Racial/ethnic disparities in the risk of intracerebral hemorrhage recurrence

ObjectiveTo estimate the risk of intracerebral hemorrhage (ICH) recurrence in a large, diverse, US-based population and to identify racial/ethnic and socioeconomic subgroups at higher risk.MethodsWe performed a longitudinal analysis of prospectively collected claims data from all hospitalizations in nonfederal California hospitals between 2005 and 2011. We used validated diagnosis codes to identify nontraumatic ICH and our primary outcome of recurrent ICH. California residents who survived to discharge were included. We used log-rank tests for unadjusted analyses of survival across racial/ethnic groups and multivariable Cox proportional hazards regression to determine factors associated with risk of recurrence after adjusting for potential confounders.ResultsWe identified 31,355 California residents with first-recorded ICH who survived to discharge, of whom 15,548 (50%) were white, 6,174 (20%) were Hispanic, 4,205 (14%) were Asian, and 2,772 (9%) were black. There were 1,330 recurrences (4.1%) over a median follow-up of 2.9 years (interquartile range 3.8). The 1-year recurrence rate was 3.0% (95% confidence interval [CI] 2.8%–3.2%). In multivariable analysis, black participants (hazard ratio [HR] 1.22; 95% CI 1.01–1.48; p = 0.04) and Asian participants (HR 1.29; 95% CI 1.10–1.50; p = 0.001) had a higher risk of recurrence than white participants. Private insurance was associated with a significant reduction in risk compared to patients with Medicare (HR 0.60; 95% CI 0.50–0.73; p < 0.001), with consistent estimates across racial/ethnic groups.ConclusionsBlack and Asian patients had a higher risk of ICH recurrence than white patients, whereas private insurance was associated with reduced risk compared to those with Medicare. Further research is needed to determine the drivers of these disparities.

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The Impact of Diabetes and Edentulism on All-Cause Mortality: Racial and Ethnic Disparities

Innovation in Aging ◽

10.1093/geroni/igab046.792 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. 206-207

Author(s):

Huabin Luo ◽

Frank Sloan ◽

Brenda Plassman ◽

Samrachana Adhikari ◽

Mark Schwartz ◽

...

Keyword(s):

Risk Factor ◽

Ethnic Groups ◽

Proportional Hazards ◽

Ethnic Disparities ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Models ◽

The Us ◽

The Impact ◽

Racial Ethnic ◽

Retirement Study

Abstract This study examined the relationships between the concomitance of diabetes mellitus (DM) and edentulism and mortality among Black, Hispanic, and White older adults in the US. We used data from the 2006-2016 Health and Retirement Study with 2,108 Black, 1,331 Hispanic, and 11,544 White respondents aged 50+. Results of weighted Cox proportional hazards models showed that the concomitance of DM and edentulism was associated with a higher mortality risk for Blacks (Hazard Ratio [HR] = 1.58, p < 0.01), Hispanics (HR = 2.16, p < 0.001) and Whites (HR = 1.61, p < 0.001). Findings also indicated that DM was a risk factor for mortality across all racial/ethnic groups, but edentulism was a risk factor only for Whites (HR = 1.30, p < 0.001). This study revealed that the risk of DM and edentulism on mortality varied among racial/ethnic groups. Our study gives alternative explanations for the observed findings.

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Racial and ethnic disparities in risk and survival in children with neuroblastoma: An updated analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.10036 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 10036-10036

Author(s):

Caileigh Pudela ◽

Mark A. Applebaum ◽

Sang Mee Lee ◽

Arlene Naranjo ◽

Julie R. Park ◽

...

Keyword(s):

