Impact of insurance status on mortality following surgical treatment of colorectal cancers.
Authors: Atulya Aman Khosla, Aagamjit Singh, Akshit Chitkara, Manas Pustake, Karan Jatwani, Muni Rubens, Venkataraghavan Ramamoorthy, Anshul Saxena, Ishmael A. Jaiyesimi
Journal: Journal of Clinical Oncology (2025)

40 Background: Healthcare disparities in colorectal cancer, driven by insurance status and socioeconomic factors, lead to delayed diagnoses and poorer surgical outcomes. We sought to examine the impact of insurance status on presentation, treatment, and in-hospital mortality in CRC patients undergoing colectomy using the Nationwide Inpatient Sample (NIS) database. Methods: We included patients aged 18-65 years diagnosed with colon cancer and undergoing colectomy, as identified by ICD-9-CM codes, who had private insurance, Medicaid, or no insurance from January 1, 2005, through December 31, 2014. The primary variable was insurance status; patient characteristics such as age, sex, race, income, and tumor type were analyzed. We used the Elixhauser comorbidity index to control for confounding and performed a subset analysis on patients without major comorbidities. The primary outcome was in-hospital postoperative death. Associations between this outcome and insurance status were analyzed using the Cox proportional hazard model, both in the full cohort and in a subset of patients without comorbidities, with models stratified by hospitals to account for clustering effects from variations in access to care. Results: The study cohort included 301,304 patients, of whom 238,158 (79.0%) were privately insured, 40,417 (13.4%) on Medicaid, and 22,729 (7.6%) were uninsured. Most patients were White (71.6%), followed by African American (12.6%), Hispanic (8.4%), Asian/Pacific Islander (3.8%), and Native American (0.5%). A total of 55.4% of cases took place in teaching hospitals. In the unadjusted analysis, the mortality rate for privately insured patients was 0.7% (95% CI, 0.6%-0.7%) compared with 2.1% for uninsured patients (95% CI, 1.7%-2.5%) and 1.5% for Medicaid recipients (95% CI, 1.2%-1.8%; p=0.001). After adjusting for patient characteristics and stratifying by hospital in patients with no comorbidity, uninsured patients still had a higher risk of experiencing in-hospital death (HR, 1.60; 95% CI, 1.24-2.07) compared with privately insured patients, while no significant disparity was found in Medicaid recipients (HR, 0.95; 95% CI, 0.75-1.22) (Table). Conclusions: Uninsured patients undergoing colectomy for colon cancer experienced the highest in-hospital mortality, a disparity not fully explained by overall health differences. These findings underscore the critical role of insurance coverage in improving surgical outcomes and highlight the need for policy interventions to reduce mortality disparities. In-hospital mortality after surgery for colorectal cancer. Covariate Full sample Patients With No Comorbidity Patients With No Comorbidity in Urban Teaching Hospitals Hazard Ratio (95% Cl) Insurance Private Reference Reference Reference Medicaid 0.95 (0.75-1.22) 1.38 (0.91-2.11) 1.66 (0.91-3.02) Uninsured 1.60 (1.24-2.07) 2.12 (1.42-3.15) 2.28 (1.25-4.16)