Dataset Information

Veterans Affairs Insurance Disparities for Metastatic Lung Cancer in the Hawaiian Islands.

ABSTRACT:

Introduction

The highest concentration of military personnel in the United States is located in Hawaii where occupational exposures, such as to asbestos in the Pacific Fleet shipyards, predispose them to thoracic malignancies. For this reason, Veterans Affairs (VA) insurance outcomes for lung cancer in Hawaii are of interest.

Methods

All cases of lung cancer in the Hawaii Tumor Registry from 2000 to 2015 were evaluated. The selection criterion included evidence of extensive-stage SCLC (ES-SCLC) or metastatic NSCLC. Overall survival was compared using the Kaplan-Meier log-rank method. Univariate analysis and multivariable analysis (MVA) were carried out to understand the variables associated with overall survival.

Results

There were 434 cases of ES-SCLC and 2139 cases of metastatic NSCLC identified. VA insurance (median survival [MS], 2 mo), Medicaid (MS, 4 mo), and Medicare (MS, 4 mo) had worse survival (log-rank p < 0.001) than private insurance (MS, 8 mo). In ES-SCLC, VA insurance (hazard ratio [HR], 2.74; 95% confidence interval [CI]: 1.50-5.01; p = 0.001) and Medicaid (HR, 1.46; 95% CI: 1.04-2.03; p = 0.027) had significantly worse survival compared with private insurance on MVA. VA insurance (HR, 1.84; 95% CI: 1.34-2.53; p < 0.001) and Medicaid (HR, 1.40; 95% CI: 1.20-1.63; p < 0.001) also had worse survival compared with private insurance in metastatic NSCLC on MVA.

Conclusions

VA insurance coverage was associated with dismal survival for metastatic lung cancer that was effectively similar to hospice or supportive care, compelling further investigation to identify reasons for this disparity.

SUBMITTER: Lin JQ

PROVIDER: S-EPMC8474251 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Publications

Veterans Affairs Insurance Disparities for Metastatic Lung Cancer in the Hawaiian Islands.

Lin John Q JQ Li Shirley Q SQ Pezzi Todd A TA Mohamed Abdallah S R ASR Fuller Clifton D CD Chen Aileen B AB Minsky Bruce D BD Schwartz David L DL Hernandez Brenda Y BY Chun Stephen G SG

JTO clinical and research reports 20200212 1

<h4>Introduction</h4>The highest concentration of military personnel in the United States is located in Hawaii where occupational exposures, such as to asbestos in the Pacific Fleet shipyards, predispose them to thoracic malignancies. For this reason, Veterans Affairs (VA) insurance outcomes for lung cancer in Hawaii are of interest.<h4>Methods</h4>All cases of lung cancer in the Hawaii Tumor Registry from 2000 to 2015 were evaluated. The selection criterion included evidence of extensive-stage ...[more]

PMID: 34589910

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Project description:ImportanceProstate cancer (PCa) disproportionately affects African American men, but research evaluating the extent of racial and ethnic disparities across the PCa continuum in equal-access settings remains limited at the national level. The US Department of Veterans Affairs (VA) Veterans Hospital Administration health care system offers a setting of relatively equal access to care in which to assess racial and ethnic disparities in self-identified African American (or Black) veterans and White veterans.ObjectiveTo determine the extent of racial and ethnic disparities in the incidence of PCa, clinical stage, and outcomes between African American patients and White patients who received a diagnosis or were treated at a VA hospital.Design, setting, and participantsThis retrospective cohort study included 7 889 984 veterans undergoing routine care in VA hospitals nationwide from 2005 through 2019 (incidence cohort). The age-adjusted incidence of localized and de novo metastatic PCa was estimated. Treatment response was evaluated, and PCa-specific outcomes were compared between African American veterans and White veterans. Residual disparity in PCa outcome, defined as the leftover racial and ethnic disparity in the outcomes despite equal response to treatment, was estimated.ExposuresSelf-identified African American (or Black) and White race and ethnicity.Main outcomes and measuresTime to distant metastasis following PCa diagnosis was the primary outcome. Descriptive analyses were used to compare baseline demographics and clinic characteristics. Multivariable logistic regression was used to evaluate race and ethnicity association with pretreatment clinical variables. Multivariable Cox regression was used to estimate the risk of metastasis.ResultsData from 7 889 984 veterans from the incidence cohort were used to estimate incidence, whereas data from 92 269 veterans with localized PCa were used to assess treatment response. Among 92 269 veterans, African American men (n = 28 802 [31%]) were younger (median [IQR], 63 [58-68] vs 65 [62-71] years) and had higher prostate-specific antigen levels (>20 ng/mL) at the time of diagnosis compared with White men (n = 63 467; [69%]). Consistent with US population-level data, African American veterans displayed a nearly 2-fold greater incidence of localized and de novo metastatic PCa compared with White men across VA centers nationwide. Among veterans screened for PCa, African American men had a 29% increased risk of PCa detection on a diagnostic prostate biopsy compared with White (hazard ratio, 1.29; 95% CI, 1.27-1.31; P < .001). African American men who received definitive primary treatment of PCa experienced a lower risk of metastasis (hazard ratio, 0.89; 95% CI, 0.83-0.95; P < .001). However, African American men who received nondefinitive treatment classified as “other” were more likely to develop metastasis (adjusted hazard ratio, 1.29; 95% CI, 1.17-1.42; P < .001). Using the actual rate of metastasis from veterans who received definitive primary treatment, a persistent residual metastatic burden for African American men was observed across all National Comprehensive Cancer Network risk groups (low risk, 4 vs 2 per 100 000; intermediate risk, 13 vs 6 per 100 000; high risk, 19 vs 9 per 100 000).Conclusions and relevanceThis cohort analysis found significant disparities in the incidence of localized and metastatic PCa between African American veterans and White veterans. This increased incidence is a major factor associated with the residual disparity in PCa metastasis observed in African American veterans compared with White veterans despite their nearly equal response to treatment.