Native American ◽

High Risk ◽

Ethnic Groups ◽

Proportional Hazards ◽

Ethnic Disparities ◽

Cox Proportional Hazards ◽

Black And White ◽

High Risk Disease ◽

Significant Difference ◽

Racial Ethnic

10036 Background: Biologic and socioeconomic factors contribute to health disparities among patients with pediatric cancer. In an analysis of Children’s Oncology Group (COG) neuroblastoma (NBL) patients (pts) diagnosed between 2001-2009, non-Hispanic Black (Black) pts were previously shown to have a higher prevalence of high-risk disease and worse event-free survival (EFS) compared to non-Hispanic White (White) pts. Here, we analyzed data in the International Neuroblastoma Risk Group Data Commons (INRGdc) to validate these findings. Methods: Three-year EFS and overall survival (OS) of COG pts diagnosed between 2001-2009 (Cohort 1; n = 4,358) and 2010-2016 (Cohort 2; n = 3,689) in the INRGdc with known race and ethnicity were estimated by the Kaplan-Meier method. Cox proportional hazards regression models were used to evaluate differences in EFS and OS between racial/ethnic groups. The association of clinical characteristics and tumor biomarkers with racial/ethnic groups were analyzed using Chi-square tests. Results: The distribution of race/ethnicity for pts in Cohort 1 and Cohort 2 was as follows, respectively: White: 72% (n = 3,136) and 70% (n = 2,575); Black: 11.4% (n = 495) and 10.7% (n = 397); Hispanic: 12.2% (n = 532) and 14.1% (n = 522); Asian and Hawaiian: 4% (n = 178) and 4.6% (n = 172); Native American: 0.4% (n = 17) and 0.6% (n = 23). In both cohorts, a higher proportion of Black pts had INSS stage 4 disease, age ≥ 18mo, and unfavorable histology tumors when compared to White pts (Cohort 1: p = 0.003; p < 0.001; p < 0.001, respectively vs Cohort 2: p = 0.014; p < 0.001; p < 0.001, respectively). No significant differences in the proportion of pts with MYCN amplified or diploid tumors were detected between Black and White pts in either cohort. Black pts had a higher prevalence of high-risk disease compared to White pts in both Cohorts 1 and 2 (p < 0.001 and p < 0.001, respectively). Among all pts in Cohort 1, EFS was 73% and OS was 83%. In Cohort 1, Black pts had worse EFS (68% vs 73%; HR = 1.31, 95%CI 1.11-1.55, p = 0.002) and OS (78% vs 84%; HR = 1.41, 95% CI 1.16-1.70, p = 0.001) compared to White pts. Among all pts in Cohort 2, EFS was 81% and OS was 88%. Black pts in Cohort 2 also had worse EFS compared to White pts (76% vs 82%; HR = 1.35, 95% CI = 1.03-1.76, p = 0.027), although no significant difference in OS was observed (p = 0.21). In analyses restricted to high-risk pts, no statistically significant difference in EFS and OS in Black vs White pts was detected in either cohort. Conclusions: In the modern treatment era, Black NBL pts continue to have a higher prevalence of high-risk disease and inferior 3-year EFS compared to White pts. The lack of significant difference in survival among high-risk NBL pts by race suggests that Black and White pts are receiving comparable treatments and responding similarly. The socioeconomic and/or genomic factors contributing to the higher proportion of Black pts with high-risk disease requires further investigation.

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Ethnic disparities in hospitalisation and hospital-outcomes during the second wave of COVID-19 infection in east London

10.1101/2021.07.05.21260026 ◽

2021 ◽

Author(s):

Yize I Wan ◽

Vanessa J Apea ◽

Rageshri Dhairyawan ◽

Zudin A Puthucheary ◽

Rupert M Pearse ◽

...

Keyword(s):

Risk Factors ◽

Hospital Admission ◽

Ethnic Groups ◽

Local Population ◽

Multivariable Analysis ◽

Ethnic Disparities ◽

Risk Of Death ◽

Asian Patients ◽

Hospitalised Patients ◽

Increased Risk

Objectives To determine if changes in public behaviours, developments in COVID-19 treatments, improved patient care, and directed policy initiatives have altered outcomes for minority ethnic groups in the second pandemic wave. Design Prospectively defined observational study using registry data. Setting Four acute NHS Hospitals in east London. Participants Patients aged ≥16 years with an emergency hospital admission with SARS-CoV-2 infection between 1st September 2020 and 17th February 2021. Main outcome measures Primary outcome was 30-day mortality from time of index COVID-19 hospital admission. Secondary endpoints were 90-day mortality and need for ICU admission. Multivariable survival analysis was used to assess associations between ethnicity and mortality accounting for predefined risk factors. Age-standardised rates of hospital admission relative to the local population were compared between ethnic groups. Results Of 5533 patients, the ethnic distribution was White (n=1805, 32.6%), Asian/Asian British (n=1983, 35.8%), Black/Black British (n=634, 11.4%), Mixed/Other (n=433, 7.8%), and unknown (n=678, 12.2%). Excluding 678 patients with missing data, 4855 were included in multivariable analysis. Relative to the White population, Asian and Black populations experienced 4.1 times (3.77-4.39) and 2.1 times (1.88-2.33) higher rates of age-standardised hospital admission. After adjustment for various patient risk factors including age, sex, and socioeconomic deprivation, Asian patients were at significantly higher risk of death within 30 days (HR 1.47 [1.24-1.73]). No association with increased risk of death in hospitalised patients was observed for Black or Mixed/Other ethnicity. Conclusions Asian and Black ethnic groups continue to experience poor outcomes following COVID-19. Despite higher-than-expected rates of admission, Black and Asian patients experienced similar or greater risk of death in hospital, implying a higher overall risk of COVID-19 associated death in these communities.

