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Insurance Affects Readmission After GI Surgery: a Longitudinal Analysis
Zeling Chau*1,2, Elan R. Witkowski1, Sing Chau NG2, Elizaveta Ragulin-Coyne1, Heena P. Santry1, Tara S. Kent3, a. James Moser2, Mark P. Callery3, Jennifer F. Tseng2,1
1Department of General Surgery, University of Massachusetts, Worcester, MA; 2Division of Surgical Oncology, Beth Israel Medical Center- Harvard Medical School, Boston, MA; 3Department of Surgery, Beth Israel Medical Center- Harvard Medical School, Boston, MA
Background: Hospital readmission rates are increasingly used to measure quality of care. The impact of insurance on postoperative readmission rates is not well characterized. We aimed to determine the impact of insurance on short-term readmissions for GI surgery.
Methods: Florida State Inpatient Database queried to identify all esophageal, gastric, pancreas, liver and colon resections performed for cancer during 2007-2009. Patients <18, ≥65 or with Medicare excluded to reduce the effect of Medicare confounding. Annual surgical volume calculated by tertiles. Readmission defined as inpatient admission ≤30 days from index discharge. Univariate and multivariate analyses performed by chi-square and logistic regression. For all, p-values <0.05 considered significant.
Results: 7585 patients underwent esophageal, gastric, pancreas, liver and colon resections 2007-2009. Of those 137 (1.8%) were esophagectomies, 516 (6.8%) gastrectomies, 458 (6.0%) pancreatectomies, 444 (5.9%) hepatectomies and 6137 (80.9%) colectomies. Mean patient age was 53.8 years. In all, 5549 patients (73%) had private insurance, 894 (11.8%) Medicaid, and 1142 (15.1%) uninsured. Medicaid patients had worse overall outcomes, including mortality, LOS, complications and readmission rates (Table). Overall 30-day readmission rate was 11.2% and increased over the study period from 10.5 to 11.9%. Medicaid had the highest readmission rates at 13.9% followed by uninsured 11.9% and private 10.6%. In multivariable analysis, Medicaid insurance (OR 1.3 95%CI 1.1-1.7), increased patient comorbidities (OR 1.3 95% CI 1.0-1.5), and high volume hospitals (OR 1.4 95%CI 1.2-1.7) demonstrated associations with readmission.
Conclusion: Early readmissions after GI surgery remain high. Multiple factors, potentially including case complexity and patient population, may make high-volume hospitals such as academic hospitals particularly vulnerable. With the rise of global payments and Accountable Care Organizations, understanding and preventing readmission, including reducing insurance-related disparities, will be of paramount importance.
Table: Outcomes by insurance
| Mortality (%) | Mean LOS (days) | Complications (%) | Readmission Rates (%) | | Medicaid | 7.2 | 13.0 | 35.1 | 13.9 | | Uninsured | 4.4 | 10.5 | 28 | 11.9 | | Private | 3.7 | 8.5 | 23.7 | 10.6 |
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