Insurance Payer Status and Race Explains Much of the Variability in Colorectal Cancer Survival

Timothy L Fitzgerald,Cary Suzanne Lea,Prashanti M Atluri,Jason Brinkley,Emmanuel E Zervos

doi:10.4236/jct.2014.513124

Abstract

Health care inequalities exist for patients with colon cancer. We hypothesize that factors such as payers and medical comorbidities may explain much of this inequality. Methods: Patients with colon cancer in the NCDB from 2003-2010 were identified in this study. Results: 541,649 patients were identified. Median age and survival were 68.6 years and 62.5 months. A majority of them (80.2%) were non-Hispanic white (NHW). African American (AA) and Hispanic (HS) patients were more likely to have medicaid (MD) or be uninsured (UI) and reside in counties with lower socio-economic status (SES). From univariate analysis, it was found that private insurance (PI) had superior survival (98.7 months) compared to MD (46.0 months), medicare (MC) (50.4 months) and UI (54.4 months). Survival was highest for HS (70.9 months) followed by NHW (63.2 months) and AA (53.0 months). Also, survival was linked to comorbidity index (CI), SES, chemotherapy, gender and surgical resection. On multivariate analysis, it was found that male (RR 1.11), SES, surgery (RR 2.29), chemotherapy (RR 1.96), CI, and stage were associated with survival. Race was a predictor of survival, with a survival advantage for HS (RR 0.87) and others (0.87) compared to NHW (1) and AA (1.2). Insurance status was strongly linked to survival. Compared to PI all other groups had poorer survival: MC RR 1.11; MD RR 1.44; and NI RR 1.42.Conclusions: Inequality in outcomes for colon cancer patients is strongly associated with race and underinsurance.

Highlights

Healthcare inequalities have been associated with multiple risk factors including race, socioeconomic status (SES), geography, population density, gender and payer status [1]-[5]
Such outcomes inequalities have been noted for gastrointestinal malignancies, the most striking being associated with colorectal cancer [4]
In order to better understand determinates of survival, data were analyzed only if Charlson Comorbidity Index (CCI) was available; this limited our analysis to patients diagnosed between 2003 and 2010

Summary

Introduction

Healthcare inequalities have been associated with multiple risk factors including race, socioeconomic status (SES), geography, population density, gender and payer status [1]-[5]. Such outcomes inequalities have been noted for gastrointestinal malignancies, the most striking being associated with colorectal cancer [4]. African-American (AA) race has been the most consistently sighted factor associated with poorer outcomes [4] [6]-[8] Such studies often do not (or cannot) account for access to care, SES, insurance or comorbidities [6] [9]-[11]. It is likely that poorer outcomes for AA are, in part, secondary to unequal use of screening, surgical resection, adjuvant therapy and appropriate follow-up [13] [16]-[20]

Methods

Discussion

Conclusion