Insurance status and disparities in disease presentation, treatment, and outcomes for men with germ cell tumors

BACKGROUND

People aged 26 to 34 years represent the greatest proportion of the uninsured, and they have the highest incidence of testicular cancers. The aim of this study was to investigate the association between insurance status and cancer outcomes in men diagnosed with germ cell tumors.

METHODS

The Surveillance, Epidemiology, and End Results database was used to identify 10,211 men diagnosed with germ cell gonadal neoplasms from 2007 to 2011. Associations between insurance status and characteristics at diagnosis and receipt of treatment were examined with log-binomial regression. The association between insurance status and mortality was assessed with Cox proportional hazards regression.

RESULTS

Uninsured patients had an increased risk of metastatic disease at diagnosis (relative risk [RR], 1.26; 95% confidence interval [CI], 1.15-1.38) in comparison with insured patients, as did Medicaid patients (RR, 1.62; 95% CI, 1.51-1.74). Among men with metastatic disease, uninsured and Medicaid patients were more likely to be diagnosed with intermediate/poor-risk disease (RR for uninsured patients, 1.22; 95% CI, 1.04-1.44; RR for Medicaid patients, 1.39; 95% CI, 1.23-1.57) and were less likely to undergo lymph node dissection (RR for uninsured patients, 0.74; 95% CI, 0.57-0.94; RR for Medicaid patients, 0.76; 95% CI, 0.63-0.92) in comparison with insured patients. Men without insurance were more likely to die of their disease (hazard ratio [HR], 1.88; 95% CI, 1.29-2.75) in comparison with insured men, as were those with Medicaid (HR, 1.58; 95% CI, 1.16-2.15).

CONCLUSIONS

Patients without insurance and patients with Medicaid have an increased risk of presenting with advanced disease and dying of the disease in comparison with those who have insurance. Future studies should examine whether implementation of the Patient Protection and Affordable Care Act reduces these disparities. Cancer 2016. © 2016 American Cancer Society.

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Insurance status, health equity, and the cancer care continuum

As illustrated in two studies published in this issue of Cancer, an individual's sociodemographic characteristics including type of health insurance can decrease access to receiving high-quality and timely cancer care and result in adverse outcomes. Understanding the factors that create cancer health care disparities can help researchers, clinicians, and policy makers develop strategies and interventions to reduce them. See also pages.

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Influence of insurance status on survival of adults with glioblastoma multiforme: A population-based study

BACKGROUND

To the authors' knowledge, the impact of insurance status on the survival time of patients with glioblastoma multiforme (GBM) has not been fully understood. The objective of the current study was to clarify the association between insurance status and survival of patients with GBM by analyzing population-based data.

METHODS

The authors performed a cohort study using data from the Surveillance, Epidemiology, and End Results program. They included adult patients (aged ≥18 years) with GBM as their primary diagnosis from the years 2007 to 2012. Patients without information regarding insurance status were excluded. A survival analysis between insurance status and GBM-related death was performed using an accelerated failure time model. Demographic and clinical variables were included to adjust for confounding effects.

RESULTS

Among the 13,665 adult patients in the study cohort, 558 (4.1%) were uninsured, 1516 (11.1%) had Medicaid coverage, and 11,591 (84.8%) had non-Medicaid insurance. Compared with patients who were uninsured, insured patients were more likely to be older, female, white, married, and with a smaller tumor size at diagnosis. Accelerated failure time analysis demonstrated that older age (hazard ratio [HR], 1.04; P<.001), male sex (HR, 1.08; P<.001), large tumor size at the time of diagnosis (HR, 1.26; P<.001), uninsured status (HR, 1.14; P =.018), and Medicaid insurance (HR, 1.10; P =.006) were independent risk factors for shorter survival among patients with GBM, whereas radiotherapy (HR, 0.40; P<.001) and married status (HR, 0.86; P<.001) indicated a better outcome. The authors discovered an overall yearly progressive improvement in survival in patients with non-Medicaid insurance who were diagnosed from 2007 through 2011 (P =.015), but not in uninsured or Medicaid-insured patients.

