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Lima HA, Endo Y, Moazzam Z, Alaimo L, Dillhoff M, Kim A, Beane J, Ejaz A, Cloyd J, Resende V, Pawlik TM. The Impact of Medicaid Expansion on Early-Stage Hepatocellular Carcinoma Care. Ann Surg Oncol 2023; 30:4589-4599. [PMID: 37142835 DOI: 10.1245/s10434-023-13562-9] [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: 12/23/2022] [Accepted: 03/16/2023] [Indexed: 05/06/2023]
Abstract
INTRODUCTION The impact of Medicaid expansion (ME) on hepatocellular carcinoma (HCC) remains controversial, and heterogeneous effects on care processes may relate to sociodemographic factors. We sought to evaluate the association between ME and receipt of surgery in early-stage HCC. METHODS Patients diagnosed with early-stage HCC between 40 and 64 years of age were identified from the National Cancer Database and divided into pre- (2004-2012) and post- (2015-2017) expansion cohorts. Logistic regression was used to identify predictors of surgical treatment. Difference-in-difference (DID) analysis assessed changes in surgical treatment between patients living in ME and non-ME states. RESULTS Among 19,745 patients, 12,220 (61.9%) were diagnosed before ME and 7525 (38.1%) after. Although overall utilization of surgery decreased after expansion (ME, pre-expansion: 62.2% versus post-expansion: 51.6%; non-ME, pre-expansion: 62.1% versus post-expansion: 50.8%, p < 0.001), this trend varied relative to insurance status. Notably, receipt of surgery increased among uninsured/Medicaid patients living in ME states after expansion (pre-expansion: 48.1%, post-expansion: 52.3%, p < 0.001). Moreover, treatment at academic or high-volume facilities increased the likelihood of undergoing surgery before expansion. After expansion, treatment at an academic facility and living in an ME state (OR 1.28, 95% CI 1.07-1.54, p < 0.01) were predictors of surgical treatment. DID analysis demonstrated increased utilization of surgery for uninsured/Medicaid patients living in ME states relative to non-ME states (uninsured/Medicaid: 6.4%, p < 0.05), although no differences were noted among patients with other insurance statuses (overall: 0.7%, private: -2.0%, other: 0.3%, all p > 0.05). CONCLUSIONS Implementation of ME heterogeneously impacted utilization of care in early-stage HCC. Notably, uninsured/Medicaid patients residing in ME states demonstrated increased utilization of surgical treatment after expansion.
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Affiliation(s)
- Henrique A Lima
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Yutaka Endo
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Zorays Moazzam
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Laura Alaimo
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alex Kim
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joal Beane
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Vivian Resende
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Timothy M Pawlik
- Department of Surgery, James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Schmitz R, Lidsky ME. Overcoming Treatment Disparities for Early-Stage Hepatocellular Carcinoma in the Veteran Population: Is the MISSION Act the Solution? Ann Surg Oncol 2022; 29:7248-7249. [DOI: 10.1245/s10434-022-12531-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/28/2022] [Indexed: 11/18/2022]
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Karalis JD, Ju MR, Polanco PM. ASO Author Reflections: Identification of High-Performing Veterans Affairs Health System Regions to Improve Patient Outcomes of Veterans with Hepatocellular Carcinoma. Ann Surg Oncol 2022; 29:8421-8422. [PMID: 36057897 DOI: 10.1245/s10434-022-12501-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022]
Affiliation(s)
- John D Karalis
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, USA
| | - Michelle R Ju
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, USA
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, USA.
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Ju MR, Karalis JD, Chansard M, Augustine MM, Mortensen E, Wang SC, Porembka MR, Zeh HJ, Yopp AC, Polanco PM. Variation of Hepatocellular Carcinoma Treatment Patterns and Survival Across Geographic Regions in a Veteran Population. Ann Surg Oncol 2022; 29:8413-8420. [PMID: 36018517 DOI: 10.1245/s10434-022-12390-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Veteran populations have five times the incidence of hepatocellular carcinoma (HCC) compared with the general population. The incidence of HCC has increased in the Veteran's Affairs Health System (VAHS), primarily due to the increased prevalence of cirrhosis. This study aimed to characterize differences in treatment patterns and overall survival rates across the five VAHS geographic regions. METHODS Using the VA Corporate Data Warehouse, the authors built a comprehensive national dataset of Veteran patients with HCC diagnosed between 2001 and 2015 to compare patients across VAHS regions. A multivariable Cox proportional hazards model was used to identify factors associated with 5-year all-cause mortality. Kaplan-Meier curves were used to visualize the patient survival function, and the log-rank test was applied to test statistical significance. RESULTS This retrospective study analyzed 13,434 patients. The West region had the highest rate of overall treatment receipt (63.6%), and the Southwest had the lowest rate (52.9%). After adjustment for demographic, clinicopathologic, treatment, and hospital factors, treatment in a non-West region continued to be significantly associated with a 10% to 13% increased risk of 5-year mortality (Midwest: hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.03-1.17; Northeast: HR, 1.10; 95% CI, 1.03-1.17; Southeast: HR, 1.13; 95% CI, 1.06-1.21; Southwest: HR, 1.11; 95% CI, 1.03-1.19) (p < 0.01). CONCLUSIONS Treatment patterns and overall survival rates of HCC patients differ significantly across VAHS geographic regions. Targeted interventions to increase the rate of treatment in the non-West regions are needed to improve survival of HCC Veterans and provide uniformly high-quality care across VAHS facilities.
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Affiliation(s)
- Michelle R Ju
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John D Karalis
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthieu Chansard
- Department of Population and Clinical Science, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - M Mathew Augustine
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Dallas VA Medical Center, Department of Veterans Affairs, Dallas, TX, USA
| | - Eric Mortensen
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Sam C Wang
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew R Porembka
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert J Zeh
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam C Yopp
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio M Polanco
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Ju MR, Polanco PM. ASO Author Reflections: Disparities in Utilization of Curative-Intent Therapy for Veterans with Early-Stage HCC. Ann Surg Oncol 2022; 29:5498-5499. [DOI: 10.1245/s10434-022-11956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022]
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