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Private vs. public insurance: Is there a difference in survival in patients with bladder urothelial carcinoma?
Mohummad M. Siddiqui, MD, Niall M. Heney, MD, W. Scott McDougal, MD, Adam S. Feldman, MD, MPH.
Massachusetts General Hospital, Boston, MA, USA.

BACKGROUND:
Disparities in survival with bladder cancer have been described in patients of different socioeconomic status (SES). However, to date such studies have only utilized all-cause mortality and may be biased if people of lower SES die from other unrelated causes more often than people of high SES. We investigate in this study outcomes of bladder cancer patients with public versus private insurance to assess bladder cancer specific mortality and disease-free survival.
METHODS:
We performed a retrospective review of all patients that were newly diagnosed with bladder urothelial carcinoma (UC) in the years 2004 and 2005 at the Massachusetts General Hospital. Data were collected through an IRB approved electronic medical record review from January 2004 to March 2010 regarding insurance coverage, demographics, operations, surgical pathology, and clinic notes to assess for disease recurrence, progression, metastatic disease, and death. Insurance coverage by a publicly offered insurance provided for patients of limited income versus private insurance was used as a proxy for SES.
RESULTS:
A total of 225 patients were examined. Publicly insured patients were 29.8% of the total and privately insured comprised 70.2%. There were no significant differences between gender, age, or smoking by insurance status. 56% of privately insured patients had a college education as compared to 36% of those with public insurance (p<0.01). The public insurance group first presented in the ED more commonly than the private group (22.5% vs. 8.8%, p=0<0.01). The publicly insured group presented with similar disease stage (33% T2+ public vs. 25% private, p=0.25) and grade (54% grade 3/3 public vs. 55% private, p=0.88). Upon treatment, there was no difference in rate of cystectomy (22.4% vs. 17.7%, p=0.46) however BCG was utilized more for the privately insured (31% vs. 13%, p<0.01). All-cause 5-year mortality was 46% for the publicly insured vs. 26% for privately insured, (p=0.005). Disease-specific 5-year mortality was 30% for publicly insured vs. 16.5% for the privately insured (p=0.03). Disease specific mortality in the first 6 months after diagnosis was 9% of the public group versus 1.3% in the private group (p=0.001). Eighty percent of the patients that died within the first 6 months were publicly insured. Kaplan-Meier analysis demonstrated a lower overall survival (p=0.003) and UC specific survival (p=0.01) in the publicly insured group vs. the privately insured group (Fig. 1). At the 5-year time point, UC disease free status was also significantly worse for the publicly insured group (45.1% vs. 64.6%, p=0.017).
CONCLUSIONS:
We found disparities in publicly and privately insured patients with bladder cancer as to their venue of presentation, utilization of BCG, all-cause and disease-specific mortality, and disease free survival at 5 years follow-up. This is the first study to demonstrate different disease specific mortality and disease free survival with differing SES.


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