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Factors impacting contemporary management of high-grade extremity sarcoma: An analysis of 12,020 patients.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.15_suppl.11017 ◽

2017 ◽

Vol 35 (15_suppl) ◽

pp. 11017-11017

Author(s):

Stephen Ramey ◽

David Asher ◽

Wei Zhao ◽

Joyson Kodiyan ◽

Felix Chinea ◽

...

Keyword(s):

Educational Attainment ◽

Private Insurance ◽

Local Treatment ◽

Ethnic Disparities ◽

Cox Proportional Hazards ◽

Limb Salvage Surgery ◽

High Grade ◽

Community Programs ◽

Integrated Network ◽

Racial Ethnic

11017 Background: Previous studies noted racial/ethnic disparities in high-grade extremity soft tissue sarcoma (ESS) treatment and overall survival (OS). Retrospective series have noted worse OS for Amputation (Amp) vs limb salvage surgery (LSS) and for LSS alone vs LSS plus radiation (RT). Given superior functional outcomes, LSS is now favored over Amp when possible. This study examines racial/ethnic disparities in receipt of Amp vs LSS and impact on OS using modern data from a national registry. Methods: The National Cancer Database was used to identify patients (pts) with stage II-III, high-grade ESS diagnosed between 2004-2014 and treated definitively with 1) Amp alone, 2) LSS alone, 3) Preoperative RT [pre RT] + LSS or 4) LSS + Post-operative RT [post RT]. Multivariate analyses (MVA) utilized logistic regressions for patterns of local treatment and Cox proportional hazards regression for OS. The Kaplan-Meier method was used to estimate 5-year OS. Results: Among 12,020 pts, receipt of LSS vs Amp did not differ significantly by race, ethnicity, age, insurance status, income, or educational attainment on MVA. The rate of Amp was higher in academic centers (OR 2.42; p = .006) or integrated network programs (OR 2.30; p = .014) vs community programs and rural vs. Metro settings (OR 1.88; p = .035). Actuarial 5-year OS by treatment was Amp 43%, LSS 59%, pre RT + LSS 61%, and LSS + post RT 66% (p < .001). On MVA, OS was worse with Amp vs. LSS alone (HR 1.37; p < .001) while pre RT + LSS (HR 0.70; p < .001) and LSS + post RT (HR 0.72; p < .001) had improved OS vs LSS alone. Treatment at a comprehensive community, academic, or integrated network programs vs community program; private insurance vs none; Hispanic vs. non-Hispanic (HR 0.85, p = .048); and higher educational attainment were associated with improved OS. More comorbidities, other primary cancers, older age, and no transitions in care were associated with worse OS. Conclusions: The only racial/ethnic disparity identified when evaluating rates of Amp and OS for ESS was a small OS benefit for Hispanic pts. OS was inferior with Amp and best with LSS with either pre RT or post RT. OS was improved at non-community programs, potentially indicating a need for referral to experienced centers.

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Poststroke epilepsy in long-term survivors of primary intracerebral hemorrhage

Neurology ◽

10.1212/wnl.0000000000004009 ◽

2017 ◽

Vol 88 (23) ◽

pp. 2169-2175 ◽

Cited By ~ 21

Author(s):

Anna-Maija Lahti ◽

Pertti Saloheimo ◽

Juha Huhtakangas ◽

Henrik Salminen ◽

Seppo Juvela ◽

...

