Medicaid Status Research Articles

Emergency department use for acute rhinosinusitis: Insurance dependent for children and adults.

Patients with Medicaid or self-pay insurance status are more likely to present to the emergency department (ED) for uncomplicated acute rhinosinusitis (ARS). Our aim was to determine if this pattern holds true for both pediatric and adult visits. Cross-sectional study using the 2005 to 2012 National Hospital Ambulatory Medical Care Surveys and National Ambulatory Medical Care Surveys. We included all visits with International Classification of Diseases, Ninth Revision codes for ARS and without codes for ARS complications. We tested for associations between insurance type and presentation to an ED versus a primary care physician (PCP), stratifying children versus adults. We used univariate and multivariable logistic regression modeling, controlling for clinical and demographic characteristics for analysis. There were 51,579,977 uncomplicated ARS visits to PCPs (48,213,335 visits) and EDs (3,366,642 visits). Medicaid and uninsured patients were under-represented for ARS visits. Medicaid insurance was significantly associated with ED presentation for ARS for both children (adjusted odds ratio [OR] = 7.0, P < 0.001) and adults (adjusted OR = 6.8, P < 0.001). Children with ARS and self-pay insurance status were much more likely to present to the ED (adjusted OR = 48.8, P < 0.001) than adults (adjusted OR = 5.2, P < 0.001); this difference between children and adults with self-pay insurance was significant (P = 0.001). With respect to absolute numbers of visits, patients with Medicaid or no insurance use less care overall for uncomplicated ARS than do privately insured patients. Medicaid is associated with ED presentation for ARS for pediatric and adult visits. Self-pay insurance status is strongly associated with ED presentation for adult and pediatric visits, and is significantly more common for children. These results suggest limitations in primary care access for uncomplicated ARS based on insurance status, particularly for uninsured pediatric patients. 4. Laryngoscope, 128:299-303, 2018.

Effect of Medicaid Status on up-to-date Vaccination Rates Among two-year-old Children in Georgia, 2015

Effect of Medicaid Status on up-to-date Vaccination Rates Among two-year-old Children in Georgia, 2015

The Breast and Cervical Cancer Early Detection Program, Medicaid, and breast cancer outcomes among Ohio's underserved women.

As an organized screening program, the national Breast and Cervical Cancer Early Detection Program (BCCEDP) was launched in the early 1990s to improve breast cancer outcomes among underserved women. To analyze the impact of the BCCEDP on breast cancer outcomes in Ohio, this study compared cancer stages and mortality across BCCEDP participants, Medicaid beneficiaries, and "all others." This study linked data across the Ohio Cancer Incidence Surveillance System, Medicaid, the BCCEDP database, death certificates, and the US Census and identified 26,426 women aged 40 to 64 years who had been diagnosed with incident invasive breast cancer during the years 2002-2008 (deaths through 2010). The study groups were as follows: BCCEDP participants (1-time or repeat users), Medicaid beneficiaries (women enrolled in Medicaid before their cancer diagnosis [Medicaid/prediagnosis] or around the time of their cancer diagnosis [Medicaid/peridiagnosis]), and all others (women identified as neither BCCEDP participants nor Medicaid beneficiaries). The outcomes included advanced-stage cancer at diagnosis and mortality. A multivariable logistic and survival analysis was conducted to examine the independent association between the BCCEDP and Medicaid status and the outcomes. The percentage of women presenting with advanced-stage disease was highest among women in the Medicaid/peridiagnosis group (63.4%) and lowest among BCCEDP repeat users (38.6%). With adjustments for potential confounders and even in comparison with Medicaid/prediagnosis beneficiaries, those in the Medicaid/peridiagnosis group were twice as likely to be diagnosed with advanced-stage disease (adjusted odds ratio, 2.20; 95% confidence interval, 1.83-2.66). Medicaid/peridiagnosis women are at particularly high risk to be diagnosed with advanced-stage disease. Efforts to reduce breast cancer disparities must target this group of women before they present to Medicaid. Cancer 2017;123:3097-106. © 2017 American Cancer Society.

Rates and Risk Factors for Opioid Dependence and Overdose after Urological Surgery.

