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THE INFLUENCE OF PAYOR STATUS ON OUTCOMES ASSOCIATED WITH SURGICAL REPAIR OF PERFORATED PEPTIC ULCER DISEASE IN THE UNITED STATES
Vijaya T. Daniel*1, Didem Ayturk2, Doyle V. Ward3, Beth McCormick3, Heena P. Santry4
1Surgery, University of Massachusetts, Worcester, MA; 2Department of Quantitative Health Sciences, University of Massachusetts, Worcester, MA; 3Center for Microbiome Research, University of Massachusetts, Worcester, MA; 4Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
Background: Perforated peptic ulcer disease (PUD) is a common emergency general surgery (EGS) condition that has been increasing in incidence in the US. However, little is known about the relationship of payor status and outcomes of patients undergoing EGS for perforated PUD. We evaluated the association between payor status on in-hospital mortality for patients undergoing EGS for perforated PUD.
Methods: Nationwide Inpatient Sample (NIS) was queried to identify patients between 18-65 years of age who underwent emergent (open or laparoscopic) repair for PUD (2010-2014). Primary outcome was in-hospital mortality. Secondary outcomes were 30-day postoperative major and minor complications. The main predictor outcome was insurance status (Private, Medicaid, Uninsured). Univariate analyses were performed. Three multivariable regression models were created. The primary multivariable model's outcome was in-hospital mortality with payor status being the forced variable of interest. The second multivariable model's outcome was major postoperative complications (postoperative myocardial infarction, postoperative acute respiratory distress syndrome). The third multivariable model's outcome was minor postoperative complications (postoperative pulmonary embolus, postoperative wound infection, postoperative pneumonia).
Results: 21,190 patients underwent open (95.4%) and laparoscopic (4.6%) surgical repair for perforated PUD. Patients with private insurance represented the largest payor group (47%) compared to Medicaid (24%) and uninsured (29%). Prior to adjusting for other factors, in-hospital mortality was highest among those with Medicaid (Medicaid 3.2%, Private 2.7%, Uninsured 1.6%, p<0.0001). However, after adjustment of other factors, payor status did not remain statistically significant (Medicaid vs. Private: [OR] 1.1; 95% [CI] 0.67-1.76; Uninsured vs. Private: OR 0.9, 95% CI 0.50-1.53). Payor status remained a statistically significant predictor of minor postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.9; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.6), but did not remain a statistically significant predictor of major postoperative complications (Medicaid vs. Private: ([OR]1.2, 95% CI 0.8, 2.0); Uninsured vs. Private: [OR] 1.0, 95% CI 0.6, 1.7).
Conclusions: Surgery for perforated PUD is associated with high mortality and morbidity across all payor classes; however, patients with Medicaid insurance experience more minor complications and longer lengths of stay. There continues to be large gaps of unequal care to those with government insurance. While optimizing processes of care at the time of presentation may improve outcomes for those with government insurance, preventing perforation through preventative measures will be key to reducing the burden of PUD across all populations.
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