JACS: Insurance type can affect cardiac valve operation outcomes

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The type of primary insurance patients carry affects outcomes of cardiac valve operations in the U.S., according to a study in the May issue of the Journal of the American College of Surgeons. As a result, the authors suggested that the type of primary insurance should be considered as an independent risk factor during preoperative risk stratification and planning.

From 2007 to 2008, the study states, the number of uninsured Americans rose by 600,000. Patients covered by government assistance insurance programs (i.e., Medicaid and Medicare) increased by 4.4 million and the number of Americans covered by private insurance decreased by one million.

Previous research has shown that Medicaid and uninsured patients have worse outcomes than privately insured patients after medical admissions. However, while there have been studies on insurance status as a predictor of disease and the differences in allocation of surgical treatment as a function of payor status, no study has examined the impact of primary payor status among patients undergoing cardiac valve procedures, nor have they been evaluated in a national database, according to the authors. 

Thus, Damien J. LaPar, MD, from the department of surgery at the University of Virginia Health System in Charlottesville, and colleagues evaluated 477,932 patients undergoing cardiac valve operations over a six-year period using discharge data from the Nationwide Inpatient Sample database. Patients in each payor group had different demographics, income and risk factors; and risk adjustment identified the independent effect of payor status.

The study population included: Medicare (57,249 people, 74 years), Medicaid (5,868 people, 41.2 years), uninsured (2,349 people, 49.7 years) and private insurance (31,808 people, 53.3 years).

After adjusting for risk factors, payor status remained a highly significant predictor of mortality. Specifically, uninsured, Medicaid and Medicare statuses showed a 100 percent, 70 percent and 36 percent increase in the odds of in-hospital death, respectively, compared with private insurance, the researchers reported. A review of multiple variables for postoperative complications identified uninsured, Medicaid and Medicare payor statuses as important independent predictors of morbidity as well.

In addition, LaPar et al found that those uninsured and those under Medicaid independently increased the risk of adjusted in-hospital mortality and the likelihood of postoperative complications even after accounting for socioeconomic status, hospital-related factors and several measures of co-morbid disease that are frequently encountered in low-income patient groups. In addition, Medicaid patients accrued the longest average hospital stay and highest total costs.

"The study findings indicate that primary payor status should be considered as an independent risk factor during preoperative patient risk evaluation," said LaPar. "Our study findings highlight complex socioeconomic and health system-related factors that could be targeted to improve patient outcomes after cardiac valve operations." 

They found that those who are uninsured and those covered by Medicaid associated with increased risk-adjusted in-hospital mortality and morbidity among patients undergoing cardiac valve operations compared to those who carry Medicare and private insurance.