Chen
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Daniel Pucheril
- Department of Surgery, Booshoft School of Medicine, Wright State University, Dayton, OH USA
| | - Khalid Al Khatib
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Mayra Lucas
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - David-Dan Nguyen
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Julia McNabb-Baltar
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Stuart R. Lipsitz
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Nelya Melnitchouk
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Division of General and Gastrointestinal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Alexander P. Cole
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA ,Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
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Hao S, Mitsakos A, Popowicz P, Irish W, Snyder RA, Parikh AA. Differential effects of the Affordable Care Act on the stage at presentation and receipt of treatment for pancreatic adenocarcinoma. J Surg Oncol 2022; 126:698-707. [PMID: 35699593 DOI: 10.1002/jso.26984] [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: 03/28/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES For pancreatic ductal adenocarcinoma (PDAC) which lacks a recommended screening modality, the benefit of the Affordable Care Act (ACA) may not be an earlier diagnosis, but rather improved rates of treatment. The objective of this study was to examine change in the stage of PDAC presentation and treatment disparities following the ACA. METHODS A retrospective cohort study of patients with primary PDAC identified in the 2004-2017 National Cancer Database was divided into pre- and post-ACA, for which the primary outcomes of a stage of presentation, receipt of surgical resection, and systemic therapy (termed multimodality) (Stage I-II), and receipt of systemic therapy (Stage III-IV) were compared by multivariable analysis. RESULTS 228,015 patients were included. Odds of presenting with Stage I-II PDAC were significantly higher in 2011-2017 versus 2004-2010 (odds ratio 1.44, 95% confidence interval 1.40-1.47). Black patients with early-stage disease had a lower likelihood of multimodality therapy and those with advanced disease were less likely to receive systemic therapy, before and after the ACA. Uninsured patients were less likely to receive any therapy compared with insured patients; this disparity increased in the post-ACA period. CONCLUSIONS An earlier presentation of PDAC increased following the ACA. However, racial, insurance, and socioeconomic treatment disparities persist.
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Affiliation(s)
- Scarlett Hao
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Anastasios Mitsakos
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - Patrycja Popowicz
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
| | - William Irish
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
- Department of Public Health, East Carolina University, Greenville, North Carolina, USA
| | - Rebecca A Snyder
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
- Department of Public Health, East Carolina University, Greenville, North Carolina, USA
| | - Alexander A Parikh
- Department of Surgery, Division of Surgical Oncology, Brody School of Medicine at East Carolina University, Greenville, North Carolina, USA
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Changes in the Proportion of Patients Presenting With Early Stage Colon Cancer Over Time Among Medicaid Expansion and Nonexpansion States: A Cross-sectional Study. Dis Colon Rectum 2022; 65:1084-1093. [PMID: 34803146 DOI: 10.1097/dcr.0000000000002086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The 2010 Patient Protection and Affordable Care Act mandated preventive screening coverage and provided support to participating states for Medicaid coverage. The association of Medicaid expansion with colon cancer stage at diagnosis is unknown. OBJECTIVE This study aimed to determine whether the proportion of patients diagnosed with early stage colon cancer changed over time within states that expanded Medicaid compared with nonexpansion states. DESIGN This is a cross-sectional cohort study. SETTING This study evaluated multicenter registry data from the National Cancer Database (2006-2016). PATIENTS There were 25,462 uninsured or Medicaid-insured patients with newly diagnosed colon cancer who resided in 2014 Medicaid expansion or nonexpansion states. MAIN OUTCOME MEASURES This study assessed the annual proportion of patients with early stage (I-II) versus late stage (III-IV) colon cancer. RESULTS A total of 10,289 patients were identified in expansion states and 15,173 patients in nonexpansion states. Cohorts were similar in age (median 55 years) and sex (46.7% female). A greater proportion of patients in nonexpansion states were Black (33.4% vs 24.0%) and resided in a zip code with median income <$38,000 (39.7% vs 28.2%) and lower educational status (37.4% vs 28.1%). In 2006, the proportions of patients with early stage colon cancer in expansion and nonexpansion cohorts were similar (33.2% vs 32.5%). The proportion of patients with early stage colon cancer within nonexpansion states declined by 0.8% per year after 2014, whereas the proportion within expansion states increased by 0.9% per year after 2014 ( p < 0.05). By 2016, the absolute difference in the propensity-adjusted proportion of early stage colon cancer was 8.8% (39.7% vs 30.9%, p < 0.001). LIMITATIONS National Cancer Database data are obtained only from Commission on Cancer-accredited sites and are not population based. CONCLUSIONS After Medicaid expansion in 2014, the proportion of patients diagnosed and treated at Commission on Cancer-accredited facilities with early stage colon cancer increased within expansion states and decreased in nonexpansion states. Increase in insurance coverage may have facilitated earlier diagnosis among patients in expansion states. See Video Abstract at http://links.lww.com/DCR/B804 . CAMBIOS EN LA PROPORCIN DE PACIENTES QUE PRESENTAN CNCER DE COLON EN ESTADIO TEMPRANA A LO LARGO DEL TIEMPO ENTRE LOS