Department of Surgery, The University of Virginia, Charlottesville, VA, USA.
J Pediatr Surg. 2013 Jan;48(1):81-7. doi: 10.1016/j.jpedsurg.2012.10.021.
Current healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative mortality, morbidity, and resource utilization in pediatric surgical patients within the United States.
A weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids' Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung's disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51,862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes.
Overall median patient age was 12 years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.0001). Importantly, these results were dependent on operation type.
Primary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.
当前的医疗改革努力强调了保险状况对患者结局的潜在影响。在儿科手术患者群体中，主要付款人身份（PPS）的影响尚不清楚。本研究的目的是检查美国儿科手术患者的 PPS 与术后死亡率、发病率和资源利用之间的风险调整关联。
使用全国儿童住院数据库（2003 年和 2006 年）对 153333 名儿科手术患者进行加权总计：阑尾切除术、肠套叠、去皮质术、幽门肌切开术、先天性膈疝修补术和结肠切除术治疗先天性巨结肠。患者根据 PPS 分层：医疗保险（n=180）、医疗补助（n=51862）、无保险（n=12539）和私人保险（n=88753）。利用多变量分层回归模型评估 PPS 与结局之间的风险调整关联。
总体中位数患者年龄为 12 岁，手术主要是非选择性（92.4%），阑尾切除术占病例的比例最高（81.3%）。在调整患者、医院和手术相关因素后，PPS 与院内死亡（p<0.0001）和术后并发症（p<0.02）独立相关， Medicaid 和无保险人群的风险增加。此外， Medicaid PPS 还与调整后的住院时间和总住院费用增加相关（p<0.0001）。重要的是，这些结果取决于手术类型。
主要付款人身份与儿科手术患者的风险调整后术后死亡率、发病率和资源利用相关。无保险患者术后死亡率增加，而 Medicaid 患者发病率、住院时间和总费用增加。这些结果突出了社会经济和患者相关因素之间的复杂相互作用，应在儿科患者术前风险分层中考虑主要付款人身份。