Keyword(s):

Risk Factors ◽

Intracerebral Hemorrhage ◽

Proportional Hazards ◽

Multivariable Analysis ◽

Cox Proportional Hazards ◽

Long Term Follow Up ◽

Gcs Score ◽

Long Term Survivors ◽

Early Seizures

Objective:To identify the incidence and predisposing factors for development of poststroke epilepsy (PSE) after primary intracerebral hemorrhage (PICH) during a long-term follow-up.Methods:We performed a retrospective study of patients who had had their first-ever PICH between January 1993 and January 2008 in Northern Ostrobothnia, Finland, and who survived for at least 3 months. These patients were followed up for PSE. The associations between PSE occurrence and sex, age, Glasgow Coma Scale (GCS) score on admission, hematoma location and volume, early seizures, and other possible risk factors for PSE were assessed using the Cox proportional hazards regression model.Results:Of the 615 PICH patients who survived for longer than 3 months, 83 (13.5%) developed PSE. The risk of new-onset PSE was highest during the first year after PICH with cumulative incidence of 6.8%. In univariable analysis, the risk factors for PSE were early seizures, subcortical hematoma location, larger hematoma volume, hematoma evacuation, and a lower GCS score on admission, whereas patients with infratentorial hematoma location or hypertension were less likely to develop PSE (all variables p < 0.05). In multivariable analysis, we found subcortical location (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.35–3.81, p < 0.01) and early seizures (HR 3.63, 95% CI 1.99–6.64, p < 0.01) to be independent risk factors, but patients with hypertension had a lower risk of PSE (HR 0.54, 0.35–0.84, p < 0.01).Conclusions:Subcortical hematoma location and early seizures increased the risk of PSE after PICH in long-term survivors, while hypertension seemed to reduce the risk.

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Reporting of Multivariable Methods in the Medical Literature

Journal of Investigative Medicine ◽

10.2310/jim.0b013e31818914ff ◽

2008 ◽

Vol 56 (7) ◽

pp. 954-957 ◽

Cited By ~ 12

Author(s):

Jeanette M. Tetrault ◽

Maor Sauler ◽

Carolyn K. Wells ◽

John Concato

Keyword(s):

Logistic Regression ◽

New England ◽

Proportional Hazards ◽

Medical Literature ◽

Multivariable Analysis ◽

Cox Proportional Hazards ◽

Primary Method ◽

Primary Analysis ◽

Proportional Hazards Assumption ◽

Complete Reporting

BackgroundMultivariable models are frequently used in the medical literature, but many clinicians have limited training in these analytic methods. Our objective was to assess the prevalence of multivariable methods in medical literature, quantify reporting of methodological criteria applicable to most methods, and determine if assumptions specific to logistic regression or proportional hazards analysis were evaluated.MethodsWe examined all original articles in Annals of Internal Medicine, British Medical Journal, Journal of the American Medical Association, Lancet, and New England Journal of Medicine, from January through June 2006. Articles reporting multivariable methods underwent a comprehensive review; reporting of methodological criteria was based on each article's primary analysis.ResultsAmong 452 articles, 272 (60%) used multivariable analysis; logistic regression (89 [33%] of 272) and proportional hazards (76 [28%] of 272) were most prominent. Reporting of methodological criteria, when applicable, ranged from 5% (12/265) for assessing influential observations to 84% (222/265) for description of variable coding. Discussion of interpreting odds ratios occurred in 13% (12/89) of articles reporting logistic regression as the primary method and discussion of the proportional hazards assumption occurred in 21% (16/76) of articles using Cox proportional hazards as the primary method.ConclusionsMore complete reporting of multivariable analysis in the medical literature can improve understanding, interpretation, and perhaps application of these methods.

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The Efficacy of Etoposide-Based Therapy in Adult Secondary Hemophagocytic Lymphohistiocytosis

Acta Haematologica ◽

10.1159/000514920 ◽

2021 ◽

pp. 1-9

Author(s):

Leonard Naymagon ◽

Douglas Tremblay ◽

John Mascarenhas

Keyword(s):