ESTADOS DE EXPANSIN Y NO EXPANSIN DE MEDICAID UN ESTUDIO TRANSVERSAL ANTECEDENTES:La Ley del Cuidado de Salud a Bajo Precio del 2010 ordenó la cobertura de exámenes preventivos y brindó apoyo a los estados participantes para la cobertura de Medicaid. Se desconoce la asociación de la expansión de Medicaid con el estadio del cáncer de colon en el momento del diagnóstico.OBJETIVO:Determinar si la proporción de pacientes diagnosticados con cáncer de colon en estadio temprano cambió con el tiempo dentro de los estados que expandieron Medicaid en comparación con los estados sin expansión.DISEÑO:Estudio de cohorte transversal.ENTORNO CLINICO:Datos de registro multicéntrico de la Base de datos nacional de cáncer (2006-2016).PACIENTES:Había 25,462 pacientes sin seguro o asegurados por Medicaid con cáncer de colon recién diagnosticado. Exposición: Residencia en estados de expansión o no expansión de Medicaid en el 2014.PRINCIPALES MEDIDAS DE RESULTADO:Proporción anual de pacientes con cáncer de colon en estadio temprano (I-II) versus tardío (III-IV).RESULTADOS:Se identificaron un total de 10.289 pacientes en estados de expansión y 15.173 pacientes en estados de no expansión. Las cohortes fueron similares en edad (mediana de 55 años) y sexo (46,7% mujeres). Una mayor proporción de pacientes en estados sin expansión eran de raza negra (33,4% vs 24,0%) y residían en un código postal con ingresos medios <$38 000 (39,7% vs 28,2%) y un nivel educativo más bajo (37,4% vs 28,1%). En el 2006, las proporciones de pacientes con cáncer de colon en estadio temprano en cohortes en expansión y sin expansión fueron similares (33,2% vs 32,5%). La proporción de pacientes con estadio temprano dentro de los estados sin expansión disminuyó en un 0,8% por año después del 2014, mientras que la proporción dentro de los estados de expansión aumentó en un 0,9% por año después del 2014 (p <0,05). Para el 2016, la diferencia absoluta en la proporción ajustada por propensión de cáncer de colon en estadio temprano fue de 8.8% (39.7% vs 30.9%, p <0.001).LIMITACIONES:Los datos de la Base de datos nacional de cáncer se obtienen únicamente de los sitios acreditados por la Comisión de cáncer y no se basan en la población.CONCLUSIONES:Después de la expansión de Medicaid en el 2014, la proporción de pacientes diagnosticados y tratados en instalaciones acreditadas por la Comisión de Cáncer en pacientes con cáncer de colon en estadio temprano aumentó dentro de los estados de expansión y disminuyó en los estados de no expansión. El aumento de la cobertura del seguro puede haber facilitado un diagnóstico más temprano entre los pacientes en estados de expansión. Consulte Video Resumen en http://links.lww.com/DCR/B804 . (Traducción- Dr. Francisco M. Abarca-Rendon ).
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Huepenbecker SP, Fu S, Sun CC, Zhao H, Primm KM, Giordano SH, Meyer LA. Medicaid expansion and 2-year survival in women with gynecologic cancer: a difference-in-difference analysis. Am J Obstet Gynecol 2022; 227:482.e1-482.e15. [PMID: 35500609 PMCID: PMC9420833 DOI: 10.1016/j.ajog.2022.04.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 04/15/2022] [Accepted: 04/23/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Affordable Care Act implemented optional Medicaid expansion starting in 2014, but the association between Medicaid expansion and gynecologic cancer survival is unknown. OBJECTIVE To evaluate the impact of Medicaid expansion by comparing 2-year survival among gynecologic cancers before and after 2014 in states that did and did not expand Medicaid using a difference-in-difference analysis. STUDY DESIGN We searched the National Cancer Database for women aged 40 to 64 years, diagnosed with a primary gynecologic malignancy (endometrial, ovarian, cervical, vulvar, and vaginal) between 2010 and 2016. We used a quasiexperimental difference-in-difference multivariable Cox regression analysis to compare 2-year survival between states that expanded Medicaid in January 2014 and states that did not expand Medicaid as of 2016. We performed univariable subgroup difference-in-difference Cox regression analyses on the basis of stage, income, race, ethnicity, and geographic location. Adjusted linear difference-in-difference regressions evaluated the proportion of uninsured patients on the basis of expansion status after 2014. We evaluated adjusted Kaplan-Meier curves to examine differences on the basis of study period and expansion status. RESULTS Our sample included 169,731 women, including 78,669 (46.3%) in expansion states and 91,062 (53.7%) in nonexpansion states. There was improved 2-year survival on adjusted difference-in-difference Cox regressions for women with ovarian cancer in expansion than in nonexpansion states after 2014 (hazard ratio, 0.88; 95% confidence interval, 0.82-0.94; P<.001) with no differences in endometrial, cervical, vaginal, vulvar, or combined gynecologic cancer sites on the basis of expansion status. On univariable subgroup difference-in-difference Cox analyses, women with ovarian cancer with stage III-IV disease (P=.008), non-Hispanic ethnicity (P=.042), those in the South (P=.016), and women with vulvar cancer in the Northeast (P=.022), had improved 2-year survival in expansion than in nonexpansion states after 2014. In contrast, women with cervical cancer in the South (P=.018) had worse 2-year survival in expansion than in nonexpansion states after 2014. All cancer sites had lower proportions of uninsured patients in expansion than in nonexpansion states after 2014. CONCLUSION There was a significant association between Medicaid expansion and improved 2-year survival for women with ovarian cancer in states that expanded Medicaid after 2014. Despite improved insurance coverage, racial, ethnic, and regional survival differences exist between expansion and nonexpansion states.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Shuangshuang Fu
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Hui Zhao
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Kristin M Primm
- Department of Epidemiology, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Sharon H Giordano
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX.
