University of Utah, Department of Surgery, Division of General Surgery, Salt Lake City, Utah.
University of Toronto, Department of Surgery, Division of Thoracic Surgery, Ontario, Canada.
Surgery. 2018 Dec;164(6):1287-1293. doi: 10.1016/j.surg.2018.07.020. Epub 2018 Aug 28.
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.
在现代循证指南时代，保险对结果的影响尚不清楚。我们旨在研究保险覆盖范围对早期非小细胞肺癌患者治疗和结局的差异。
在 2004 年至 2014 年国家癌症数据库中确定了临床 T1-3N0-1 期非小细胞肺癌病例，并按 4 组进行比较：私人保险、医疗保险、医疗补助和无保险。使用多变量线性回归模型，根据患者和医疗机构特征，研究保险状况对根治性手术治疗时间的影响。使用多变量逻辑回归检验不同治疗方法的应用。使用 Cox 回归进行生存分析。
共有 240361 例早期非小细胞肺癌患者（私人保险 60532 例，医疗保险 164377 例，医疗补助 11001 例，无保险 4451 例）。调整后，医疗补助和无保险患者接受手术治疗的时间晚于私人保险患者（分别为 9.5 天和 7.0 天，P<.001），更有可能延迟>8 周（优势比 1.64，95%置信区间 1.55-1.73 和优势比 1.46，95%置信区间 1.34-1.58），且接受手术治疗的可能性明显降低（优势比 0.53，95%置信区间 0.50-0.56 和优势比 0.50，95%置信区间 0.47-0.55）。无保险患者更有可能不接受任何治疗（优势比 2.15，95%置信区间 1.92-2.41），其次是医疗补助患者（优势比 1.66，95%置信区间 1.53-1.80）。医疗补助和无保险人群的 5 年总生存率明显较差。
即使在现代时代，无保险和医疗补助的早期非小细胞肺癌患者接受潜在根治性手术的几率降低，结局较差。鉴于医疗补助计划的大量支出，需要制定增加医疗补助肺癌患者根治性手术使用率的策略。
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