Effect of insurance expansion on utilization of inpatient surgery

Impacts of health insurance on tympanostomy tube outcomes in the pediatric population

OBJECTIVES

Tympanostomy tube (TT) placement is a common surgical procedure for treating pediatric patients with chronic otitis media with effusion (COME) with or without recurrent acute otitis media (rAOM). Prior work suggests children from low-income families face significant disparities in access to care for rAOM or COME. The impact of these health disparities in the care of children with rAOM or COME has yet to be investigated in a state with an expanded public health insurance model. We seek to examine differences in care for patients with rAOM and COME based on insurance status and socioeconomic status (SES) in Massachusetts.

METHODS

Retrospective review of 560 pediatric patients referred for TT insertion at a tertiary academic medical center between 2017 and 2019. Demographic data collected included age, ethnicity, insurance type (public, private, none) and zip code. Otologic history collected included prior AOM episodes, time to postoperative follow-up, postoperative "no-show" appointments, and number of postoperative audiograms. Multinomial logistic regression was used to isolate the effects of race and ethnicity.

RESULTS

We found no major differences in preoperative outcome measures between cohorts. Postoperatively, public insurance was independently associated with decreased odds of undergoing an audiogram (OR 0.35, 95% Cl 0.16-0.76) and increased odds of "no-showing" for an appointment (OR 3.1, 95% CI 1.8-5.3). SES was not independently associated with differences in postoperative outcomes.

CONCLUSION

In a state with an early expanded public health insurance model, access to care for rAOM and COME is comparable despite differences in insurance type and SES. However, enrollment in public health insurance is associated with worse measures of follow up care. Despite improvements in access to care with expanded health insurance models, retention continues to be a challenge for vulnerable populations.

Changes in Elective and Urgent Surgery Among TRICARE Beneficiaries During the COVID-19 Pandemic

BACKGROUND

COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System.

METHODS

We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March-September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status.

RESULTS

During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97-1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97-1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care.

CONCLUSIONS

We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.

Medicaid Expansion: the impact of health policy on bariatric surgery

BACKGROUND

Underutilization of bariatric surgery in uninsured and marginalized communities is well-documented. When discussing population health, healthcare access and equity are crucial components often influenced by health policy.

OBJECTIVES

This study aims to determine if disparities in the use of bariatric surgery were influenced by changes in healthcare policy from the Affordable Care Act's 2014 expansion of Medicaid.

SETTING

A retrospective analysis of the 2012-2018 Healthcare Cost and Utilization Project National Inpatient Sample was performed for elective Roux-en-Y gastric bypass and sleeve gastrectomy surgeries performed within the United States.

METHODS

States were grouped into regions as defined by the U.S. Census Bureau. Medicaid as the primary payor for bariatric surgery was compared by region and year, as well as utilization by marginalized populations.

RESULTS

Analysis included 212,776 bariatric surgeries. Medicaid as the primary payor increased from 9% to 19% from 2012 to 2018. A greater share of bariatric surgeries with Medicaid as the primary payor was located in the Northeast and West, as compared with those located in the Midwest and South. Medicaid beneficiaries in marginalized communities (Black race, Hispanic race, lowest income quartile, rural communities) made up a larger share of the bariatric surgery population over time.

CONCLUSIONS

The Affordable Care Act's Medicaid Expansion improved health coverage and access to care, including bariatric surgery. An increase in bariatric surgeries among Medicaid beneficiaries correlated with the 2014 expansion of Medicaid. Social and economic disparities regarding bariatric surgery have improved though more progress may be seen with the adoption of Medicaid Expansion by the remaining U.S. states.

Inverse Probability of Treatment Weighting in 5-Year Quality-of-Life Comparison among Three Surgical Procedures for Hepatocellular Carcinoma

This prospective longitudinal cohort study analyzed long-term changes in individual subscales of quality-of-life (QOL) measures and explored whether these changes were related to effective QOL predictors after hepatocellular carcinoma (HCC) surgery. All 520 HCC patients in this study had completed QOL surveys before surgery and at 6 months, 2 years, and 5 years after surgery. Generalized estimating equation models were used to compare the 5-year QOL among the three HCC surgical procedures. The QOL was significantly (p < 0.05) improved at 6 months after HCC surgery but plateaued at 2−5 years after surgery. In postoperative surveys, the effect size was largest in the nausea and vomiting subscales in patients who had received robotic surgery, and the effect size was smallest in the dyspnea subscale in patients who had received open surgery. It revealed the following explanatory variables for postoperative QOL: surgical procedure type, gender, age, hepatitis C, smoking, tumor stage, postoperative recurrence, and preoperative QOL. The comparisons revealed that, when evaluating QOL after HCC surgery, several factors other than the surgery itself should be considered. The analysis results also implied that postoperative quality of life might depend not only on the success of the surgical procedure, but also on preoperative quality of life.

Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis

Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.

Association of Insurance Coverage With Adoption of Sleeve Gastrectomy vs Gastric Bypass for Patients Undergoing Bariatric Surgery

IMPORTANCE

Instrumental variables can control for selection bias in observational research. However, valid instruments are challenging to identify.

OBJECTIVE

To evaluate regional variation in sleeve gastrectomy following insurance coverage implementation as an instrumental variable in comparative effectiveness research.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or Roux-en-Y gastric bypass from 2012 to 2017. Data analysis was performed from January to June 2021.

EXPOSURES

Laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

MAIN OUTCOMES AND MEASURES

The association of the instrumental variable with treatment (ie, undergoing sleeve gastrectomy), as well as mortality, complications, emergency department visits, hospitalization, reinterventions, and surgical revision.

RESULTS

A total of 76 077 patients underwent bariatric surgery, of whom 44 367 underwent sleeve gastrectomy (mean [SD] age, 56.9 [11.9] years; 32 559 [73.5%] women) and 31 710 underwent gastric bypass (mean (SD) age, 55.9 (11.8) years; 23 750 [74.9%] women). After insurance coverage initiation, there was substantial regional and temporal variation in adoption of sleeve gastrectomy. Prior-year state-level utilization of sleeve gastrectomy was highly associated with undergoing sleeve gastrectomy (Kleibergen-Paap Wald F statistic, 910.3). All but 2 patient characteristics (race and diagnosis of depression) were well-balanced between the top and bottom quartiles of the instrumental variable. Regarding 1-year outcomes, compared with patients undergoing gastric bypass, patients undergoing sleeve gastrectomy had a lower 1-year risk of mortality (0.9%; 95% CI, 0.8%-1.1% vs 1.7%; 95% CI, 1.3%-2.0%), complications (11.6%; 95% CI, 10.9%-12.3% vs 14.1%; 95% CI, 13.0%-15.3%), emergency department visits (48.3%; 95% CI, 46.9%-49.8% vs 53.6%; 95% CI, 52.3%-55.0%), hospitalization (23.4%; 95% CI, 22.4%-24.4% vs 26.5%; 95% CI, 25.1%-28.0%), and reinterventions (8.7%; 95% CI, 8.0%-9.4% vs 12.2%; 95% CI, 11.2%-13.3%). The risk of revision was not different between groups (0.6%; 95% CI, 0.3%-0.8% vs 0.4%; 95% CI, 0.3%-0.6%).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of patients undergoing bariatric surgery, there was significant geographic variation in the use of sleeve gastrectomy following initiation of insurance coverage, which served as a strong instrument to compare 2 bariatric surgical procedures. This approach could be applied to other areas of health services research to serve as a complement to clinical trials.

Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department

Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.