Effective pain management is a critical component of the perioperative process with opioids representing a mainstay of therapy. The opioid epidemic is a growing concern in the United States. The goal of this study was to quantify the risk of opioid dependence or overdose among patients undergoing urological surgery and to identify risk factors of opioid dependence or overdose. We retrospectively reviewed data on urological surgery from 2007 to 2011. Data sources included the HCUP (Healthcare Cost and Utilization Project) inpatient, ambulatory surgery and emergency department data sets. Outcomes of postoperative opioid dependence and overdose were identified by previously validated ICD-9 codes. Multivariable logistic regression adjusted for surgical procedure was performed to identify predictors of opioid dependence or overdose following urological surgery. Overall 675,527 patients underwent urological surgery, of whom 0.09% were diagnosed with opioid dependence or overdose. Patients in whom opioid dependence or overdose developed were younger (median age 51 vs 62 years), carried nonprivate insurance (69.6% vs 66%), underwent an inpatient procedure (81.0% vs 42.4%) and had a longer length of stay (median 3 vs 0 days) and a history of depression (14.4% vs 3.4%) or chronic obstructive pulmonary disease (20.3% vs 8.9%, all p <0.001). On adjusted multivariable analysis these factors remained independent risk factors for opioid dependence or overdose. Postoperative opioid dependence or overdose affects 1 of 1,111 urological surgery patients. Risk factors for opioid dependence or overdose included younger age, inpatient surgery and increasing hospitalization duration, baseline depression, tobacco use and chronic obstructive pulmonary disease as well as insurance provider, including Medicaid, Medicare (age less than 65 years) and noninsured status.

The impact of delayed commencement of adjuvant chemotherapy (eight or more weeks) on survival in stage II and III colon cancer: a national population-based cohort study.

BackgroundTo examine the impact of chemotherapy delay on survival in patients with stage II or III colon cancer and the factors associated with the delay (≥8 weeks) of adjuvant chemotherapy.MethodsPatients undergoing curative resection and adjuvant chemotherapy in a national population-based cohort were included.ResultsAmong 5355 patients, 154 (2.9%) received chemotherapy more than 8 weeks after surgery. Based on a multivariate analysis, the risk factors associated with chemotherapy delay ≥8 weeks were older age [65 to 74 years (hazard ratio [HR]=1.48) and ≥75 years (HR=1.69), p=0.0354], medical aid status in the health security system (HR=1.76, p=0.0345), and emergency surgery (HR=2.43, p=0.0002). Using an 8-week cutoff, the 3-year overall survival rate was 89.62% and 80.98% in the <8 weeks and ≥8 weeks groups, respectively (p=0.008). Independent prognostic factors for inferior overall survival included chemotherapy delay ≥8 weeks (HR=1.49, p=0.0365), older age [65 to 74 years (HR=1.94) and ≥75 years (HR=3.41), p<0.0001], TNM stage III (HR=2.46, p<0.0001), emergency surgery (HR=1.89, p<0.0001), American Society of Anesthesiologists score of 3 or higher (HR=1.50, p<0.0001), and higher transfusion amounts (HR=1.09, p=0.0392).ConclusionsThis study shows that delayed commencement of adjuvant chemotherapy, defined as ≥ 8 weeks, is associated with inferior overall survival in colon cancer patients with stage II or III disease. The delay to initiation of adjuvant chemotherapy is influenced by several multidimensional factors, including patient factors (older age), insurance status (medical aid), and treatment-related factors (emergency surgery).

Examining the inter-correlated effects of low income, life stress, and race on birth outcomes: A representative state study

ABSTRACTProgramming of the stress response system during gestation has lifelong effects that put the infant at risk for multiple stress-related pathologies. Populations most vulnerable to prenatal stress are African-Americans and individuals of low socioeconomic status. The Pregnancy Risk Assessment Monitoring System (PRAMS) research project, a collaboration between the Centers for Disease Control and Prevention and individual state health departments, was employed for this study. Tennessee data from 2009 were compiled from individual birth certificates and PRAMS questionnaire responses to examine the influence of maternal stressors, race and low income on birth outcomes. The number of stressors was only a significant predictor of having an infant small for gestational age when moderated by Medicaid status. Medicaid status was a positive predictor of both problematic birth and preterm delivery, but did not predict small or large for gestational age. The relationship between race and birth outcomes overall was moderated by age, with young African-American mothers less likely than European-Americans and older African-American mothers to have adverse birth outcomes.

