Impact of insurance status on receipt of definitive surgical therapy and posttreatment outcomes in early stage lung cancer

Abstract

The impact of insurance on outcomes in the modern era of evidence-based guidelines is unclear. We sought to examine differences in receipt of therapy and outcomes for early stage, non-small cell lung cancer patients by insurance coverage. Clinical T1-3 N0-1 non-small cell lung cancer cases were identified in the 2004 to 2014 National Cancer Database and compared across 4 groups: private, Medicare, Medicaid, and uninsured. A multivariable, linear regression model was used to examine the effects of insurance status on time to curative surgical therapy, adjusting for patient and facility characteristics. Receipt of different therapies was examined with multivariable logistic regression. Survival analysis was conducted with Cox regression. A total of 240,361 patients presented with early stage non-small cell lung cancer (60,532 private, 164,377 Medicare, 11,001 Medicaid, and 4,451 uninsured). After adjustment, Medicaid and uninsured patients received surgical therapy later than privately insured patients (9.5 days and 7.0 days, respectively, P < .001), were more likely to be delayed > 8 weeks (odds ratio 1.64, 95% confidence interval 1.55-1.73 and odds ratio 1.46, 95% confidence interval 1.34-1.58), and were significantly less likely to receive surgery (odds ratio 0.53, 95% confidence interval 0.50-0.56 and odds ratio 0.50, 95% confidence interval 0.47-0.55). Uninsured patients were more likely to receive no treatment (odds ratio 2.15, 95% confidence interval 1.92-2.41), followed by Medicaid patients (odds ratio 1.66, 95% confidence interval 1.53-1.80). The 5-year overall survival was significantly worse in the Medicaid and uninsured populations. Even in the modern era, uninsured and Medicaid early stage non-small cell lung cancer patients have decreased odds of receiving a potentially curative operation and experience inferior outcomes. Given substantial expenditures on the Medicaid program, strategies for increasing utilization of curative surgery in Medicaid patients with lung cancer are needed.