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How has the Affordable Care Act changed outcomes in emergency general surgery?

Hamel, Michelle G., MD, PhD; Godat, Laura N., MD; Coimbra, Raul, MD, PhD; Doucet, Jay J., MD

Journal of Trauma and Acute Care Surgery: May 2018 - Volume 84 - Issue 5 - p 693–701
doi: 10.1097/TA.0000000000001805
AAST 2017 Podium Paper
Editor's Choice
EAST Journal Club

INTRODUCTION Lack of insurance coverage increases complications and mortality from surgical procedures. The 2014 Affordable Care Act (ACA) Open Enrollment (OE) insured more Americans, but it is unknown if this improved outcomes from emergency general surgery (EGS) procedures. This study seeks to determine how ACA OE coverage changes outcomes in EGS.

METHODS This is a retrospective review using the Nationwide Inpatient Sample database from 2012 to 2014. Patients aged 18 to 64 years undergoing EGS procedures were identified by International Classification of Diseases, Ninth Revision, codes. Medicare patients were excluded. Patient demographics, hospital characteristics, and Charlson comorbidity index were obtained. Outcomes were measured by mortality, complications, and calculated costs. Univariate and difference-in-differences multivariate analyses were performed to determine the effect of the ACA OE on EGS outcomes.

RESULTS A total of 304,110 EGS cases were identified. After Medicare patients were excluded, there were 275,425 cases. In 2014, Medicaid admissions increased 18.2% from 18,495 to 22,615 (p < 0.001) and self-pay admissions decreased 33% from 14,938 to 10,630 (p < 0.001). Mortality significantly increased for self-pay patients in 2014 from 0.81% to 1.22% (p < 0.001). Difference-in-differences analysis indicated that, after risk adjustment, the ACA OE was associated with a small reduction in mortality for insured patients (−0.12%, p = 0.034), increased complications (1.4%, p = 0.009), and increased wage-index adjusted mean costs (4.6%, p < 0.001). There was a significant increase in Medicare (+26.5%) and private (+12.2%, p < 0.001) insurance admissions in teaching hospitals, while nonteaching hospitals had fewer EGS admissions with a greater reduction in uninsured EGS admissions.

CONCLUSIONS The ACA OE created a significant reduction in uninsured EGS admissions but did not reduce EGS mortality. Mortality decreased in insured patients but increased in uninsured patients, indicating that the ACA OE primarily insured lower-risk patients. The ACA OE did increase cost and complications in insured admissions. Teaching hospitals saw the majority of the increase in Medicaid and private insurance EGS admissions. A national registry would improve future study of insurance policy on EGS outcomes.

LEVEL OF EVIDENCE Economic analysis, level IV.

From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, California.

Submitted: September 2, 2017, Revised: December 24, 2017, Accepted: December 28, 2017, Published online: January 24, 2018.

This study was presented at the 76th Annual Meeting of AAST and Clinical Congress of Acute Care Surgery, September 13–16, 2017, in Baltimore, MD.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s website (

Address for reprints: Jay Doucet, MD, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, 200 W, Arbor Dr, MC 8896, San Diego, CA 92103; email:

© 2018 Lippincott Williams & Wilkins, Inc.