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UPJ INSIGHT: Racial Disparity in Outcomes Among Prostate Cancer Patients in the Post–Affordable Care Act Period
By: Sumedha Chhatre, PhD, MS, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia; S. Bruce Malkowicz, MD, Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Joseph J. Gallo, MD, MPH Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; Ravishankar Jayadevappa, PhD, MS, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia | Posted on: 17 Mar 2023
Chhatre S, Malkowicz SB, Gallo JJ, Jayadevappa R. Racial disparity in outcomes among prostate cancer patients in the post–Affordable Care Act period. Urol Pract. 2023;10(2):122-130.
Study Need and Importance
In the U.S., prostate cancer is the most common malignancy in men. The Patient Protection and Affordable Care Act of 2010 has expanded Medicaid coverage to adults with income up to 138% of the federal poverty level. We assessed whether Medicaid expansion was associated with reduced racial disparity in quality of care (30-day mortality, 90-day mortality, 30-day readmission) among surgically treated African American and White men with prostate cancer.
What We Found
From the National Cancer database (NCDB) we extracted a cohort of African American and White men diagnosed with prostate cancer between 2004 and 2015 and surgically treated. We used data from 2004-2009 (pre–Medicaid expansion) and from 2010-2015 (post–Medicaid expansion) to assess racial disparity in quality-of-care outcomes. During the pre-expansion period, African American men experienced higher odds of 30- and 90-day mortality and 30-day readmission compared to White men. During the post-expansion period, compared to White men, African American men had higher odds of 30-day mortality (OR=1.96, 95% CI=1.46, 2.67), 90-day mortality (OR=1.40, 95% CI=1.11, 1.77), and 30-day readmission (OR=1.28, 95% CI=1.19, 1.38). The interactions between race and Medicaid expansion were not significant, indicating Medicaid expansion did not reduce the racial disparity in outcomes (see Table).
Table. Multivariable Logistic Regression to Study the Association Between Race, Medicaid Expansion Status, and Interaction in African American and White Men With Prostate Cancer
| Outcome | Diagnosis year 2004-2009 Model 1 (main effects) OR (95% CI) |
Diagnosis year 2010-2015 |
|
|---|---|---|---|
| Model 1 (main effects) OR (95% CI) |
Model 2 (interaction effects) OR (95% CI) |
||
| 30-Day mortality | |||
| African American White (reference) |
2.09 (1.52, 2.90) – |
1.96 (1.46, 2.67) – |
|
| Interaction statistics X2 P value African American - Medicaid expansion African American - nonexpansion |
2.28 .1306 1.05 (0.70, 1.59) 1.25 (0.99, 1.56) |
||
| 90-Day mortality | |||
| African American White (reference) |
1.51 (1.16, 1.96) – |
1.40 (1.11, 1.77) – |
|
| Interaction statistics X2 P value African American - Medicaid expansion African American - nonexpansion |
0.0039 .9499 1.17 (0.90, 1.53) 1.18 (1.02, 1.37) |
||
| 30-Day readmission | |||
| African American White (reference) |
1.42 (1.32, 1.51) – |
1.28 (1.19, 1.38) – |
|
| Interaction statistics X 2 P value African American - Medicaid expansion African American - nonexpansion |
0.4381 .5080 1.15 (1.06, 1.25) 1.14 (1.09, 1.19) |
||
| Abbreviation: CI, confidence interval. | |||
Limitations
NCDB is a hospital-based database with limited generalizability to the U.S. population. NCDB lacks clinical endpoints like disease-free survival, cause of death, and patient-reported outcomes. Our study did not capture the long-term impact of Medicaid expansion. This is important as additional states have undergone Medicaid expansion since 2015.
Interpretation for Patient Care
Improved access to care via Medicaid expansion may not translate into reduced racial disparity in quality of prostate cancer care. Racial disparities reflect structural and social inequities. Patient preferences and availability of and referrals to care may help improve quality of care and lower disparities.
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