National Trends for Reverse Shoulder Arthroplasty After the Affordable Care Act: An Analysis From 2011 to 2015

Few studies have investigated nationwide patient trends and health care costs for reverse shoulder arthroplasty (RSA) after 2014. This study uses a large validated nationwide database to retrospectively assess changes in patient and hospital demographic features, hospital costs, and hospital charges for inpatient RSA procedures before and after implementation of the Affordable Care Act. The National Inpatient Sample database was used to identify all patients who underwent RSA between January 2011 and December 2015, yielding 163,171 patients (63.4% female; mean age, 72 years). Categorical data were assessed with chi-square/Fisher's exact test, and continuous data were assessed with analysis of variance. There was an increased proportion of RSA recipients identifying as Hispanic (4.1% to 4.8%) and Native American (0.1% to 0.4%; P<.0001). The proportion of patients who had Medicaid (1.4% to 2.4%) and private insurance (15.1% to 16.6%) increased as well (P<.0001). A decrease in mean hospital costs occurred between 2011 and 2015 (-$256; P=.002), whereas an increase occurred in hospital charges (+$6,314; P<.001). These findings provide insight on RSA use and patient demographic trends in the United States. Additionally, these results help to capture the effects of extended health coverage and new reimbursement models on hospital costs and charges. [Orthopedics. 2022;45(2):97-102.].

Associations of Chinese diagnosis-related group systems with inpatient expenditures for older people with hip fracture

Background

Hip fracture is frequent in older people and represents a major public health issue worldwide. The increasing incidence of hip fracture and the associated hospitalization costs place a significant economic burden on older patients and their families. On January 1, 2018, the Chinese diagnosis-related group (C-DRG) payment system, which aims to reduce financial barriers, was implemented in Sanming City, southern China. This study aimed to evaluate the associations of C-DRG system with inpatient expenditures for older people with hip fracture.

Methods

An uncontrolled before-and-after study employed data of all the patients with hip fracture aged 60 years or older from all the public hospitals enrolled in the Sanming Basic Health Insurance Scheme from January 1, 2016 to December 31, 2018. The ‘pre C-DRG sample’ included patients from January 1, 2016 to December 31, 2017. The ‘post C-DRG sample’ included patients from January 1, 2018 to December 31, 2018. A propensity score matching analysis was used to adjust the difference in baseline characteristic parameters between the pre and post samples. Data were analyzed using generalized linear models adjusted for the demographic, clinical, and institutional factors. Robust tests were performed by accounting for time trend, the fixed effects of the year and hospitals, and clustering effect within hospitals.

Results

After propensity score matching, we obtained two homogeneous groups of 1123 patients each, and the characteristic variables of the two matched groups were similar. We found that C-DRG reform was associated with a 19.51% decrease in out-of-pocket (OOP) payments (p < 0.001) and a 99.93% decrease in OOP payments as a share of total inpatient expenditure (p < 0.001); whereas total inpatient expenditure was not significantly associated with the C-DRG reform. All the sensitivity analyses did not change the results significantly.

Conclusion

The implementation of C-DRG payment system reduced both the absolute amount of OOP payments and OOP payments as a share of total inpatient expenditure for older patients with hip fracture, without affecting total inpatient expenditure. These results may provide significant insights for policymakers in reducing the financial burden on older patients with hip fracture in other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02865-3.

National Variation in Elective Colon Resection for Diverticular Disease

OBJECTIVE

This study aims to characterize the extent of geographic variation in elective sigmoid resection for diverticulitis and to identify factors associated with observed variation.

INTRODUCTION

National guidelines for treatment of recurrent diverticulitis fail to offer strong recommendations for or against surgical intervention. We hypothesize that healthcare market factors will be significantly associated with geographic variation in colon resection for diverticulitis, a discretionary surgical intervention.

METHODS

We used Center for Medicare Services 100% inpatient Limited Data Set (LDS) files from January 2013 through September 2015 to calculate an observed to expected standardized colon resection ratio for each hospital referral region (HRR). We then analyzed patient, hospital-, and market-level factors associated with variation of colectomy. For each HRR, a Herfindahl-Hirschman index, a measure of market competition, was calculated.

RESULTS

A total of 19,557 Medicare patients underwent an elective colon resection for diverticulitis at 2462 hospitals over the study period. Standardized colon resection ratios ranged from 0 in the Tuscaloosa HRR to 3.7 in the Royal Oak, MI HRR. Few patient factors were associated with variation, but a number of hospital factors (size, area, profit status, and critical access designation) all were associated with variation. In an analysis of market factors, increased surgeon density, and decreased market competition were associated with higher predicted rates of colon resection.

CONCLUSION

We observed pronounced variation (excess of 3-fold) in standardized colon resection ratios for recurrent diverticulitis. Surgeon density and hospital level factors were strongly associated with this variation and may be the main drivers of colonic resection for diverticular disease. Further investigation and stronger national guidelines are needed to optimize patient selection for colectomy.

Association of Medicaid expansion under the Affordable Care Act with access to elective spine surgical care

OBJECTIVE

The Affordable Care Act expanded Medicaid eligibility in many states, improving access to some forms of elective healthcare in the United States. Whether this effort increased access to elective spine surgical care is unknown. This study's objective was to evaluate the impact of Medicaid expansion under the Affordable Care Act on the volume and payer mix of elective spine surgery in the United States.

METHODS

This study evaluated elective spine surgical procedures performed from 2011 to 2016 and included in the all-payer State Inpatient Databases of 10 states that expanded Medicaid access in 2014, as well as 4 states that did not expand Medicaid access. Adult patients aged 18-64 years who underwent elective spine surgery were included. The authors used a quasi-experimental difference-in-difference design to evaluate the impact of Medicaid expansion on hospital procedure volume and payer mix, independent of time-dependent trends. Subgroup analysis was conducted that stratified results according to cervical fusion, thoracolumbar fusion, and noninstrumented surgery.

RESULTS

The authors identified 218,648 surgical procedures performed in 10 Medicaid expansion states and 118,693 procedures performed in 4 nonexpansion states. Medicaid expansion was associated with a 17% (95% CI 2%-35%, p = 0.03) increase in mean hospital spine surgical volume and a 23% (95% CI -0.3% to 52%, p = 0.054) increase in Medicaid volume. Privately insured surgical volumes did not change significantly (incidence rate ratio 1.13, 95% CI -5% to 34%, p = 0.18). The increase in Medicaid volume led to a shift in payer mix, with the proportion of Medicaid patients increasing by 6.0 percentage points (95% CI 4.1-7.0, p < 0.001) and the proportion of private payers decreasing by 6.7 percentage points (95% CI 4.5-8.8, p < 0.001). Although the magnitude of effects varied, these trends were similar across procedure subgroups.

CONCLUSIONS

Medicaid expansion under the Affordable Care Act was associated with an economically and statistically significant increase in spine surgery volume and the proportion of surgical patients with Medicaid insurance, indicating improved access to care.

Racial disparity in recommendation for surgical resection of skull base chondrosarcomas: A Surveillance, Epidemiology, and End Results (SEER) analysis

INTRODUCTION

There is increased appreciation of racial disparities in the delivery of neurosurgical care. Here, we explore whether race influences surgical recommendations in the management of skull base chondrosarcomas.

METHODS

We identified 493 patients with skull base chondrosarcoma using the Surveillance, Epidemiology, and End Results (SEER) registry (November 2017 submission). Regression analyses were performed to identify demographic variables associated with recommendation against surgery. Univariate and multivariate cox proportional hazards models were used for survival analysis.

RESULTS

In a univariate analysis, we found that the African-American race was associated with an increased likelihood of surgeon recommendation against surgery (OR = 4.416, 95% CI = 1.893-10.302, p = 0.001). This association remained robust in the multivariate model that controlled for other covariates, including age of diagnosis (OR = 5.091, 95% CI = 2.127-12.187, p < 0.001). For patients who received a recommendation against surgery, the likelihood of dying from non-chondrosarcoma causes was comparable between Caucasian and African-American patients, suggesting that the prevalence and severity of medical conditions that increase the risk of death were comparable between these cohorts (HR = 0.466, 95% CI = 0.057-3.802, p = 0.475). The likelihood of dying from chondrosarcoma was comparable between Caucasian and African-American patients who underwent surgery (HR = 0.982, 95% CI = 0.353-2.732, p = 0.973), suggesting absence of race-specific surgical benefits.

