Insurance Status and Hospital Payer Mix Are Linked With Variation in Metastatic Site Resection in Patients With Advanced Colorectal Cancers

Abstract

Background: Despite substantially improved survival with metastatic site resection in colorectal cancers, uptake of aggressive surgical approaches remains low among certain patients. It is unknown whether financial determinants of care, such as insurance status, play a role in this treatment gap.

Objective: We sought to evaluate the effect of insurance status on metastasectomy in patients with advanced colorectal cancers.

Design: This was a retrospective cohort study.

Settings: Using the National Cancer Data Base Participant User File, incident cases of colorectal cancer metastatic to the lung and/or liver with diagnosis from 2010 to 2013 were identified.

Patients: We identified 42,300 patients in our cohort with a mean age 64 years.

Main outcome measures: Controlling for patient, tumor, and hospital characteristics, hierarchical regression was used to examine associations between hospital payer mix and metastatic site resection. Metastatic site resection occurred in 12.3% of all patients.

Results: Adjusting for patient and hospital fixed effects, we found that patients who were uninsured or on Medicaid were 38% less likely to undergo metastasectomy (OR = 0.62 (95% CI, 0.56-0.66)). Patients in hospitals with staff treating a high percentage of uninsured patients or patients with Medicaid were less likely to undergo metastasectomy, even after controlling for individual patient insurance status.

Limitations: The study was limited by its retrospective design and the granularity and accuracy of the National Cancer Data Base.

Conclusions: Differences in insurance status and hospital payer mix are associated with differences in rates of metastatic site resection in patients with colorectal cancer that is metastatic to the lung and/or liver. There is a need for improved access to metastatic site resection for individual patients who are uninsured or who have Medicaid insurance, as well as for all patients who seek care at hospitals treating a large proportion of patients who are uninsured or on Medicaid. Remedies for individual patients could include improved access to private insurance through employment or individual plans or improved reimbursement from Medicaid for this procedure. Strategies for patients at low-performing hospitals include selective referral to centers that perform mestastectomy more frequently when appropriate.

Figure 1

Variation in payer mix across hospital quintiles.

Figure 2

Adjusted mean probability of metastatic site resection by hospital quintile, controlling for age, disease site, race, ethnicity, geographic location and hospital type.