21-Gene recurrence score testing among Medicare beneficiaries with breast cancer in 2010-2013.

We evaluated national patient-level utilization of the 21-gene recurrence score (21-gene RS) test among Medicare beneficiaries with breast cancer. We analyzed clinical, demographic, and regional factors that predict testing. Using 2010-2013 Medicare claims, we conducted a retrospective study of breast cancer patients. The outcome variable was whether the patient underwent testing. Independent variables expected to predict testing were age, gender, race, Medicaid status, clinical characteristics, and hospital referral region (HRR). From 2010 to 2013, the number of test orders increased by 23.0%. Of the 256,818 patients identified in 2011-2012 claims, 25,352 (9.9%) underwent the 21-gene RS test. Estrogen receptor-positive status was the strongest positive predictor of testing (odds ratio (OR) 2.58, 95% confidence interval (CI) 2.48-2.69). White patients were more likely to be tested than minorities (OR 1.46, 95% CI 1.39-1.52). Secondary cancer was the strongest negative predictor. Medicaid recipients were less likely to be tested (OR 0.74, 95% CI 0.71-0.78). The likelihood of testing decreased with increasing age and comorbidities. Despite widespread implementation of the 21-gene RS test, minorities and Medicaid recipients had less access to testing. Many patients with serious comorbidities or advanced age were tested even though the risk algorithm may not have been applicable to them.Genet Med advance online publication 23 March 2017.

2: Patient, surgeon, and hospital disparities associated with hysterectomy approach and perioperative complications

Hysterectomies are among one of the most common major surgical procedures performed in women. However, little is known regarding contemporary U.S. hysterectomy trends for women with benign disease with respect to both operative technique and perioperative complications. We sought to document these trends and to determine the association between these two factors with patient, surgeon, and hospital characteristics. Hysterectomies performed for benign indications by generalist gynecologists from 2012-2014 were analyzed in the all-payer Maryland Health Services Cost Review Commission database. We included both open hysterectomies and those performed by minimally invasive surgery (MIS). Perioperative complications were defined using the Agency for Healthcare Research and Quality Patient Safety Indicators. Surgeon hysterectomy volume was analyzed by quartiles (0-5 = very low, 6-10 = low, 11-20 = medium, and 21+ cases = high volume). We utilized negative binomial regression and logistic regression to identify patient, surgeon, and hospital characteristics associated with MIS utilization and perioperative complications, respectively. A total of 5660 hospitalizations were identified during the study period. Most patients (61.5%) had an open hysterectomy; the remaining (38.6%) underwent a MIS procedure (25.1% robotic, 46.6% laparoscopic, and 28.3% vaginal). Most surgeons (68.2%) performed 10 or fewer hysterectomies during the 2+ year study period. Factors associated with a lower likelihood of undergoing MIS were older patient age (ref: 45-64 years; 20-44: OR = 1.17, 95% CI = 1.06-1.28), black race (ref: white; OR = 0.72, 95% CI = 0.65-0.80), Hispanic ethnicity (OR = 0.62, 95% CI = 0.48-0.79), smaller hospital size (ref: large; small: OR = 0.25, 95% CI = 0.15-0.44; medium: OR = 0.83, 95% CI = 0.75-0.91), and lower surgeon volume (ref: high; medium: OR = 0.87, 95% CI = 0.78-0.97). Complications occurred in 25.8% of open and 8.2% of MIS hysterectomies (P < 0.0001). While MIS hysterectomy was associated with fewer complications (OR = 0.22, 95% CI = 0.17-0.27), patient payer, including Medicare (ref: private; OR = 1.88, 95% CI = 1.34-2.64), Medicaid (OR = 1.70, 95% CI = 1.34-2.11) and self-pay status (OR = 2.49, 95% CI = 1.47-4.27), and low surgeon hysterectomy volume (ref: high; very low: OR = 1.91, 95% CI = 1.34-2.73; low: OR = 1.73, 95% CI = 1.22-2.47) were associated with perioperative complications. Use of minimally invasive hysterectomy for benign indications remains variable, with most patients undergoing open, more morbid procedures. Older and black patients, lower volume surgeons, and smaller hospitals were associated with open hysterectomy. Patient race and payer and lower surgeon volume were also associated with perioperative complications. Hysterectomies performed by high volume surgeons, and especially those with expertise in minimally invasive techniques, may represent an opportunity to reduce adverse events.

