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P130

Differences in mortality and patient characteristics between national health service patients and those with private health insurance post radical cystectomy

By: Robinson S., Rao A.
Institutes: Wexham Park Hospital, Dept. of Urology, Slough, Berkshire

Introduction & Objectives

Mortality from cancer appears to be due to a complex of demographic and clinical factors of which insurance is a part.
We looked at 257 patients undergoing radical cystectomy and compared their presenting characteristics and their mortality rates, all cause, disease specific and progression rates between those treated in the national health service (NHS) and those with private health insurance (PHI).

Material & Methods

Various characteristics were compared using Fishers and t tests.
Kaplan Meier curves were generated for the two cohorts for progression and mortality and logistic regression applied to generate significant predictors. The operations were all performed by the same surgeon.

Results

Characteristic NHS n = 225 PHI n = 32 P
Age years 68 64 0.026
Tumour volume cc 22 11 0.18
Positive surgical margins 32 (14%) 2 (6%) 0.27
Stage localised
          Locally advanced
146 (56%)
99 (44%)
20 (62%)
12 (38%)
0.84
Carcinoma in situ 92 (41%) 19 (59%) 0.057
Mean number of nodes dissected 9 13 0.006
Patients with nodal involvement 43 (19%) 7 (22%) 0.811
Nodal extracapsular extension 24/43 4/7 1.0
Complications 89 (40%) 4 (13%) 0.002
Additional treatment given 38 (17%) 4 (13%) 0.79
Neobladder 40 (18%) 12 (38%) 0.16

 
 

All cause mortality      
  coefficient P Odds ratio
Neobladder -0.8 0.0154 0.42
Private patient -1.4 0.0013 0.24
T3 1.007 0.0008 2.7
T4 1.97 <0.0001 7.18
Disease specific mortality      
Additional treatment 0.77 0.021 2.17
Complication 0.73 0.013 2.08
Neobladder -0.95 0.015 0.38
Node density 2.26 0.014 9.67
Private patient -1.08 0.035 0.33
Progression      
Additional treatment 0.74 0.029 2.11
Private patient -1.92 0.002 0.14
T2 1.18 0.010 3.28
T3 1.99 <0.0001 7.3
T4 1.89 0.0001 6.6

Conclusions

The PHI cohort generated negative protective coefficents on all three survival analyses.
PHI younger, with more nodes taken during nodal dissection and have less complications.
Regarding prognosis, PHI was a significant protective risk variable for ACM (OR 0.24),  DSM (OR 0.33) and PFM (0.14).
 
Also (but not statistically significant), those with PHI had smaller tumours, less PSM, less locally advanced disease, less additional treatments (adjuvant, neoadjuvant, radiotherapy and chemotherapy), more neobladders and more CIS.
However, stage, additional treatment and neobladder were all significant predictors of survival. These were all favourable in those with PHI.
 
The higher ACM may be due to overall poorer health, more comorbidities, unhealthy behaviour? Inadequate preventive health care, poor management of chronic conditions, barriers to receiving treatment, inability to navigate health care system, high cost, misinformation and distrust of healthcare system, lack of transport, lack of time off work. Lower quality of treatment offered by providers  serving Medicaid and uninsured. Further, there is no lead time bias (perceived increased survival time with no effect on course of cancer) with bladder cancer as there is no screening protocol, unlike prostate.
 
This study shows significant differences in prognosis post cystectomy to those treated in the NHS and those treated privately.

  • Type: Abstract
  • Date: 12-11-2015
  • Rating: 0,0
  • Views: 751
  • Event: 7th European Multidisciplinary Meeting on Urological Cancers
  • Nr: P130
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