Disparities in hepatocellular carcinoma survival by Medicaid-status: A national population-based risk analysis

https://doi.org/10.1016/j.ejso.2022.12.001Get rights and content

Abstract

Background

Previous studies have demonstrated disparities in survival surrounding hepatocellular carcinoma (HCC) across a variety of socio-demographic factors; however, the relationship between Medicaid-status and HCC survival is poorly understood.

Methods

We constructed 5-year, disease-specific survival curves using the Kaplan-Meier method and performed an adjusted survival analysis using multivariate Cox-proportional hazard regression.

Results

We analyzed 17,059 non-elderly patients (12,194 non-Medicaid, 4875 Medicaid) diagnosed between 2006 and 2013 and found that Medicaid status was not associated with higher risk of diseases-specific death compared to other insurance types (p = .232, aHR 1.02, 95% CI: 0.983–1.07) after for controlling for a variety of co–variates (ie. marital status, urbanicity, etc.). We found no difference in the risk of death between patients enrolled in Medicaid for more than three years versus those enrolled for less than three years. In all models, rurality and unmarried status were also associated with an increased risk of death (aHR 1.11, 95% CI: 1.03–1.18, p = .002 and aHR 1.18, 95% CI: 1.13–1.23, p < .001, respectively).

Discussion

Those enrolled in Medicaid prior to HCC diagnosis may not be associated with a higher risk of disease-specific death compared to non-Medicaid enrolled patients.

Section snippets

Funding

None.

Data and linkage

Cancer-related data consisted of de-identified patient information from SEER, thus IRB exemption from review was granted. The SEER program, which began collecting data in 1973, is a robust source of information regarding cancer survival and incidence in the United States and has been widely utilized. Patients' information was collected from SEER registries from 12 states for all persons diagnosed with cancer between 2006 and 2013.

Cancer data files were linked to Medicaid enrollment files from

Patient characteristics

Table 1 describes the baseline characteristics of our studied cohort. There were ultimately 17,059 patients with HCC that were analyzed (4875 enrolled in Medicaid, 12,184 not enrolled). All patients were diagnosed between 2006 and 2013. The final follow-up date was December 31st, 2018. The mean clinical follow up time among all patients was 454 days.

Unadjusted survival outcomes

The median days of survival for those not enrolled in Medicaid (456 days; 95% CI, 426–487) was significantly higher than that of those enrolled in

Medicaid as an equalizer

In our unadjusted analysis, there was an indication that those enrolled in Medicaid had worse outcomes than those not enrolled in Medicaid across all stratifications. We found in our analysis that patients were more likely to be coded as Black, live in a high poverty neighborhood, and more likely to be unmarried (p < .001). Numerous studies, for both HCC and other cancer types, have shown that living in a high-poverty neighborhood and being unmarried are significant risk factors for high rates

Conclusions

We found that Medicaid was associated with approximately equal survival of hepatocellular carcinoma when compared to non-Medicaid patients, even after controlling for factors such as stage of diagnosis and tumor-directed surgery. Our results warrant additional study into the role of Medicaid status and cancer survival as more nuanced research is needed to better understand the factors that drive cancer survival.

CRediT authorship contribution statement

Eric J. Kim: Conceptualization, Data curation, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Roles, Writing – original draft, Writing – review & editing. Arjun Ganga: Conceptualization, Data curation, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Roles, Writing – original draft, Writing – review & editing. James Y. Lee: Conceptualization, Data curation, Investigation, Methodology, Project administration,

Declaration of competing interest

The authors (EJK, AG, JYL, RSZ, WA, RW, GC, PSS) of this work report no competing interests.

Acknowledgments

This study used the linked SEER-Medicaid database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the National Cancer Institute; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicaid database.

The collection of cancer incidence data used in this

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