Background
Combined effects of being underinsured and living in extremely poor communities
Methods
Variables
Poverty and payers
Colon cancer care
Statistical analyses
Results
Sample description
Neighborhood poverty | Women | Men | ||||||
---|---|---|---|---|---|---|---|---|
By primary payer | No.a
| Prevalence | PR | (95%CI) | No.a
| Prevalence | PR | (95%CI) |
Low Poverty | ||||||||
Uninsured | 60 | .056 | 1.00 | 67 | .066 | 1.00 | ||
Medicaid | 12 | .017 | 1.00 | 16 | .014 | 1.00 | ||
Medicare | 437 | .402 | 1.00 | 358 | .381 | 1.00 | ||
Private | 552 | .535 | 1.00 | 598 | .542 | 1.00 | ||
Middle Poverty | ||||||||
Uninsured | 74 | .069 | 1.23 | (0.91, 1.67) | 77 | .075 | 1.14 | (0.83, 1.56) |
Medicaid | 48 | .050 |
2.94
| (1.79, 4.83) | 26 | .026 |
1.86
| (1.04, 3.33) |
Medicare | 549 | .453 |
1.13
| (1.02, 1.25) | 408 | .436 |
1.14
| (1.03, 1.26) |
Private | 438 | .430 |
0.80
| (0.73, 0.87) | 480 | .467 |
0.86
| (0.79, 0.94) |
High Poverty | ||||||||
Uninsured | 105 | .098 |
1.75
| (1.30, 2.35) | 107 | .103 |
1.56
| (1.17, 2.07) |
Medicaid | 110 | .110 |
6.47
| (4.29, 9.75) | 72 | .068 |
4.86
| (2.89, 7.93) |
Medicare | 587 | .501 |
1.25
| (1.14, 1.37) | 451 | .486 |
1.28
| (1.16, 1.42) |
Private | 319 | .295 |
0.55
| (0.50, 0.61) | 349 | .347 |
0.64
| (0.58, 0.71) |
Sample | % | Sample | % | ||
---|---|---|---|---|---|
Stratification Characteristics | |||||
Places | Poverty prevalence (%) in neighborhood | ||||
Large urban | 2,100 | 33.3 | < 5 | 2,100 | 33.3 |
Smaller urban | 2,100 | 33.3 | 5–29 | 2,100 | 33.3 |
Rural | 2,100 | 33.3 | ≥ 30 | 2,100 | 33.3 |
Demographic Characteristics | |||||
Age at diagnosis, y | Gender | ||||
25–59 | 1,347 | 21.4 | Female | 3,291 | 52.2 |
60–69 | 1,372 | 21.8 | Male | 3,009 | 47.8 |
70–79 | 1,919 | 30.5 | |||
≥ 80 | 1,662 | 26.3 | |||
Race/ethnicity | Primary Payers | ||||
Non-Hispanic white | 4,199 | 66.7 | Medicare | 2,790 | 44.3 |
Non-Hispanic black | 688 | 10.9 | Private insurers | 2,736 | 43.4 |
Hispanic | 810 | 12.9 | Medicaid | 284 | 4.5 |
API or American Indian | 603 | 9.6 | Uninsured | 490 | 7.8 |
Investigation and Staging Characteristics | |||||
Number of regional lymph nodes examined | Stage at diagnosisa
| ||||
< 6 | 2,199 | 37.5 | I | 1,300 | 22.5 |
6–10 | 1,513 | 25.8 | II | 1,882 | 32.6 |
11–14 | 874 | 14.9 | III | 1,392 | 24.1 |
≥ 15 | 1,278 | 21.8 | IV | 1,202 | 20.8 |
Missing data | 436 | 6.9 | Missing data | 524 | 8.3 |
Cancer Care Characteristics | |||||
Received surgeryb
| 5,506 | 88.7 | Received chemotherapy | 1,751 | 28.3 |
Missing data | 90 | 1.4 | Missing data | 115 | 1.8 |
Wait time from diagnosis to surgery, d | Wait time after surgery for chemotherapy, d | ||||
< 14 | 3,960 | 71.7 | < 14 | 194 | 12.0 |
