The impact of national health insurance of Indonesia on delay in diagnosis, treatment and survival of nasopharyngeal carcinoma patients

Abstract

Background: Indonesia introduced a national health insurance program (known as JKN) in 2014. This program aims to provide insurance to all Indonesian citizens and to protect them from health-related financial shocks, including cancer treatment. However, its impact on cancer treatment, especially in patients with nasopharyngeal carcinoma (NPC) has not yet been evaluated. The present study aimed to determine the effect of introducing national health insurance on symptom-to-visit interval (SVI), diagnosis-to-chemotherapy interval (DCI), and chemotherapy-to-radiotherapy inter-val (CRI) of patients with locally advanced NPC. In addition, we evaluated its impact on patients' 3 year overall survival (OS). Methods: A total 92 locally advanced NPC who were treated with neoadjuvant chemotherapy (NACT)θradiotherapy (RT)or concurrent chemoradiationtherapy (CCRT) and diagnosed in 2007-2011 and 2014 were retrospectively analyzed. Data were analyzed using T-test, Chi square and Kaplan-Meier test. Results: Of 92 patients, 59 (64.1%) patients were diagnosed before JKN era and 33 (35.9%) patients were diagnosed afterward. Total mean of SVI, DCI, and CRI were 7.5 months (1-24 months), 58 days (3-405 days), and 57 days (0-195 days). A total 61 (66.3%) patients received NACT θCCRT and 31(33.7%) patients received NACT θ RT. National health insurance reduced delay on diagnosis (mean difference SVI= 3.3561.52 months, p =0.032). Contrarily, it increased delay on getting chemotherapy (mean difference DCI= 40.77617.54 days, p = 0.025), but not in getting radiotherapy (mean difference CRI= 14.26610.90 days, p= 0.197). It also changed preference of treatment setting from NACTθCCRT to NACTθRT (p<0, 000). There wasno significant difference of survival between patients diagnosed between before and on JKN era (meanOS=29vs.30 months, p=0.510). Conclusions: Introduction of JKN have reduced delay in diagnosis, but increased delay in treatment. This probably because the program increased the total cancer patients without any significant increase of treatment facilities. Even though no significance difference on OS, delayed treatment already happen before JKN era, might confound its impact on patients' survival.