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Insurance, chronic health conditions, and utilization of primary and specialty outpatient services: a Childhood Cancer Survivor Study report

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Abstract

Purpose

Survivors of childhood cancer require life-long outpatient healthcare, which may be impacted by health insurance. This study sought to understand survivors’ utilization of outpatient healthcare provider services.

Methods

The study examined cross-sectional survey data using an age-stratified sample from the Childhood Cancer Survivor Study of self-reported annual use of outpatient services. Multivariable logistic regression analyses were used to identify risk factors associated with utilization of services.

Results

Six hundred ninety-eight survivors were surveyed, median age 36.3 years (range 22.2–62.6), median time from diagnosis 28.8 years (range 23.1–41.7). Almost all (93%) of survivors had at least one outpatient visit during the previous year; 81.3% of these visits were with a primary care providers (PCP), 54.5% were with specialty care physicians, 30.3% were with nurse practitioner/physician’s assistants (NP/PA), and 14.2% were with survivorship clinic providers. Survivors with severe to life-threatening chronic health conditions had greater odds of utilizing a specialty care physician (OR = 5.15, 95% CI 2.89–9.17) or a survivorship clinic (OR = 2.93, 95% CI 1.18–7.26) than those with no chronic health conditions. Having health insurance increased the likelihood of seeking care from NP/PA (private, OR = 2.76, 95% CI 1.37–5.58; public, OR = 2.09, 95% CI 0.85–5.11), PCP (private, OR = 7.82, 95% CI 3.80–13.10; public, OR = 7.24, 95% CI 2.75–19.05), and specialty care (private, OR = 2.96, 95% CI 1.48–5.94; public, OR = 2.93, 95% CI 1.26–6.84) compared to without insurance.

Conclusion

Most childhood cancer survivors received outpatient care from a PCP, but a minority received care from a survivorship clinic provider. Having health insurance increased the likelihood of outpatient care.

Implications for Cancer Survivors

Targeted interventions in the primary care setting may improve risk-based, survivor-focused care for this vulnerable population.

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Abbreviations

ACA:

Affordable Care Act

CCSS:

Childhood Cancer Survivor Study

NP:

Nurse Practitioner

PA:

Physician Assistant

PCP:

Primary Care Provider

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Funding

Dr. Elyse Park was funded by Livestrong Foundation. CCSS is supported by the National Cancer Institute (U24 CA 55727, Armstrong GT, principal investigator). Support to St. Jude Children’s Research Hospital was also provided by the Cancer Center Support (CORE) grant (CA21765, C. Roberts, Principal Investigator) and the American Lebanese-Syrian Associated Charities (ALSAC). For a portion of this work, Dr. Mueller was sponsored by a training grant from the National Institute of Child Health and Human Development (T32 HD07534).

Author information

Authors and Affiliations

  1. Indiana University, 410 West 10th Street, Suite 2000A, Indianapolis, IN, 46202, USA

    Emily L. Mueller

  2. Massachusetts General Hospital, Boston, MA, USA

    Elyse R. Park, Karen Kuhlthau, Giselle K. Perez, Julia Rabin & Karen Donelan

  3. University of Utah, Salt Lake City, UT, USA

    Anne C. Kirchhoff

  4. The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada

    Paul C. Nathan

  5. University of Michigan, Ann Arbor, MI, USA

    Raymond Hutchinson

  6. Memorial Sloan Kettering Cancer Center, New York, NY, USA

    Kevin C. Oeffinger

  7. Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA

    Leslie L. Robison & Gregory T. Armstrong

  8. Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Wendy M. Leisenring

Authors
  1. Emily L. Mueller
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  2. Elyse R. Park
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  3. Anne C. Kirchhoff
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  8. Raymond Hutchinson
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  9. Kevin C. Oeffinger
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  10. Leslie L. Robison
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  12. Wendy M. Leisenring
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  13. Karen Donelan
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Contributions

Emily L Mueller: conceptualization, formal analysis, writing of original draft, and writing–review and editing. Elyse R. Park: Conceptualization, funding acquisition, investigation, data curation, and writing–review and editing. Anne C. Kirchhoff: Conceptualization, data curation, methodology, writing–review and editing. Karen Kuhlthau: writing–review and editing. Paul C. Nathan: conceptualization, writing–review and editing. Giselle Perez: writing–review and editing. Julia Rabin: data curation and project administration. Raymond Hutchinson: conceptualization, writing–review and editing. Kevin C. Oeffinger: writing–review and editing. Leslie L. Robison: conceptualization, funding acquisition, writing–review and editing. Gregory T. Armstrong: conceptualization, funding acquisition, writing–review and editing. Wendy M. Leisenring: data curation, formal analysis, methodology, and software. Karen Donelan: conceptualization, writing–review and editing.

Corresponding author

Correspondence to Emily L. Mueller.

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All authors have no financial relationships relevant to this article to disclose.

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The authors declare that they have no conflict of interest.

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Mueller, E.L., Park, E.R., Kirchhoff, A.C. et al. Insurance, chronic health conditions, and utilization of primary and specialty outpatient services: a Childhood Cancer Survivor Study report. J Cancer Surviv 12, 639–646 (2018). https://doi.org/10.1007/s11764-018-0700-1

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  • DOI: https://doi.org/10.1007/s11764-018-0700-1

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