CONCLUSIONS

Variations existed in insurance status within the GBM population. Uninsured status and Medicaid insurance suggested shorter survival compared with non-Medicaid insurance among a population of patients with GBM. Cancer 2016. © 2016 American Cancer Society.

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Role of physician perception of patient smile on pretest probability assessment for acute pulmonary embolism

Background

Many clinicians use a global visual interpretation of patient appearance to decide if a patient looks sick or not. For patients with suspected acute pulmonary embolism (PE), we tested the relationship between visual appearance of a happy patient facial affect and probability of PE+ on CT pulmonary angiography (CTPA).

Methods

Eligible patients were selected by usual care to undergo CTPA, the criterion standard for PE+ or PE–. Prior to CTPA result, trained study personnel obtained physician pretest probability using the gestalt method (visual analogue scale, 0%–100%), the Wells score (0–12) and physicians’ impression of whether the patient smiled during the initial examination (smile+). Patients' faces were also video recorded and analysed with an automated neural network-based algorithm (Noldus FaceReader) for happy affect.

Results

Of the 208 patients enrolled, 27 were PE+ and smile+ was more frequent in patients with PE+ than PE–, a finding confirmed by the Noldus. The diagnostic sensitivity and specificity of smile was low, and physicians overestimated presence of an alternative diagnosis more likely to PE with smile+ than smile– patients in patients with true PE. As a result, the area under the receiver operating characteristic curve (AUROC) was lower for the Wells score in smile+ patients. However, the physicians’ mean gestalt estimate of PE did not differ with smile status, nor did smile status affect the AUROC for gestalt.

Conclusions

In patients with suspected PE, physician recollection of patients’ smile+ was more common in PE+ patients, and was associated with a less accurate Wells score, primarily because physicians overestimated probability of alternative diagnosis. However, the overall diagnostic accuracy of physicians’ gestalt did not differ with perceived smile status. These data suggest that the patients’ smile had less effect on the numeric gestalt pretest probability assessment than on the binary decision about an alternative diagnosis.

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Out-of-hospital cardiac arrest attended by ambulance services in Ireland: first 2 years results from a nationwide registry

Background

National data collection provides information on out-of-hospital cardiac arrest (OHCA) incidence, management and outcomes that may not be generalisable from smaller studies. This retrospective cohort study describes the first 2 years' results from the Irish National Out-of-Hospital Cardiac Arrest Register (OHCAR).

Methods

Data on OHCAs attended by emergency medical services (EMS) where resuscitation was attempted (EMS-treated) were collected from ambulance services and entered onto OHCAR. Descriptive analysis of the study population was performed, and regression analysis was performed on the subgroup of adult patients with a bystander-witnessed event of presumed cardiac aetiology and an initial shockable rhythm (Utstein group).

Results

3701 EMS-treated OHCAs were recorded for the study period (1 January 2012–31 December 2013). Incidence was 39/100 000 population/year. In the Utstein group (n=577), compared with the overall group, there was a higher proportion of male patients, public event location, bystander cardiopulmonary resuscitation (CPR) and early defibrillation. Median EMS call–response interval was similar in both groups. A higher proportion of patients in the Utstein group achieved return of spontaneous circulation (35% vs 17%) and survival to hospital discharge (22% vs 6%). After multivariate adjustment for the Utstein group, the following variables were found to be independent predictors of the outcome survival to hospital discharge: public event location (OR 3.1 (95% CI 1.9 to 5.0)); bystander CPR (2.4 (95% CI 1.2 to 4.9)); EMS response of 8 min or less (2.2 (95% CI 1.3 to 3.6)).

Conclusions

This study highlights the role of nationwide registries in quantifying, monitoring and benchmarking OHCA incidence and outcome, providing baseline data upon which service improvement effects can be measured.

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