Elsevier

Surgery

Volume 134, Issue 2, August 2003, Pages 142-145
Surgery

Society of University Surgeons
Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States*,**

Presented at the 64th Annual Meeting of the Society of University Surgeons, Houston, Texas, February 12-15, 2003.
https://doi.org/10.1067/msy.2003.214Get rights and content

Abstract

Background. The hypothesis of this study was that differences exist among patients with private insurance compared with patients with Medicaid or no insurance, regarding access to the timely treatment of abdominal aortic aneurysms (AAAs) and the outcomes of AAA repair. Methods. The study comprised 5363 patients aged less than 65 years (mean age, 59 years) with a diagnostic code for intact or ruptured AAA and a procedure code for AAA repair in the National Inpatient Sample for 1995 to 2000. Dependent variables included ruptured AAA, intact AAA, and in-hospital postoperative mortality rates. Independent variables included payer status, median income, race, gender, age, and comorbid disease. Risk-adjusted analyses were performed with the use of binary logistic regression. Results. AAA rupture was most likely (P <.001) to affect patients with no insurance (36%) or Medicaid (18%), compared with patients with private insurance (13%). After an adjustment for case-mix had been made, data showed that patients without insurance had an increased risk of rupture compared with patients with private insurance (odds ratio, 2.3; 95% CI, 1.5-3.5; P <.001). Operative mortality rates after elective AAA repair were greater (P =.04) for patients with no insurance (2.6%) or Medicaid (2.7%), compared with patients with private insurance (1.2%). Similarly, operative mortality rates for AAA repair after rupture were greater (P =.001) in patients without insurance (45.3%) or Medicaid (31.3%), compared with patients with private insurance (26.2%). Conclusion. Uninsured patients more often seek treatment of ruptured AAAs compared with patients with private insurance. Operative mortality rates in uninsured patients are greater for elective and emergent AAA repair. These data support the tenet that payer status is associated with mortality rates after AAA repair. (Surgery 2003;134:142-5.)

Section snippets

Data source

Patient and provider information regarding AAAs were obtained from the National Inpatient Sample (NIS) database for the time period 1995 to 2000. The NIS is a 20% stratified random sample of all hospital discharges in the United States, which is maintained by the Agency for Healthcare Research and Quality as part of the Healthcare Cost and Utilization Project.6 The study population included all patients with an International Classification of Diseases, Ninth Revision, Clinical Modification

Patient characteristics

After undergoing AAA repair from 1995-2000, 40,610 patients in the NIS were discharged from hospitals; 35,247 patients who were 65 years of age and older were excluded from further study. The mean age of the remaining 5363 patients who were less 65 years of age included for study was 59 ± 4.7 years. Eighty-six percent of the latter patients were men, and 72% were white (Table I).Patients were similar with respect to demographics, except as noted in Table I.

Proportion with rupture

The overall proportion of patients

Discussion

The issue of insurance as a predictor of timely access to health care is based on 3 principles. First, patients without insurance tend to have delayed examination because of the increased financial barriers to their health care. Second, they could have decreased access or delayed surgical referral because of physician-related gate keeping. Third, they may have delayed diagnosis because of hospital or other global health system deterrents to the uninsured.10 The current study is the first to

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*

Reprint requests: Gilbert R. Upchurch, Jr, MD, 1500 East Medical Center Dr, Taubman Center 2210, Ann Arbor, MI 48109-0329.

**

0039-6060/2003/$30.00 + 0

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