Interaction of Insurance and Neighborhood Income on Operative Colorectal Cancer Outcomes Within a National Database

Abstract

IntroductionSociodemographic disparities in colorectal cancer (CRC) surgical patients are known. Few studies, however, have examined the intersection of insurance type and median household income (MHI). MethodsIn this retrospective analysis of the National Inpatient Sample from 2000 to 2019, all CRC surgery patients between 50 and 64 y old were included. Patients were further stratified based on insurance type (commercial, Medicaid, and uninsured) as well as county-level MHI quartiles. Outcomes included nonelective surgery (primary outcome), inpatient mortality, complications, and blood transfusions. Multivariate logistic regression adjusted for sociodemographic variables, medical comorbidities, and hospital-level factors. ResultsOf 108,606 patients, 80.5% of patients had commercial insurance, while 5.8% were uninsured. On multivariate analysis, Medicaid or no insurance, especially when living in a lower-income community, were associated with significantly higher odds of nonelective surgery (ORs: 1.11-4.54). There was a stepwise effect on nonelective surgery by insurance type (uninsured with lower odds than insured) and MHI (each lower quartile had higher odds). There were similar trends for inpatient blood transfusions, but there were no significant differences in mortality or complications. ConclusionsEspecially when considered together, noncommercial insurance and lower MHI were associated with worse outcomes in CRC patients. Insurance was more protective than MHI against worse outcomes. These findings among a screening-aged cohort have policy planning implications for insurance expansions and healthcare funding allocations. Further research is needed to understand the complex underlying mechanisms that create this interaction between insurance and MHI.