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Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis

  • Gynecologic Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid.

Methods

We searched the National Cancer Database for women aged 40–64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010–2013) and post-2014 (2014–2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest.

Results

Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26–0.67) and ovarian cancer (OR 0.67, 95% CI 0.46–0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12–13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31–0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05–0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50–0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26–0.91).

Conclusions

State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.

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Acknowledgment

This work was supported in part by the National Institutes of Health. This work was supported in part by an MD Anderson Cancer Center Support Grant from the National Cancer Institute of the National Institutes of Health (NIH/NCI P30 CA016672, CA217685) and the T32 training grant CA101642. The NCDB is a joint project of the Commission on Cancer (CoC) of the American College of Surgeons and the American Cancer Society. The CoC’s NCDB and the hospitals participating in the CoC’s NCDB are the source of the de-identified data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

Funding

This work was supported in part by the National Institutes of Health and an MD Anderson Cancer Center Support Grant from the National Cancer Institute of the National Institutes of Health (NIH/NCI P30 CA016672, CA217685), as well as the T32 training Grant No. CA101642. LAM is supported by an NIH-NCIK07-CA201013 Grant No.; SHG is supported by CPRIT RP160674 and Komen SAC150061; and KMP is supported by CPRIT RP 170259.

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Author notes

  1. Shuangshuang Fu PhD

    Present address: Becton, Dickinson and Company, Franklin Lakes, NJ, USA

Authors and Affiliations

  1. Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA

    Sarah P. Huepenbecker MD, MPH, Charlotte C. Sun DrPH & Larissa A. Meyer MD, MPH

  2. Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Shuangshuang Fu PhD, Hui Zhao PhD & Sharon H. Giordano MD, MPH

  3. Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Kristin M. Primm PhD

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Correspondence to Larissa A. Meyer MD, MPH.

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Disclosure

Larissa A. Meyer reports consulting fees from Bristol Meyers Squibb, advisory board participation for GlaxoSmithKline, and stocks in Crisper, Invitae, and Bristol-Myers Squibb. Charlotte C. Sun reports partial research funding from AstraZeneca and stock in Inform Genomics. Sarah P. Huepenbecker, Shuangshuang Fu, Hui Zhao, Kristin M. Primm, and Sharon H. Giordano report no conflicts of interest.

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Supplementary Information

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10434_2022_12663_MOESM1_ESM.docx

Supplementary 1 Database population selection. Supplementary 2 Parallel trends test for difference-in-difference baseline trend assumption – visual assessment of time plots in the pre-2014 study period. Supplementary 3 Parallel trends test for difference-in-difference baseline trend assumption – Cox regression model examining hazard ratios for expansion status, pre-2014 period, and the interaction term between expansion status and pre-2014 period: 30-day postoperative mortality. Supplementary 4 Parallel trends test for difference-in-difference baseline trend assumption – Cox regression model examining hazard ratios for expansion status, pre-2014 period, and the interaction term between expansion status and pre-2014 period: 90-day postoperative mortality (DOCX 39 KB)

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Huepenbecker, S.P., Fu, S., Sun, C.C. et al. Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis. Ann Surg Oncol 30, 1508–1519 (2023). https://doi.org/10.1245/s10434-022-12663-1

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