Insurance status may affect access to high-quality, guideline-concordant cancer care
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Insurance status contributes to considerable disparities in care quality for patients with head and neck cancer, according to retrospective study results.
The findings underscore the need for ongoing health insurance reform to close gaps in care, researchers concluded.
Uchechukwu C. Megwalu, MD, MPH, professor of otolaryngology — head and neck surgery at Stanford Health Care, and colleagues used California Cancer Registry data, as well as discharge records and hospital characteristics from California Department of Health Care Access and Information, to conduct the analysis.
Researchers identified 23,933 adults diagnosed with head and neck cancer between 2010 and 2019 who had commercial insurance, Medicare, Medicaid, no insurance, other insurance or unknown insurance status.
Quality of the treating hospital — categorized in tertiles — as well as receipt of National Comprehensive Cancer Network guideline-concordant care and OS served as the study’s main outcomes.
Results showed treatment at hospitals in the top tertile of quality correlated with improved OS compared with treatment at bottom-tertile hospitals (HR = 0.87; 95% CI, 0.79-0.95).
Compared with commercial insurance, those with Medicare (OR = 0.78; 95%CI, 0.73-0.84), Medicaid (OR = 0.6; 95% CI, 054-0.66) or uninsured status (OR, 0.38; 95%CI, 0.29-0.49) less frequently received treatment at high-quality hospitals.
“Our study highlights the fact that insurance status definitely affects the quality of care patients receive as well as where they receive care,” Megwalu told Healio. “We need to move beyond just detecting disparities and focus on finding potential solutions.”
Healio spoke with Megwalu about the motivation for the study, the key findings and their implications, and next steps in research.
Healio: Why did you conduct this study?
Megwalu: There is a lot of documentation in the literature about disparities in head and neck cancer outcomes. Previous studies have shown that uninsured patients and those with Medicaid tend to have worse outcomes than those with private insurance. However, we don’t really know why this happens, and there are few studies aimed at understanding the drivers of these disparities.
Our study chose to look at the differences in quality of care and the use of high-quality hospitals. One question that arose was how to define hospital quality. Previous studies in this area have used surrogates such as case volume, academic versus community centers or cancer center accreditation. The problem is that those are not direct measures of quality, and we don’t know if they actually are associated with outcomes. So, we chose to examine this using a composite measure of head and neck cancer-specific hospital quality.
Healio: How did you conduct the study?
Megwalu: We used data from the California Cancer Registry, which is a robust dataset. Because cancer reporting is mandated in California, it’s representative of cancer cases in the state. Then we linked this with discharge records from California so we could evaluate variables not usually recorded in cancer registries.
We looked at a number of hospital-level variables, including traditional variables like case volume, and also cancer center designation statuses. We also looked at process measures, like NCCN guideline-compliant care. We looked at quality of neck dissection, as well as adverse event rates, and evaluated which of these variables were associated with survival among patients with head and neck cancer. We then used the significant variables to create a composite head and neck cancer hospital quality score. We classified hospitals as top, middle and bottom tier as far as quality.
Healio: What are the implications of the findings?
Megwalu: It will be important for us to understand the drivers of these associations, because that will highlight potential targets for future interventions to address this. Our study showed that insurance status affects quality of care, as well as where people receive care. It highlighted the need to refine our health insurance reform. The Affordable Care Act has done a good job increasing access to health insurance. However, part of what we need to look at is improving the quality of the insurance coverage that is available.
Healio: Could this finding be extrapolated to patients with other types of cancer?
Megwalu: It’s difficult to say for sure without doing the studies. This is a problem in other cancers. Specifically, there was a study that the New York state Medicaid program instituted, which limited breast cancer surgery to high-performing hospitals. These were hospitals that performed a certain number of cases per year. They found it helped improve survival for patients with lower socioeconomic status. Interestingly, though, this effect was not only seen among patients with lower socioeconomic status. There was an overall improvement in survival for all patients. So, another potential intervention might be to regionalize care to high-performing hospitals.
Healio: Do you have more research planned on this topic?
Megwalu: A study we’re working on now is looking at racial disparities in quality of care for head and neck cancer, and the role insurance status plays as a driver of that.
Further down the line, we’re trying to quantify the extent to which insurance status and quality of care mediate the relationship between race and head and neck cancer survival.
Reference:
For more information:
Uchechukwu C. Megwalu, MD, MPH, can be reached at umegwalu@stanford.edu.
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