Association of delayed commencement of adjuvant chemotherapy (AC) with inferior survival in colon cancer patients with stage II and III diseases: A national population-based cohort study.

669 Background: To evaluate factors affecting the delay ( ≥ 8 weeks) of AC and the impact of chemotherapy delay on survival in patients with colon cancer(CC). Methods: The study cohort consisted of patients with stage II and III colon cancer, diagnosed between January 1, 2011 and December 31, 2012, who underwent curative resection and AC at all hospitals registered in the Korean Health Insurance Review and Assessment Service (HIRA). Detailed clinical data are from monitoring and evaluation of quality of colon cancer care. Results: Among 5355 patients, 154 (2.9%) received AC more than 8 weeks after surgery. Based on multivariate analysis, risk factors associated with AC delay ≥ 8 weeks were: older age [65 to 74 years (hazard ratio, HR = 1.48) and 75 years (HR = 1.69), p = 0.0354], medical aid status in health security system (HR = 1.76, p = 0.0345), emergency surgery (HR = 2.43, p = 0.0002), and chemotherapy with fluoropyrimidine (HR = 1.49, p = 0.0373). Independent prognostic factors for inferior OS included AC delay ≥ 8 weeks (HR = 1.49, p = 0.0365), older age [65 to 74 years (HR = 1.94) and 75 years (HR = 3.41), p &lt; 0.0001], TNM III stage (HR = 2.46, p &lt; 0.0001), emergency surgery (HR = 1.89, p &lt; 0.0001), ASA score with 3 or higher (HR = 1.50, p &lt; 0.0001), and higher transfusion amount (HR = 1.09, p = 0.0392). OS rates in patients with stage II / III CCs according to delay of AC using 8 weeks cutoff showed inferior OS in the delayed chemotherapy group (p = 0.008).Detailed OS rates were 97.81% at 1 year, 93.77% at 2 year, 89.62% at 3 year, and 85.79% at 4 year in the chemotherapy group within 8weeks. In the delayed chemotherapy group ≥ 8 weeks, OS rates were 96.1% at 1 year, 87.66% at 2 year, 80.98% at 3 year, and 80.2% at 4 year. Conclusions: This national population-based cohort study shows that delayed commencement of AC, defined as ≥ 8 weeks, is associated with inferior OS in CC patients with stage II / III. To reduce the proportion of patients receiving delayed AC, multidimensional aspects such as health insurance status or age should be considered. Based on our results, the time of commencement of chemotherapy can be incorporated as another quality indicator for colon cancer care.

The impact of maternal factors on the association between temperature and preterm delivery

BackgroundFew studies have examined maternal modifiers of temperature and adverse birth outcomes because of lack of data. We assessed the relationship between apparent temperature, preterm delivery (PTD) and maternal demographics, medical and mental health conditions, and behaviors. MethodsA time-stratified case-crossover analysis was conducted using 14,466 women who had a PTD (20 to less than 37 gestational weeks) from 1995 to 2009 using medical records from a large health maintenance organization in Northern California. Effect modifiers considered by stratification included several maternal factors: age, race/ethnicity, depression, hypertension, diabetes, smoking, alcohol use, pre-pregnancy body mass index, and Medicaid status. Apparent temperature data for women who had a monitor located within 20km of their residential zip codes were included. All analyses were stratified by warm (May 1 through October 31) and cold (November 1 through April 30) seasons. ResultsFor every 10°F (5.6°C) increase in average cumulative weekly apparent temperature (lag06), a greater risk was observed for births occurring during the warm season (11.63%; 95% CI: 4.08, 19.72%) compared to the cold season (6.18%; −2.96, 16.18%), especially for mothers who were younger, Black, Hispanic, underweight, smoked or consumed alcohol during pregnancy, or had pre-existing /gestational hypertension, diabetes, or pre-eclampsia. ConclusionsOur findings suggest that warmer apparent temperatures exacerbate the risk of PTD, particularly for subgroups of more vulnerable women.

