平价医疗法案的医疗补助扩张计划与卵巢癌患者 1 年生存率的关联。
Association of the Affordable Care Act's Medicaid Expansion With 1-Year Survival Among Patients With Ovarian Cancer.
机构信息
Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, Pennsylvania; and the Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland.
出版信息
Obstet Gynecol. 2022 Jun 1;139(6):1123-1129. doi: 10.1097/AOG.0000000000004750. Epub 2022 May 2.
OBJECTIVE
The Affordable Care Act's (ACA) 2014 Medicaid expansion is associated with gains in insurance and early-stage diagnosis among patients with gynecologic cancer, but its association with mortality remains unknown. This study aims to assess whether the ACA's Medicaid expansion was associated with improved survival among patients with ovarian cancer.
METHODS
In this retrospective cohort study of patients with newly diagnosed ovarian cancer, we compared 1-year survival before and after 2014 Medicaid expansion in patients aged 40-64 years in Medicaid expansion states (intervention group) to patients aged 40-64 years in non-Medicaid expansion states using a difference-in-difference analysis. Results were adjusted for age, comorbidities, treatment at an academic center, and variables associated with Medicaid insurance status (race, income, high-school education, distance traveled for care, and living in a rural area).
RESULTS
Our sample included 19,558 patients with ovarian cancer: 9,013 in Medicaid expansion states and 10,545 in nonexpansion states. The ACA's Medicaid expansion was associated with increased 1-year survival among patients in expansion states compared with nonexpansion states (adjusted difference-in-difference 2.2%, 95% CI 0.4-4.1). After adding stage at diagnosis, the mortality difference between expansion and nonexpansion states was no longer evident. Medicaid expansion was associated with a significant improvement in 1-year survival for White patients (2.4%, 95% CI 0.4-4.4), but the difference was not significant for Black patients (1.3%, 95% CI -5.7 to 8.2) or rural patients (9.5%, 95% CI -8.0 to 26.9).
CONCLUSION
The ACA's Medicaid expansion was associated with improvements in 1-year survival among patients with ovarian cancer, which was mediated by an earlier stage at diagnosis. Continued insurance expansion to nonexpansion states may improve survival and reduce disparities for patients with ovarian cancer.
目的
平价医疗法案（ACA）2014 年的医疗补助扩张计划与妇科癌症患者的保险覆盖和早期诊断的改善相关，但与死亡率的关联尚不清楚。本研究旨在评估 ACA 的医疗补助扩张计划是否与卵巢癌患者的生存改善相关。
方法
本回顾性队列研究纳入了新诊断为卵巢癌的患者，我们比较了在医疗补助扩张州（干预组）和非医疗补助扩张州（对照组）年龄在 40-64 岁的患者在医疗补助扩张前后的 1 年生存率，采用差异中的差异分析。结果根据年龄、合并症、在学术中心接受治疗以及与医疗补助保险状况相关的变量（种族、收入、高中学历、就医距离和居住在农村地区）进行了调整。
结果
我们的样本包括 19558 名卵巢癌患者：9013 名在医疗补助扩张州，10545 名在非扩张州。与非扩张州相比，ACA 的医疗补助扩张计划与扩张州患者的 1 年生存率提高相关（调整后的差异中的差异为 2.2%，95%CI 为 0.4-4.1）。在加入诊断时的分期后，扩张州和非扩张州之间的死亡率差异不再明显。医疗补助扩张与白种患者的 1 年生存率显著提高相关（2.4%，95%CI 为 0.4-4.4），但对黑种患者（1.3%，95%CI 为-5.7 至 8.2）或农村患者（9.5%，95%CI 为-8.0 至 26.9）则不显著。
结论
ACA 的医疗补助扩张计划与卵巢癌患者的 1 年生存率提高相关，这是通过更早的诊断分期来介导的。向非扩张州继续扩大保险范围可能会改善生存并减少卵巢癌患者的差异。
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