The Impact of Underinsurance on Bladder Cancer Diagnosis, Survival, and Care Delivery

Abstract

Purpose: Health inequity in the United States are closely linked to patients’ ability to afford their care. We sought to determine the association between underinsurance and outcomes in bladder cancer, a disease that confers a substantial financial burden upon diagnosed individuals. Methods: We used the Surveillance, Epidemiology, and End Results (SEER) registry and National Cancer Database (NCDB) to identify individuals aged <65 years who were diagnosed with bladder cancer from 2007 to 2014. We evaluated the association between insurance status and outcomes related to prognosis (diagnosis with advanced disease, cancer-specific survival) and care delivery (delay in care, treatment in a high-volume hospital, and receipt of neoadjuvant chemotherapy). Results: Compared to those with private insurance, uninsured and Medicaid-insured individuals were nearly twice as likely to receive a diagnosis of muscle-invasive bladder cancer (Uninsured OR: 1.90; 95% CI: 1.70 – 2.12. Medicaid OR: 2.03; 95% CI: 1.87 – 2.20). These groups were also more likely to die of bladder cancer (Uninsured adjusted hazard ratio [AHR]: 1.49; 95% CI: 1.31 – 1.71. Medicaid AHR: 1.61; 95% CI: 1.46 – 1.79). Delays in treatment > 90 days were more likely for the uninsured (OR: 1.36; 95% CI: 1.12 – 1.65) and Medicaid-insured (OR: 1.22; 95% CI: 1.03 – 1.44) compared to the private-insured. Uninsured patients had lower odds of treatment in a high-volume facility (OR: 0.66; 95% CI: 0.52 – 0.83), and Medicaid-insured patients had lower odds of receiving neoadjuvant chemotherapy (OR: 0.74; 95%CI: 0.60 – 0.91). Conclusions: Uninsured and Medicaid-insured individuals are more likely than those with private insurance to be diagnosed with advanced bladder cancer as well as die from the disease; they are also subject to poorer care quality. Expanding high-quality insurance coverage to marginalized populations may help to reduce the burden of this disease.