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10
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Sharon CE, Song Y, Straker RJ, Kelly N, Shannon AB, Kelz RR, Mahmoud NN, Saur NM, Miura JT, Karakousis GC. Impact of the affordable care act's medicaid expansion on presentation stage and perioperative outcomes of colorectal cancer. J Surg Oncol 2022; 126:1471-1480. [PMID: 35984366 DOI: 10.1002/jso.27070] [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: 05/05/2022] [Revised: 06/17/2022] [Accepted: 07/24/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Medicaid expansion has improved healthcare coverage and preventive health service use. To what extent this has resulted in earlier stage colorectal cancer diagnoses and impacted perioperative outcomes is unclear. METHODS This was a retrospective difference-in-difference study using the National Cancer Database on adults (40-64) with Medicaid or no insurance, diagnosed with colorectal adenocarcinomas before (2010-2013) and after (2015-2018) expansion. The primary outcome was early-stage (American Joint Committee on Cancer Stage 0-1) diagnosis. The secondary outcomes were rate of local excision, emergency surgery, postoperative length of stay, rates of minimally invasive surgery, postoperative mortality, and overall survival (OS). RESULTS Medicaid expansion was associated with an increase in early-stage diagnoses for patients with colorectal cancers (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 1.15-1.43), an increase in local excision (OR: 1.39, 95% CI: 1.13-1.69), and a decreased rate of emergent surgery (OR: 0.85, 95% CI: 0.75-0.97) and 90-day mortality (OR: 0.75, 95% CI: 0.59-0.97). Additionally, patients in expansion states postexpansion had an improved 5-year OS (hazard ratio: 0.88, 95% CI: 0.83-0.94). CONCLUSIONS Insurance coverage expansion may be particularly important for optimizing stage of diagnosis, subsequent survival, and perioperative outcomes for socioeconomically vulnerable patients.
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Affiliation(s)
- Cimarron E Sharon
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yun Song
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard J Straker
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas Kelly
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Adrienne B Shannon
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel R Kelz
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Najjia N Mahmoud
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole M Saur
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John T Miura
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Giorgos C Karakousis
- Department of Surgery, Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Carrasco-Aguilar A, Galán JJ, Carrasco RA. Obamacare: A bibliometric perspective. Front Public Health 2022; 10:979064. [PMID: 36033824 PMCID: PMC9416003 DOI: 10.3389/fpubh.2022.979064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/22/2022] [Indexed: 01/25/2023] Open
Abstract
Obamacare is the colloquial name given to the Affordable Care Act (ACA) signed into law by President Obama in the USA, which ultimately aims to provide universal access to health care services for US citizens. The aim of this paper is to provide an overview of the political-legal, economic, social, management (or administrative), and medical (or health) repercussions of this law, using a bibliometric methodology as a basis. In addition, the main contributors to research on ACA issues have been identified in terms of authors, organizations, journals, and countries. The downward trend in scientific production on this law has been noted, and it has been concluded that a balance has not yet been reached between the coexistence of private and public health care that guarantees broad social coverage without economic or other types of barriers. The law requires political consensus to be implemented in a definitive and global manner for the whole of the United States.
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12
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Davidoff AJ, Akif K, Halpern MT. Research on the Economics of Cancer-Related Health Care: An Overview of the Review Literature. J Natl Cancer Inst Monogr 2022; 2022:12-20. [PMID: 35788372 DOI: 10.1093/jncimonographs/lgac011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/21/2022] [Indexed: 01/16/2023] Open
Abstract
We reviewed current literature reviews regarding economics of cancer-related health care to identify focus areas and gaps. We searched PubMed for systematic and other reviews with the Medical Subject Headings "neoplasms" and "economics" published between January 1, 2010, and April 1, 2020, identifying 164 reviews. Review characteristics were abstracted and described. The majority (70.7%) of reviews focused on cost-effectiveness or cost-utility analyses. Few reviews addressed other types of cancer health economic studies. More than two-thirds of the reviews examined cancer treatments, followed by screening (15.9%) and survivorship or end-of-life (13.4%). The plurality of reviews (28.7%) cut across cancer site, followed by breast (20.7%), colorectal (11.6%), and gynecologic (8.5%) cancers. Specific topics addressed cancer screening modalities, novel therapies, pain management, or exercise interventions during survivorship. The results indicate that reviews do not regularly cover other phases of care or topics including financial hardship, policy, and measurement and methods.
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Affiliation(s)
- Amy J Davidoff
- Healthcare Assessment Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Kaitlin Akif
- Office of the Associate Director, Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Michael T Halpern
- Healthcare Assessment Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
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Balan N, Braschi C, Kirkland P, Kaji AH, Chen KT. The Impact of Primary Care Physicians on the Surgical Presentation and Outcomes of Colorectal Cancer in Vulnerable Populations. Am Surg 2022; 88:2596-2601. [PMID: 35703089 DOI: 10.1177/00031348221109474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple socioeconomic and clinical factors have been implicated in the health disparities that exist amongst vulnerable populations with colorectal cancer. Efforts have been directed toward addressing these factors to improve outcomes. We evaluate the impact of primary care physicians (PCP) on the surgical presentation and outcomes of colorectal cancer at a safety-net hospital. METHODS A retrospective chart review of 331 patients diagnosed with colorectal adenocarcinoma between 2014 and 2020 at a single-institution urban county medical center. RESULTS The cohort was predominantly male (59%) and Hispanic (52.1%). Thirty-two percent of patients had a PCP at time of diagnosis. Patients with PCPs compared to those without PCPs had significantly lower rates of acute presentation (perforation or obstruction) (17.0 vs 38.1%, P < .001), higher rates of surgical resection (83.0 vs 70.7%, P = .016), and were less likely to have metastatic disease at presentation (20.4 vs 33.5%, P = .02). Overall, having a PCP also improved probability of survival (HR 1.36, P < .04). CONCLUSION Having a PCP at the time of colorectal cancer diagnosis is associated with improved outcomes in a safety-net population, with significant differences in surgical presentation and resection.
