Tetley Jasmine C, Jacobs Michael A, Kim Jeongsoo, Schmidt Susanne, Brimhall Bradley B, Mika Virginia, Wang Chen-Pin, Manuel Laura S, Damien Paul, Shireman Paula K
Department of Surgery, University of Texas Health San Antonio, San Antonio, TX.
Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX.
Ann Surg Open. 2022 Nov 7;3(4):e215. doi: 10.1097/AS9.0000000000000215. eCollection 2022 Dec.
Association of insurance type with colorectal surgical complications, textbook outcomes (TO), and cost in a safety-net hospital (SNH).
SNHs have higher surgical complications and costs compared to low-burden hospitals. How does presentation acuity and insurance type influence colorectal surgical outcomes?
Retrospective cohort study using single-site National Surgical Quality Improvement Program (2013-2019) with cost data and risk-adjusted by frailty, preoperative serious acute conditions (PASC), case status and open versus laparoscopic to evaluate 30-day reoperations, any complication, Clavien-Dindo IV (CDIV) complications, TO, and hospitalization variable costs.
Cases (Private 252; Medicare 207; Medicaid/Uninsured 619) with patient mean age 55.2 years (SD = 13.4) and 53.1% male. Adjusting for frailty, open abdomen, and urgent/emergent cases, Medicaid/Uninsured patients had higher odds of presenting with PASC (adjusted odds ratio [aOR] = 2.02, 95% confidence interval [CI] = 1.22-3.52, = 0.009) versus Private. Medicaid/Uninsured (aOR = 1.80, 95% CI = 1.28-2.55, < 0.001) patients were more likely to undergo urgent/emergent surgeries compared to Private. Medicare patients had increased odds of any and CDIV complications while Medicaid/Uninsured had increased odds of any complication, emergency department or observations stays, and readmissions versus Private. Medicare (aOR = 0.51, 95% CI = 0.33-0.88, = 0.003) and Medicaid/Uninsured (aOR = 0.43, 95% CI = 0.30-0.60, < 0.001) patients had lower odds of achieving TO versus Private. Variable cost %change increased in Medicaid/Uninsured patients to 13.94% ( = 0.005) versus Private but was similar after adjusting for case status. Urgent/emergent cases (43.23%, < 0.001) and any complication (78.34%, < 0.001) increased %change hospitalization costs.
Decreasing the incidence of urgent/emergent colorectal surgeries, possibly by improving access to care, could have a greater impact on improving clinical outcomes and decreasing costs, especially in Medicaid/Uninsured insurance type patients.
保险类型与结直肠手术并发症、教科书式结局（TO）以及安全网医院（SNH）成本之间的关联
与负担较轻的医院相比，安全网医院的手术并发症和成本更高。就诊敏锐度和保险类型如何影响结直肠手术结局？
采用单中心国家外科质量改进计划（2013 - 2019年）进行回顾性队列研究，纳入成本数据，并根据虚弱程度、术前严重急性病症（PASC）、病例状态以及开腹与腹腔镜手术进行风险调整，以评估30天再次手术、任何并发症、Clavien - Dindo IV（CDIV）并发症、TO以及住院可变成本。
病例（私人保险252例；医疗保险207例；医疗补助/无保险619例），患者平均年龄55.2岁（标准差 = 13.4），男性占53.1%。在对虚弱程度、开腹手术和急诊/紧急情况病例进行调整后，与私人保险患者相比，医疗补助/无保险患者出现PASC的几率更高（调整后的优势比[aOR] = 2.02，95%置信区间[CI] = 1.22 - 3.52，P = 0.009）。与私人保险患者相比，医疗补助/无保险患者（aOR = 1.80，95% CI = 1.28 - 2.55，P < 0.001）更有可能接受急诊/紧急手术。医疗保险患者发生任何并发症和CDIV并发症的几率增加，而医疗补助/无保险患者发生任何并发症、急诊科就诊或观察住院以及再入院的几率相对于私人保险患者增加。医疗保险患者（aOR = 0.51，95% CI = 0.33 - 0.88，P = 0.003）和医疗补助/无保险患者（aOR = 0.43，95% CI = 0.30 - 0.60，P < 0.001）实现TO的几率低于私人保险患者。医疗补助/无保险患者的可变成本百分比变化相对于私人保险患者增加至13.94%（P = 0.005），但在调整病例状态后相似。急诊/紧急情况病例（43.23%，P < 0.001）和任何并发症（78.34%，P < 0.001）增加了住院成本的百分比变化。
降低急诊/紧急结直肠手术的发生率，可能通过改善医疗服务可及性来实现，这对改善临床结局和降低成本可能产生更大影响，尤其是在医疗补助/无保险类型的患者中。
