Background and Objectives
Medicaid expansion has improved healthcare coverage and preventive health service use. To what extent this has resulted in earlier stage colorectal cancer diagnoses and ...impacted perioperative outcomes is unclear.
Methods
This was a retrospective difference‐in‐difference study using the National Cancer Database on adults (40–64) with Medicaid or no insurance, diagnosed with colorectal adenocarcinomas before (2010–2013) and after (2015–2018) expansion. The primary outcome was early‐stage (American Joint Committee on Cancer Stage 0–1) diagnosis. The secondary outcomes were rate of local excision, emergency surgery, postoperative length of stay, rates of minimally invasive surgery, postoperative mortality, and overall survival (OS).
Results
Medicaid expansion was associated with an increase in early‐stage diagnoses for patients with colorectal cancers (odds ratio OR: 1.28, 95% confidence interval CI: 1.15–1.43), an increase in local excision (OR: 1.39, 95% CI: 1.13–1.69), and a decreased rate of emergent surgery (OR: 0.85, 95% CI: 0.75–0.97) and 90‐day mortality (OR: 0.75, 95% CI: 0.59–0.97). Additionally, patients in expansion states postexpansion had an improved 5‐year OS (hazard ratio: 0.88, 95% CI: 0.83–0.94).
Conclusions
Insurance coverage expansion may be particularly important for optimizing stage of diagnosis, subsequent survival, and perioperative outcomes for socioeconomically vulnerable patients.
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Insurance status has been strongly associated with both access to and outcomes of colon resection (CRS). Under the Affordable Care Act (ACA), individual states opted to participate in Medicaid ...expansion (ME) and adopt essential health benefits (EHB).
We performed a quasi-experimental difference-in-differences (DID) analysis of 2012–2017 state-level inpatient claims with risk adjustment. We examined frequency of emergent presentation and in-hospital death. Subset analyses were performed by insurance type.
Among the 73,961 CRS patients, 49.6% were in a state with both ME and EHB, 34.7% presented emergently, and 2.0% died. Adoption of ME and EHB was associated with a significant, 24%, reduction in the likelihood of in-hospital mortality, and no significant change in emergent presentation for CRS.
The ACA’s ME was strongly associated with a decrease in mortality following colon resection among Medicaid beneficiaries. These findings support the adoption of healthcare policies that improve access to insurance.
•The Affordable Care Act (ACA) is associated with a decrease in the odds of in-hospital mortality following colon resection.•The decrease in odds of mortality is even stronger in the Medicaid-only population.•No change in odds of mortality is seen in the commercial-payer population.•No change is seen in the odds of emergent presentation for colon resection after the ACA.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
It is unclear how the Affordable Care Act’s state-based Medicaid Expansion (ME) has impacted surgeon selection for colorectal resections (CRS).
We performed a risk-adjusted DID analysis on state ...discharge data of CRS patients aged 26–64 from NY (Expansion) and FL (non-Expansion) before (2012–2013) and after (2016–2017) ME. Primary outcome was use of a high-volume or colorectal-boarded surgeon. Subset analysis performed on insurance status.
Among 78,866 CRS patients, ME was associated with a 5.9% increase in Medicaid enrollment. ME was associated with a 0.73 (95%CI: 0.67–0.69; p < 0.001) reduced odds of high-volume surgeon usage by commercially insured patients when compared to usage by commercially insured patients in the non-expansion state. No statistically significant difference was noted in the use of a colorectal-boarded surgeon following reform.
ME was associated with an increase in Medicaid enrollment and a decrease in the use of high-volume surgeons by the commercially insured.
•Medicaid expansion increased enrollment in Medicaid in the Expansion State.•Medicaid expansion in the Expansion State is associated with reduced use of high-volume surgeons by commercially insured.•Medicaid expansion may necessitate incentives to maintain high-volume surgeon engagement.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
We aimed to evaluate ethnic differences in patterns of care following an index nonoperative admission for acute diverticulitis amongst a universally insured patient cohort.
We identified nationwide ...Medicare beneficiaries aged 65.5 years or older hospitalized between 1 July 2015 and 1 November 2017 for nonoperative management of an index admission for diverticulitis. Patients were followed for 1 year to examine patterns of care. Primary categorical outcomes included receipt of an elective operation, emergency operation, nonoperative readmission or no further hospitalizations for diverticulitis. Multinomial regression was performed to determine the association between ethnicity and receipt of each primary outcome category whilst adjusting for potential confounders. We examined the use of percutaneous drainage during the index admission to better understand its association with subsequent care patterns.
Amongst 22 630 study patients, subsequent operative treatment was less common for Black, Hispanic, Asian and American Indian patients relative to White patients. Multinomial logistic regression noted that Black (relative risk 0.40; 95% CI 0.32-0.50) and Asian (relative risk 0.37; 95% CI 0.15-0.91) patients were associated with the lowest relative risk of undergoing an elective interval operation compared to White patients. Black patients were also associated with a 1.43 (95% CI 1.19-1.73) increased risk of requiring subsequent nonoperative readmissions for disease recurrence compared to White patients. The use of percutaneous drainage was higher amongst White patients relative to Black patients (6.9% vs. 4.0%, P value < 0.001).