Closing in on Crisis: Informing Clinical Practice Regarding Nonsuicidal Self-Injury in Youth

Nonsuicidal self-injury (NSSI) in youth is a major public health concern. A retrospective chart review was conducted within a hospital system to examine (a) youth self-reports of reasons for engaging in NSSI and (b) additional contextual circumstances that may contribute to youth NSSI. Detailed history, physical examination, and treatment/discharge data were extracted by thoroughly reviewing all electronic documents in each medical record. The final sample (N = 135) were predominantly female (71.1%), and well over half (63.8%) reported Medicaid or uninsured status. Qualitative content analysis of youth self-reports and hospital progress notes showed that NSSI served as an emotional and functional coping mechanism. Five primary themes characterized the contextual influences on youth engaging in NSSI: (1) Personal Emotions, (2) Trauma, (3) Relationship Quality, (4) Sense of Loss, and (5) Risk Behaviors. Practical clinical practice suggestions for working with youth are discussed using these themes as a template for assessing risk and protective factors.

Disparities in the Local Management of Breast Cancer in the US according to Health Insurance Status.

Although standard practice guidelines for breast cancer are clear, the interplay between insurance and practice patterns for the US is poorly defined. This study was performed to test for associations between patient insurance status and presentation of breast cancer as well as local therapy patterns in the US, via a large national dataset. We queried the NCI Surveillance, Epidemiology, and End Results data base for breast cancer cases diagnosed from 2007 to 2011 in women aged 18-64 with nonmetastatic ductal/lobular cancers, treated surgically. We tested for associations between insurance status (insured/Medicaid/uninsured) and choice of surgical procedure (mastectomy/breast conserving surgery [BCS]), omission of radiotherapy (RT) following BCS, and administration of post-mastectomy radiation (PMRT). There were 129,565 patients with localized breast cancer analyzed. The health insurance classification included insured (84.5%), Medicaid (11.5%), uninsured (2.1%) and unknown (1.9%). Medicaid or uninsured status was associated with large, node positive tumors, black race, and low income. The BCS rate varied by insurance status: insured (52.2%), uninsured (47.7%), and Medicaid (45.2%), p < 0.001. In multivariable analysis, Medicaid insurance remained significantly associated with receipt of mastectomy (OR [95% CI] = 1.07 [1.03-1.11]), while RT was more frequently omitted after BCS in both Medicaid (OR [95% CI] = 1.14 [1.07-1.21]) and uninsured (OR [95% CI] = 1.29 [1.14-1.47]) patients. Insurance status was associated with significant variations in breast cancer care in the US. Although patient choice cannot be determined from this dataset, departure from standard of care is associated with specific types of insurance coverage. Further investigation into the reasons for these departures is strongly suggested.

Hospitalization, inpatient burden and comorbidities associated with bullous pemphigoid in the U.S.A.

Bullous pemphigoid (BP) is associated with significant disability and comorbid health disorders that may lead to or result from hospitalization. However, little is known about the inpatient burden and comorbidities of BP. To obtain data on the inpatient burden and comorbidities of BP in the U.S.A. We analysed data from the 2002 to 2012 National Inpatient Sample, including a representative 20% sample of all hospitalizations in the U.S.A. (72 108 077 adults). The prevalence of hospitalization for BP increased from 25·84 to 32·60 cases per million inpatients from 2002 to 2012. In multivariate logistic regression models with stepwise selection, increasing age, nonwhite ethnicity, higher median household income, being insured with Medicare or Medicaid, and increasing number of chronic conditions were all associated with hospitalization for BP (P < 0·05 for all). The top three primary discharge diagnoses for patients with a secondary diagnosis of BP were septicaemia (prevalence 5·51%, 95% confidence interval 5·03-5·99), pneumonia (4·60%, 4·19-5·01) and urinary tract infection (3·52%, 3·15-3·89). Patients with BP also had numerous autoimmune, infectious, cardiovascular and other comorbidities. Interestingly, BP was associated with multiple neuropsychiatric disorders, including demyelinating disorders, dementias (presenile, senile, vascular and other), paralysis, neuropathy (diabetic, other polyneuropathy), Parkinson disease, epilepsy, psychoses and depression. The mean annual age- and sex-adjusted in-hospital mortality rate was significantly higher in patients with a secondary diagnosis of BP compared with no BP (2·9%, range 2·8-3·9% vs. 2·1%, range 1·9-2·2%). Significant predictors of mortality in patients with BP included increasing age, nonwhite ethnicity and insurance with Medicaid or other payment status (P < 0·05 for all). Hospitalization for BP increased significantly between 2002 and 2012. Moreover, there were significant ethnic and healthcare disparities with respect to hospitalization and inpatient mortality from BP.

