Association of Insurance Type With Colorectal Surgery Outcomes and Costs at a Safety-Net Hospital: A Retrospective Observational Study

Jasmine C Tetley; Michael A Jacobs; Jeongsoo Kim; Susanne Schmidt; Bradley B Brimhall; Virginia Mika; Chen-Pin Wang; Laura S Manuel; Paul Damien; Paula K Shireman

doi:10.1097/AS9.0000000000000215

Association of Insurance Type With Colorectal Surgery Outcomes and Costs at a Safety-Net Hospital: A Retrospective Observational Study

Ann Surg Open. 2022 Nov 7;3(4):e215. doi: 10.1097/AS9.0000000000000215. eCollection 2022 Dec.

Authors

Jasmine C Tetley¹, Michael A Jacobs¹, Jeongsoo Kim¹, Susanne Schmidt², Bradley B Brimhall^{3

4}, Virginia Mika⁴, Chen-Pin Wang², Laura S Manuel², Paul Damien⁵, Paula K Shireman^{1

4

6}

Affiliations

¹ Department of Surgery, University of Texas Health San Antonio, San Antonio, TX.
² Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX.
³ Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio, TX.
⁴ University Health, San Antonio, TX.
⁵ Department of Information, Risk, and Operations Management, Red McCombs School of Business, University of Texas, Austin, TX.
⁶ Departments of Primary Care & Rural Medicine and Medical Physiology, School of Medicine, Texas A&M Health, Bryan, TX.

Abstract

Association of insurance type with colorectal surgical complications, textbook outcomes (TO), and cost in a safety-net hospital (SNH).

Background: SNHs have higher surgical complications and costs compared to low-burden hospitals. How does presentation acuity and insurance type influence colorectal surgical outcomes?

Methods: Retrospective cohort study using single-site National Surgical Quality Improvement Program (2013-2019) with cost data and risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status and open versus laparoscopic to evaluate 30-day reoperations, any complication, Clavien-Dindo IV (CDIV) complications, TO, and hospitalization variable costs.

Results: Cases (Private 252; Medicare 207; Medicaid/Uninsured 619) with patient mean age 55.2 years (SD = 13.4) and 53.1% male. Adjusting for frailty, open abdomen, and urgent/emergent cases, Medicaid/Uninsured patients had higher odds of presenting with PASC (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI] = 1.22-3.52, P = 0.009) versus Private. Medicaid/Uninsured (aOR = 1.80, 95% CI = 1.28-2.55, P < 0.001) patients were more likely to undergo urgent/emergent surgeries compared to Private. Medicare patients had increased odds of any and CDIV complications while Medicaid/Uninsured had increased odds of any complication, emergency department or observations stays, and readmissions versus Private. Medicare (aOR = 0.51, 95% CI = 0.33-0.88, P = 0.003) and Medicaid/Uninsured (aOR = 0.43, 95% CI = 0.30-0.60, P < 0.001) patients had lower odds of achieving TO versus Private. Variable cost %change increased in Medicaid/Uninsured patients to 13.94% (P = 0.005) versus Private but was similar after adjusting for case status. Urgent/emergent cases (43.23%, P < 0.001) and any complication (78.34%, P < 0.001) increased %change hospitalization costs.

Conclusions: Decreasing the incidence of urgent/emergent colorectal surgeries, possibly by improving access to care, could have a greater impact on improving clinical outcomes and decreasing costs, especially in Medicaid/Uninsured insurance type patients.

Keywords: colorectal surgery; insurance status; preoperative acute serious conditions; social risk factors; textbook outcomes; variable costs.

Abstract

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