Patients discharged from the hospital after surgical resection of non–small cell lung cancer (NSCLC) had significant decreases in postoperative mortality if they lived in states that opted into Medicaid expansion after implementation of the Affordable Care Act (ACA). No survival difference was seen in patients living in non-expansion states according to a study by researchers at the American Cancer Society (ACS).¹

The study included nearly 15,000 adults aged 45–64 years who underwent surgical resection of NSCLC between 2008 and 2019; 62.1% of these adults lived in Medicaid expansion states. Researchers looked at early 30- and 90-day postoperative mortality among patients before implementation of the ACA (2008–2013) and after implementation (2014–2019) when some states opted into Medicaid expansion.

Patients living in a Medicaid expansion state had significant decreases in postoperative mortality at both 30 days (from 0.97% before the ACA to 0.25% with Medicaid expansion) and 90 days (from 2.63% to 1.32%), whereas patients living in non-expansion states showed no significant difference in 30- (0.75% vs. 0.68%) or 90-day postoperative mortality (2.43% vs. 2.20%).

According to the lead author of the study, Leticia Nogueira, PhD, MPH, scientific director of health services research at ACS, the decreased postoperative mortality seen in patients living in Medicaid expansion states is unlikely due to random fluctuations in mortality through time, as shown by the statistically significant difference in differences of –0.64 percentage points (30-day mortality) and –1.08 percentage points (90-day mortality) (p = .03 for both) found in the study. (Difference in differences is a statistical approach often used in public health research to compare differences in outcomes before and after an intervention and between groups.)

No significant differences in in-hospital mortality were found between patients living in Medicaid expansion states and those in non-expansion states.

“Our study showed that policies aimed at expanding access to health insurance coverage are associated with improved survival among patients recovering from lung cancer surgery, a period when postoperative complications and health complications are common, and timely access to care is critical,” says Dr Nogueira.

Commenting on the study, Daniel Morgensztern, MD, professor of medicine and clinical director of thoracic oncology at Washington University School of Medicine, called the study excellent but said that it should be viewed only as a hypothesis-generating study “and is not definitive proof that the Medicaid expansion is associated with reduced early postoperative mortality.”

He cites a number of limitations of the study, including absent information on the type of health insurance patients had before a cancer diagnosis, the type of postoperative care they received, and the causes of death. He also cites other factors, including surgical complications, overall survival, mortality by stages, type of surgery, and type of hospital.

“Perhaps a multivariable analysis could be helpful for better interpretation, particularly with the very low rate of complications and differences between the cohorts,” he says.

Dr Nogueira notes that the study evaluated only the association between Medicaid expansion and mortality following lung cancer surgery. “Future studies should evaluate whether these results hold for other cancer sites,” she says.

非小细胞肺癌 (NSCLC) 手术切除后出院的患者，如果居住在平价医疗法案 (ACA) 实施后选择扩大医疗补助的州，术后死亡率会显着降低。根据美国癌症协会 (ACS) 研究人员的一项研究，生活在非扩张状态的患者的生存率没有差异。¹

该研究纳入了近 15,000 名 45-64 岁的成年人，他们在 2008 年至 2019 年间接受了 NSCLC 手术切除；其中 62.1% 的成年人居住在医疗补助扩张州。研究人员研究了 ACA 实施前（2008-2013 年）和实施后（2014-2019 年）患者术后早期 30 天和 90 天的死亡率（当一些州选择扩大医疗补助范围时）。

生活在医疗补助扩展状态的患者在 30 天（从 ACA 之前的 0.97% 降至医疗补助扩展后的 0.25%）和 90 天（从 2.63% 降至 1.32%）术后死亡率均显着下降，而生活在非扩展状态的患者各州的术后 30 天死亡率（0.75% vs. 0.68%）或 90 天死亡率（2.43% vs. 2.20%）没有显着差异。

该研究的主要作者、ACS 卫生服务研究科学主任 Leticia Nogueira 博士表示，由于死亡率随时间的随机波动，居住在医疗补助扩张州的患者术后死亡率不太可能下降，如图所示研究中发现，统计显着性差异为 –0.64 个百分点（30 天死亡率）和 –1.08 个百分点（90 天死亡率）（两者均p = 0.03）。 （差异中的差异是公共卫生研究中经常使用的一种统计方法，用于比较干预前后以及组间结果的差异。）

生活在医疗补助扩展州和非扩展州的患者之间的院内死亡率没有显着差异。

“我们的研究表明，旨在扩大健康保险覆盖范围的政策与肺癌手术恢复期患者的生存率提高有关，在这段时期术后并发症和健康并发症很常见，及时获得护理至关重要，”诺盖拉博士说。

华盛顿大学医学院医学教授兼胸部肿瘤学临床主任 Daniel Morgensztern 医学博士在评论这项研究时称这项研究非常出色，但表示它应该仅被视为一项假设生成研究“而不是决定性的证据”医疗补助的扩大与术后早期死亡率的降低有关。”

他列举了该研究的一些局限性，包括缺乏关于患者在癌症诊断前拥有的健康保险类型、他们接受的术后护理类型以及死亡原因的信息。他还引用了其他因素，包括手术并发症、总生存率、分期死亡率、手术类型和医院类型。

“也许多变量分析有助于更好地解释，特别是在并发症发生率非常低且队列之间存在差异的情况下，”他说。

Nogueira 博士指出，该研究仅评估了医疗补助扩大与肺癌手术后死亡率之间的关联。 “未来的研究应该评估这些结果是否适用于其他癌症部位，”她说。