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Affiliation(s)
- Naveen Balan
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Caitlyn Braschi
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Patrick Kirkland
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Amy H Kaji
- Department of Emergency Medicine, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Kathryn T Chen
- Department of Surgery, 21640Harbor-UCLA Medical Center, Torrance, CA, USA
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Association of the Affordable Care Act's Medicaid Expansion With 1-Year Survival Among Patients With Ovarian Cancer. Obstet Gynecol 2022; 139:1123-1129. [DOI: 10.1097/aog.0000000000004750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
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15
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Targeted Nursing Combined with Endoscopic Submucosal Injection of Carbon Nanoparticles in the Treatment of Colorectal Cancer. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:8663645. [PMID: 35685723 PMCID: PMC9173991 DOI: 10.1155/2022/8663645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/28/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Aim To evaluate the effectiveness of targeted nursing in an endoscopic submucosal injection of carbon nanoparticles to locate colorectal cancer. Methods From September 2017 to September 2019, 82 patients with colorectal cancer who underwent endoscopic submucosal injection of carbon nanoparticles for locating the tumor were recruited and assigned via the random number table method (1 : 1) to receive either conventional nursing (control group) or targeted nursing (observation group). Outcome measures included psychological status, compliance, nursing satisfaction, quality of life, and daily living ability. Results After intervention, the self-rating anxiety scale (SAS) scores and self-rating depression scale (SDS) scores were decreased in both groups, with lower results in the observation group (P < 0.001). Patients given target nursing were associated with higher compliance and nursing satisfaction of patients versus conventional nursing (P < 0.05). Patients receiving targeted nursing had a better quality of life versus those receiving conventional nursing (P < 0.001). Targeted nursing resulted in a higher Barthel index (BI) in patients versus conventional nursing 1 d, 7 d, and 14 d after nursing (P < 0.05). Conclusion Targeted nursing alleviates the negative emotions of patients with colorectal cancer and improves their compliance, nursing satisfaction, daily living ability, and quality of life.
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16
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Farr DE, Cofie LE, Brenner AT, Bell RA, Reuland DS. Sociodemographic correlates of colorectal cancer screening completion among women adherent to mammography screening guidelines by place of birth. BMC Womens Health 2022; 22:125. [PMID: 35449050 PMCID: PMC9022316 DOI: 10.1186/s12905-022-01694-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/31/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Colorectal cancer screening rates in the U.S. still fall short of national goals, while screening rates for other cancer sites, such as breast, remain high. Understanding characteristics associated with colorectal cancer screening among different groups of women adherent to breast cancer screening guidelines can shed light on the facilitators of colorectal cancer screening among those already engaged in cancer prevention behaviors. The purpose of this study was to explore which demographic characteristics, healthcare access factors, and cancer-related beliefs were associated with colorectal cancer screening completion among U.S. and foreign-born women adherent to mammography screening recommendations. METHODS Analyses of the 2015 National Health Interview Survey were conducted in 2019. A sample of 1206 women aged 50-74 who had a mammogram in the past 2 years and were of average risk for colorectal cancer was examined. Logistic regression was used to determine demographic, health service, and health belief characteristics associated with colorectal cancer screening completion. RESULTS Fifty-five percent of the sample were adherent to colorectal cancer screening recommendations. Women over the age of 65 (AOR = 1.76, 95% CI 1.06-2.91), with any type of health insurance, and who were bilingual (AOR = 3.84, 95% CI 1.83-8.09) were more likely to complete screening, while foreign-born women (AOR = 0.53, 95% CI 0.34-0.83) were less likely. Cancer-related beliefs did not influence adherence. Stratified analyses by nativity revealed additional associations. CONCLUSIONS Demographic and health service factors interact to influence colorectal cancer screening among women completing breast cancer screening. Colorectal cancer screening interventions targeting specific underserved groups and financing reforms may enhance women's colorectal cancer screening rates.
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Affiliation(s)
- Deeonna E Farr
- Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, 2307 Carol G. Belk Building, Mail Stop 529, Greenville, NC, 27858, USA.
| | - Leslie E Cofie
- Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, 2307 Carol G. Belk Building, Mail Stop 529, Greenville, NC, 27858, USA
| | - Alison T Brenner
- Department of Medicine, Department of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Ronny A Bell
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Daniel S Reuland
- Department of Medicine, Department of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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Malinowski C, Lei X, Zhao H, Giordano SH, Chavez-MacGregor M. Association of Medicaid Expansion With Mortality Disparity by Race and Ethnicity Among Patients With De Novo Stage IV Breast Cancer. JAMA Oncol 2022; 8:863-870. [PMID: 35389432 PMCID: PMC8990354 DOI: 10.1001/jamaoncol.2022.0159] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Patients who are uninsured and belong to racial and ethnic minority groups or have low socioeconomic status have suboptimal access to health care, likely affecting outcomes. The association of the Affordable Care Act's Medicaid expansion with survival among patients with metastatic breast cancer is unknown. Objective To examine the association between Medicaid expansion and mortality disparity among patients with de novo stage IV breast cancer. Design, Setting, and Participants Cross-sectional, population-based study of survival using Cox proportional hazards regression and difference-in-difference (DID) analysis of data from the National Cancer Database and patients diagnosed as having de novo stage IV breast cancer between January 1, 2010, and December 31, 2016, residing in states that underwent Medicaid expansion on January 1, 2014. The preexpansion period was January 1, 2010, to December 31, 2013; the postexpansion period was January 1, 2014, to December 31, 2016. Data were analyzed between September 4, 2020, and November 16, 2021. Exposures Comparison of survival improvement between patients of racial and ethnic minority groups and White patients in the preexpansion and postexpansion periods. Because of small numbers in the specific racial and ethnic minority groups, these patients were combined into 1 category for comparisons. Main Outcomes and Measures Overall survival (OS) and 2-year mortality rate. Results Among 9322 patients included (mean [SD] age, 55 [7] years), 5077 were diagnosed in the preexpansion and 4245 in the postexpansion period. The racial and ethnic minority group comprised 2545 (27.3%), which included 500 (5.4%) Hispanic (any race), 1515 (16.3%) non-Hispanic Black, and 530 (5.7%) non-Hispanic other including 25 (0.3%) American Indian or Alaska Native, 357 (3.8%) Asian or Pacific Islander, and 148 (1.6%) unknown, and 6777 (72.7%) were in the White patient group. In the preexpansion period, White patients had increased OS compared with patients of racial and ethnic minority groups (adjusted hazard ratio [aHR], 1.22; 95% CI, 1.10-1.35); this difference was not observed in the postexpansion period (aHR, 0.96; 95% CI, 0.86-1.08). A reduction in 2-year mortality was observed between the preexpansion and postexpansion periods (32.2% vs 26.0%). The adjusted 2-year mortality decreased from 40.6% to 36.3% among White patients and from 45.6% to 35.8% among patients of racial and ethnic minority groups (adjusted DID, -5.5%; 95% CI, -9.5 to -1.6; P = .006). Among patients in the lowest income quartile (n = 1510), patients of racial and ethnic minority groups had an increased risk of death in the preexpansion period (aHR, 1.28; 95% CI, 1.01-1.61) but lower risk in the postexpansion period (aHR, 0.75; 95% CI, 0.59-0.95). In this subset of patients, those of racial and ethnic minority groups had a greater reduction in 2-year mortality compared with White patients (adjusted DID, -12.8%; 95% CI, -22.2 to -3.5; P = .007). Conclusions and Relevance In this cross-sectional study, survival differences observed between patients of racial and ethnic minority groups and White patients in the preexpansion period were no longer present in the postexpansion period. A greater reduction in 2-year mortality was observed among patients of racial and ethnic minority groups compared with White patients. These results suggest that policies aimed at improving equity and increasing access to health care may reduce racial and ethnic disparities in breast cancer outcomes.