We have identified ongoing inequities in the consumption of medical resources, with White patients being more likely to undergo elective colectomy and percutaneous drainage. Differences in care are not fully alleviated by equal access to insurance.
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Few studies have confirmed a benefit for adjuvant chemotherapy (aCTX) in stage II colon cancer. We used the National Cancer Database to explore the use and efficacy of aCTX in patients with both ...normal-risk (NR) and high-risk (HR) young stage II colon cancer.
We identified patients with stage II colon cancer who underwent colectomy between 2010 and 2015. HR patients included at least: lymphovascular or perineural invasion, < 12 lymph nodes, poor/un-differentiation, T4, or positive margins. Rates of aCTX by age and risk were calculated, and adjusted factors associated with aCTX were identified. Overall survival was estimated using the Kaplan-Meier method and Cox multivariable analyses for patients < 50 years.
Among the 81,066 stage II patients who underwent colectomy, 6093 (7.5%) were < 50 years old. Of these, 2669 patients were HR. Thirty percent of NR and almost 60% of HR patients < 50 years received aCTX, compared with 8% and 23% of patients > 50 years (P < .001). In NR patients < 50 years, 35.3% with microsatellite-stable tumors and 18% with microsatellite unstable tumors received aCTX (P < .001), whereas 63.6% and 43.2%, respectively, of HR patients did (P < .001). The most significant multivariable predictors of aCTX were risk status and age. On univariate analysis, there was no survival benefit associated with aCTX in patients < 50 years. Multivariate analysis failed to demonstrate a survival benefit for aCTX for either group (HR, 0.97; P = .84; NR, 0.1.03; P = .90).
Young patients with HR and NR colon cancer received aCXT more frequently than older patients with no demonstrable survival benefit. This bears further evaluation to avoid the real risks of over-treatment in this increasing population.
The benefit of adjuvant chemotherapy in stage II colon cancer is debated. A retrospective analysis of the National Cancer Database demonstrates more frequent use of chemotherapy in patients with both high- and normal-risk stage II colon cancer who are younger than 50 years compared with older patients. No survival benefit was found to be associated with adjuvant chemotherapy in either risk group.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Oncogenic forms of NRAS are frequently associated with hematologic malignancies and other cancers, making them important therapeutic targets. Inhibition of individual downstream effector molecules ...(eg, RAF kinase) have been complicated by the rapid development of resistance or activation of bypass pathways. For the purpose of identifying novel targets in NRAS-transformed cells, we performed a chemical screen using mutant NRAS transformed Ba/F3 cells to identify compounds with selective cytotoxicity. One of the compounds identified, GNF-7, potently and selectively inhibited NRAS-dependent cells in preclinical models of acute myelogenous leukemia and acute lymphoblastic leukemia. Mechanistic analysis revealed that its effects were mediated in part through combined inhibition of ACK1/AKT and of mitogen-activated protein kinase kinase kinase kinase 2 (germinal center kinase). Similar to genetic synthetic lethal approaches, these results suggest that small molecule screens can be used to identity novel therapeutic targets in cells addicted to RAS oncogenes.
•We report a cell-based pharmacologic screening strategy to identify new therapeutic targets in mutant NRAS transformed leukemia cells.•The screen and mechanistic analysis identified a previously unknown synergy between germinal center kinase and ACK1/AKT in mutant NRAS transformed cells.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Using the idea of “performative essentialism,” meaning that gender in the Middle Ages was both a product of and a reaction to biology, social roles, and personal actions, Gender in Medieval Culture ...explores the roles men and women fulfilled in medieval Europe, while also suggesting that these functions were often surprisingly flexible. Although most facets of medieval life, including the law, literature, science, and religion, worked together to ensure that the natural state of woman was a fundamentally lesser being than man, there were exceptional situations where gender became fluid or malleable. For instance, when a woman chose a life of vowed virginity, rejecting the traditional female role of motherhood, she transcended the confines of her flesh, and performed in a rational masculine manner instead. Similarly, Christ was equally constructed as the ideal man and spouse, yet was also the ultimate model of perpetual virginity and was deemed maternal for his suffering for and nurturing of humanity. Ultimately, this volume examines the medieval world through the lens of gender and sexuality in order to create a fuller understanding of the gendered expectations we still live with today.
Cancer care in elderly patients is complex. A recent survey showed that among mostly academic surgeons, practice patterns varied in the care of elderly patients. The authors suggested three areas of ...intervention in improving care of this population: frailty assessment, nutritional assessment, and assessment of quality of life.
The process of determining the best treatments that should be offered to patients with newly diagnosed colon and rectal cancer remains highly variable around the world. The aim of this expert review ...was to agree the key elements of good quality preoperative treatment decision making.
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