Elsevier

Surgery

Volume 156, Issue 2, August 2014, Pages 345-351
Surgery

Society of University Surgeons
Worse outcomes among uninsured general surgery patients: Does the need for an emergency operation explain these disparities?

Presented at the 9th Annual Academic Surgical Congress in San Diego, CA, February 4–6, 2014.
https://doi.org/10.1016/j.surg.2014.04.039Get rights and content

Background

We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation.

Methods

A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005–2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled.

Results

The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage.

Conclusion

Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.

Section snippets

Methods

The 2005–2011 Nationwide Inpatient Sample (NIS) was used to conduct a retrospective analysis of payor status and common surgical procedures. The NIS was investigated for all emergent and elective biliary, colorectal, and hernia procedural International Classification of Disease, 9th Edition, Clinical Modification codes, which were chosen based on definitions of Acute Care Surgery (ACS) scope of practice by the American Association for the Surgery of Trauma.7 A list of the procedure codes used

Results

A total of 749,537 patients included in the NIS from 2005 to 2011 met inclusion criteria. The majority of patients, n = 400,162 (53.3%) were included in the group of biliary operations. Colorectal procedures were performed in 189,763 (25.4%), and 159,648 patients (21.3%) had hernia operations. Table I includes demographic data of each of these groups.

Discussion

Our manuscript describes one possible link between payor status and outcomes for patients undergoing emergent operations. We found risk of emergent operation to be high in patients with government coverage and in patients with no insurance compared with patients with private insurance, but we found that major complications were most apparent in the groups with government coverage. This finding contradicts the intuitive notion that patients without insurance are at the greatest disadvantage to

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Supported by the National Institutes of Health/ NIGMS K23GM093112-01 and American College of Surgeons C. James Carrico Fellowship for the study of Trauma and Critical Care.

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