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Affiliation(s)
- Catalina Malinowski
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Xiudong Lei
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston.,Breast Medical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston
| | - Mariana Chavez-MacGregor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston.,Breast Medical Oncology Department, The University of Texas MD Anderson Cancer Center, Houston
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18
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Lee C, Kushi LH, Reed ME, Eldridge EH, Lee JK, Zhang J, Spiegelman D. Impact of the Affordable Care Act on Colorectal Cancer Incidence and Mortality. Am J Prev Med 2022; 62:387-394. [PMID: 34763959 PMCID: PMC8863627 DOI: 10.1016/j.amepre.2021.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/13/2021] [Accepted: 08/17/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The Patient Protection and Affordable Care Act eliminated cost sharing for preventive services, including colorectal cancer screening for individuals aged 50-75 years with private health insurance. This study examines the impact of the Affordable Care Act's removal of cost sharing for colorectal cancer screening on colorectal cancer incidence and mortality. METHODS Trends in colorectal cancer incidence and colorectal cancer‒related mortality were modeled among 2,113,283 Kaiser Permanente Northern California members aged ≥50 years between 2003 and 2016 using an interrupted time-series design. As a sensitivity analysis, a controlled analysis utilized a comparison group of members covered with pre‒Affordable Care Act zero cost sharing for colorectal cancer screening. Analyses were performed in 2019 and 2020. RESULTS The colorectal cancer incidence dropped by 17% around the time the Affordable Care Act was enacted (change in level incidence rate ratio; 95% CI=0.77, 0.90, 2-sided p-value <0.0001), followed by a 3% further decrease per year (95% CI=0.93, 1.00, p=0.05). A similar pattern was observed for colorectal cancer‒related mortality. The controlled results indicated that the elimination of cost sharing for screening due to the Affordable Care Act was associated with greater improvements in colorectal cancer outcomes among members previously covered by health plans with out-of-pocket costs for screening than among those with health plans with zero cost sharing for screening before the Affordable Care Act. CONCLUSIONS The elimination of cost sharing for colorectal cancer screening due to the Affordable Care Act was associated with a decrease in age-, race/ethnicity-, and sex-adjusted colorectal cancer incidence and colorectal cancer‒related mortality, implying that policies that remove barriers to screening, particularly financial burden from cost sharing, can result in improved colorectal cancer outcomes.
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Affiliation(s)
- Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California.
| | - Lawrence H Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Mary E Reed
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California; San Francisco Medical Center, Kaiser Permanente, San Francisco, California
| | - Jie Zhang
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Donna Spiegelman
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, Connecticut; Center for Methods in Implementation and Prevention Science (CMIPS), Yale School of Public Health, Yale University, New Haven, Connecticut
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Ermer T, Walters SL, Canavan ME, Salazar MC, Li AX, Doonan M, Boffa DJ. Understanding the Implications of Medicaid Expansion for Cancer Care in the US: A Review. JAMA Oncol 2021; 8:139-148. [PMID: 34762101 DOI: 10.1001/jamaoncol.2021.4323] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Insurance status has been linked to important differences in cancer treatment and outcomes in the US. With more than 15 million individuals gaining health insurance through Medicaid expansion, there is an increasing need to understand the implications of this policy within the US cancer population. This review provides an overview of the fundamental principles and nuances of Medicaid expansion, as well as the implications for cancer care. Observations The Patient Protection and Affordable Care Act presented states with an option to expand Medicaid coverage by broadening the eligibility criteria (eg, raising the eligible income level). During the past 10 years, Medicaid expansion has been credited with a 30% reduction in the population of uninsured individuals in the US. Such a significant change in the insurance profile could have important implications for the 1.7 million patients diagnosed with cancer each year, the oncology teams that care for them, and policy makers. However, several factors may complicate efforts to characterize the effect of Medicaid expansion on the US cancer population. Most notably, there is considerable variation among states in terms of whether Medicaid expansion took place, when expansion occurred, eligibility criteria for Medicaid, and coverage types that Medicaid provides. In addition, economic and health policy factors may be intertwined with factors associated with Medicaid expansion. Finally, variability in the manner in which cancer care has been captured and depicted in large databases could affect the interpretation of findings associated with expansion. Conclusions and Relevance The expansion of Medicaid was a historic public policy initiative. To fully leverage this policy to improve oncological care and to maximize learning for subsequent policies, it is critical to understand the effect of Medicaid expansion. This review aims to better prepare investigators and their audiences to fully understand the implications of this important health policy initiative.