Project description:ImportanceMany veterans enrolled in the Veterans Affairs (VA) health care system have access to non-VA care through insurance and VA-purchased community care. Prior comparisons of VA and non-VA hospital outcomes have been limited to subpopulations.ObjectiveTo compare outcomes for 6 acute conditions in VA and non-VA hospitals for younger and older veterans using VA and all-payer discharge data.Design, setting, and participantsThis cohort study used a repeated cross-sectional analysis of hospitalization records for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), gastrointestinal (GI) hemorrhage, heart failure (HF), pneumonia, and stroke. Participants included VA enrollees from 11 states at VA and non-VA hospitals from 2012 to 2017. Analysis was conducted from July 1, 2022, to October 18, 2023.ExposuresTreatment in VA or non-VA hospital.Main outcome and measuresThirty-day mortality, 30-day readmission, length of stay (LOS), and costs. Average treatment outcomes of VA hospitals were estimated using inverse probability weighted regression adjustment to account for selection into hospitals. Models were stratified by veterans' age (aged less than 65 years and aged 65 years and older).ResultsThere was a total of 593 578 hospitalizations and 414 861 patients with mean (SD) age 75 (12) years, 405 602 males (98%), 442 297 hospitalizations of non-Hispanic White individuals (75%) and 73 155 hospitalizations of non-Hispanic Black individuals (12%) overall. VA hospitalizations had a lower probability of 30-day mortality for HF (age ≥65 years, -0.02 [95% CI, -0.03 to -0.01]) and stroke (age <65 years, -0.03 [95% CI, -0.05 to -0.02]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.03]). VA hospitalizations had a lower probability of 30-day readmission for CABG (age <65 years, -0.04 [95% CI, -0.06 to -0.01]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.02]), GI hemorrhage (age <65 years, -0.04 [95% CI, -0.06 to -0.03]), HF (age <65 years, -0.05 [95% CI, -0.07 to -0.03]), pneumonia (age <65 years, -0.04 [95% CI, -0.06 to -0.03]; age ≥65 years, -0.03 [95% CI, -0.04 to -0.02]), and stroke (age <65 years, -0.11 [95% CI, -0.13 to -0.09]; age ≥65 years, -0.13 [95% CI, -0.16 to -0.10]) but higher probability of readmission for AMI (age <65 years, 0.04 [95% CI, 0.01 to 0.06]). VA hospitalizations had a longer mean LOS and higher costs for all conditions, except AMI and stroke in younger patients.Conclusions and relevanceIn this cohort study of veterans, VA hospitalizations had lower mortality for HF and stroke and lower readmissions, longer LOS, and higher costs for most conditions compared with non-VA hospitalizations with differences by condition and age group. There were tradeoffs between better outcomes and higher resource use in VA hospitals for some conditions.

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Project description:ImportanceRecent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking.ObjectiveTo compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals.Design, setting, and participantsThis coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older.ExposuresSurgical care in VA or private-sector hospitals.Main outcomes and measuresPostoperative 30-day mortality and failure to rescue (FTR).ResultsAmong 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures.Conclusions and relevanceAlthough women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.

Dataset Information

Veterans Affairs Insurance Disparities for Metastatic Lung Cancer in the Hawaiian Islands.

Introduction

Methods

Results

Conclusions

Publications

Veterans Affairs Insurance Disparities for Metastatic Lung Cancer in the Hawaiian Islands.

Similar Datasets

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