Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA.
Division of Digestive Health and Liver Disease, Department of Medicine, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, USA.
HPB (Oxford). 2021 Jun;23(6):868-876. doi: 10.1016/j.hpb.2020.11.1150. Epub 2020 Dec 29.
Access to health insurance and curative interventions [surgery/liver-directed-therapy (LDT)] affects survival for early-stage hepatocellular carcinoma (HCC). The aim of this multi-institutional study of high-volume safety-net hospitals (SNHs) and their tertiary-academic-centers (AC) was to identify the impact of type/lack of insurance on survival disparities across hospitals, particularly SNHs whose mission is to minimize insurance related access-to-care barriers for vulnerable populations.
Early-stage HCC patients (2012-2014) from the US Safety-Net Collaborative were propensity-score matched by treatment at SNH/AC. Overall survival (OS) was the primary outcome. Multivariable Cox proportional-hazard analysis was performed accounting for sociodemographic/clinical parameters.
Among 925 patients, those with no insurance (NI) had decreased curative surgery, compared to those with government insurance (GI) and private insurance [PI, (PI-SNH:60.5% vs. GI-SNH:33.1% vs. NI-SNH:13.6%, p < 0.001)], and decreased median OS (PI-SNH:32.1 vs. GI-SNH:22.8 vs. NI-SNH:9.4 months, p = 0.002). On multivariable regression controlling for sociodemographic/clinical parameters, NI-SNH (HR:2.5, 95% CI:1.3-4.9, p = 0.007) was the only insurance type/hospital system combination with significantly worse OS.
NI-SNH patients received less curative treatment than other insurance/hospitals types suggesting that treatment barriers, beyond access-to-care, need to be identified and addressed to achieve survival equity in early-stage HCC for vulnerable populations (NI-SNH).
获得医疗保险和治疗干预措施[手术/肝定向治疗（LDT）]会影响早期肝细胞癌（HCC）患者的生存率。这项来自高容量保障医院（SNH）和其三级学术中心（AC）的多机构研究旨在确定保险类型/缺乏保险对医院间生存差异的影响，特别是 SNH 的使命是为弱势群体减少与保险相关的获得医疗服务的障碍。
使用美国保障网协作的数据，通过在 SNH/AC 处接受治疗对 2012-2014 年早期 HCC 患者进行倾向评分匹配。总生存率（OS）是主要结局。采用多变量 Cox 比例风险分析，考虑社会人口统计学/临床参数。
在 925 名患者中，无保险（NI）患者接受根治性手术的比例低于有政府保险（GI）和私人保险的患者[PI，（PI-SNH：60.5%比 GI-SNH：33.1%比 NI-SNH：13.6%，p<0.001）]，中位 OS 也较短（PI-SNH：32.1 比 GI-SNH：22.8 比 NI-SNH：9.4 个月，p=0.002）。在多变量回归中，控制社会人口统计学/临床参数后，NI-SNH（HR：2.5，95%CI：1.3-4.9，p=0.007）是唯一与 OS 显著较差相关的保险类型/医院系统组合。
NI-SNH 患者接受的根治性治疗少于其他保险/医院类型，这表明需要确定和解决治疗障碍，以实现弱势群体（NI-SNH）早期 HCC 的生存公平。
