Health Insurance as a Mediator of Neighborhood Deprivation and Pediatric Cancer Survival: An Analysis of State Cancer Registry Data.
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INTRODUCTION: To develop interventions to reduce neighborhood-level disparities in pediatric cancer outcomes, it is necessary to understand their underlying mechanisms. It has been suggested that individual-level health insurance is a mediator of neighborhood deprivation and pediatric cancer survival. METHODS: This study was a population-based longitudinal study of children with cancer from 2000 to 2020 in the Iowa Cancer Registry and Louisiana Tumor Registry. Neighborhood deprivation was measured using the Area Deprivation Index. Log-binomial regression models were used to identify predictors of health insurance status at diagnosis. Cox regression models were used to assess the association between health insurance status at diagnosis and cancer-specific survival. Causal mediation analyses were conducted to investigate whether health insurance status serves as a mediator of the relationship between neighborhood deprivation and survival. RESULTS: The study included 5782 children with cancer: 2069 in Iowa and 3723 in Louisiana. Children in more deprived neighborhoods, non-White children, and children in Louisiana were more likely to have non-private insurance. Compared with children with private insurance, those with non-private insurance had a 32% higher hazard of cancer death (aHR = 1.32, 95% CI: 1.13-1.55). Insurance status was observed to mediate the association between ADI and cancer-specific survival, mediating 7.33%-14.59% of the estimated association. CONCLUSION: While individual-level health insurance status was a mediator of neighborhood-level disparities in pediatric cancer survival, it did not explain a large proportion of the observed disparities. This suggests that structural and systemic factors, beyond just individual insurance coverage, may play a significant role in shaping pediatric cancer outcomes.