14–29 | 1,031 | 18.7 | 14–29 | 415 | 25.7 |
30–59 | 408 | 7.4 | 30–59 | 733 | 45.3 |
≥ 60 | 120 | 2.2 | 60–89 | 159 | 9.8 |
Missing data | 781 | 12.4 | ≥ 90 | 116 | 7.2 |
Missing data | 134 | 7.6 |
Mediation (poverty-payer-survival) and moderation (poverty-by-payer) survival hypotheses
Women | Men | ||||||||
---|---|---|---|---|---|---|---|---|---|
Predictor variables | No.a
| OR | (95%CI) | No.a
| OR | (95%CI) | |||
Single predictor models | |||||||||
Neighborhood poverty | |||||||||
< 5% poor | 1,061 | 1.00 | 1,039 | 1.00 | |||||
5-29% poor | 1,109 |
0.76
| (0.64, 0.91) | 991 |
0.68
| (0.57, 0.82) | |||
≥ 30% poor | 1,121 |
0.62
| (0.52, 0.74) | 979 |
0.57
| (0.48, 0.69) | |||
Primary payer | |||||||||
Uninsured | 239 | 1.00 | 251 | 1.00 | |||||
Medicaid | 170 |
2.01
| (1.31, 3.08) | 114 | 1.24 | (0.78, 1.99) | |||
Medicare | 1,573 |
2.48
| (1.79, 3.43) | 1,217 |
1.82
| (1.34, 2.48) | |||
Private | 1,309 |
2.78
| (2.02, 3.83) | 1,427 |
2.36
| (1.76, 3.16) | |||
Full models | |||||||||
Neighborhood poverty | |||||||||
< 5% poor | 1,061 | 1.00 | 1,039 | 1.00 | |||||
5-29% poor | 1,109 | 1.07 | (0.78, 1.48) | 991 |
0.70
| (0.58, 0.84) | |||
≥ 30% poor | 1,121 | 1.25 | (0.71, 2.18) | 979 |
0.62
| (0.52, 0.75) | |||
Primary payer | |||||||||
Uninsured | 239 | 1.00 | 251 | 1.00 | |||||
Medicaid | 170 |
2.40
| (1.55, 3.73) | 114 | 1.33 | (0.83, 2.12) | |||
Medicare | 1,573 |
3.93
| (2.33, 6.64) | 1,217 |
1.79
| (1.31, 2.44) | |||
Private | 1,309 |
3.66
| (2.36, 5.67) | 1,427 |
2.19
| (1.63, 2.93) | |||
Poverty by payer | 3,291 |
0.87
| (0.78, 0.98) | Null interaction removed | |||||
Poverty by payer interaction among women | |||||||||
> 30% poor | 5-29% poor | < 5% poor | |||||||
No.a
| OR | (95% CI) | No.a
| OR | (95% CI) | No.a
| OR | (95% CI) | |
Primary payer | |||||||||
Uninsured | 105 | 1.00 | 74 | 1.00 | 60 | 1.00 | |||
Medicaid | 110 | 1.60 | (0.90, 2.84) | 48 | 1.83 | (0.82, 4.07) | 12 |
5.94
| (1.50, 23.54) |
Medicare | 587 |
1.68
| (1.03, 2.74) | 549 |
2.65
| (1.48, 4.75) | 437 |
4.69
| (2.30, 9.57) |
Private | 319 |
1.92
| (1.18, 3.13) | 438 |
2.61
| (1.47, 4.64) | 552 |
5.03
| (2.51, 10.08) |
Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer investigations, diagnoses and treatments
Investigation and stage at diagnosis
15 or more regional lymph nodes examined | Stage I or stage II at the time of diagnosis | ||||||||
---|---|---|---|---|---|---|---|---|---|
Predictor variables | No.a
| OR | (95%CI) | No.a
| OR | (95%CI) | |||
Single predictor models | |||||||||
Neighborhood poverty | |||||||||
< 5% poor | 1,727 | 1.00 | 1,959 | 1.00 | |||||
5-29% poor | 1,646 | 0.92 | (0.79, 1.07) | 1,923 |
0.81
| (0.72, 0.92) | |||
≥ 30% poor | 1,583 | 0.95 | (0.81, 1.11) | 1,894 | 0.89*
