From the Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California, San Diego, California.
J Trauma Acute Care Surg. 2018 May;84(5):693-701. doi: 10.1097/TA.0000000000001805.
Lack of insurance coverage increases complications and mortality from surgical procedures. The 2014 Affordable Care Act (ACA) Open Enrollment (OE) insured more Americans, but it is unknown if this improved outcomes from emergency general surgery (EGS) procedures. This study seeks to determine how ACA OE coverage changes outcomes in EGS.
This is a retrospective review using the Nationwide Inpatient Sample database from 2012 to 2014. Patients aged 18 to 64 years undergoing EGS procedures were identified by International Classification of Diseases, Ninth Revision, codes. Medicare patients were excluded. Patient demographics, hospital characteristics, and Charlson comorbidity index were obtained. Outcomes were measured by mortality, complications, and calculated costs. Univariate and difference-in-differences multivariate analyses were performed to determine the effect of the ACA OE on EGS outcomes.
A total of 304,110 EGS cases were identified. After Medicare patients were excluded, there were 275,425 cases. In 2014, Medicaid admissions increased 18.2% from 18,495 to 22,615 (p < 0.001) and self-pay admissions decreased 33% from 14,938 to 10,630 (p < 0.001). Mortality significantly increased for self-pay patients in 2014 from 0.81% to 1.22% (p < 0.001). Difference-in-differences analysis indicated that, after risk adjustment, the ACA OE was associated with a small reduction in mortality for insured patients (-0.12%, p = 0.034), increased complications (1.4%, p = 0.009), and increased wage-index adjusted mean costs (4.6%, p < 0.001). There was a significant increase in Medicare (+26.5%) and private (+12.2%, p < 0.001) insurance admissions in teaching hospitals, while nonteaching hospitals had fewer EGS admissions with a greater reduction in uninsured EGS admissions.
The ACA OE created a significant reduction in uninsured EGS admissions but did not reduce EGS mortality. Mortality decreased in insured patients but increased in uninsured patients, indicating that the ACA OE primarily insured lower-risk patients. The ACA OE did increase cost and complications in insured admissions. Teaching hospitals saw the majority of the increase in Medicaid and private insurance EGS admissions. A national registry would improve future study of insurance policy on EGS outcomes.
Economic analysis, level IV.
保险覆盖范围的不足会增加手术过程中的并发症和死亡率。2014 年平价医疗法案（ACA）的开放注册（OE）使更多的美国人获得了保险，但尚不清楚这是否改善了紧急普通外科（EGS）手术的结果。本研究旨在确定 ACA OE 覆盖范围如何改变 EGS 的结果。
这是一项使用 2012 年至 2014 年全国住院患者样本数据库的回顾性研究。通过国际疾病分类，第九版代码识别 18 至 64 岁接受 EGS 手术的患者。排除医疗保险患者。获得患者人口统计学，医院特征和 Charlson 合并症指数。通过死亡率，并发症和计算成本来衡量结果。进行单变量和差异差异多元分析，以确定 ACA OE 对 EGS 结果的影响。
共确定了 304,110 例 EGS 病例。排除医疗保险患者后，有 275,425 例。2014 年，医疗补助患者增加了 18.2％，从 18,495 例增加到 22,615 例（p <0.001），自付费患者减少了 33％，从 14,938 例减少到 10,630 例（p <0.001）。自付费患者的死亡率在 2014 年从 0.81％显著增加到 1.22％（p <0.001）。差异差异分析表明，经过风险调整后，ACA OE 与保险患者的死亡率降低有关（-0.12％，p = 0.034），并发症增加（1.4％，p = 0.009），以及增加工资指数调整后的平均费用（4.6％，p <0.001）。教学医院的医疗保险（+ 26.5％）和私人保险（+ 12.2％，p <0.001）的保险入院人数显著增加，而非教学医院的 EGS 入院人数减少，未保险的 EGS 入院人数减少幅度更大。
ACA OE 大大减少了未保险的 EGS 入院人数，但并未降低 EGS 的死亡率。保险患者的死亡率下降，但未保险患者的死亡率上升，这表明 ACA OE 主要承保低风险患者。ACA OE 确实增加了保险入院患者的成本和并发症。教学医院的医疗补助和私人保险 EGS 入院人数增加最多。国家登记册将改善未来对 EGS 结果的保险政策研究。
经济分析，四级。
