Association of health insurance status with presentation and outcomes of coronary artery disease among nonelderly adults undergoing percutaneous coronary intervention

Effect of Insurance Status on Outcomes of Acute Ischemic Stroke Patients Receiving Intra-Arterial Treatment: Results from the Paul Coverdell National Acute Stroke Program

BACKGROUND

Stroke continues to be a leading cause of death and disability in the United States. Rates of intra-arterial reperfusion treatments (IAT) for acute ischemic stroke (AIS) are increasing, and these treatments are associated with more favorable outcomes. We sought to examine the effect of insurance status on outcomes for AIS patients receiving IAT within a multistate stroke registry.

METHODS

We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) from 2014 to 2019 to quantify rates of IAT (with or without intravenous thrombolysis) after AIS. We modeled outcomes based on insurance status: private, Medicare, Medicaid, or no insurance. Outcomes were defined as rates of discharge to home, in-hospital death, symptomatic intracranial hemorrhage (sICH), or life-threatening hemorrhage during hospitalization.

RESULTS

During the study period, there were 486,180 patients with a clinical diagnosis of AIS (mean age 70.6 years, 50.3% male) from 674 participating hospitals in PCNASP. Only 4.3% of patients received any IAT. As compared to private insurance, uninsured patients receiving any IAT were more likely to experience in-hospital death (AOR 1.36 [95% CI 1.07-1.73]). Medicare (AOR 0.78 [95% CI 0.71-0.85]) and Medicaid (AOR 0.85 [95% CI 0.75-0.96]) beneficiaries were less likely but uninsured patients were more likely (AOR 1.90 [95% CI 1.61-2.24]) to be discharged home. Insurance status was not found to be independently associated with rates of sICH.

CONCLUSIONS

Insurance status was independently associated with in-hospital death and discharge to home among AIS patients undergoing IAT.

Association Between Health Insurance Status and In-Hospital Outcomes After ST-Segment Elevation Myocardial Infarction

Lack of health insurance is associated with adverse clinical outcomes; however, association between health insurance status and outcomes in patients presenting with ST-elevation myocardial infarction (STEMI) is unclear. Using the Nationwide Inpatient Sample data from 2003 to 2014, hospitalizations with STEMI in patients 18 years of age and older were extracted. Based on health insurance status, patients were categorized into insured and uninsured groups. The primary outcome measure was in-hospital mortality. Adjusted analysis using inverse probability weighting with multivariable regression was performed to identify independent predictors of in-hospital mortality. Of 2,710,375 patients included in the final analysis, 220,770 patients were uninsured. Unadjusted in-hospital mortality was lower in uninsured patients (5.1% vs 9.3%; p <0.001). Adjusted analysis showed that lack of health insurance was associated with the worst in-hospital mortality (odds ratio [OR] = 1.77, 95% confidence interval [CI] 1.72 to 1.82; p <0.001). Other independent predictors of in-hospital mortality were low household income (OR = 1.08, 95% CI 1.07 to 1.09; p <0.001), acute stroke (OR = 2.87, 95% CI 2.80 to 2.95; p <0.001), acute kidney injury (OR = 2.60, 95% CI 2.57 to 2.64; p <0.001), cardiac arrest (OR = 8.88, 95% CI 8.77 to 8.99; p <0.001), cardiogenic shock (OR = 5.81, 95% CI 5.74 to 5.88; p <0.001), requirement of pericardiocentesis (OR = 10.54, 95% CI 9.64 to 11.52; p <0.001), gastrointestinal bleeding (OR = 1.41, 95% CI 1.38 to 1.54; p <0.001), and pneumonia (OR = 1.43, 95% CI 1.41 to 1.45; p <0.001). The multivariate model demonstrated good statistical discrimination (c-statistic = 0.89). In conclusion, lack of health insurance is independently associated with increased in-hospital mortality in patients presenting with STEMI.