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Affiliation(s)
- Theresa Ermer
- Faculty of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.,London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom.,Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Samantha L Walters
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Maureen E Canavan
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle C Salazar
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,National Clinician Scholars Program, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew X Li
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Doonan
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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20
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Shete S, Deng Y, Shannon J, Faseru B, Middleton D, Iachan R, Bernardo B, Balkrishnan R, Kim SJ, Huang B, Millar MM, Fuemmler B, Jensen JD, Mendoza JA, Hu J, Lazovich D, Robertson L, Demark-Wahnefried W, Paskett ED. Differences in Breast and Colorectal Cancer Screening Adherence Among Women Residing in Urban and Rural Communities in the United States. JAMA Netw Open 2021; 4:e2128000. [PMID: 34605915 PMCID: PMC8491105 DOI: 10.1001/jamanetworkopen.2021.28000] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 07/30/2021] [Indexed: 12/13/2022] Open
Abstract
Importance Screening for breast and colorectal cancer has resulted in reductions in mortality; however, questions remain regarding how these interventions are being diffused to all segments of the population. If an intervention is less amenable to diffusion, it could be associated with disparities in mortality rates, especially in rural vs urban areas. Objectives To compare the prevalence of breast and colorectal cancer screening adherence and to identify factors associated with screening adherence among women residing in rural vs urban areas in the United States. Design, Setting, and Participants This population-based cross-sectional study of women aged 50 to 75 years in 11 states was conducted from 2017 to 2020. Main Outcomes and Measures Adherence to cancer screening based on the US Preventative Services Task Force guidelines. For breast cancer screening, women who had mammograms in the past 2 years were considered adherent. For colorectal cancer screening, women who had (1) a stool test in the past year, (2) a colonoscopy in the past 10 years, or (3) a sigmoidoscopy in the past 5 years were considered adherent. Rural status was coded using Rural Urban Continuum Codes, and other variables were assessed to identify factors associated with screening. Results The overall sample of 2897 women included 1090 (38.4%) rural residents; 2393 (83.5%) non-Hispanic White women; 263 (9.2%) non-Hispanic Black women; 68 (2.4%) Hispanic women; 1629 women (56.2%) aged 50 to 64 years; and 712 women (24.8%) with a high school education or less. Women residing in urban areas were significantly more likely to be adherent to colorectal cancer screening compared with women residing in rural areas (1429 [82%] vs 848 [78%]; P = .01), whereas the groups were equally likely to be adherent to breast cancer screening (1347 [81%] vs 830 [81%]; P = .78). Multivariable mixed-effects logistic regression analyses confirmed that rural residence was associated with lower odds of being adherent to colorectal cancer screening (odds ratio [OR], 0.81; 95% CI, 0.66-0.99, P = .047). Non-Hispanic Black race was associated with adherence to breast cancer screening guidelines (OR, 2.85; 95% CI, 1.78-4.56; P < .001) but not colorectal cancer screening guidelines. Conclusions and Relevance In this cross-sectional study, women residing in rural areas were less likely to be adherent to colorectal cancer screening guidelines but were similarly adherent to breast cancer screening. This suggests that colorectal cancer screening, a more recent intervention, may not be as available in rural areas as breast cancer screening, ie, colorectal screening has lower amenability.
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Affiliation(s)
- Sanjay Shete
- Division of Cancer Prevention, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Jackilen Shannon
- Oregon Health & Sciences University, Portland State University School of Public Health, Portland
| | - Babalola Faseru
- Department of Population Health, University of Kansas Medical Center, Kansas City
| | | | | | - Brittany Bernardo
- Division of Population Sciences, The Ohio State University Comprehensive Cancer Center, Columbus
| | | | - Sunny Jung Kim
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond
| | - Bin Huang
- Department of Cancer Biostatistics, University of Kentucky, Lexington
| | | | - Bernard Fuemmler
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond
| | | | - Jason A. Mendoza
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle
| | - Jinxiang Hu
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City
| | - DeAnn Lazovich
- University of Minnesota School of Public Health, Minneapolis
| | - Linda Robertson
- UPMC Hillman Cancer Center, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Electra D. Paskett
- Division of Cancer Prevention and Control, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, College of Medicine, Columbus
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Mehta SJ, Reitz C, Niewood T, Volpp KG, Asch DA. Effect of Behavioral Economic Incentives for Colorectal Cancer Screening in a Randomized Trial. Clin Gastroenterol Hepatol 2021; 19:1635-1641.e1. [PMID: 32623005 PMCID: PMC7775888 DOI: 10.1016/j.cgh.2020.06.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Financial incentives might increase participation in prevention such as screening colonoscopy. We studied whether incentives informed by behavioral economics increase participation in risk assessment for colorectal cancer (CRC) and completion of colonoscopy for eligible adults. METHODS Employees of a large academic health system (50-64 y old; n = 1977) were randomly assigned to groups that underwent risk assessment for CRC screening and direct access colonoscopy scheduling (control), or risk assessment, direct access colonoscopy scheduling, a $10 loss-framed incentive to complete risk assessment, and a $25 unconditional incentive for colonoscopy completion (incentive). The primary outcome was the percentage of participants who completed screening colonoscopy within 3 months of initial outreach. Secondary outcomes included the percentage of participants who scheduled colonoscopy and the percentage who completed the risk assessment. RESULTS At 3 months, risk assessment was completed by 19.5% of participants in the control group (95% CI, 17.0-21.9%) and 31.9% of participants in the incentive group (95% CI, 29.0-34.8%) (P < .001). At 3 months, 0.7% of controls had completed a colonoscopy (95% CI, .2%-1.2%) compared with 1.2% of subjects in the incentive group (95% CI, .5%-1.9%) (P = .25). CONCLUSIONS In a randomized trial of participants who underwent risk assessment for CRC with vs without financial incentive, the financial incentive increased CRC risk assessment completion but did not result in a greater completion of screening colonoscopy. Clinicaltrials.gov no: NCT03068052.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania
