Quality of gastrointestinal surgical oncology care according to insurance status

Despite efforts to expand insurance coverage, substantial inequalities persist, particularly in cancer treatment. This study aimed to evaluate whether quality disparities exist across major insurance plans for patients undergoing curative-intent resection for gastrointestinal (GI) cancers.

This was a retrospective study of adult patients in the National Cancer Database diagnosed with GI malignant neoplasms between January 1, 2004, and December 31, 2020. The primary tumor organ sites include the anus, colon, esophagus, gallbladder, liver, other biliary organ, pancreas, peritoneum, rectum, rectosigmoid, small intestine, and stomach. Multivariate linear regression was used to evaluate the effect of insurance status on resection margin, adequacy of lymphadenectomy, and receipt of lymphadenectomy. A Cox proportional hazards model was used for survival analysis.

Of the 1,084,555 patients in this study, 594,013 (54.8%) had Medicare insurance, 380,287 (35.1%) had private insurance, 57,402 (5.3%) had Medicaid insurance, and 29,133 (2.7%) were uninsured. Privately insured patients were more likely to have negative margins (odds ratio [OR], 1.08; 95% CI, 1.06-1.10) and adequate lymphadenectomies (OR, 1.06; 95% CI, 1.04-1.06) than Medicare-insured patients. Uninsured patients were the least likely to have negative margins (OR, 0.78; 95% CI, 0.75-0.81) and adequate lymphadenectomies (OR, 0.95; 95% CI, 0.92-0.99) than Medicare-insured patients. Non-Medicare-insured patients were more likely to receive adjuvant therapy, whereas Medicare-insured patients had higher omission rates because of comorbidities. Finally, multivariate survival analysis showed that Medicare-insured patients had a 14% increased risk of death compared with non-Medicare-insured patients.

Significant disparities in the quality of surgical oncology care exist based on insurance status. Healthcare policy interventions may be necessary to ensure equitable access to high-quality surgical GI cancer care in the United States.