Variation in access to pediatric surgical care among coexisting public and private providers: inguinal hernia as a model

BACKGROUND

Faced with growing healthcare demand, the Saudi government is increasingly relying on privatization as a tool to improve patient access to care. Variation in children's access to surgical care between public (PB) and private providers (PV) has not been previously analyzed.

OBJECTIVES

To compare access to pediatric surgical services between two coexisting PB and PV.

DESIGN

Retrospective comparative study.

SETTINGS

A major teaching hospital and the largest PV group in Saudi Arabia.

PATIENTS AND METHODS

The outcomes for children who underwent inguinal herniotomy (IH) between May 2010 and December 2014 at both providers were with IH serving as the model. Data collected included patient demographics, insurance coverage, referral pattern and access parameters including time-to-surgery (TTS), surgery wait time (SWT) and duration of symptoms (DOS).

MAIN OUTCOME MEASURE(S)

TTS, SWT and DOS.

RESULTS

Of 574 IH cases, 56 cases of in-hospital referrals were excluded leaving 290 PB and 228 PV cases. PV patients were younger (12.0 vs 16.4 months, P=.043) and more likely to be male (81.6% vs 72.8%, P=.019), expatriates (18% vs 3.4%, P < .001) and insured (47.4% vs 0%, P < .001). The emergency department was more frequently the source for PB referrals (35.2% vs 12.7%, P < .001) while most PV patients were self-referred (72.8% vs 16.7%, P < .001). Access parameters were remarkably better at PV: TTS (21 vs 66 days, P < .001), SWT (4 vs 31 days, P < .001) and DOS (33 vs 114 days, P < .001).

CONCLUSION

When coexisting, PV offers significantly better access to pediatric surgical services compared to PB. Diverting public funds to expand children's access to PV can be a valid choice to improve access to care in case when outcomes with the two providers are similar.

LIMITATIONS

Although it is the first and largest comparison in the pediatric population, the sample may not represent the whole population since it is confined to a single selected surgical condition.

Analysis of Total Ankle Arthroplasty Survival in the United States Using Multiple State Databases

The aim of this study was to evaluate survivorship and risk factors for failure of total ankle arthroplasty (TAA) in the United States using large statewide, multipayer databases of inpatient discharges. TAA patients from 2005 to 2009 were identified from the Healthcare Cost and Utilization Project databases for 5 states (California, Florida, Nebraska, North Carolina, and Utah) and the New York Department of Health Statewide Planning and Research Cooperative System database. Patient demographics and clinical characteristics were extracted, and a multivariable logistic regression model was developed to assess risk factors for 90-day all-cause readmission and failure. Failure was defined as revision, arthrodesis, amputation, or implant removal. During the period of interest, 1545 patients received 1593 TAA. The coded etiology of arthritis was primary osteoarthritis (n = 854, 55.2%), posttraumatic arthritis (n = 466, 30.2%), rheumatoid arthritis (n = 129, 8.4%), and other (n = 96, 6.2%). The 5-year survival rate was 90.1%. Patients with a coded diagnosis of rheumatoid arthritis (odds ratio [OR] = 2.18; 95% confidence interval [CI] = 1.04-4.01) or who were readmitted within 90 days of TAA (OR = 3.41; 95% CI = 1.67-6.97) had significantly increased risk of failure. Risk factors for readmission were Charlson-Deyo Score ≥2 (OR = 3.05; 95% CI = 1.51-6.15) and increased length of stay during the arthroplasty (OR = 1.30; 95% CI = 1.16-1.47).

LEVELS OF EVIDENCE

Therapeutic, Level IV: Observational study.

Complications following primary and revision transsphenoidal surgeries for pituitary tumors

OBJECTIVES/HYPOTHESIS

This study aimed to determine the incidence of major complications following both primary and revision transsphenoidal pituitary surgery. Major complications included endocrinopathic, skull base, orbital, hemorrhagic and thromboembolic complications, respiratory failure, and death. Secondarily, this study aimed to examine factors associated with the occurrence of complications.

STUDY DESIGN

Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008.

