Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, The University of Texas, Houston, TX.
Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, Houston, TX.
Am J Obstet Gynecol. 2022 Sep;227(3):482.e1-482.e15. doi: 10.1016/j.ajog.2022.04.045. Epub 2022 Apr 29.
The Affordable Care Act implemented optional Medicaid expansion starting in 2014, but the association between Medicaid expansion and gynecologic cancer survival is unknown.
To evaluate the impact of Medicaid expansion by comparing 2-year survival among gynecologic cancers before and after 2014 in states that did and did not expand Medicaid using a difference-in-difference analysis.
We searched the National Cancer Database for women aged 40 to 64 years, diagnosed with a primary gynecologic malignancy (endometrial, ovarian, cervical, vulvar, and vaginal) between 2010 and 2016. We used a quasiexperimental difference-in-difference multivariable Cox regression analysis to compare 2-year survival between states that expanded Medicaid in January 2014 and states that did not expand Medicaid as of 2016. We performed univariable subgroup difference-in-difference Cox regression analyses on the basis of stage, income, race, ethnicity, and geographic location. Adjusted linear difference-in-difference regressions evaluated the proportion of uninsured patients on the basis of expansion status after 2014. We evaluated adjusted Kaplan-Meier curves to examine differences on the basis of study period and expansion status.
Our sample included 169,731 women, including 78,669 (46.3%) in expansion states and 91,062 (53.7%) in nonexpansion states. There was improved 2-year survival on adjusted difference-in-difference Cox regressions for women with ovarian cancer in expansion than in nonexpansion states after 2014 (hazard ratio, 0.88; 95% confidence interval, 0.82-0.94; P<.001) with no differences in endometrial, cervical, vaginal, vulvar, or combined gynecologic cancer sites on the basis of expansion status. On univariable subgroup difference-in-difference Cox analyses, women with ovarian cancer with stage III-IV disease (P=.008), non-Hispanic ethnicity (P=.042), those in the South (P=.016), and women with vulvar cancer in the Northeast (P=.022), had improved 2-year survival in expansion than in nonexpansion states after 2014. In contrast, women with cervical cancer in the South (P=.018) had worse 2-year survival in expansion than in nonexpansion states after 2014. All cancer sites had lower proportions of uninsured patients in expansion than in nonexpansion states after 2014.
There was a significant association between Medicaid expansion and improved 2-year survival for women with ovarian cancer in states that expanded Medicaid after 2014. Despite improved insurance coverage, racial, ethnic, and regional survival differences exist between expansion and nonexpansion states.
平价医疗法案于 2014 年开始实施可选的医疗补助扩展计划，但医疗补助扩展与妇科癌症生存之间的关联尚不清楚。
通过比较在实施和未实施医疗补助扩展的州中，2014 年前后妇科癌症的 2 年生存率，使用差异中的差异分析来评估医疗补助扩展的影响。
我们在国家癌症数据库中搜索了年龄在 40 至 64 岁之间的女性，她们在 2010 年至 2016 年期间被诊断出患有原发性妇科恶性肿瘤（子宫内膜癌、卵巢癌、宫颈癌、外阴癌和阴道癌）。我们使用准实验差异中的差异多变量 Cox 回归分析比较了 2014 年 1 月扩大医疗补助的州和截至 2016 年未扩大医疗补助的州之间的 2 年生存率。我们根据分期、收入、种族、族裔和地理位置进行了单变量差异中的差异 Cox 回归分析。调整后的差异中的差异线性回归评估了 2014 年后按扩展状态划分的无保险患者比例。我们评估了调整后的 Kaplan-Meier 曲线，以根据研究期间和扩展状态检查差异。
我们的样本包括 169731 名女性，其中 78669 名（46.3%）在扩展州，91062 名（53.7%）在非扩展州。在调整后的差异中的差异 Cox 回归分析中，与 2014 年后非扩展州相比，卵巢癌女性的 2 年生存率有所提高（风险比，0.88；95%置信区间，0.82-0.94；P<.001），但根据扩展状态，子宫内膜癌、宫颈癌、阴道癌、外阴癌或妇科癌症综合部位没有差异。在单变量差异中的差异 Cox 分析中，患有 III-IV 期疾病的卵巢癌女性（P=.008）、非西班牙裔（P=.042）、南部地区（P=.016）和东北地区外阴癌女性（P=.022），与 2014 年后非扩展州相比，在扩展州的 2 年生存率有所提高。相比之下，南部地区的宫颈癌女性（P=.018）在 2014 年后在扩展州的 2 年生存率比非扩展州更差。所有癌症部位在 2014 年后，扩展州的无保险患者比例均低于非扩展州。
在 2014 年后扩大医疗补助的州中，卵巢癌女性的医疗补助扩展与 2 年生存率的显著提高之间存在显著关联。尽管保险覆盖面有所改善，但在扩展州和非扩展州之间仍存在种族、族裔和地区生存差异。