| | - Tess Niewood
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center
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22
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Obrochta CA, Murphy JD, Tsou MH, Thompson CA. Disentangling Racial, Ethnic, and Socioeconomic Disparities in Treatment for Colorectal Cancer. Cancer Epidemiol Biomarkers Prev 2021; 30:1546-1553. [PMID: 34108139 PMCID: PMC8338765 DOI: 10.1158/1055-9965.epi-20-1728] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/12/2021] [Accepted: 05/26/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Colorectal cancer is curable if diagnosed early and treated properly. Black and Hispanic patients with colorectal cancer are more likely to experience treatment delays and/or receive lower standards of care. Socioeconomic deprivation may contribute to these disparities, but this has not been extensively quantified. We studied the interrelationship between patient race/ethnicity and neighborhood socioeconomic status (nSES) on receipt of timely appropriate treatment among patients with colorectal cancer in California. METHODS White, Black, and Hispanic patients (26,870) diagnosed with stage I-III colorectal cancer (2009-2013) in the California Cancer Registry were included. Logistic regression models were used to examine the association of race/ethnicity and nSES with three outcomes: undertreatment, >60-day treatment delay, and >90-day treatment delay. Joint effect models and mediation analysis were used to explore the interrelationships between race/ethnicity and nSES. RESULTS Hispanics and Blacks were at increased risk for undertreatment [Black OR = 1.39; 95% confidence interval (CI) = 1.23-1.57; Hispanic OR = 1.17; 95% CI = 1.08-1.27] and treatment delay (Black/60-day OR = 1.78; 95% CI = 1.57-2.02; Hispanic/60-day OR = 1.50; 95% CI = 1.38-1.64) compared with Whites. Of the total effect (OR = 1.15; 95% CI = 1.07-1.24) of non-white race on undertreatment, 45.71% was explained by nSES. CONCLUSIONS Lower nSES patients of any race were at substantially higher risk for undertreatment and treatment delay, and racial/ethnic disparities are reduced or eliminated among non-white patients living in the highest SES neighborhoods. Racial and ethnic disparities persisted after accounting for neighborhood socioeconomic status, and between the two, race/ethnicity explained a larger portion of the total effects. IMPACT This research improves our understanding of how socioeconomic deprivation contributes to racial/ethnic disparities in colorectal cancer.
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Affiliation(s)
- Chelsea A Obrochta
- School of Public Health, San Diego State University, San Diego, California
- University of California San Diego, School of Medicine, San Diego, California
| | - James D Murphy
- University of California San Diego, Moores Cancer Center, San Diego, California
| | - Ming-Hsiang Tsou
- Department of Geography, San Diego State University, San Diego, California
- Center for Human Dynamics in the Mobile Age, San Diego State University, San Diego, California
| | - Caroline A Thompson
- School of Public Health, San Diego State University, San Diego, California.
- University of California San Diego, School of Medicine, San Diego, California
- University of California San Diego, Moores Cancer Center, San Diego, California
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23
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Minas TZ, Kiely M, Ajao A, Ambs S. An overview of cancer health disparities: new approaches and insights and why they matter. Carcinogenesis 2021; 42:2-13. [PMID: 33185680 PMCID: PMC7717137 DOI: 10.1093/carcin/bgaa121] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/01/2020] [Accepted: 11/06/2020] [Indexed: 12/13/2022] Open
Abstract
Cancer health disparities remain stubbornly entrenched in the US health care system. The Affordable Care Act was legislation to target these disparities in health outcomes. Expanded access to health care, reduction in tobacco use, uptake of other preventive measures and cancer screening, and improved cancer therapies greatly reduced cancer mortality among women and men and underserved communities in this country. Yet, disparities in cancer outcomes remain. Underserved populations continue to experience an excessive cancer burden. This burden is largely explained by health care disparities, lifestyle factors, cultural barriers, and disparate exposures to carcinogens and pathogens, as exemplified by the COVID-19 epidemic. However, research also shows that comorbidities, social stress, ancestral and immunobiological factors, and the microbiome, may contribute to health disparities in cancer risk and survival. Recent studies revealed that comorbid conditions can induce an adverse tumor biology, leading to a more aggressive disease and decreased patient survival. In this review, we will discuss unanswered questions and new opportunities in cancer health disparity research related to comorbid chronic diseases, stress signaling, the immune response, and the microbiome, and what contribution these factors may have as causes of cancer health disparities.
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Affiliation(s)
- Tsion Zewdu Minas
- Laboratory of Human Carcinogenesis, Center of Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Maeve Kiely
- Laboratory of Human Carcinogenesis, Center of Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Anuoluwapo Ajao
- Laboratory of Human Carcinogenesis, Center of Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Stefan Ambs
- Laboratory of Human Carcinogenesis, Center of Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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24
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Brooks ES, Tong J, Mavroudis CW, Wirtalla C, Karakousis GC, Saur NM, Aarons CB, Mahmoud NN, Kelz RR. The effects of the Affordable Care Act on access and outcomes of colon surgery. Am J Surg 2021; 222:613-618. [PMID: 33487402 DOI: 10.1016/j.amjsurg.2021.01.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/03/2021] [Accepted: 01/11/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Insurance status has been strongly associated with both access to and outcomes of colon resection (CRS). Under the Affordable Care Act (ACA), individual states opted to participate in Medicaid expansion (ME) and adopt essential health benefits (EHB). METHODS We performed a quasi-experimental difference-in-differences (DID) analysis of 2012-2017 state-level inpatient claims with risk adjustment. We examined frequency of emergent presentation and in-hospital death. Subset analyses were performed by insurance type. RESULTS Among the 73,961 CRS patients, 49.6% were in a state with both ME and EHB, 34.7% presented emergently, and 2.0% died. Adoption of ME and EHB was associated with a significant, 24%, reduction in the likelihood of in-hospital mortality, and no significant change in emergent presentation for CRS. CONCLUSIONS The ACA's ME was strongly associated with a decrease in mortality following colon resection among Medicaid beneficiaries. These findings support the adoption of healthcare policies that improve access to insurance.