METHODS

The major complication rate following both primary and revision transsphenoidal pituitary surgery was calculated. Bivariate analyses were performed to investigate the relationship of patient characteristics with complication occurrence, and a multivariate model was constructed to determine risk factors associated with these complications.

RESULTS

There were 5,277 primary cases and 192 revision cases that met inclusion criteria. There was a nonsignificant absolute difference of 3.09% (95% confidence interval [CI]: -11.00 to 16.14) between the rate of complications following primary (n = 443, 8.39%) and revision (n = 22, 11.46%) surgeries. Multivariate analyses showed that patients with Medicare (odds ratio [OR]:1.74, 95% CI: 1.17 to 2.61), Medicaid (OR: 2.13, 95% CI: 1.59 to 2.86), or a malignant neoplasm (OR: 3.10, 95% CI: 1.62 to 5.93) were more likely to have complications.

CONCLUSIONS

The rate of major complications following transsphenoidal pituitary surgery is lower than earlier retrospective reports. The overall complication rate following revision surgery was not significantly different from primary surgery. Insurance status and a diagnosis of a malignant neoplasm were associated with a higher rate of complications.

LEVEL OF EVIDENCE

2C.

Medicaid status is associated with higher surgical site infection rates after spine surgery

STUDY DESIGN

The Spine End Results Registry (2003-2004) is a registry of prospectively collected data of all patients undergoing spinal surgery at the University of Washington Medical Center and Harborview Medical Center. Insurance data were prospectively collected and used in multivariate analysis to determine risk of perioperative complications.

OBJECTIVE

Given the negative financial impact of surgical site infections (SSIs) and the higher overall complication rates of patients with a Medicaid payer status, we hypothesized that a Medicaid payer status would have a significantly higher SSI rate.

SUMMARY OF BACKGROUND DATA

The medical literature demonstrates lesser outcomes and increased complication rates in patients who have public insurance than those who have private insurance. No one has shown that patients with a Medicaid payer status compared with Medicare and privately insured patients have a significantly increased SSI rate for spine surgery.

METHODS

The prospectively collected Spine End Results Registry provided data for analysis. SSI was defined as treatment requiring operative debridement. Demographic, social, medical, and the surgical severity index risk factors were assessed against the exposure of payer status for the surgical procedure.

RESULTS

The population included Medicare (N = 354), Medicaid (N = 334), the Veterans' Administration (N = 39), private insurers (N = 603), and self-pay (N = 42). Those patients whose insurer was Medicaid had a 2.06 odds (95% confidence interval: 1.19-3.58, P = 0.01) of having a SSI compared with the privately insured.

CONCLUSION

The study highlights the increased cost of spine surgical procedures for patients with a Medicaid payer status with the passage of the Patient Protection and Affordable Care Act of 2010. The Patient Protection and Affordable Care Act of 2010 provisions could cause a reduction in reimbursement to the hospital for taking care of patients with Medicaid insurance due to their higher complication rates and higher costs. This very issue could inadvertently lead to access limitations.

LEVEL OF EVIDENCE

3.

Early results of Massachusetts healthcare reform on racial, ethnic, and socioeconomic disparities in cardiovascular care

BACKGROUND

Insured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex.

METHODS AND RESULTS

Using hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63-0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74-0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01-1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform.

CONCLUSIONS

Reducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures.

Complications of primary and revision functional endoscopic sinus surgery for chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The goal of this study was to determine the incidence of major complications following primary and revision functional endoscopic sinus surgery (FESS). In addition, this study aimed to determine factors associated with the occurrence of complications including patient and provider characteristics and the use of image guidance system (IGS) technology.

STUDY DESIGN

Retrospective cohort analysis of California and Florida all-payer databases from 2005 to 2008.

METHODS

The rates of major surgical complications (skull base, orbital, and hemorrhagic) after primary and revision FESS were calculated, and bivariate analyses were performed to investigate relationships of complications with demographic and clinical characteristics. A multivariate model was used to determine risk factors for the occurrence of major complications.

