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Primary Payer Status Affects Mortality for Major Surgical Operations

LaPar, Damien J. MD*; Bhamidipati, Castigliano M. DO*; Mery, Carlos M. MD, MPH*; Stukenborg, George J. PhD†; Jones, David R. MD*; Schirmer, Bruce D. MD*; Kron, Irving L. MD*; Ailawadi, Gorav MD*

doi: 10.1097/SLA.0b013e3181e8fd75
Original Articles

Objectives: Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following major surgical operations in the United States is dependent on primary payer status.

Methods: From 2003 to 2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n = 491,829), Medicaid (n = 40,259), Private Insurance (n = 337,535), and Uninsured (n = 24,035). Multivariate regression models were applied to assess outcomes.

Results: Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality.

Conclusions: Medicaid and Uninsured payer status confers increased risk-adjusted mortality. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors or operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US Patients.

From 2003 to 2007, 893,658 major operations were evaluated using the Nationwide Inpatient Sample database. Patients were stratified according to primary payer status. Medicaid and Uninsured status conferred increased risk of adjusted mortality. Medicaid patients accrued the greatest adjusted length of stay and total costs despite risk factors or operation.

From the *Departments of Surgery and †Public Health Sciences, University of Virginia Health System, Charlottesville, VA.

Supported by the National Heart, Lung, and Blood Institute, award number T32HL007849 (to D.J.L., C.M.B.) and the Thoracic Surgery Foundation for Research and Education Research Grant (to G.A.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute or the National Institutes of Health.

Presented at the 130th Annual Meeting of the American Surgical Association, Chicago, IL, April 8–10, 2010.

Reprints: Gorav Ailawadi, MD, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, PO Box 800679, Charlottesville, VA 22908–0679. E-mail: gorav@virginia.edu.

© 2010 Lippincott Williams & Wilkins, Inc.