title: Health insurance status and survival among patients with head and neck cancer in Japan.
abstract: BACKGROUND
  Healthcare systems vary among countries, and in many countries, insurance and economic statuses significantly impact the mortality associated with head and neck squamous cell carcinoma (HNSCC). Japan prides itself on its unique healthcare and health insurance system, which provides equal coverage and healthcare access with low individual payments to most citizens. Additionally, citizens in poverty are covered by insurance for the poor (public assistance) and receive medical and other types of assistance. Hence, they have no barriers to healthcare services. This study aimed to determine the impact of health insurance status on mortality in Japanese patients with HNSCC.
  
  
  METHODS
  We reviewed 409 patients with HNSCC, using the Kaplan-Meier method to estimate overall survival. The association between insurance status and disease stage at diagnosis was analyzed via logistic regression. Cox and Fine-Gray proportional hazard models were employed to investigate the impact of insurance status on survival.
  
  
  RESULTS
  The public assistance and other insurances groups did not significantly differ in clinical stage distribution. The 5-year overall survival, cumulative incidence of HNSCC death, and cumulative incidence of other death rates were 63.3 and 59.1 %, 27.0 and 31.8 %, and 10.3 and 9.7 % for the public assistance and other insurances groups, respectively. The adjusted subdistribution hazard ratio for the association between public assistance and HNSCC death was 0.73 (95 % confidence interval 0.44-1.21).
  
  
  CONCLUSIONS
  The demonstrated non-inferiority of public assistance regarding HNSCC-specific mortality indicates the equality of healthcare in Japan, irrespective of the insurance status, and the superiority of the Japanese healthcare system.
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan. ysktakenaka@gmail.com.
authors.forename: Yukinori
authors.initials: Y
authors.lastname: Takenaka
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Toshimichi
authors.initials: T
authors.lastname: Yasui
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Keisuke
authors.initials: K
authors.lastname: Enomoto
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Haruka
authors.initials: H
authors.lastname: Miyabe
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Natsue
authors.initials: N
authors.lastname: Morizane
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Naoki
authors.initials: N
authors.lastname: Ashida
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Kotaro
authors.initials: K
authors.lastname: Shimizu
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Masayuki
authors.initials: M
authors.lastname: Hirose
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Yoshifumi
authors.initials: Y
authors.lastname: Yamamoto
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi, Osaka, Japan.
authors.forename: Atsuhiko
authors.initials: A
authors.lastname: Uno
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000401:mortality*; D005260:Female; D006258:Head and Neck Neoplasms / Q000401:mortality* / Q000473:pathology*; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data*; D007564:Japan / Q000453:epidemiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009313:National Health Programs / Q000706:statistics & numerical data*; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D015996:Survival Rate
keywords: Head and neck cancer; Health insurance; Income