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Disparities in Hepatocellular Carcinoma Survival by Insurance Status: A Population-Based Study in China.

ABSTRACT: Objective: Health disparities related to basic medical insurance in China have not been sufficiently examined, particularly among patients with hepatocellular carcinoma (HCC). This study aims to investigate the disparities in HCC survival by insurance status in Tianjin, China. Methods: This retrospective analysis used data from the Tianjin Basic Medical Insurance claims database, which consists of enrollees covered by Urban Employee Basic Medical Insurance (UEBMI) and Urban and Rural Resident Basic Medical Insurance (URRBMI). Adult patients newly diagnosed with HCC between 2011 and 2016 were identified and followed until death from any cause, withdrawal from UEBMI or URRBMI, or the latest data in the dataset (censoring as of December 31st 2017), whichever occurred first. Patients' overall survival during the follow-up was assessed using Kaplan-Meier and extrapolated by six parametric models. The hazard ratio (HR) and 95% confidence intervals (CI) were calculated with the adjusted Cox proportional hazards model including age at diagnosis, sex, baseline comorbidities and complications, baseline healthcare resources utilization and medical costs, tumor metastasis at diagnosis, the initial treatment after diagnosis and antiviral therapy during the follow-up. Results: Two thousand sixty eight patients covered by UEBMI (N = 1,468) and URRBMI (N = 570) were included (mean age: 60.6 vs. 60.9, p = 0.667; female: 31.8 vs. 27.7%, p = 0.074). The median survival time for patients within the UEBMI and URRBMI were 37.8 and 12.2 months, and the 1-, 3-, 5-, 10-year overall survival rates were 63.8, 50.2, 51.0, 33.4, and 44.4, 22.8, 31.5, 13.1%, respectively. Compared with UEBMI, patients covered by URRBMI had 72% (HR: 1.72; 95% CI: 1.47-2.00) higher risk of death after adjustments for measured confounders above. The survival difference was still statistically significant (HR: 1.49; 95% CI: 1.21-1.83) in sensitivity analysis based on propensity score matching. Conclusions: This study reveals that HCC patients covered by URRBMI may have worse survival than patients covered by UEBMI. Further efforts are warranted to understand healthcare disparities for patients covered by different basic medical insurance in China.

SUBMITTER: Wu J

PROVIDER: S-EPMC8602862 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:Policy Points Patients with low socioeconomic status (SES) experience poorer survival rates after diagnosis of breast cancer, even when enrolled in Medicare and Medicaid. Most of the difference in survival is due to more advanced cancer on presentation and the general poor health of lower SES patients, while only a very small fraction of the SES disparity is due to differences in cancer treatment. Even when comparing only low- versus not-low-SES whites (without confounding by race) the survival disparity between disparate white SES populations is very large and is associated with lower use of preventive care, despite having insurance.ContextDisparities in breast cancer survival by socioeconomic status (SES) exist despite the "safety net" programs Medicare and Medicaid. What is less clear is the extent to which SES disparities affect various racial and ethnic groups and whether causes differ across populations.MethodsWe conducted a tapered matching study comparing 1,890 low-SES (LSES) non-Hispanic white, 1,824 black, and 723 Hispanic white women to 60,307 not-low-SES (NLSES) non-Hispanic white women, all in Medicare and diagnosed with invasive breast cancer between 1992 and 2010 in 17 US Surveillance, Epidemiology, and End Results (SEER) regions. LSES Medicare patients were Medicaid dual-eligible and resided in neighborhoods with both high poverty and low education. NLSES Medicare patients had none of these factors.Measurements5-year and median survival.FindingsLSES non-Hispanic white patients were diagnosed with more stage IV disease (6.6% vs 3.6%; p < 0.0001), larger tumors (24.6 mm vs 20.2 mm; p < 0.0001), and more chronic diseases such as diabetes (37.8% vs 19.0%; p < 0.0001) than NLSES non-Hispanic white patients. Disparity in 5-year survival (NLSES - LSES) was 13.7% (p < 0.0001) when matched for age, year, and SEER site (a 42-month difference in median survival). Additionally, matching 55 presentation factors, including stage, reduced the disparity to 4.9% (p = 0.0012), but further matching on treatments yielded little further change in disparity: 4.6% (p = 0.0014). Survival disparities among LSES blacks and Hispanics, also versus NLSES whites, were significantly associated with presentation factors, though black patients also displayed disparities related to initial treatment. Before being diagnosed, all LSES populations used significantly less preventive care services than matched NLSES controls.ConclusionsIn Medicare, SES disparities in breast cancer survival were large (even among non-Hispanic whites) and predominantly related to differences of presentation characteristics at diagnosis rather than differences in treatment. Preventive care was less frequent in LSES patients, which may help explain disparities at presentation.

Project description:BackgroundLow socioeconomic status (SES) has been linked to worse survival in patients with colorectal cancer (CRC); however, the impact of SES on early-onset CRC remains undescribed.Materials and methodsRetrospective analysis of data from the National Cancer Database (NCDB) between 2004 and 2016 was conducted. We combined income and education to form a composite measure of SES. Logistic regression and χ2 testing were used to examine early-onset CRC according to SES group. Survival rates and Cox proportional hazards models compared stage-specific overall survival (OS) between the SES groups.ResultsIn total, 30,903 patients with early-onset CRC were identified, of whom 78.7% were White; 14.5% were Black. Low SES compared with high SES patients were more likely to be Black (26.3% vs. 6.1%) or Hispanic (25.3% vs. 10.5%), have T4 tumors (21.3% vs. 17.8%) and/or N2 disease (13% vs. 11.1%), and present with stage IV disease (32.8% vs. 27.7%) at diagnosis (p < .0001, all comparisons). OS gradually improved with increasing SES at all disease stages (p < .001). In stage IV, the 5-year survival rate was 13.9% vs. 21.7% for patients with low compared with high SES. In multivariable analysis, SES (low vs. high group; adjusted hazard ratio [HRadj ], 1.35; 95% confidence interval [CI], 1.26-1.46) was found to have a significant effect on survival (p < .0001) when all of the confounding variables were adjusted. Insurance (not private vs. private; HRadj , 1.38; 95% CI, 1.31-1.44) mediates 31% of the SES effect on survival.ConclusionPatients with early-onset CRC with low SES had the worst outcomes. Our data suggest that SES should be considered when implementing programs to improve the early detection and treatment of patients with early-onset CRC.Implications for practiceLow socioeconomic status (SES) has been linked to worse survival in patients with colorectal cancer (CRC); however, the impact of SES on early-onset CRC remains undescribed. In this retrospective study of 30,903 patients with early-onset CRC in the National Cancer Database, a steady increase in the yearly rate of stage IV diagnosis at presentation was observed. The risk of death increased as socioeconomic status decreased. Race and insurance status were independent predictors for survival. Implementation of programs to improve access to care and early diagnostic strategies among younger adults, especially those with low SES, is warranted.

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Disparities in Hepatocellular Carcinoma Survival by Insurance Status: A Population-Based Study in China.

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