| (0.79, 1.01) | |||
Primary payer | |||||||||
Uninsured | 241 | 1.00 | 310 | 1.00 | |||||
Medicaid | 229 | 2.01 | (0.74, 1.65) | 261 | 1.06 | (0.77, 1.48) | |||
Medicare | 2,221 | 1.11 | (0.81, 1.53) | 2,601 |
1.33
| (1.04, 1.71) | |||
Private | 2,265 | 0.97 | (0.72, 1.30) | 2,604 |
1.30
| (1.03, 1.65) | |||
Full models | |||||||||
Neighborhood poverty | |||||||||
< 5% poor | 1,727 | 1.00 | 1,959 | 1.00 | |||||
5-29% poor | 1,646 | 1.34*
| (0.99, 1.80) | 1,923 |
0.82
| (0.72, 0.93) | |||
≥ 30% poor | 1,583 |
1.97
| (1.17, 3.32) | 1,894 | 0.91 | (0.80, 1.04) | |||
Primary payer | |||||||||
Uninsured | 241 | 1.00 | 310 | 1.00 | |||||
Medicaid | 229 | 1.30 | (0.86, 1.98) | 261 | 1.07 | (0.77, 1.49) | |||
Medicare | 2,221 |
2.03
| (1.22, 3.41) | 2,601 |
1.33
| (1.03, 1.70) | |||
Private | 2,265 | 1.49*
| (0.97, 2.29) | 2,604 |
1.28
| (1.01, 1.63) | |||
Poverty by payer | 4,956 |
0.85
| (0.76, 0.94) | Null interaction removed | |||||
Poverty by payer interaction on high quality investigation | |||||||||
> 30% poor | 5-29% poor | < 5% poor | |||||||
No.a
| OR | (95% CI) | No.a
| OR | (95% CI) | No.a
| OR | (95% CI) | |
Primary payer | |||||||||
Uninsured | 114 | 1.00 | 72 | 1.00 | 55 | 1.00 | |||
Medicaid | 144 | 1.11 | (0.65, 1.88) | 63 | 0.70 | (0.32, 1.53) | 22 | 1.91 | (0.63, 5.79) |
Medicare | 794 | 0.93 | (0.58, 1.48) | 753 | 0.92 | (0.52, 1.63) | 674 |
2.01
| (1.02, 3.99) |
Private | 531 | 1.00 | (0.64, 1.57) | 758 | 0.85 | (0.50, 1.45) | 976 | 1.32 | (0.68, 2.55) |
Surgery and adjuvant chemotherapy
Women | Men | |||||
---|---|---|---|---|---|---|
Predictor variables | No.a
| OR | (95%CI) | No.a
| OR | (95%CI) |
Single predictor models | ||||||
Neighborhood poverty | ||||||
< 5% poor | 774 | 1.00 | 713 | 1.00 | ||
5-29% poor | 762 | 0.50*
| (0.24, 1.06) | 675 |
0.32
| (0.11, 0.90) |
≥ 30% poor | 761 |
0.38
| (0.19, 0.78) | 637 | 0.35*
| (0.12, 1.01) |
Primary payer | ||||||
Uninsured | 94 | 1.00 | 109 | 1.00 | ||
Medicaid | 113 |
9.66
| (1.12, 83.68) | 74 | 2.49 | (0.26, 23.47) |
Medicare | 1,135 |
5.12
| (1.85, 14.20) | 844 |
3.80
| (1.06, 13.58) |
Private | 955 |
3.39
| (1.30, 8.88) | 998 |
10.09
| (2.62, 38.85) |
Full models | ||||||
Neighborhood poverty | ||||||
< 5% poor | 774 | 1.00 | 713 | 1.00 | ||
5-29% poor | 762 | 0.49*
| (0.23, 1.03) | 675 |
0.32
| (0.11, 0.91) |
≥ 30% poor | 761 |
0.37
| (0.18, 0.77) | 637 | 0.41 | (0.14, 1.19) |
Primary payer | ||||||
Uninsured | 94 | 1.00 | 109 | 1.00 | ||
Medicaid | 113 |
10.14
| (1.17, 87.92) | 74 | 2.82 | (0.30, 26.85) |
Medicare | 1,135 |
4.43
| (1.58, 12.47) | 844 |
3.93
| (1.08, 14.27) |
Private | 955 | 2.65*
| (0.99, 7.08) | 998 |
9.98
| (2.53, 39.33) |
Single predictor models | Full models | |||||