CONCLUSION

We identified a racial disparity against African-Americans in recommendations for surgical resection of skull base chondrosarcomas.

Association of Medicare and Medicaid Insurance Status with Increased Spine Surgery Utilization Rates

STUDY DESIGN

Retrospective single-institution study.

OBJECTIVE

The aim of this study was to determine the relationship between patients' insurance status and the likelihood for them to be recommended various spine interventions upon evaluation in our neurosurgical clinics.

SUMMARY OF BACKGROUND DATA

Socioeconomically disadvantaged populations have worse outcomes after spine surgery. No studies have looked at the differential rates of recommendation for surgery for patients presenting to spine surgeons based on socioeconomic status.

METHODS

We studied patients initially seeking spine care from spine-fellowship trained neurosurgeons at our institution from July 1, 2018 to June 30, 2019. Multivariable logistic regression was used to assess the association between insurance status and the recommended patient treatment.

RESULTS

Overall, 663 consecutive outpatients met inclusion criteria. Univariate analysis revealed a statistically significant association between insurance status and treatment recommendations for surgery (P < 0.001). Multivariate logistic regression demonstrated that compared with private insurance, Medicare (odds ratio [OR] 3.54, 95% confidence interval [CI] 1.21-7.53, P = 0.001) and Medicaid patients (OR 2.46, 95% CI 1.21-5.17, P = 0.014) were more likely to be recommended for surgery. Uninsured patients did not receive recommendations for surgery at significantly different rates than patients with private insurance.

CONCLUSION

Medicare and Medicaid patients are more likely to be recommended for spine surgery when initially seeking spine care from a neurosurgeon. These findings may stem from a number of factors, including differential severity of the patient's condition at presentation, disparities in access to care, and differences in shared decision making between surgeons and patients.Level of Evidence: 3.

The Effects of the Affordable Care Act on Utilization of Bariatric Surgery

INTRODUCTION

The Affordable Care Act (ACA) expanded Medicaid (ME) and instituted Essential Health Benefits (EHB) that included bariatric surgery coverage on a state-by-state opt-in basis, increasing insurance coverage of bariatric surgery.

MATERIALS AND METHODS

Using a difference-in-differences framework, changes in bariatric surgery rates, defined as utilization in the population of people with obesity, before and after the ACA were evaluated in four states. Bariatric surgery procedure data were taken from the Healthcare Cost and Utilization Project's State In-patient Database 2012-2015. Adjusted multivariable regressions were run in the Medicaid and commercially insured populations.

RESULTS

We identified 36,456 bariatric surgeries across the 286 Health Service Areas and time periods, with 31,732 covered by commercial insurers and 4724 covered by Medicaid. An unadjusted increase in utilization rates was seen in the Medicaid and Commercial populations in both ME- and EHB-covered states as well as non-expansion and EHB opt-out states over time. In the Medicaid population, after adjusting for confounders, there was a significant increase of 24.77 cases per 100,000 people with obesity (95% confidence interval: 12.41, 37.13) in the expansion states relative to the control and pre-period. The commercial population experienced a nonsignificant change in the rates of bariatric surgery, decreasing by 2.89 cases per 100,000 people with obesity (95% confidence interval: - 21.59, 15.81).

CONCLUSIONS

There was a significant increase in bariatric surgery rates among Medicaid beneficiaries associated with Medicaid expansion, but there was no change among the commercially insured.

A Systematic Review of Health Disparities Research in Plastic Surgery

BACKGROUND

In this systematic review, the authors report on the current state of health disparities research in plastic surgery and consider how equity-oriented interventions are taking shape at the patient, provider, and health care system levels.

METHODS

The authors performed a systematic literature search of the PubMed/MEDLINE and Embase databases using search terms related to the social determinants of both health and plastic surgery. Two independent reviewers screened the article titles and abstracts for relevance and identified the plastic surgery focus and study characteristics of the included literature. The articles were then categorized as detecting, understanding, or reducing health disparities according to a conceptual framework. This review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

One hundred forty-seven articles published between 1997 and 2019 met the inclusion criteria. Health disparities research in gender-affirming, craniofacial, cosmetic, and hand surgery was lacking relative to breast reconstruction. Racial/ethnic and socioeconomic disparities were reported across subspecialties. Place of residence was also a large determinant of access to care and quality of surgical outcomes. Half of the included studies were in the detecting phase of research. Meanwhile, 40 and 10 percent were in the understanding and reducing phases, respectively.

CONCLUSIONS

Investigators suggested several avenues for reducing health disparities in plastic surgery, yet there is limited evidence on the actual effectiveness of equity-oriented initiatives. More comprehensive research is needed to disentangle the patient, provider, and system-level factors that underlie inequity across subspecialties.

Factors Affecting Patient Decision-Making Regarding Midshaft Clavicle Fracture Treatment

Introduction Midshaft clavicle fractures are a common problem encountered by orthopedic surgeons. There remains debate between non-surgical and surgical treatment options for certain midshaft clavicle fractures. Due to the lack of a clear treatment strategy, this presents an opportunity for shared decision-making, which has been shown to be important to patients. Methods A 19-question survey was created encompassing basic demographic information, then taking respondents through a simulation of a midshaft clavicle fracture patient encounter. Subjects were subsequently asked their preferred treatment choice as well as shared decision-making preferences for the simulated encounter. A pilot study was performed with medical students from our home institution to assess study sample size. The survey was then distributed through an online software platform (Amazon Mechanical Turk). Statistical analysis was performed using STATA, Microsoft Excel, and Qualtrics. Results 253 subjects responded to the online survey. Over 70% of respondents had no to minimal knowledge of clavicle fractures and potential medical interventions/treatments. 67.6% of respondents preferred shared decision-making, over autonomous or paternalistic models. 45.5% of respondents wanted additional time outside the physician-patient consultation before making a treatment decision. A majority of the respondents who selected surgery (44.3%; 43/97) and no surgery (69.9%; 109/156), based their decisions on outcomes data provided in the simulation alone. There was no statistically significant relationship between income, race/ethnicity, education level, work status, sex, or type of visual fracture representation (i.e., radiograph vs. cartoon image) and treatment decision (p>0.05). Younger age (p=0.007) and being married (p=0.001) were associated with increased likelihood to select surgery as the treatment decision.  Conclusion Most respondents had no-to-minimal knowledge about clavicle fractures, placed a high value in shared decision-making for midshaft clavicle fractures, and prioritized outcomes data in making treatment decisions. Younger age and marital status may increase the likelihood of a patient selecting to proceed with surgery over non-operative treatment.

The Affordable Care Act and emergency department use by low acuity patients in a US hospital

BACKGROUND

The Affordable Care Act (ACA) is one of the biggest healthcare reforms in US history. A key issue is the ACAs effect on low acuity, potentially primary care patients. This study evaluates the effect of the ACA on low acuity patients seen in the emergency department (ED).

METHODS

This is an age-period-cohort analysis for a community hospital ED in Michigan, from 2009 to 2015. Patients were stratified by age, year seen, emergency severity index (ESI) and insurance status. Data were compared between before and after ACA along with descriptive statistics, Chi-square and Student t-tests. The primary outcome was the change in ED usage by low acuity. Patients > 65 were used as a temporal control.