Preterm Birth and Maternal Occupation in a Hispanic Population

Abstract Introduction: The goal of this study was to examine the differences in preterm birth (PTB) among Hispanic and non-Hispanic White women in regard to occupation in the service industry.PTB outcomes for Hispanic women by country of origin were also analyzed. Methods: We conducted a retrospective population-based study using Nevada’s electronic birth records from January 2010 to December 2014 to extract maternal and infant characteristics and information on occupation. We calculated crude and adjusted odds ratios of PTB (<37 weeks) using multiple logistic regression. Results: Hispanic women working in the service industry had higher odds of delivering a premature infant (AOR=1.40; 95% CI=1.04-1.89). By nativity, women from Spain (AOR=1.93; 95% CI=1.02-3.64) and Central South America (AOR=1.26; 95% CI=1.09-1.44) had higher odds of a PTB. Hispanic mothers who were students had increased odds of PTB. Maternal risk factors associated with PTB included: high school education or less, previous PTB, Medicaid status, and smoking and/or drinking during pregnancy. Prenatal care utilization was a protective factor for PTB. Conclusion: Hispanic women working in the service industry are exposed to environmental tobacco smoke which increases their risk of PTB. The increased odds could be further modified by nativity. Therefore, maternal occupation should be accounted for when examining ethnic disparities in preterm birth.

247EMF Cluster Analysis of Acute Care Utilization Yields Insights for Tailored Pediatric Asthma Interventions

247EMF Cluster Analysis of Acute Care Utilization Yields Insights for Tailored Pediatric Asthma Interventions

Accounting For Patients' Socioeconomic Status Does Not Change Hospital Readmission Rates.

There is an active public debate about whether patients' socioeconomic status should be included in the readmission measures used to determine penalties in Medicare's Hospital Readmissions Reduction Program (HRRP). Using the current Centers for Medicare and Medicaid Services methodology, we compared risk-standardized readmission rates for hospitals caring for high and low proportions of patients of low socioeconomic status (as defined by their Medicaid status or neighborhood income). We then calculated risk-standardized readmission rates after additionally adjusting for patients' socioeconomic status. Our results demonstrate that hospitals caring for large proportions of patients of low socioeconomic status have readmission rates similar to those of other hospitals. Moreover, readmission rates calculated with and without adjustment for patients' socioeconomic status are highly correlated. Readmission rates of hospitals caring for patients of low socioeconomic status changed by approximately 0.1percent with adjustment for patients' socioeconomic status, and only 3-4percent fewer such hospitals reached the threshold for payment penalty in Medicare's HRRP. Overall, adjustment for socioeconomic status does not change hospital results in meaningful ways.

Abstract 1429: The effect of payer status on early stage laryngeal cancer survival

