Impact of insurance status on disease severity and care utilization in hospitalized melanoma patients.

Abstract

e21609 Background: Insurance status is a key determinant of access to cancer screening, timely diagnosis, and advanced oncologic care. Among patients with melanoma, disparities in insurance coverage may contribute to differences in metastatic burden, neurologic complications, and patterns of supportive and end-of-life care at the time of hospitalization. We examined the relationship between insurance type and metastatic patterns, central nervous system (CNS) complications, and healthcare utilization in a nationally representative inpatient cohort. Methods: We conducted a retrospective, survey-weighted cohort study using the Nationwide Inpatient Sample, identifying adult hospitalizations with a primary diagnosis of melanoma. The primary exposure was insurance status, categorized as Medicare, Medicaid, private insurance, and self-pay. Multivariable logistic regression models were adjusted for patient demographics, hospital characteristics, and Elixhauser comorbidities. Outcomes included site-specific metastases (brain/CNS, lung, bone, and liver), CNS complications (seizures, increased intracranial pressure [ICP], neurosurgical intervention, and composite CNS events), palliative care consultation, and do-not-resuscitate (DNR) status. Results: Among an estimated 162,150 melanoma hospitalizations, 44.3% had metastatic disease, including 11.2% with brain/CNS metastases. Compared with Medicare beneficiaries, Medicaid (adjusted odds ratio (aOR) 1.52), privately insured (aOR 1.45), and self-pay patients (aOR 1.46) had higher odds of brain/CNS metastases (all p < 0.001). Medicaid insurance was additionally associated with increased odds of lung metastases (aOR 1.33; p < 0.001). CNS complications were frequent, with 27.9% of patients experiencing at least one CNS event. Relative to Medicare, higher odds of composite CNS events were observed among Medicaid (aOR 1.41), self-pay (aOR 1.45), and privately insured patients (aOR 1.30) (all p < 0.001). Increased intracranial pressure occurred more often among Medicaid (aOR 1.45; p < 0.001) and self-pay patients (aOR 1.53; p = 0.004), while neurosurgical intervention was more common among privately insured (aOR 1.54; p < 0.001) and self-pay patients (aOR 1.82; p = 0.002). Medicaid and self-pay patients also demonstrated higher odds of palliative care consultation (Medicaid aOR 1.38; self-pay aOR 1.62; both p < 0.001) and DNR orders (Medicaid aOR 1.31; self-pay aOR 1.49; both p < 0.001). Conclusions: In this study, insurance status was independently associated with metastatic burden, CNS complications, and patterns of supportive and end-of-life care among hospitalized melanoma patients. These findings suggest persistent insurance-related disparities at the time of hospitalization and highlight the need for improved access to early melanoma detection and equitable oncologic care across payer groups.