Health insurance status and outcomes in children, adolescents, and young adults: a systematic review and meta-analysis.

BACKGROUND: The impacts of health insurance status on survival outcomes in children, adolescents, and young adults (aged 0-39 years) with malignant tumors have not been addressed in depth. The present study aimed to identify significant relationships of health insurance condition with overall survival or all-cause mortality among children (age 0-14 years) and adolescents and young adults (AYAs, age 15-39 years) with malignant tumors. METHODS: PubMed, Wiley Cochrane Central Register of Controlled Trials, Econlit, CINAHL, Web of Knowledge, PsychInfo, Business Source Premier, ProQuest Dissertation & Theses Database, and SCOPUS were systematically searched from inception to February 29, 2020 with no language restriction. All related articles comparing the effect of health insurance status on the risk of overall survival and the risk of all-cause mortality in malignant conditions affecting children and AYAs were identified. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were computed using a random- or fixed-effect model as per the heterogeneity evaluated using Cochran`s Q and I < sup > 2 < /sup > statistics. RESULTS: Fourteen studies including 149,680 individuals were selected for this meta-analysis. The pooled RR for all-cause mortality with insurance versus without insurance was 0.78 (95%CI, 0.71-0.86; I2=33.7%). Among the insurance types, patients with private insurance presented with a lower all-cause mortality (RR 0.70, 95% CI 0.60-0.82), with considerable heterogeneity (I2=83.3%). CONCLUSIONS: The findings of this review suggest that a lack of or insufficient insurance is related to all-cause mortality of AYAs with malignant cancers. Strategies aimed at identifying causality and reducing disparities are warranted.