Medicaid Expansion and Overall Survival Among Patients with Esophageal Cancer in the National Cancer Database 公开

Abstract

Importance: Medicaid expansion under the Patient protection and Affordable Care Act may be associated with improved access to earlier esophageal cancer treatment, but its impact on esophageal cancer survival is uncertain. Objective: To determine whether there is an association between Medicaid expansion and improved survival rates among esophageal cancer patients. Design, Setting, Participants: A retrospective study of adults (40-64 years) included in the National Cancer Database with newly diagnosed esophageal cancer from January 1, 2004, to December 31, 2018. Exposure: Living in a Medicaid expansion state by December 31, 2018, vs a Medicaid non-expansion state. Main Outcomes and Measures: The primary outcome was overall survival (OS) defined as years from diagnosis to death or last contact. We measured this outcome by constructing three Cox Proportional Hazard Models. Results: The dataset included 12,760 patients, 8,216 in the Medicaid expansion group and 4,544 in the Medicaid non-expansion group. Approximately half of all participants (48% in the expansion group and 50% in the non-expansion group) were between 50- 59 years old and 82-83% of patients were male. We ran three Cox models: first adjusted for race, age and sex, then further adjusted for cancer stage, education and income levels based on 2008-2012 data, and finally replacing 2008-2012 education and income variables with corresponding variables for 2012-2016. The multivariable models demonstrated no appreciable difference in survival between expansion and non-expansion states with HR (95% CI) estimates of 0.98 (0.93, 1.03) in the first model 0.98 (0.93, 1.04) in the second model and 0.99 (0.93, 1.04) in the third model. Patients diagnosed with Stage 4 disease had a 76% higher mortality rate relative to patients who had early-stage cancer. Those living in zip codes with the highest proportion of person who did not finish high school had a 13% to 16% higher rates of death following diagnosis. Conclusion and Relevance: Esophageal cancer remains an important contributor to cancer-related mortality worldwide. Among adults with newly diagnosed esophageal cancer, Medicaid expansion was not associated with improved overall survival.

Table of Contents

Chapter 1: Introduction ………………………………………………………………………...1

           Esophageal cancer epidemiology …………………………………………………............1

           Survival ……………………………………………………………………………...........2

           Risk factors ………………………………………………………………………….........2

           Clinical presentations and screening ……………………………………………………...4

           Treatment ……………………………………………………………………………........6

           Cost ………………………………………………………………………………….........7

           Medicaid expansion overview ……………………………………………………………8

           Benefits ……………………………………………………………………………….......8

           Medicaid expansion and esophageal cancer ………………………………………….…..9

           National Cancer Database …………………………………………………………….…12

           Summary ………………………………………………………………………………...13

Chapter 2: Manuscript ………………………………………………………………………...14

           Abstract …………………………………………………………………………………14

           Introduction …………………………………………………………………………….15

           Methods …………………………………………………………………………………17

           Data source ………………………………………………………………………………17

           Study population ………………………………………………………………………...17

Study variables …………………………………………………………………………..18

Statistical analysis ……………………………………………………………………….18

Results …………………………………………………………………………………..19

           General characteristics of the study population …………………………………………19

           Multivariable analyses …………………………………………………………………..19

           Discussion ………………………………………………………………………………20

Chapter 3: Conclusion ………………………………………………………………………....22

           References ………………………………………………………………………………23

           Tables …………………………………………………………………………………...29

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
关键词	Esophageal Cancer
Committee Chair / Thesis Advisor	Wicklin Gillespie, Theresa, Emory University
Committee Members	Goodman, Michael, Emory University

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