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Disparities in Surgical Oncologic Care

E149: Underutilization of Surgery in Medicaid Patients with Pancreatic Adenocarcinoma

ePoster Abstract Author(s)

Mohammad S. Ali, MD

Complex General Surgical Oncology Fellow
Boston University-Roger Williams Medical Center
Providence, Rhode Island, United States

Submitter(s)

Mohammad S. Ali, MD

Complex General Surgical Oncology Fellow
Boston University-Roger Williams Medical Center
Providence, Rhode Island, United States

Author(s)

PS

Ponnandai Somasundar, MD,FACS,

Chief of Surgical Oncology Division
Boston University, United States
SK

Steve Kwon, MD, MPH, FACS

Associate Surgical Oncology Attending
Boston University, United States

Introduction: While numerous studies have demonstrated worse cancer outcomes in Medicaid patients, disparities in utilization of surgery in the Medicaid population as a factor of worse outcomes is understudied. Our objective was to compare the utilization rates of surgery in Medicaid and non-Medicaid populations, and explore the impact of social determinants of health on Medicaid population with pancreatic adenocarcinoma (PAC).

Methods: SEER-Medicaid database is a unique population-based resource to study the impact of Medicaid on cancer and surgical treatment, and survival. We looked at patients with PAC stages I to III diagnosed between 2006 and 2013 in this database. We analyzed the proportion of cancer-directed surgery performed in Medicaid and non-Medicaid population, and looked at reasons for no surgery. Lastly, we evaluated the impact of socioeconomic status using the YOST index and neighborhood factors using neighborhood poverty level (NPL) on utilization rate of surgery.

Results: There were a total of 13,154 patients in our cohort (1,648 Medicaid and 11,506 non-Medicaid). While average ages were similar between Medicaid and non-Medicaid population, Medicaid group represented a significantly different population with lower proportion of males (37.8% vs. 49.98%), married status (31.74% vs. 61.55%), and Whites (61.41% vs. 84.35%). More proportion of Medicaid patients lived in rural regions (2.25% vs. 1.26%) and neighborhoods with NPL between 20%-100% (31.86% vs. 14.37%), and had a YOST index in the lowest quintile (33.73% vs. 13.19%). Clinically, Medicaid p</span>atients had earlier stages at diagnosis with 47.38% presenting at stage I and IIA PAC compared to 40.93% in non-Medicaid p</span>atients. Yet, we found that cancer-directed surgery was performed in just 19.78% of Medicaid compared to 31.77% in non-Medicaid population (p-value< 0.01). The biggest reason for no surgery was that surgery was not recommended (66.26% Medicaid vs. 55.61% non-Medicaid). Lastly, multivariate logistic regression analysis adjusting for sex, race, stage, NPL, and YOST index demonstrated that Medicaid population were significantly more unlikely to undergo surgery (OR 0.55, 95% CI 0.48–0.63).

Conclusions: There was a significantly lower utilization of surgery in Medicaid compared to non-Medicaid population even though higher proportions of Medicaid patients with PAC presented with earlier stages. The lower surgery utilization rates in Medicaid patients did not change with adjustment for important social determinants of health.

Learning Objectives:

Demonstrate the underutilization of surgery in Medicaid patients.
List factors associated with patients in the Medicaid group that may contribute to decreased surgery rates.
Define that even after adjusting for social determinants, disparities of underutilization continue to result in the Medicaid population.