Abstract Background It is estimated that there will be 13,560 new cases of larynx cancer and an estimated 3,640 people will die of this disease, in 2015. There are many risk factors affecting survival outcomes in larynx cancer. Previous studies on laryngeal cancer found several discrepancies for mortality in patients with various racial and socioeconomic backgrounds. However, further studies indicate that reduced survival outcomes for African-American or uninsured patients are not affected by tumor biology hinting that some disparities can be overcome through healthcare equity. In the wake of the Affordable Care Act and its impact on insurance coverage, evaluating the effect of insurance status on health outcomes is urgently necessary. This study characterizes the relationship between payer status and overall survival for larynx cancer patients by analyzing data from the large National Cancer Data Base (NCDB). Methods We analyzed data from the National Cancer Data Base of 22,177 patients with laryngeal cancer of stage I and II who received laser surgery or radiation treatment. The outcome variable was overall survival and the primary predictor variable was payer status. Additional variables addressed and adjusted for included sex, age, race, Charlson Comorbidity index, education, income, distance traveled facility type, diagnosing/treating facility, treatment delay, stage, grade and type of treatment received. Results Among these 22,177 patients, approximately 90% were over age 50 years, and 80% of the patients were male. 48.5%, 39.4%, 5.4%, 3.8% and 2.7% of patients had Medicare, private, Medicaid, uninsured, and unknown status, respectively. There was 83% of patients received radiation treatment only whereas 5.2% received laser surgery and 3.2% received both laser surgery and radiation. In multivariate analysis, after adjusting for secondary predictor variables, payer status was a statistically significant predictor of overall survival. Relative to privately insured patients, patients with Medicaid had a 76% increased risk, no insurance had a 29% increased risk, Medicare had a 38% increased risk and unknown insurance had a 25% increased risk of mortality. Compared to patients without treatment (no radiation, no laser surgery), patient with laser surgery, patients with laser and radiation therapy were 77% and 76% less likely to die while patients receiving radiation therapy was not significant different from no treatment. Conclusion We observed that payer status has a statistically significant relationship with overall survival from laryngeal cancer. This remained true after adjusting for other predictive factors. Medicaid Medicare and uninsured patients had the highest mortality while privately insured patients had the lowest mortality. Further research is necessary how the disparities associated with different types of insurance result in inferior treatment outcomes and the ways to address them. Citation Format: Samip R. Master, Peter Zhang, Glenn Mills, Runhua Shi. The effect of payer status on early stage laryngeal cancer survival. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1429.

Are cancer-related decision aids appropriate for socially disadvantaged patients? A systematic review of US randomized controlled trials.

BackgroundShared decision-making (SDM) is considered a key component of high quality cancer care and may be supported by patient decision aids (PtDAs). Many patients, however, face multiple social disadvantages that may influence their ability to fully participate in SDM or to use PtDAs; additionally, these social disadvantages are among the determinants of health associated with greater cancer risk, unwarranted variations in care and worse outcomes. The purpose of this systematic review is to describe the extent to which disadvantaged social groups in the United States (US) have been included in trials of cancer-related PtDAs and to highlight strategies, lessons learned and future opportunities for developing and evaluating PtDAs that are appropriate for disadvantaged populations.MethodsWe selected cancer-related US studies from the Cochrane 2014 review of PtDAs and added RCTs meeting Cochrane criteria from searches of PubMed, CINAHL, PsycINFO (January 2010 to December 2013); and reference lists. Two reviewers independently screened titles/abstracts; three reviewers independently screened full text articles, performed data extraction and assessed: 1) inclusion of participants based on seven indicators of social disadvantage (limited education; female gender; uninsured or Medicaid status; non-U.S. nativity; non-White race or Hispanic ethnicity; limited English proficiency; low-literacy), and 2) attention to social disadvantage in the development or evaluation of PtDAs.ResultsTwenty-three of 39 eligible RCTs included participants from at least one disadvantaged subgroup, most frequently racial/ethnic minorities or individuals with limited education and/or low-literacy. Seventeen studies discussed strategies and lessons learned in attending to the needs of disadvantaged social groups in PtDA development; 14 studies targeted disadvantaged groups or addressed subgroup differences in PtDA evaluation.ConclusionsThe diversity of the US population is represented in a majority of cancer-related PtDA RCTs, but fewer studies have tailored PtDAs to address the multiple social disadvantages that may impact patients’ participation in SDM. More detailed attention to the comprehensive range of social factors that determine cancer risk, variations in care and outcomes is needed in the development and evaluation of PtDAs for disadvantaged populations.Trial registrationRegistered 24 October 2014 in PROSPERO International prospective register of systematic reviews (CRD42014014470).Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0303-6) contains supplementary material, which is available to authorized users.