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Affiliation(s)
- Ezra S Brooks
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Jason Tong
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Catherine W Mavroudis
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Christopher Wirtalla
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Giorgos C Karakousis
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Nicole M Saur
- University of Pennsylvania, Department of Surgery, Philadelphia, PA, USA
| | - Cary B Aarons
- University of Pennsylvania, Department of Surgery, Philadelphia, PA, USA
| | - Najjia N Mahmoud
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
| | - Rachel R Kelz
- University of Pennsylvania, Center for Surgery and Health Economics, Department of Surgery, Philadelphia, PA, USA
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25
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Gawron AJ, Staub J, Bielefeldt K. Impact of Health Insurance, Poverty, and Comorbidities on Colorectal Cancer Screening: Insights from the Medical Expenditure Panel Survey. Dig Dis Sci 2021; 66:70-77. [PMID: 32816210 DOI: 10.1007/s10620-020-06541-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/06/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Despite national campaigns and other efforts to improve colorectal cancer (CRC) screening, participation rates remain below targets set by expert panels. We hypothesized that availability and practice patterns of healthcare providers may contribute to this gap. METHOD Using data of the Medical Expenditure Panel Survey for the years between 2000 and 2016, we extracted demographic, socioeconomic, and health-related data as well as reported experiences about barriers to care, correlating results with answers about recent participation in colorectal cancer screening. As CRC screening guidelines recommend initiation of testing at age 50, we focused on adults 50 years or older. RESULTS We included responses of 163,564 participants for the period studied. There was a significant increase in CRC screening rates over time. Comorbidity burden, poverty, race, and ethnicity independently predicted participation in screening. Lack of insurance coverage and cost of care played an important role as reported barrier. Convenient access to care, represented by availability of appointments beyond typical business hours, and frequency of provider interactions, correlated with higher rates of screening. CONCLUSION Our data show a positive effect of educational efforts and healthcare reform with coverage of screening. Easy and more frequent access to individual providers predicted a higher likelihood of completed screening tests. This finding could translate into more widespread implementation of screening programs, as the increasingly common virtual care delivery offers a new and convenient option to patients.
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Affiliation(s)
- Andrew J Gawron
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Judith Staub
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Klaus Bielefeldt
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, UT, USA.
- George E. Whalen VA Medical Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Salt Lake City, UT, 84148, USA.
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26
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Jayakrishnan TT, Bakalov V, Chahine Z, Finley G, Monga D, Wegner RE. Impact of affordable care act on the treatment and outcomes for stage-IV colorectal cancer. Cancer Treat Res Commun 2020; 24:100204. [PMID: 32805532 DOI: 10.1016/j.ctarc.2020.100204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/02/2020] [Accepted: 08/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with advanced cancers are among the most vulnerable group of patients. We sought to analyze the impact of Affordable Care Act (ACA) on the interaction of socioeconomic factors with treatment and survival in patients with metastatic colorectal cancers. METHODS National Cancer Database (NCDB) was queried for patients with Stage-IV colon(CCa) and rectal cancers(R-Ca) diagnosed 2004-2015 and excluded those who did not receive any therapies within 6 months of diagnosis. Enrollment-rates were calculated as receipt of primary therapy as the incident-event (numerator) over time-to-initiation of therapy (denominator) and used to calculate incident-rate ratios that was analyzed using Poisson regression analysis- reported as enrollment-rate ratios (ER, <1 indicating lower enrollment rate). Multivariate Cox-proportional hazard model was performed for survival analysis and reported as calculate Hazard Ratios (HR). RESULTS For CCa, enrollment to primary therapies was significantly associated (p-value < 0.05) with gender, race, insurance status, educational status and treatment facility. The HR for non-Hispanic Blacks (NHB) vs. Whites (NHW) improved from 1.1(1.03-1.11),p-value<0.005 to no-significant difference post-ACA. For R-Ca, the enrollment rates were favorable for NHB vs. NHW and ER improved from 1.15(1.0-1.32),p-value = 0.054) to 1.29(1.06-1.58),p-value = 0.013 post-ACA. Despite this, the HR for mortality were unfavorable - 1.19(1.06-1.33),p-value = 0.003 that persisted through the post-ACA period. The HR was favorable for the insured group in both cancer groups (0.84 for R-Ca,0.86 for CCa) and for high-income vs. low-income group-0.90(0.87-0.94),p-value < 0.005 in CCa. CONCLUSION The ACA appears to have had a positive impact overall but further research and ongoing interventions are warranted to mitigate disparities in this population.
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Affiliation(s)
- Thejus T Jayakrishnan
- Allegheny Health Network, Department of Internal Medicine, Pittsburgh, PA, United States
| | - Veli Bakalov
- Allegheny Health Network, Department of Internal Medicine, Pittsburgh, PA, United States
| | - Zena Chahine
- Allegheny Health Network, Department of Internal Medicine, Pittsburgh, PA, United States
| | - Gene Finley
- Allegheny Health Network Cancer Institute, Division of Medical Oncology, Pittsburgh, PA, United States
| | - Dulabh Monga
- Allegheny Health Network Cancer Institute, Division of Medical Oncology, Pittsburgh, PA, United States
| | - Rodney E Wegner
- Allegheny Health Network Cancer Institute, Division of Radiation Oncology, Pittsburgh, PA, United States.
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