RESULTS

305,350 ED visits were analyzed. ED visits with ESI 4/5 increased from 11.9% to 14.8%. Patients < 19 years increased from 25.5% to 34.3% (p = .0026). Ages 19-25 increased from 16.3% to 19.7% (p = 0.0515). Ages 26-64 increased from 11% to 14.9% (p = 0.0129). Ages > 65 increased from 5.1% to 6.5%. Patients < 65 showed a decreased uninsured rate from 12.30% to 6.28% (p < 0.0001). Comparatively, for age > 65: uninsured rate remained the same 0.46% to 0.49%.

CONCLUSION

Low acuity ED visits increased with the ACA reform in conjunction with a more insured population.

Medicaid Expansion and Mechanical Ventilation in Asthma, Chronic Obstructive Pulmonary Disease, and Heart Failure

Rationale: The Affordable Care Act's Medicaid expansion has led to increased access to chronic disease care among newly insured adults. Despite this, its effects on clinical outcomes, particularly for patients with asthma, chronic obstructive pulmonary disease, and heart failure, are uncertain. Objectives: To assess whether Medicaid expansion was associated with changes in mechanical ventilation rates among hospitalized patients with heart failure, asthma, and chronic obstructive pulmonary disease. Methods: Difference-in-differences analysis comparing discharge data from four states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and three comparison states that did not (North Carolina, Nebraska, and Wisconsin) was performed. Models were adjusted for patient and hospital factors. Results: Mechanical ventilation rates at baseline were 7.2% in nonexpansion states and 8.8% in expansion states. Medicaid expansion was associated with a decline in mechanical ventilation rates at -0.2% per quarter (95% confidence interval [CI], -0.3% to 0.0%; P = 0.010). We did not observe a change in the rate of ICU admission (-0.4% per quarter; 95% CI, -0.8% to 0.1%; P = 0.10) or in-hospital mortality (0.1% per quarter; 95% CI, 0.0% to 0.1%; P = 0.30). In a negative control among adults aged 65 years or older, changes in mechanical ventilation rates were similar, though the CIs crossed zero (-0.1%; 95% CI, -0.2% to 0.0%; P = 0.08). Conclusions: Medicaid expansion may have been associated with a decline in mechanical ventilation rates among uninsured and Medicaid-covered patients admitted with heart failure, chronic obstructive pulmonary disease, and asthma.

The Relationship Between Medicaid Coverage and Outcomes Following Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article.

RESULTS

A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates.

CONCLUSIONS

Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform

BACKGROUND

In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy.

METHODS

Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure.

RESULTS

After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG).

CONCLUSIONS

This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.

Community level socioeconomic status association with surgical outcomes and resource utilisation in a regional cohort: a prospective registry analysis

BACKGROUND

Socioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation.

METHODS

All patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0-100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation.

RESULTS

A total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, p<0.0001) resulting in higher ACS-NSQIP predicted risk of any complication (8.0% vs 7.1%, p<0.0001). Patients from severely distressed communities had increased 30-day mortality (1.8% vs 1.4%, p=0.01), postoperative complications (9.8% vs 8.5%, p<0.0001), hospital readmission (7.7 vs 6.8, p<0.0001) and resource utilisation. DCI was independently associated with postoperative complications (OR 1.07, 95% CI 1.04 to 1.10, p<0.0001) as well as resource utilisation after adjusting for ACS-NSQIP predicted risk CONCLUSION: Increasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives.

Changes in healthcare delivery following spinal fracture in Medicare Accountable Care Organizations

BACKGROUND CONTEXT

Accountable Care Organizations (ACOs) were designed to reduce healthcare costs while simultaneously improving quality. Given that the success of ACOs is predicated on controlling costs, concerns have been expressed that patients could be adversely affected through restricted access to surgery, including in the context of spine fracture care.

PURPOSE

Evaluate the impact of Medicare ACO formation on the utilization of surgery and outcomes following spinal fractures.

STUDY DESIGN

Retrospective review of Medicare claims (2009-2014).

PATIENT SAMPLE

Patients treated for spinal fractures in an ACO or non-ACO.

OUTCOME MEASURES

The utilization of surgery as treatment for spinal fractures, in-hospital mortality, 90-day complications, or hospital readmission within 90-days injury.

METHODS

We used a pre-post study design to compare outcomes for patients treated in ACOs versus non-ACOs. Receipt of surgery for treatment of a spinal fracture was the primary outcome, with mortality, complications and readmissions treated secondarily. We used multivariable logistic regression adjusting for confounders to determine the association between environment of care (ACO vs. non-ACO) and the outcomes of interest. In all testing, beneficiaries treated in non-ACOs during 2009 to 2011 were used as the referent.

RESULTS

During 2009 to 2011, 9% (n=10,866) of patients treated in non-ACOs received surgery, whereas a similar percentage (9%; n=210) underwent surgery in ACOs. This figure decreased to 8% (n=9,857) for individuals treated in non-ACOs over 2012 to 2014, although the surgical rate remained unchanged for those receiving care in an ACO (9%; n=227). There was no difference in the use of surgery among patients treated in ACOs (OR 0.96; 95% CI 0.79, 1.18) over 2012 to 2014. Similar increases in the odds of mortality were observed for both ACOs and non-ACOs during this period. A marginal, yet significant increase in complications was observed among ACOs, although there was no change in the odds of readmission.

CONCLUSIONS

Our study found that the formation of ACOs did not result in alterations in the use of surgery for spinal fractures or substantive changes in outcomes. As ACOs continue to evolve, more emphasis should be placed on the incorporation of measures directly related to surgical and trauma care in the determinants of risk-based reimbursements.

Adult-Oriented Health Reform and Children's Insurance and Access to Care: Evidence from Massachusetts Health Reform

Objective A national debate is underway about the value of key provisions within the adult-oriented Affordable Care Act (ACA)-the individual mandate, expansion of Medicaid eligibility, and essential benefits. How these provisions affect child health insurance and access to care may help us anticipate how children may be affected if the ACA is repealed. We study Massachusetts health reform because it enacted these key provisions statewide in 2006. Methods We used a difference-in-differences (DD) approach to assess the impact of Massachusetts health reform on uninsurance and access to care among children 0-17 years in Massachusetts compared to children in other New England states. The National Survey of Children's Health provided the pre-reform year and two post-reform years (1 and 5 years post-reform). We analyzed outcomes for children overall and children previously and newly-eligible for Medicaid under Massachusetts health reform, adjusting for age, sex, race/ethnicity, non-English language, and having special health care needs. Results Compared to other New England states, Massachusetts's enactment of the individual mandate, Medicaid expansion, and essential benefits was associated with trends at 5 years post-reform toward lower uninsurance for children overall (DD = - 1.1, p-for-DD = 0.05), increased access to specialty care (DD = 7.7, p-for-DD = 0.06), but also with a decrease in access to preventive care (DD=-3.4, p-for-DD = 0.004). At 1 year post-reform, access to specialty care improved for children newly-Medicaid-eligible (DD = 18.3, p-for-DD = 0.03). Conclusions for Practice Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.

Incidence of thyroid cancer in Puerto Rico and the US by racial/ethnic group, 2011-2015

BACKGROUND

Puerto Rico has the highest incidence rate of thyroid cancer (TC) in the Americas and the third highest rate worldwide. The purpose of this study was to compare the burden of TC between the population of PR and United States (US) non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), and US Hispanics (USH) during the period 2011-2015.

METHODS

TC data for the period 2011-2015 was obtained from the Puerto Rico Central Cancer Registry (PRCCR) and the Surveillance Epidemiology and Ends Results Program (SEER) 18 Registries Research Data. TC was categorized in: papillary carcinoma (PTC), and other TC histologic types. Data was analyzed by sex, age groups, and histologic type. Racial/ethnic differences by sex, age, and histologic types were assessed using the Standardized Rate Ratio (SRR) and its 95% CI.

