Objectives Safety-net hospitals (SNH) are important sites of care especially for vulnerable groups (e.g., uninsured/Medicaid). We examined the relative contributions of individual insurance status and hospital payer mix on quality of care and survival for women with cervical cancer.

Methods We used the National Cancer Database to identify cervical cancer patients diagnosed 2004–2017. Patients were classified by insurance status (Medicaid/uninsured vs. private) and hospitals were grouped into quartiles based on the proportion of uninsured/Medicaid patients (payer mix) (top quartile defined as SNHs). Quality-of-care was assessed by adherence to evidence-based metrics and survival by proportional hazards models. Individual contributions of insurance status and hospital payer mix on quality-of-care and survival were assessed.

Results A total of 124,339 patients including 11,338 uninsured (9.1%) and 27,281 Medicaid (21.9%) recipients treated at 1156 hospitals were identified. Quality-of-care was not significantly different across hospital quartiles. Adjusting for clinical/demographic characteristics and hospital payer mix, treatment at a SNH was associated with a 14% higher mortality (HR=1.14; 95%CL, 1.08–1.20) than Q1 hospitals. Adjusting for individual insurance, uninsured women had 32% increased mortality (HR=1.32; 95%CI, 1.26–1.38) and Medicaid recipients 40% increased (HR=1.40; 95%CI, 1.35–1.44) compared to privately insured subjects. Adjusting for both payer mix and insurance status, only individual insurance retained a significant impact on mortality (table 1).

Conclusions Individual insurance status (having Medicaid or no insurance) may be a more important predictor of survival than site of care and hospital payer mix for women with cervical cancer.