Hemophagocytic Lymphohistiocytosis ◽

Proportional Hazards ◽

Multivariable Analysis ◽

Cox Proportional Hazards ◽

Rank Test ◽

Kaplan Meier ◽

Hazard Ratios ◽

Significant Difference ◽

The Impact

Data supporting the use of etoposide-based therapy in hemophagocytic lymphohistiocytosis (HLH) arise largely from pediatric studies. There is a lack of comparable data among adult patients with secondary HLH. We conducted a retrospective study to assess the impact of etoposide-based therapy on outcomes in adult secondary HLH. The primary outcome was overall survival. The log-rank test was used to compare Kaplan-Meier distributions of time-to-event outcomes. Multivariable Cox proportional hazards modeling was used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs). Ninety adults with secondary HLH seen between January 1, 2009, and January 6, 2020, were included. Forty-two patients (47%) received etoposide-based therapy, while 48 (53%) received treatment only for their inciting proinflammatory condition. Thirty-three patients in the etoposide group (72%) and 32 in the no-etoposide group (67%) died during follow-up. Median survival in the etoposide and no-etoposide groups was 1.04 and 1.39 months, respectively. There was no significant difference in survival between the etoposide and no-etoposide groups (log-rank <i>p</i> = 0.4146). On multivariable analysis, there was no association between treatment with etoposide and survival (HR for death with etoposide = 1.067, 95% CI: 0.633–1.799, <i>p</i> = 0.8084). Use of etoposide-based therapy was not associated with improvement in outcomes in this large cohort of adult secondary HLH patients.

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Abstract TP241: Race-ethnic Differentials Time and Acute Stroke Emergency Presentation: The ASPIRE Study

Stroke ◽

10.1161/str.44.suppl_1.atp241 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Bernadette Boden-Albala ◽

Dorothy F Edwards ◽

Jeffrey J Wing ◽

Shauna S Clair ◽

Stephen Fernandez ◽

...

Keyword(s):

Black Women ◽

Acute Stroke ◽

Intervention Program ◽

Arrival Time ◽

Proportional Hazards ◽

Ethnic Disparities ◽

Cox Proportional Hazards ◽

Urban Setting ◽

Intervention Period ◽

Post Intervention

BACKGROUND: There is sparse data about the nature of race-ethnic disparities in the acute stroke setting including differentials in stroke preparedness. The aim of this analysis was to explore race-ethnic differentials in time to arrival for acute stroke in a racial and ethnically diverse urban setting. METHODS: ASPIRE is a multi-dimensional intervention program (community, hospital, and EMS) for acute stroke preparedness targeted to increase IV tPA utilization in underserved black communities in the DC metro area. We prospectively identified stroke admissions and EMS utilization including acute stroke arrival time parameters for the 6 month pre and post intervention periods. Cox proportional hazards models were used to examine predictors of arrival time. Proportionality of the hazards was checked. RESULTS: In the 6 month pre-intervention period, data was collected on 943 stroke cases; 53% female; 74% black; mean age 67 yrs. Of the subjects from the pre-intervention period with arrival times less than 48 hrs, the median arrival time to the emergency department (ED) was 9 hours; 20% presented under 3 hours. In multivariable Cox PH models, subjects were 38% more likely to arrive earlier if they had arrived by EMS (HR: 1.38, 95%CI: 1.21-1.58). Black subjects were 25% less likely to arrive earlier (HR: 0.75, 95%CI: 0.60-0.93), but this effect was dampened over time (p=0.03). The model included the interaction between black race and time and adjusted for insurance status, risk factors (hypertension and diabetes), gender, age and prior stroke. Ina gender by race analysis, there was a trend towards black women being less likely to arrive earlier to the ED (HR 0.78, 95% CI 0.6 -1.0). However, overall, there was no race-ethnic interaction with arrival by EMS. CONCLUSIONS: Contrary to the perceived perception by the community suggesting there is a disparity in EMS utilization by the black DC community, we found no overall significant racial difference in EMS utilization for acute stroke. While there was a trend towards delayed overall arrival in black females, this was independent of EMS utilization.

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Abstract P423: Race and Ethnicity Influence Perihematomal Edema Volume in Supratentorial Intracerebral Hemorrhage

Stroke ◽

10.1161/str.52.suppl_1.p423 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Julian N Acosta ◽

Yasheng Chen ◽

Cameron Both ◽

Audrey C Leasure ◽

Fernando Testai ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Race And Ethnicity ◽