RESULTS

During the period 2011-2015 there were 5175 and 65,528 cases of TC diagnosed in PR and the US, respectively. The overall age-adjusted incidence rate of PTC was almost two-fold higher in PR than in the US (25.8/100,000 vs. 12.9/100,000). Among PR women, the incidence rate of PTC was 40.0/100,000 compared to 19.4/100,000 in US. PR women had 83% increased risk of being diagnosed with PTC than NHW women, a 2.25-fold increased risk than USH, and 3.45-fold increased risk than NHB women. For men, PR had 34% increased risk of being diagnosed with PTC than NHW men, 2.2-fold increased risk than USH men, and 3.2-fold higher risk than in NHB men.

CONCLUSION

Further research is needed to understand this disparity in the island. This research should address the extent of overdiagnosis in PR, the role of health insurance status and insurance type, characteristics of the healthcare delivery system as well as the role of patient and environmental factors.

Changes in Discharge to Rehabilitation: Potential Unintended Consequences of Medicare Total Hip Arthroplasty/Total Knee Arthroplasty Bundled Payments, Should They Be Implemented on a Nationwide Scale?

BACKGROUND

As a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale.

METHODS

A nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation.

RESULTS

Following bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains.

CONCLUSION

The results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.

Changes in hospital service demand, cost, and patient illness severity following health reform

OBJECTIVE

To estimate the effects of the health insurance exchange and Medicaid coverage expansions on hospital inpatient and emergency department (ED) utilization rates, cost, and patient illness severity, and also to test the association between changes in outcomes and the size of the uninsured population eligible for coverage in states.

DATA SOURCES

Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases, 2011-2015, Nielsen Demographic Data, and the American Community Survey.

STUDY DESIGN

Retrospective study using fixed-effects regression to estimate the effects in expansion and nonexpansion states by age/sex demographic groups.

FINDINGS

In Medicaid expansion states, rates of uninsured inpatient discharges and ED visits fell sharply in many demographic groups. For example, uninsured inpatient discharge rates across groups, except young females, decreased by ≥39 percent per capita on average in expansion states. In nonexpansion states, uninsured utilization rates remained unchanged or increased slightly (0-9.2 percent). Changes in all-payer and private insurance rates were more muted. Changes in inpatient costs per discharge were negative, and all-payer inpatient costs per discharge declined <6 percent in most age/sex groups. The size of the uninsured population eligible for coverage was strongly associated with changes in outcomes. For example, among males aged 35-54 years in expansion states, there was a 0.793 percent decrease in the uninsured discharge rate per unit increase in the coverage expansion ratio (the ratio of the size of the population eligible for coverage to the size of the previously covered population within an age/sex/payer/geographic group).

CONCLUSIONS

Significant shifts in cost per discharge and patient severity were consistent with selective take-up of insurance. The "treatment intensity" of expansions may be useful for anticipating future effects.

Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion

BACKGROUND

Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid).

METHODS

Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois' Medicaid expansion date: January 1, 2014).

RESULTS

The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012).

CONCLUSION

Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.

Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice

BACKGROUND

Insurance coverage of vascular surgery patients may differ from patients with less chronic surgical pathologies. The goal of this study is to identify trends in insurance status of vascular surgery patients over the last 10 years at a busy academic center.

METHODS

All consecutive patient visits for a vascular procedure from 2006 to 2016 were retrospectively reviewed from a prospectively collected institutional database. Data points included insurance status, procedures performed, and date of admission. The insurance status was categorized as Medicare, Medicaid, and uninsured. Samples were divided between 2006-2009 and 2011-2016 for comparison. Unpaired t-test, chi-squared test, and regression analysis were used to determine significant trends over the study period.

RESULTS

From 2006 to 2016, 6,007 vascular surgery procedures were performed. Procedure volume increased significantly from 1,309 to 4,698 between the 2 timeframes (P < 0.05), whereas the percentage of Medicaid and Medicare patients trended upward but did not achieve significance. There was a significant decrease in the percentage of uninsured patients between the cohorts (5.65% vs. 2.96%, P < 0.05). In 2012, 10.14% of patients were uninsured compared with 2.56% in 2016 (P < 0.05).

CONCLUSIONS

Insurance status affects access to care and subsequent outcomes. In our busy academic center, insurance coverage for vascular surgery has significantly increased over the past decade. The number of Medicaid and Medicare patients has slowly increased, but a significant and continuing decline in uninsured patients was observed. Implementation of the Affordable Care Act during this time period may have played a role in providing coverage for patient needing vascular surgery.

Impact of the Affordable Care Act on elective general surgery clinical practice

BACKGROUND

The Affordable Care Act (ACA) dramatically changed the healthcare system in the United States. This study aims to analyze the impact of the ACA on general surgery clinic visits and resultant procedures.

METHODS

A retrospective review was conducted on new patients who presented to the elective general surgery clinic at an academic medical center between Jan. 1, 2012 and Dec. 31, 2015. Based on the open enrollment start date of Jan.1, 2014 patients were divided into pre-ACA and post-ACA periods. Data on demographics, type of insurance, missed appointments, and elective surgical procedures performed were collected.

RESULTS

Medi-Cal insurance coverage increased post-ACA from 20.9% to 56.7%, p < 0.001; self-pay status went from 9.8% to 0%. There were 296 (35.4%) surgical procedures performed pre-ACA and 347 (37.1%) post-ACA (p = 0.445). Missed clinic visits decreased after implementation of the ACA, with 26.8% no-shows pre-ACA and 20.7% no-shows post-ACA (p = 0.003).

CONCLUSION

The ACA had a profound impact on the general surgery clinic with fewer uninsured patients, fewer no-shows and a modest increase in the number of procedures performed.

SUMMARY

In 2014 the Affordable Care Act mandate was implemented. This legislation impacted healthcare by significantly decreasing the number of uninsured patients and increasing overall volume in one general surgery clinic.

The Affordable Care Act's Medicaid expansion and utilization of discretionary vs. non-discretionary inpatient surgery

BACKGROUND

While pre-Affordable Care Act expansions in Medicaid eligibility led to increased utilization of elective inpatient procedures, the impact of the Affordable Care Act on such preference-sensitive procedures (also known as discretionary procedures) versus time-sensitive non-discretionary procedures remains unknown. As such, we performed a hospital-level quasi-experimental evaluation to measure the differential effects of the Affordable Care Act's Medicaid expansion on utilization of discretionary procedures versus non-discretionary procedures.

METHODS

The State Inpatient Database (2012-2014) yielded 476 hospitals providing selected discretionary procedures or non-discretionary procedures performed on 288,446 non-elderly, adult patients across 3 expansion states and 2 non-expansion control states. Discretionary procedures included non-emergent total knee and hip arthroplasty, while non-discretionary procedures included nine cancer surgeries. Mixed Poisson interrupted time series analyses were performed to determine the impact of the Affordable Care Act's Medicaid expansion on the number of discretionary procedures versus non-discretionary procedures provided among non-privately insured patients (Medicaid and uninsured patients) and privately insured patients.

RESULTS

Analysis of the number of non-privately insured procedures showed an increase in discretionary procedures of +15.1% (IRR 1.15, 95% CI:1.11-1.19) vs -4.0% (IRR 0.96, 95% CI:0.94-0.99) and non-discretionary procedures of +4.1% (IRR 1.04, 95% CI:1.0-1.1) vs -5.3% (IRR 0.95, 95% CI:0.93-0.97) in expansion states compared to non-expansion states, respectively. Analysis of privately insured procedures showed no statistically meaningful change in discretionary procedures or non-discretionary procedures in either expansion or non-expansion states.

CONCLUSION

In this multi-state evaluation, the Affordable Care Act's Medicaid expansion preferentially increased utilization of discretionary procedures versus non-discretionary procedures in expansion states compared to non-expansion states among non-privately insured patients. These preliminary findings suggest that increased Medicaid coverage may have contributed to the increased use of inpatient surgery for discretionary procedures.