Clinical Characteristics, Oral Anticoagulation Patterns, and Outcomes of Medicaid Patients With Atrial Fibrillation: Insights From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I) Registry.

BackgroundWhereas insurance status has been previously associated with care patterns, little is currently known about the association between Medicaid insurance and the clinical characteristics, treatment, or outcomes of patients with atrial fibrillation (AF).Methods and ResultsWe used data from adults with AF enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT‐AF), a national outpatient registry conducted at 176 community, multispecialty sites. The primary outcome of interest was the proportion of patients prescribed any oral anticoagulation (OAC; warfarin or novel oral anticoagulants [NOAC]). Secondary outcomes of interest included the proportion of patients prescribed NOACs (dabigatran or rivaroxaban); time in therapeutic range (TTR) for warfarin users, all‐cause mortality, stroke/systemic embolism, and major bleed. Of 10 133 patients, N=470 (4.6%) had Medicaid insurance. Medicaid patients were similarly likely to receive OAC at baseline (72.8% vs 76.3%; unadjusted P=0.079), but less likely to receive NOAC at baseline or follow‐up (12.1% vs 16.3%; unadjusted P=0.019). After risk adjustment, Medicaid status was associated with lower use of OAC at baseline among patients with high stroke risk (odds ratio [OR]=0.68; 95% CI=0.49, 0.94), but was not associated with OAC use overall (OR=0.82; 95% CI=0.61, 1.09). Among warfarin users, median TTR was lower among Medicaid patients (60% vs 68%; P<0.0001; adjusted TTR difference, −2.9; 95% CI=−5.7, −0.2; P=0.04). Use of an NOAC over 2 years of follow‐up was not statistically different by insurance. Compared with non‐Medicaid patients, Medicaid patients had higher unadjusted rates of mortality, stroke/systemic embolism, and major bleeding; however, these differences were attenuated following adjustment for clinical characteristics.ConclusionsIn a contemporary AF cohort, use of OAC overall and use of NOACs were not significantly lower among Medicaid patients relative to others. However, among warfarin users, Medicaid patients spent less time in therapeutic range compared with those with other forms of insurance.

Disparities in the management and outcome of cervical cancer in the United States according to health insurance status

IntroductionOur study sought to characterize the presentation, local management and outcomes of invasive cervical cancer with regard to patient insurance status. MethodsWe queried the NCI-SEER database for invasive cervical cancer cases in patients aged 18–64 from 2007 to 2011. We analyzed clinical and socioeconomic data with regard insurance status (insured, Medicaid, or uninsured). We tested for associations between patient insurance status and treatment with definitive surgery for FIGO IA2-IB1 patients, and treatment with suboptimal radiation therapy (RT) for FIGO IB2-IVA patients (other than combination external beam and brachytherapy). We evaluated overall and cause specific survival according to insurance status. Results11,714 cases were analyzed: 60% insured, 31% Medicaid, and 9% uninsured. FIGO III/IV stage at presentation was more frequent with Medicaid (40%) and uninsured (42%) compared to insured patients (28%) (p<0.001). For FIGO IA2-IB1 patients, receipt of definitive surgery was inversely associated with uninsured status (OR [95%CI]=0.65 [0.47–0.90], p<0.001) in univariable analysis; however the relationship lost significance after multivariable adjustment. For FIGO IB2-IVA patients, the use of suboptimal RT was associated with uninsured status (OR [95%CI]=1.33 [1.07–1.65], p=0.011) in adjusted analyses. Among all patients, overall mortality was increased with Medicaid (HR [95%CI]=1.16 [1.05–1.28], p=0.003) and uninsured status (HR [95%CI]=1.17 [1.01–1.34], p=0.031) in multivariable analysis. Cancer specific mortality survival trended towards significance in multivariable analyses for both Medicaid (HR [95%CI]=1.11 [1.00–1.24] and uninsured status (HR [95%CI]=1.14 [0.98–1.33]). ConclusionsDisparities in cervical cancer treatment with regard to insurance status are apparent in a recent cohort of American patients. Later stage at presentation and differences in management partially account for the inferior prognostic outcomes associated with Medicaid and uninsured status.