Learning Algorithm ◽

Multivariable Analysis ◽

Secondary Brain Injury ◽

Racial Groups ◽

Deep Learning Algorithm ◽

Perihematomal Edema ◽

Study Participants ◽

Racial Ethnic

Introduction: Perihematomal Edema (PHE) is a neuroimaging biomarker of secondary brain injury in patients with spontaneous, non-traumatic intracerebral hemorrhage (ICH). There are limited data on racial/ethnic differences in the development of PHE. This dearth of data is partially driven by the time-consuming process of manually segmenting PHE. Leveraging a validated automated pipeline for PHE segmentation, we evaluated whether race and ethnicity influence baseline PHE volume in patients with ICH. Methods: The Ethnic/Racial Variations in Intracerebral Hemorrhage (ERICH) study is a prospective, multicenter study of ICH that recruited 1,000 adult participants from each of three racial/ethnic groups (non-Hispanic White, non-Hispanic Black, and Hispanic). We applied a previously validated deep learning algorithm to automatically determine PHE volumes on baseline CTs in these study participants. Quality control procedures were used to include only sufficiently accurate PHE measurements. Linear regression was used to identify factors associated with log-transformed PHE volume and to identify differences across Ethnic/Racial groups. Results: Our imaging pipeline provided good quality baseline PHE measurements on 2,008 out of 3,000 ERICH study participants. After excluding infratentorial hemorrhages (273) and those with missing or null baseline ICH volume (49), 1,686 remained for analysis (median age 59 [IQR 51-71], 687 [41%] female sex). Median PHE volume was 12.0 (IQR 4.8-27.1) for whites, 11.9 (IQR 4.5-26.1) for Hispanics and 8.3 (IQR 3.0-19.2) for blacks. Compared to Blacks, Hispanics (beta 0.22; 95%CI 0.11-0.32; p<0.001) and Whites (beta 0.20; 95%CI 0.07-0.33; p=0.003) had higher baseline PHE volumes, in multivariable analysis adjusting for age, sex, ICH location, log-baseline ICH volume, log-baseline intraventricular volume, and systolic blood pressure on admission. Conclusion: Race and ethnicity influence the volume of baseline PHE. Further studies are needed to validate our results and investigate the biological underpinnings of this difference.

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The effect of insurance status on overall survival among children and adolescents with cancer

International Journal of Epidemiology ◽

10.1093/ije/dyaa079 ◽

2020 ◽

Vol 49 (4) ◽

pp. 1366-1377 ◽

Cited By ~ 1

Author(s):

Xiaoyan Wang ◽

Rohit P Ojha ◽

Sonia Partap ◽

Kimberly J Johnson

Keyword(s):

Children And Adolescents ◽

Cancer Survival ◽

Proportional Hazards ◽

Private Insurance ◽

Insurance Coverage ◽

Cox Proportional Hazards ◽

Insurance Status ◽

Risk Of Death ◽

Adolescent Cancer ◽

Privately Insured

Abstract Background Differences in access, delivery and utilisation of health care may impact childhood and adolescent cancer survival. We evaluated whether insurance coverage impacts survival among US children and adolescents with cancer diagnoses, overall and by age group, and explored potential mechanisms. Methods Data from 58 421 children (aged ≤14 years) and adolescents (15–19 years), diagnosed with cancer from 2004 to 2010, were obtained from the National Cancer Database. We examined associations between insurance status at initial diagnosis or treatment and diagnosis stage; any treatment received; and mortality using logistic regression, Cox proportional hazards (PH) regression, restricted mean survival time (RMST) and mediation analyses. Results Relative to privately insured individuals, the hazard of death (all-cause) was increased and survival months were decreased in those with Medicaid [hazard ratio (HR) = 1.27, 95% confidence interval (CI): 1.22 to 1.33; and −1.73 months, 95% CI: −2.07 to −1.38] and no insurance (HR = 1.32, 95% CI: 1.20 to 1.46; and −2.13 months, 95% CI: −2.91 to −1.34). The HR for Medicaid vs. private insurance was larger (pinteraction <0.001) in adolescents (HR = 1.52, 95% CI: 1.41 to 1.64) than children (HR = 1.16, 95% CI: 1.10 to 1.23). Despite statistical evidence violation of the PH assumption, RMST results supported all interpretations. Earlier diagnosis for staged cancers in the Medicaid and uninsured populations accounted for an estimated 13% and 19% of the survival deficit, respectively, vs. the privately insured population. Any treatment received did not account for insurance-associated survival differences in children and adolescents with cancer. Conclusions Children and adolescents without private insurance had a higher risk of death and shorter survival within 5 years following cancer diagnosis. Additional research is needed to understand underlying mechanisms.

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