---|---|---|---|---|---|---|
Predictor variables | No.a
| OR | (95%CI) | No.a
| OR | (95%CI) |
Received chemotherapy after surgery | ||||||
Neighborhood poverty | ||||||
< 5% poor | 1,103 | 1.00 | 1,103 | 1.00 | ||
5-29% poor | 1,066 |
0.80
| (0.65, 0.98) | 1,066 |
0.80
| (0.65, 0.98) |
≥ 30% poor | 1,045 |
0.63
| (0.52, 0.78) | 1,045 |
0.65
| (0.52, 0.80) |
Primary payer | ||||||
Uninsured | 164 | 1.00 | 164 | 1.00 | ||
Medicaid | 147 |
0.49
| (0.30, 0.81) | 147 |
0.51
| (0.31, 0.85) |
Medicare | 1,436 | 0.75 | (0.51, 1.11) | 1,436 | 0.71*
| (0.48, 1.04) |
Private | 1,467 | 0.85 | (0.60, 1.22) | 1,467 | 0.75 | (0.52, 1.09) |
Waited 60 days or more for adjuvant chemotherapy | ||||||
Neighborhood poverty | ||||||
< 5% poor | 421 | 1.00 | 421 | 1.00 | ||
5-29% poor | 369 |
1.48
| (1.01, 2.18) | 369 | 1.45*
| (0.98, 2.14) |
> 30% poor | 326 |
1.55
| (1.04, 2.30) | 326 | 1.33 | (0.88, 2.02) |
Primary payer | ||||||
Uninsured | 90 | 1.00 | 90 | 1.00 | ||
Medicaid | 58 | 0.87 | (0.40, 1.86) | 58 | 0.85 | (0.39, 1.83) |
Medicare | 364 |
0.42
| (0.24, 0.76) | 364 |
0.43
| (0.24, 0.77) |
Private | 604 |
0.41
| (0.24, 0.69) | 604 |
0.43
| (0.25, 0.73) |
Women | Men | |||||
---|---|---|---|---|---|---|
Predictor variables | No.b
| OR | (95%CI) | No.b
| OR | (95%CI) |
Single predictor models | ||||||
Neighborhood poverty | ||||||
< 5% poor | 133 | 1.00 | 133 | 1.00 | ||
5-29% poor | 131 |
0.53
| (0.32, 0.88) | 115 | 0.98 | (0.58, 1.66) |
≥ 30% poor | 109 |
0.55
| (0.32, 0.95) | 103 | 0.88 | (0.51, 1.50) |
Primary payer | ||||||
Uninsured | 29 | 1.00 | 27 | 1.00 | ||
Medicaid | 24 | 0.84 | (0.26, 2.72) | 15 | 0.67 | (0.19, 2.42) |
Medicare | 131 | 0.52 | (0.21, 1.30) | 119 | 1.47 | (0.59, 3.66) |
Private | 189 | 0.86 | (0.37, 2.00) | 190 | 1.06 | (0.46, 2.44) |
Full models | ||||||
Neighborhood poverty | ||||||
< 5% poor | 133 | 1.00 | 133 | 1.00 | ||
5-29% poor | 131 |
0.53
| (0.32, 0.89) | 115 |
0.28
| (0.10, 0.77) |
≥ 30% poor | 109 |
0.55
| (0.31, 0.98) | 103 |
0.08
| (0.01, 0.47) |
Primary payer | ||||||
Uninsured | 29 | 1.00 | 27 | 1.00 | ||
Medicaid | 24 | 0.82 | (0.25, 2.68) | 15 | 0.41 | (0.10, 1.70) |
Medicare | 131 | 0.47 | (0.19, 1.21) | 119 | 0.22*
| (0.04, 1.20) |
Private | 189 | 0.72 | (0.30, 1.72) | 190 | 0.27*
| (0.07, 1.06) |
Poverty by payer | Null Interaction removed | 351 |
1.75
| (1.19, 2.57) | ||
Poverty by payer interaction among men | ||||||
> 30% poor | < 30% poor | |||||
No.b
| OR | (95% CI) | No.b
| OR | (95% CI) | |
Primary payer | ||||||
Uninsured | 10 | 1.00 | 17 | 1.00 | ||
Medicaid | 9 | 3.03 | (0.43, 21.33) | 6 | 0.22 | (0.03, 1.69) |
Medicare | 37 |
13.33
| (2.42, 73.50) | 82 | 0.40 | (0.10, 1.60) |
Private | 47 | 3.69*
| (0.81, 16.84) | 143 | 0.41 | (0.11, 1.51) |