To investigate the dynamics between both patient-level Medicaid status and facility-level Medicaid share and receipt of guideline-concordant care for localized PCa.

Using the National Cancer Database, we identified a cohort of individuals aged 21-64 diagnosed with localized PCa from 2014 to 2021. The primary outcome was receipt of guideline-concordant management, defined as active surveillance for “low risk,” and either radical prostatectomy or androgen deprivation therapy and radiation therapy for “unfavorable intermediate” and “high risk” PCa. We evaluated the association between Medicaid insurance status, a facility’s share of Medicaid-insured patients, and their association with guideline-concordant care using random effects logistic regression, accounting for clustering of patients within facilities.

At the patient level, Medicaid insurance was associated with higher odds of guideline-concordant care among the subset with low-risk PCa (OR 1.25, 95% CI 1.12-1.40, P < .01) but lower odds in the high-risk subsets (OR 0.67, IQR 0.62-0.73 P < .01), reflecting less definitive treatment overall in this group. Similarly, higher facility Medicaid share was independently associated with guideline-concordant care for patients with low-risk disease (OR 1.39, IQR 1.26-1.55, P < .01) but inversely associated for those with high-risk disease (OR 0.86, IQR 0.82-0.91, P < .01).

Medicaid insurance and higher facility-level Medicaid share were associated with greater use of guideline-concordant care in low-risk disease and lower use in unfavorable intermediate- and high-risk disease, indicating risk-dependent differences in treatment intensity and alignment with guideline-based care.