TREATMENT OF ACUTE CHOLECYSTITIS: DO MEDICAID AND NON-MEDICAID ENROLLED PATIENTS RECEIVE THE SAME CARE?
Amanda Fazzalari*3,1, Natalie Pozzi1, David Alfego2, Nathaniel Erskine2, Gary Tourony2, Jomol Mathew2, Mitchell A. Cahan3, Demetrius Litwin3
1Surgery, Saint Mary's Hospital, Waterbury, CT; 2University of Massachusetts Medical School, Worcester, MA; 3Surgery, University of Massachusetts Medical School, Worcester, MA
Background:
Studies using national datasets have shown that Medicaid enrollees with emergency surgical conditions experience less frequent operations, longer times to surgery (TTS), longer length of hospital stay (LOS) and more frequent readmissions. These large databases lack the granularity that smaller single institution series can provide. The goal of this study is to identify socioeconomic and geographic factors that may account for disparities in care between Medicaid and Non-Medicaid enrollees (excluding Medicare) with acute cholecystitis in Central Massachusetts.
Methods:
This retrospective cohort included all adult patients with acute cholecystitis at an academic medical center in Central Massachusetts from October 2017 - October 2018. Sociodemographic and clinical characteristics were compared based on Medicaid enrollment status. Univariate and multivariate analyses were used to compare the frequency of surgery performed, TTS, LOS, and readmission rates between those with and without Medicaid.
Results:
The sample included 203 patients with acute cholecystitis, mean age was 44.4 years, 59.1% were female and 69 were enrolled in Medicaid. Medicaid enrollees were significantly younger (40.6 vs 46.3 years, p=0.0006), had lower levels of formal education (83.4% vs 92.8% with high school diploma, p<0.0001), were more likely to be unmarried (63.7% vs 31.3%, p<0.0001), Non-White (36.2% vs 14.9%, p=0.0012) and to require the use of an interpreter (36.2% vs 9.7%, p<0.0001). Medicaid enrollees were more likely to live in a neighborhood with a lower annual income ($51,000.00 vs $75,000.00, p<0.0001) and a larger proportion of residents belonging to a racial/ethnic minority (22.9% vs 15.6%, p<0.0001). There was a trend for Medicaid enrollees to live closer to the hospital (4.3 vs 7.9 miles, p=0.064) and to be smokers (9.9% vs 18.8%, p=0.020). The proportion of patients undergoing laparoscopic cholecystectomy was similar in both groups (94.1% vs 95.5%, p=0.818), as were TTS (15h53m vs 20h51m, p=0.050) and LOS (20h12m vs 15h22m, p=0.279), however Medicaid enrollees experienced significantly more readmissions within 30 days (30.4% vs 17.9%, p<0.001).
Conclusions:
This study highlights the importance of local data in understanding delivery of care at the institutional level. Despite anticipated population differences, the treatment of acute cholecystitis did not differ based on insurance type in this single institution series. Further research is needed to identify factors contributing to higher readmission rates among Medicaid enrollees. These could include discrepancies in the delivery of discharge instructions, patient's adherence to follow-up recommendations, availability of household and community support systems, logistical issues within the health care system, all potentially leading to increased readmission rates among Medicaid enrollees.
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