Trends in Total Hip Arthroplasty Under the Patient Protection and Affordable Care Act: A National Database Analysis Between 2008 and 2015

The Patient Protection and Affordable Care Act expanded health coverage for low-earning individuals and families. With more Americans having access to care, the use of elective procedures, such as total hip arthroplasty (THA), was expected to increase. Therefore, the aim of this study was to evaluate trends in THA before and after the initiation of the Patient Protection and Affordable Care Act regarding race, age, body mass index, and sex between 2008 and 2015. The National Surgical Quality Improvement Program database was queried for all individuals who had undergone primary THA between 2008 and 2015. This yielded a total of 104,209 patients. Descriptive statistics were used to analyze patient-level data. A Cochran-Armitage test assessed trends in categorical data points over time. Analysis indicated an increased percentage of blacks or African Americans undergoing THA (7.8% vs 9.2%, P<.001), followed by Native Americans or Pacific Islanders (0.0% vs 0.4%, P<.001), American Indians or Alaskan Natives (0.3% vs 0.5%, P=.016), and Asians (1.4% vs 1.5%, P=.002). An increased percentage of patients 55 to 80 years old received THAs (68.6% vs 74.1%, P<.001). The percentage of patients with a body mass index of 25.0 to 29.9 kg/m², 30.0 to 34.9 kg/m², and 35.0 to 39.9 kg/m² increased (32.9% vs 33.1%, 24.2% vs 25.6%, 12.6% vs 13.3%, respectively, P<.001 for all). These findings may provide insight on the changing patient characteristics for orthopedic surgeons performing THA. Furthermore, these findings may inform health policy makers interested in increasing access to procedures underutilized by specific patient populations and the creation of strategies to meet increased demand. [Orthopedics. 2018; 41(4):e534-e540.].

The Impact of the Affordable Care Act on Urogynecologic Surgery Cancelation Rates

OBJECTIVES

We examined the impact of the implementation of the Affordable Care Act (ACA) on female pelvic medicine and reconstructive surgery (FPMRS) surgical cancelation rates.

METHODS

A retrospective cohort study was performed on patients scheduling FPMRS procedures 1 year before and after ACA implementation at a regional academic medical center. We compared cancelation rates as well as sociodemographic, surgical, and medical history data. Analysis included χ test, t test, and univariable and multivariable logistic regression.

RESULTS

We included 746 subjects, 373 each before and after ACA implementation (January 2014). Subjects were 59.2 ± 14.0 years old, predominantly white (94.9%), employed (45.8%), and married (66.6%), with a body mass index of 28.8 ± 6.2. Subjects lived a median of 24 miles from the hospital. None of these were significant predictors of cancelations. Surgery cancelation rate was 17.1% and occurred 9 days before surgery.On univariable analysis, cancelation rates did not differ relative to the ACA (15.5% before vs 18.6% after; mean difference, 3.16%; 95% confidence interval [CI], -2.29% to 8.69%; P = 0.254). Only 3 variables impacted cancelation rate on univariable analysis: women whose surgery was scheduled for later in the week, liver/renal disease, and minor vs major surgery.On multivariable regression including variables with P < 0.20 as candidate variables, the same 3 variables remained significant. Cancelations increased with procedures scheduled later in the week (odds ratio [OR], 1.169 per day; 95% CI, 1.004-1.361) and liver or renal disease (OR, 2.342; 95% CI, 1.015-5.405). Major procedures had fewer cancelations (OR, 0.625; 95% CI, 0.414-0.943). The ACA implementation of still did not impact cancelations (OR, 1.230; 95% CI, 0.831-1.821).

CONCLUSIONS

The implementation of the ACA did not impact FPMRS cancelation rates. Significant predictors of surgical cancelation included later day of the week, comorbid renal or liver disease, and performance of a minor procedure.

Health Reform and Utilization of High-Volume Hospitals for Complex Cancer Operations

PURPOSE

Underinsured patients are less likely to receive complex cancer operations at hospitals with high surgical volumes (high-volume hospitals, or HVHs), which contributes to disparities in care. To date, the impact of insurance coverage expansion on site of complex cancer surgery remains unknown.

METHODS

Using the 2006 Massachusetts coverage expansion as a natural experiment, we searched the Hospital Cost and Utilization Project state inpatient databases for Massachusetts and control states (New York, New Jersey, and Florida) between 2001 and 2011 to evaluate changes in the utilization of HVHs for resections of bladder, esophageal, stomach, pancreatic, rectal, or lung cancer after the expansion of insurance coverage. We studied nonelderly, adult patients with private insurance and those with government-subsidized or self-pay (GSSP) coverage with a difference-in-differences framework.

RESULTS

We studied 11,687 patients in Massachusetts and 56,300 patients in control states. Compared with control states, the 2006 Massachusetts insurance expansion was associated with a 14% increased rate of surgical intervention for GSSP patients (incident rate ratio, 1.14; P = .015), but there was no significant change in the probability of GSSP patients undergoing surgery at an HVH (1.0 percentage-point increase; P = .710). The reform was associated with no change in the uninsured payer-mix at HVHs (0.6 percentage-point increase; P = .244) and with a 5.1 percentage-point decrease for the uninsured payer mix at low-volume hospitals ( P < .001).

CONCLUSION

The 2006 Massachusetts insurance expansion, a model for the Affordable Care Act, was associated with increased rates of complex cancer operations and increased insurance coverage but with no change in utilization of HVH for complex cancer operations.

The impact of the 2006 Massachusetts health care reform law on spine surgery patient payer-mix status and age

OBJECTIVE Several similarities exist between the Massachusetts health care reform law of 2006 and the Affordable Care Act (ACA). The authors' prior neurosurgical research showed a decrease in uninsured surgeries without a significant change in surgical volume after the Massachusetts reform. An analysis of the payer-mix status and the age of spine surgery patients, before and after the policy, should provide insight into the future impact of the ACA on spine surgery in the US. METHODS Using the Massachusetts State Inpatient Database and spine ICD-9-CM procedure codes, the authors obtained demographic information on patients undergoing spine surgery between 2001 and 2012. Payer-mix status was assigned as Medicare, Medicaid, private insurance, uninsured, or other, which included government-funded programs and workers' compensation. A comparison of the payer-mix status and patient age, both before and after the policy, was performed. The New York State data were used as a control. RESULTS The authors analyzed 81,821 spine surgeries performed in Massachusetts and 248,757 in New York. After 2008, there was a decrease in uninsured and private insurance spine surgeries, with a subsequent increase in the Medicare and "other" categories for Massachusetts. Medicaid case numbers did not change. This correlated to an increase in surgeries performed in the age group of patients 65-84 years old, with a decrease in surgeries for those 18-44 years old. New York showed an increase in all insurance categories and all adult age groups. CONCLUSIONS After the Massachusetts reform, spine surgery decreased in private insurance and uninsured categories, with the majority of these surgeries transitioning to Medicare. Moreover, individuals who were younger than 65 years did not show an increase in spine surgeries, despite having greater access to health insurance. In a health care system that requires insurance, the decrease in private insurance is primarily due to an increasing elderly population. The Massachusetts model continues to show that this type of policy is not causing extreme shifts in the payer mix, and suggests that spine surgery will continue to thrive in the current US health care system.

Association of Insurance Expansion With Surgical Management of Thyroid Cancer

Importance

To our knowledge, thyroid cancer incidence is increasing faster than any other cancer type and is currently the fifth most common cancer among women. While this rise is likely multifactorial, there has been scarce consideration of the effect of insurance statuses on the treatment of thyroid cancer.

Objective

We evaluate the association of insurance expansion with thyroid cancer treatment using the 2006 Massachusetts health reform, which serves as a unique natural experiment.

