Medicaid expansion and 2-year survival in women with gynecologic cancer: a difference-in-difference analysis - 23/08/22
Abstract |
Background |
The Affordable Care Act implemented optional Medicaid expansion starting in 2014, but the association between Medicaid expansion and gynecologic cancer survival is unknown.
Objective |
To evaluate the impact of Medicaid expansion by comparing 2-year survival among gynecologic cancers before and after 2014 in states that did and did not expand Medicaid using a difference-in-difference analysis.
Study Design |
We searched the National Cancer Database for women aged 40 to 64 years, diagnosed with a primary gynecologic malignancy (endometrial, ovarian, cervical, vulvar, and vaginal) between 2010 and 2016. We used a quasiexperimental difference-in-difference multivariable Cox regression analysis to compare 2-year survival between states that expanded Medicaid in January 2014 and states that did not expand Medicaid as of 2016. We performed univariable subgroup difference-in-difference Cox regression analyses on the basis of stage, income, race, ethnicity, and geographic location. Adjusted linear difference-in-difference regressions evaluated the proportion of uninsured patients on the basis of expansion status after 2014. We evaluated adjusted Kaplan–Meier curves to examine differences on the basis of study period and expansion status.
Results |
Our sample included 169,731 women, including 78,669 (46.3%) in expansion states and 91,062 (53.7%) in nonexpansion states. There was improved 2-year survival on adjusted difference-in-difference Cox regressions for women with ovarian cancer in expansion than in nonexpansion states after 2014 (hazard ratio, 0.88; 95% confidence interval, 0.82–0.94; P<.001) with no differences in endometrial, cervical, vaginal, vulvar, or combined gynecologic cancer sites on the basis of expansion status. On univariable subgroup difference-in-difference Cox analyses, women with ovarian cancer with stage III–IV disease (P=.008), non-Hispanic ethnicity (P=.042), those in the South (P=.016), and women with vulvar cancer in the Northeast (P=.022), had improved 2-year survival in expansion than in nonexpansion states after 2014. In contrast, women with cervical cancer in the South (P=.018) had worse 2-year survival in expansion than in nonexpansion states after 2014. All cancer sites had lower proportions of uninsured patients in expansion than in nonexpansion states after 2014.
Conclusion |
There was a significant association between Medicaid expansion and improved 2-year survival for women with ovarian cancer in states that expanded Medicaid after 2014. Despite improved insurance coverage, racial, ethnic, and regional survival differences exist between expansion and nonexpansion states.
Le texte complet de cet article est disponible en PDF.Key words : Affordable Care Act, cervical cancer, endometrial cancer, epidemiology, health disparities, health insurance, health policy, ovarian cancer, vaginal cancer, vulvar cancer
Plan
L.A.M. reports obtaining consulting fees from Bristol Myers Squibb, advisory board participation for GlaxoSmithKline, and stocks in Crisper, Invitae, and Bristol Myers Squibb. C.C.S. reports partial research funding from AstraZeneca and stock in Inform Genomics. The remaining authors report no conflict of interest. |
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This work was supported in part by the MD Anderson Cancer Center Support Grant from the National Cancer Institute (NCI) of the National Institutes of Health (NIH; NIH/NCI P30 CA016672, CA217685) and the T32 training grant CA101642. L.A.M. is supported by a NIH-NCIK07-CA201013 grant. S.H.G. is supported by CPRIT RP160674 and Komen SAC150061. |
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Cite this article as: Huepenbecker SP, Fu S, Sun C, et al. Medicaid expansion and 2-year survival in women with gynecologic cancer: a difference-in-difference analysis. Am J Obstet Gynecol 2022;227:482.e1-15. |
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The National Cancer Database (NCDB) is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The CoC's NCDB and the hospitals participating in the CoC's NCDB are the source of the de-identified data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. |
Vol 227 - N° 3
P. 482.e1-482.e15 - septembre 2022 Retour au numéroBienvenue sur EM-consulte, la référence des professionnels de santé.
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