RESULTS

Among 78,944 primary FESS cases, 288 major complications were identified representing a complication rate of 0.36% (95% CI 0.32%-0.40%). The major complication rate following revision cases (n = 19; 0.46%) and primary cases (n = 288; 0.36%) was similar (OR = 1.26; 95% CI 0.79-2.00). Multivariate analysis showed that patients who were >40 years old, had a primary payer of Medicaid, had surgery involving the frontal sinus, or had image guidance during surgery were at higher risk for major complications.

CONCLUSION

The rate of major complications (0.36%) associated with primary FESS is lower than earlier reports. The rate of major complications following revision FESS (0.46%) was found to be similar to primary cases. IGS, insurance status, age, and extent of surgery were found to be associated with an increased risk of major complications following FESS.

LEVEL OF EVIDENCE

2C.

Medicaid status is associated with higher complication rates after spine surgery

STUDY DESIGN

Multivariate analysis of prospectively collected registry data.

OBJECTIVE

To determine the effect of payor status on complication rates after spine surgery.

SUMMARY OF BACKGROUND DATA

Understanding the risk of perioperative complications is an essential aspect in improving patient outcomes. Previous studies have looked at complication rates after spine surgery and factors related to increased perioperative complications. In other areas of medicine, there has been a growing body of evidence gathered to evaluate the role of payor status on outcomes and complications. Several studies have found increased complication rates and inferior outcomes in the uninsured and Medicaid insured.

METHODS

The Spine End Results Registry (2003-2004) is a collection of prospectively collected data on all patients who underwent spine surgery at our 2 institutions. Extensive demographic data, including payor status, and medical information were prospectively recorded as described previously by Mirza et al. Medical complications were defined in detail a priori and were prospectively recorded for at least 2 years after surgery. Using univariate and multivariate analysis, we determined risk of postoperative medical complications dependent on payor status.

RESULTS

A total of 1591 patients underwent spine surgery in 2003 and 2004 that met our criteria and were included in our analysis. With the multivariate analysis and by controlling for age, patients whose insurer was Medicaid had a 1.68 odds ratio (95% confidence interval: 1.23-2.29; P = 0.001) of having any adverse event when compared with the privately insured.

CONCLUSION

After univariate and multivariate analyses, Medicaid insurance status was found to be a risk factor for postoperative complications. This corresponds to an ever-growing body of medical literature that has shown similar trends and raises the concern of underinsurance.

The effect of insurance status on outcomes after laparoscopic cholecystectomy

BACKGROUND

Part of the ongoing healthcare debate is the care of uninsured patients. A common theory is that without regular outpatient care, these patients present to the hospital in the late stages of disease and therefore have worse outcomes. The purpose of this study was to evaluate any differences in outcomes after laparoscopic cholecystectomies between insured and uninsured patients.

METHODS

We reviewed all laparoscopic cholecystectomies (LC) done in our institution between 2006 and 2009. Patients were divided into two groups: insured patients (IP) and uninsured patients (UIP). Outcomes, including conversion and complication rates and postoperative length of stay (LOS), were collected and statistically analyzed using χ(2) and ANOVA tests.

RESULTS

There were 1,090 LCs done during the study period: 944 patients (86.6 %) were insured (IP) and 146 (13.4 %) were uninsured (UIP). In the IP group there were 63/944 (6.7 %) conversions and 59/944 (6.3 %) complications, while in the UIP group there were 15/146 (10.3 %) conversions and 12/146 (8.2 %) complications. There was no statistically significant difference in either of these categories. Mean (±SD) LOS was 1.73 ± 4.34 days for the IP group and 2.72 ± 4.35 days for the UIP group (p = 0.010, ANOVA). Uninsured patients were much more likely to have emergency surgery (99.3 % vs. 47.9 %, p < 0.001, χ(2)).

CONCLUSIONS

In our study group, being uninsured did not correlate with having a higher rate of conversion or complications. However, more uninsured patients had their surgery done emergently, and this led to significantly longer lengths of stay. Further research is necessary to study the cost impact of these findings and to see whether insuring these patients can lead to changes in their outcomes.