Design, Setting, and Participants

We used the Agency for Healthcare Research and Quality State Inpatient Databases to identify patients with government-subsidized or self-pay insurance or private insurance who were admitted to a hospital with thyroid cancer and underwent a thyroidectomy between 2001 and 2011 in Massachusetts (n = 8534) and 3 control states (n = 48 047). Difference-in-differences models were used to evaluate an association between the 2006 Massachusetts health care reform and thyroid cancer treatment, and participants were controlled for age, sex, comorbidities, and secular trends.

Main Outcomes and Measures

Change in the thyroidectomy rate for thyroid cancer treatment was the primary outcome evaluated.

Results

The Massachusetts cohort consisted of 6443 women (75.5%) and 2091 men (24.5%), of whom 6388 (79.6%) were white, 391 (4.9%) were black, 527 (6.6%) were Hispanic, 424 (5.3%) were Asian/Pacific Islander, 63 (0.8%) were Native American, and 228 (2.8%) were other. The participants from control states included 36 818 women (76.6%) and 11 229 men (23.4%), of whom 30 432 (65.5%) were white, 3818 (8.2%) were black, 6462 (13.9%) were Hispanic, 2591 (5.6%) were Asian/Pacific Islander, 211 (0.5%) were Native American, and 2947 (6.3%) were other. Before the 2006 Massachusetts insurance expansion, patients with government-subsidized or self-pay insurance had lower thyroidectomy rates for thyroid cancer in Massachusetts and the control states compared with patients with private insurance. The Massachusetts insurance expansion was associated with a 26% increased rate of undergoing a thyroidectomy (incident rate ratio, 1.26; 95% CI, 1.04-1.52; P = .02) and a 22% increased rate of neck dissection (incident rate ratio, 1.22; 95% CI, 1.07-1.37; P = .002) for treating cancer compared with control states.

Conclusions and Relevance

The 2006 Massachusetts health reform, which is a model for the Affordable Care Act, was associated with a 26% increased rate of thyroidectomy for treating thyroid cancer. Our study suggests that insurance expansion may be associated with increased access to the surgical management of thyroid cancer. Further studies need to be conducted to evaluate the effect of healthcare expansion at a national level.

Changes in Hospital Inpatient Utilization Following Health Care Reform

OBJECTIVE

To estimate the effects of 2014 Medicaid expansions on inpatient outcomes.

DATA SOURCES

Health Care Cost and Utilization Project State Inpatient Databases, 2011-2014; population and unemployment estimates.

STUDY DESIGN

Retrospective study estimating effects of Medicaid expansions using difference-in-differences regression. Outcomes included total admissions, referral-sensitive surgical and preventable admissions, length of stay, cost, and patient illness severity.

FINDINGS

In 2014 quarter four, compared with nonexpansion states, Medicaid admissions increased (28.5 percent, p = .006), and uninsured and private admissions decreased (-55.1 percent, p = .001, and -6.6 percent, p = .052), whereas all-payer admissions showed little change. Uninsured expansion effects were negative for preventable admissions (-24.4 percent, p = .068), length of stay (-9.3 percent, p = .039), total cost (-9.2 percent, p = .128), and illness severity (-4.5 percent, p = .397). Significant positive expansion effects were found for Medicaid referral-sensitive surgeries (11.8 percent, p = .021) and patient illness severity (2.3 percent, p = .015). Private and all-payer expansion effects for outcomes other than admission volume were small and mainly nonsignificant (p > .05).

CONCLUSION

Medicaid expansions did not change all-payer admission volumes, but they were associated with increased Medicaid and decreased uninsured volumes. Results suggest those previously uninsured with greater needs for inpatient services were most likely to gain coverage. Compositional changes in uninsured and Medicaid admissions may be due to selection.

Impact of Massachusetts Health Reform on Enrollment Length and Health Care Utilization in the Unsubsidized Individual Market

OBJECTIVE

To evaluate the impact of the 2006 Massachusetts health reform, the model for the Affordable Care Act, on short-term enrollment and utilization in the unsubsidized individual health insurance market.

DATA SOURCE

Seven years of administrative and claims data from Harvard Pilgrim Health Care.

RESEARCH DESIGN

We employed pre-post survival analysis and an interrupted time series design to examine changes in enrollment length, utilization patterns, and use of elective procedures (discretionary inpatient surgeries and infertility treatment) among nonelderly adult enrollees before (n = 6,912) and after (n = 29,207) the MA reform.

PRINCIPAL FINDINGS

The probability of short-term enrollment dropped immediately after the reform. Rates of inpatient encounters (HR = 0.83, 95 percent CI: 0.74, 0.93), emergency department encounters (HR = 0.85, 95 percent CI: 0.80, 0.91), and discretionary inpatient surgeries (HR = 0.66 95 percent CI: 0.45, 0.97) were lower in the postreform period, whereas the rate of ambulatory visits was somewhat higher (HR = 1.04, 95 percent CI: 1.00, 1.07). The rate of infertility treatment was higher after the reform (HR = 1.61, 95 percent CI: 1.33, 1.97), driven by women in individual (vs. family) plans. The reform was not associated with increased utilization among short-term enrollees.

CONCLUSIONS

MA health reform was associated with a decrease in short-term enrollment and changes in utilization patterns indicative of reduced adverse selection in the unsubsidized individual market. Adverse selection may be a problem for specific, high-cost treatments.

Outcomes are Worse in US Patients Undergoing Surgery on Weekends Compared With Weekdays

BACKGROUND

Increasing surgical access to previously underserved populations in the United States may require a major expansion of the use of operating rooms on weekends to take advantage of unused capacity. Although the so-called weekend effect for surgery has been described in other countries, it is unknown whether US patients undergoing moderate-to-high risk surgery on weekends are more likely to experience worse outcomes than patients undergoing surgery on weekdays.

OBJECTIVE

The aim of this study was to determine whether patients undergoing surgery on weekends are more likely to die or experience a major complication compared with patients undergoing surgery on a weekday.

RESEARCH DESIGN

Using all-payer data, we conducted a retrospective cohort study of 305,853 patients undergoing isolated coronary artery bypass graft surgery, colorectal surgery, open repair of abdominal aortic aneurysm, endovascular repair of abdominal aortic aneurysm, and lower extremity revascularization. We compared in-hospital mortality and major complications for weekday versus weekend surgery using multivariable logistic regression analysis.

RESULTS

After controlling for patient risk and surgery type, weekend elective surgery [adjusted odds ratio (AOR)=3.18; 95% confidence interval (CI), 2.26-4.49; P<0.001] and weekend urgent surgery (AOR=2.11; 95% CI, 1.68-2.66; P<0.001) were associated with a higher risk of death compared with weekday surgery. Weekend elective (AOR=1.58; 95% CI, 1.29-1.93; P<0.001) and weekend urgent surgery (AOR=1.61; 95% CI, 1.42-1.82; P<0.001) were also associated with a higher risk of major complications compared with weekday surgery.

CONCLUSIONS

Patients undergoing nonemergent major cardiac and noncardiac surgery on the weekends have a clinically significantly increased risk of death and major complications compared with patients undergoing surgery on weekdays. These findings should prompt decision makers to seek to better understand factors, such physician and nurse staffing, which may contribute to the weekend effect.

Did Pre-Affordable Care Act Medicaid Expansion Increase Access to Surgical Cancer Care?

BACKGROUND

Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities.

STUDY DESIGN

From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series.

RESULTS

The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion.

CONCLUSIONS

Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion.

Impact of the 2006 Massachusetts health care insurance reform on neurosurgical procedures and patient insurance status

OBJECTIVE

The Massachusetts health care insurance reform law passed in 2006 has many similarities to the federal Affordable Care Act (ACA). To address concerns that the ACA might negatively impact case volume and reimbursement for physicians, the authors analyzed trends in the number of neurosurgical procedures by type and patient insurance status in Massachusetts before and after the implementation of the state's health care insurance reform. The results can provide insight into the future of neurosurgery in the American health care system.

