The Risk-Adjusted Impact of Patient Insurance Status on Perioperative Outcomes Following Ventral Hernia Repair in New York State
Johnathan Shih, BS, Brody Wiles, BS, Jie Yang, PhD, Jianjin Xu, MS, Sami Khan, MD, FACS.
Stony Brook University, Stony Brook, NY, USA.
PURPOSE: With the implementation of the Hospital Value-Based Purchasing Program as a part of the Affordable Care Act, standardized metrics for evaluating healthcare quality at the provider level have become a cornerstone for guiding the reformation of healthcare policy and reimbursement models in the United States. For many surgical procedures, adverse perioperative outcomes and hospital readmissions have consequently been increasingly utilized as indicators of provider quality and determinants of reimbursement. While numerous studies have explored the underlying factors associated with outcome disparities following surgery, there is limited data in the literature that evaluates the relative impact of patient insurance status on perioperative outcomes. Given its high annual incidence and significant healthcare burden, ventral hernia repair (VHR) was considered an appropriate model for conducting our investigation. In this study, we used an all-payer data reporting system to characterize the association between patient insurance status and surgical outcomes following VHR.
METHODS: Following IRB approval, the New York Statewide Planning and Research Cooperative System (SPARCS) database was queried to identify the records of all patients who underwent open or laparoscopic primary VHR in the state of New York between 2009 and 2013. Patients were stratified by their insurance status into one of four categories –commercial coverage, Medicare, Medicaid, or self-pay/uninsured. Primary outcomes evaluated were perioperative complications, emergency department (ED) visits, and hospital readmissions up to one year following surgery. Data analysis also included patient characteristics and demographic information. Multivariate logistic regression was used to control for confounding differences among groups.
RESULTS: 71,409 patients underwent primary VHR in New York between 2009 and 2013. 74.2% of patients had commercial coverage, 18.3% had Medicare, 6.3% had Medicaid, and 1.3% of patients were uninsured. When individually compared to patients with other types of insurance coverage, patients with Medicare and Medicaid coverage were more likely to visit the ED within 30 days of surgery (odds ratio [OR] 1.56 and 2.03 respectively, p<0.0001) and between 31 and 90 days following surgery (OR 1.65 and 1.98 respectively, p<0.0001). Patients with Medicaid had an independently increased comparative likelihood of wound infection during their perioperative course (OR 1.96, p<0.0001). An evaluation of hospital readmission rates demonstrated that compared to patients with other types of insurance coverage, patients with Medicare and Medicaid were also more than twice as likely to experience readmission within one year of surgery (OR: 2.33 and 2.38 respectively, p<0.0001). However, there was no significant difference in the likelihood of readmission within 30 days or between 31 and 90 days for any of the insurance status groups.
CONCLUSION: In this study of a statewide patient sample, we identify significant discrepancies when evaluating risk-adjusted outcomes following VHR for patients with Medicare or Medicaid coverage and patients who are commercially insured. Despite controlling for confounding differences between patient characteristics and demographic information, our data suggest the influence of additional factors that may impact accessibility to quality care for patients with government-funded health insurance. Further studies are indicated in order to better understand the underlying factors that drive this disparity.
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