title: 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.
  
  
  METHODS
  This was a retrospective cohort study.
  
  
  METHODS
  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.
  
  
  METHODS
  We identified 42,300 patients in our cohort with a mean age 64 years.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Healy
authors.forename: Jason C
authors.initials: JC
authors.lastname: Pradarelli
authors.forename: Robert W
authors.initials: RW
authors.lastname: Krell
authors.forename: Scott E
authors.initials: SE
authors.lastname: Regenbogen
authors.forename: Pasithorn A
authors.initials: PA
authors.lastname: Suwanabol
mesh_terms: D000368:Aged; D015331:Cohort Studies; D015179:Colorectal Neoplasms / Q000191:economics / Q000473:pathology / Q000601:surgery; D004469:Economics, Hospital / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D008113:Liver Neoplasms / Q000191:economics / Q000556:secondary / Q000601:surgery; D008175:Lung Neoplasms / Q000191:economics / Q000556:secondary / Q000601:surgery; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D009367:Neoplasm Staging; D012189:Retrospective Studies; D014481:United States