It is well established that insurance status is a mediator of disease management, treatment course, and clinical outcomes in cancer patients. Our study assessed differences in clinical presentation, treatment course, mortality rates, and in-hospital complications for patients admitted to the hospital with late-stage cancer – specifically, metastatic spine disease (MSD), by insurance status.
The United States National Inpatient Sample (NIS) database (2012–2014) was queried to identify patients with visceral metastases, metastatic spinal cord compression (MSCC) or pathological fracture of the spine in the setting of cancer. Clinical presentation, type of intervention, mortality rates, and in-hospital complications were compared amongst patients by insurance coverage (Medicare, Medicaid, commercial or unknown). Multivariable logistical regression and age sensitivity analyses were performed.
A total of 48,560 MSD patients were identified. Patients with Medicaid coverage presented with significantly higher rates of MSCC (p < 0.001), paralysis (0.008), and visceral metastases (p < 0.001). Patients with commercial insurance were more likely to receive surgical intervention (OR 1.43; p < 0.001). Patients with Medicaid < 65 had higher rates of prolonged length of stay (PLOS) (OR 1.26; 95% CI, 1.01–1.55; p = 0.040) while both Medicare and Medicaid patients < 65 were more likely to have non-routine discharges. In-hospital mortality rates were significantly higher for patients with Medicaid (OR 2.66; 95% CI 1.20–5.89; p = 0.016) and commercial insurance (OR 1.58; 95% CI 1.09–2.27;p = 0.013) older than 65.
Given the differing severity in MSD presentation, mortality rates, and rates of PLOS by insurance status, our results identify disparities based on insurance coverage.
Patients with MSD who have Medicaid are more likely to present with later stage disease and more severe symptom burden.
Patients with MSD and private insurance are more likely to receive surgery than those with government insurance.
Rates of in-hospital mortality, non-routine discharge, and PLOS differ by the insurance status and age of patients with MSD.
Across the medical field, studies demonstrate that insurance status impacts both treatments and clinical outcomes . Given the significant disease burden and debilitating symptoms associated with metastatic spine disease (MSD) , patients often require frequent healthcare encounters and are thus reliant on insurance coverage throughout their care. As the prevalence of MSD increases secondary to improvements in diagnostic techniques and treatments for primary cancers so does the average age of patients with this diagnosis . With increasing age, patients may also experience shifts in insurance coverage – the impacts of which are important to assess.
There is substantial evidence that patients who have government-funded insurance plans, including Medicare and Medicaid, tend to have worse clinical outcomes than those with commercial insurance, with patients receiving Medicaid at a distinct disadvantage to those receiving Medicare . The reasons for these disparities are likely multifactorial and include but are not limited to rapid access to specific medications and procedures, availability of providers who take non-commercial insurance, lower reimbursement rates for non-commercial insurance, access to medical and non-medical resources, and patient distrust of the system . Regarding neurosurgical patient populations, the effects of different insurance statuses have been documented across many diagnoses and patient populations ; however, they have not been specifically studied in those with MSD.
The purpose of this study is to broadly assess the differences in mortality, clinical presentation, in-hospital complications, and short-term outcomes in patients with MSD, by their insurance status. This study aims to identify vulnerable patient populations who may require additional resources and support navigating their oncology care.