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Insurance Impacts Biliary Disease: a National Study
Elizaveta Ragulin-Coyne*1, Zeling Chau1, Elan R. Witkowski1, Jillian K. Smith1, Sing Chau NG3,1, Mark P. Callery3, Heena P. Santry1, Shimul a. Shah2, Jennifer F. Tseng3,1
1Department of Surgery, Surgical Outcomes Analysis & Research, University of Massachusetts Medical School, Worcester, MA; 2Department of Surgery, University of Cincinnati, Cincinnati, OH; 3Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
BACKGROUND:
Health care reform emphasizes insurance coverage to improve outcomes. Biliary disease affects all population segments, and its treatment utilizes radiology, GI, and surgical procedures. We hypothesized that insurance affects biliary procedure rates and outcomes.
METHODS:
Nationwide Inpatient Sample 2004-2009 was used to identify urgent biliary disease, including acute cholecystitis, duct obstruction, cholangitis. Insurance was defined as private, Medicaid, uninsured. To eliminate Medicare confounding, patients >64 were excluded. Hospital type was defined as for-profit vs. not-for-profit. We compared procedures, including cholecystectomy (OR), interventional radiology (IR), and endoscopic (GI). We further analyzed hospital characteristics and length of stay (LOS). Multivariable analyses were performed
RESULTS:
1,269,668 weighted patients were identified; 197,644 uninsured, 244,538 Medicaid, 827,486 private. Uninsured patients were significantly more likely than privately insured patients to have no intervention; Medicaid patient resembled uninsured [Table]. Within OR, Uninsured/Medicaid patients were more likely to undergo open vs. laparoscopic cholecystectomy. Disparities were more pronounced in for-profit compared to not-for-profit hospitals. On multivariable analysis, independent predictors for receiving no procedure included older age, nonwhite, rural, male, for-profit hospital, lower-volume
center. After multivariable adjustment, uninsured patients were 1.6x more likely (95% CI 1.5-1.8) to undergo no procedure than private patients.
CONCLUSIONS:
Treatment of biliary tract disease, including cholecystectomy, varies with insurance. As health care reform ensues, reimbursement becomes bundled and center/provider outcomes are increasingly scrutinized, standardization of care to reflect best practices for all patients will be essential.
Biliary Procedures and Outcomes by Insurance
| Uninsured | Medicaid | Private | p-value | | No Intervention | 11.7% | 12.4% | 8.1% | <0.0001 | | Cholecystectomy (OR) | 85.7% | 84.1% | 88.3% | <0.0001 | | Interventional Radiology (IR) | 1.0% | 1.2% | 1.3% | <0.0001 | | Endoscopic (GI) | 13.9% | 14.3% | 13.6% | <0.0001 | | LOS (median) days | 2.2 | 2.4 | 1.9 | <0.0001 |
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