METHODS

The authors analyzed data from the Massachusetts State Inpatient Database on patients who underwent neurosurgical procedures in Massachusetts from 2001 through 2012. These data included patients' insurance status (insured or uninsured) and the numbers of procedures performed classified by neurosurgical procedural codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Each neurosurgical procedure was grouped into 1 of 4 categories based on ICD-9-CM codes: 1) tumor, 2) other cranial/vascular, 3) shunts, and 4) spine. Comparisons were performed of the numbers of procedures performed and uninsured patients, before and after the implementation of the reform law. Data from the state of New York were used as a control. All data were controlled for population differences.

RESULTS

After 2008, there were declines in the numbers of uninsured patients who underwent neurosurgical procedures in Massachusetts in all 4 categories. The number of procedures performed for tumor and spine were unchanged, whereas other cranial/vascular procedures increased. Shunt procedures decreased after implementation of the reform law but exhibited a similar trend to the control group. In New York, the number of spine surgeries increased, as did the percentage of procedures performed on uninsured patients. Other cranial/vascular procedures decreased.

CONCLUSIONS

After the Massachusetts health care insurance reform, the number of uninsured individuals undergoing neurosurgical procedures significantly decreased for all categories, but more importantly, the total number of surgeries performed did not change dramatically. To the extent that trends in Massachusetts can predict the overall US experience, we can expect that some aspects of reimbursement may be positively impacted by the ACA. Neurosurgeons, who often treat patients with urgent conditions, may be affected differently than other specialists.

Access to Quaternary Care Surgery: Implications for Accountable Care Organizations

BACKGROUND

Accountable care organizations (ACOs) attempt to provide the most efficient and effective care to patients within a region. We hypothesized that patients who undergo surgery closer to home have improved survival due to proximity of preoperative and post-discharge care.

STUDY DESIGN

All (17,582) institutional American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) patients with a documented ZIP code and predicted risk, who underwent surgery at our institution (2005 to 2014), were evaluated. Google Maps calculated travel times, and patients were stratified by 1 hour of travel (local vs regional). Multivariable logistic regression and Cox proportional hazard models were used to evaluate the NSQIP risk-adjusted effects of travel time on operative morbidity, mortality, and long-term survival.

RESULTS

Median travel time was 65 minutes, with regional patients demonstrating significantly higher rates of ascites, hypertension, diabetes, disseminated cancer, >10% weight loss, higher American Society of Anesthesiologists (ASA) score, higher predicted risk of morbidity and mortality, and lower functional status (all p < 0.01). After adjusting for ACS NSQIP-predicted risk, travel time was not significantly associated with 30-day mortality (odds ratio [OR] 1.06; p = 0.42) or any major morbidities (all p > 0.05). However, survival analysis demonstrated that travel time is an independent predictor of long-term mortality (OR 1.24; p < 0.001).

CONCLUSIONS

Patients traveling farther for care at a quaternary center had higher rates of comorbidities and predicted risk of complications. Additionally, travel time predicts risk-adjusted long-term mortality, suggesting a major focus of ACOs will need to be integration of care at the periphery of their region.

The ACA: Impacts on Health, Access, and Employment

On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law. This comprehensive health care reform legislation sought to expand health care coverage to millions of Americans, control health care costs, and improve the overall quality of the health care system. The ACA required that all US citizens and legal residents have qualifying health insurance by 2014. In this paper we give readers a brief overview of the effects of the ACA based on recent research. We then turn our attention to the possibility of using the ACA expansion to answer important underlying questions, such as: To what extent does the holding of insurance lead to improvements in access to care? To what extent does the holding of coverage lead to improvements in health? In mental health? Are there likely general equilibrium effects on labor force participation, hours worked, employment setting, and indeed even the probability of marrying? By necessity, researchers' ability to answer these questions depends on the availability of data, so we discuss current and potential data sources relevant for answering these questions. We also look to what has been studied about the health reform in Massachusetts and early Medicaid expansions to speculate what we can expect to learn about the effects of the ACA on these outcomes in the future.

Massachusetts Healthcare Reform and Trends in Emergent Colon Resection

BACKGROUND

Insurance impacts access to therapeutic options, yet little is known about how healthcare reform might change the pattern of surgical admissions.

OBJECTIVE

We compared rates of emergent admissions and outcomes after colectomy before and after reform in Massachusetts with a nationwide control group.

DESIGN

This study is a retrospective cohort analysis in a natural experiment. Prereform was defined as hospital discharge from 2002 through the second quarter of 2006 and postreform from the third quarter of 2006 through 2012. Categorical variables were compared by χ. Piecewise functions were used to test the effect of healthcare reform on the rate of emergent surgeries.

SETTINGS

The study included acute care hospitals in the Massachusetts Healthcare Cost and Utilization Project State Inpatient Database (2002-2012) and the Nationwide Inpatient Sample (2002-2011).

PATIENTS

Patients aged 18 to 64 years with public or no insurance who underwent inpatient colectomy (via International Classification of Diseases, Ninth Revision, Clinical Modification procedural code) were included and patients with Medicare were excluded.

INTERVENTION

Massachusetts health care reform was the study intervention.

MAIN OUTCOME MEASURES

We measured the rate of emergent colectomy, complications, and mortality.

RESULTS

The unadjusted rate of emergent colectomies was lower in Massachusetts after reform but did not change nationally over the same time period. For emergent surgeries in Massachusetts, a piecewise model with an inflection point (peak) in the third quarter of 2006, coinciding with implementation of healthcare reform in Massachusetts, had a lower mean squared error than a linear model. In comparison, the national rate of emergent surgeries demonstrated no change in pattern. Postreform, length of stay decreased by 1 day in Massachusetts; however, there were no significant improvements in other outcomes.

LIMITATIONS

The study was limited by its retrospective design and unadjusted analysis.

CONCLUSIONS

There was a unique and sustained decline in the rate of emergent colon resection among publically insured and uninsured patients after 2006 in Massachusetts, in contradistinction to the national pattern, suggesting improved access to care associated with health insurance expansion. The reasons for lack of improvement in outcomes are multifactorial.

Insurance status is associated with complex presentation among emergency general surgery patients

BACKGROUND

The Affordable Care Act has the potential to significantly affect access to care for previously uninsured patients in need of emergency general surgical care. Our objective was to determine the relationship between insurance status and disease complexity at presentation among a national sample of emergency general surgical patients.

METHODS

Data from the National Emergency Department Sample from 2006-2009 were queried to identify all patients aged 18-64 years old admitted through the emergency department with a primary diagnosis of appendicitis, diverticulitis, inguinal hernia, or bowel obstruction. Primary outcome of complex presentation was defined as also presenting with generalized peritonitis, intra-abdominal abscess, perforated bowel, intestinal gangrene, or other disease-specific measures of complexity. We used multivariable logistic regression to determine the independent association between insurance status and complex presentation. Models accounted for patient- and hospital-level covariates. Counterfactual models were used to estimate the risk of complex presentation attributable to lack of insurance.

RESULTS

A total of 1,373,659 patients were included, with an overall uninsured rate of 12.3%. Uninsured patients had significantly higher, unadjusted rates of complex presentation, and uninsured payer status was independently associated with complex presentation (odds ratio 1.38, 95% confidence interval: 1.34-1.42). Counterfactual models suggest that having insurance would result in a 22.37% (95% confidence interval: 22.35-22.39%) relative decline in risk of complex emergency general surgical presentation among the uninsured population.

CONCLUSION

Insurance status is independently associated with severity of disease at presentation among emergency general surgical conditions nationally. In light of recently reaffirmed Affordable Care Act insurance expansion provisions, these results anticipate increased timely access to operative care for newly insured patients and a corresponding decline in complex, emergency general surgical presentations.