Joshua P Kronenfeld1, Emily L Ryon1, David Goldberg2, Rachel M Lee3, Adam Yopp4, Annie Wang5, Ann Y Lee5, Sommer Luu6, Cary Hsu6, Eric Silberfein6, Maria C Russell3, Nipun B Merchant1, Neha Goel7. 1. Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA. 2. 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. 3. Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, 1365-C Clifton Road NE Atlanta, 30322, Georgia. 4. Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical School, 2201 Inwood Rd 3rd Floor Suite 500, Dallas, TX 75390, USA. 5. Division of Surgical Oncology, Department of Surgery, NYU Langone Health, 160 East 34th Street, 3rd Floor, New York, NY, 10016, USA. 6. Division of Surgical Oncology, Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA. 7. Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, 1120 NW 14th Street, Suite 410, Miami, FL 33136, USA. Electronic address: neha.goel@med.miami.edu.
Abstract
BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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).
BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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).
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