Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA.
Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio, TX, USA.
J Gastrointest Surg. 2023 May;27(5):965-979. doi: 10.1007/s11605-022-05576-7. Epub 2023 Jan 23.
BACKGROUND/PURPOSE: Medicare's Hospital Readmission Reduction Program disproportionately penalizes safety-net hospitals (SNH) caring for vulnerable populations. This study assessed the association of insurance type with 30-day emergency department visits/observation stays (EDOS), readmissions, and cumulative costs in colorectal surgery patients.
Retrospective inpatient cohort study using the National Surgical Quality Improvement Program (2013-2019) with cost data in a SNH. The odds of EDOS and readmissions and cumulative variable (index hospitalization and all 30-day EDOS and readmissions) costs were modeled adjusting for frailty, case status, presence of a stoma, and open versus laparoscopic surgery.
The cohort had 245 private, 195 Medicare, and 590 Medicaid/uninsured cases, with a mean age 55.0 years (SD = 13.3) and 52.9% of the cases were performed on male patients. Most cases were open surgeries (58.7%). Complication rates were 41.8%, EDOS 12.0%, and readmissions 20.1%. Medicaid/uninsured had increased odds of urgent/emergent surgeries (aOR = 2.15, CI = 1.56-2.98, p < 0.001) and complications (aOR = 1.43, CI = 1.02-2.03, p = 0.042) versus private patients. Medicaid/uninsured versus private patients had higher EDOS (16.6% versus 4.1%) and readmissions (22.9% versus 14.3%) rates and higher odds of EDOS (aOR = 4.81, CI = 2.57-10.06, p < 0.001), and readmissions (aOR = 1.62, CI = 1.07-2.50, p = 0.025), while Medicare patients had similar odds versus private. Cumulative variable cost %change was increased for Medicare and Medicaid/uninsured, but Medicaid/uninsured was similar to private after adjusting for urgent/emergent cases.
Increased urgent/emergent cases in Medicaid/uninsured populations drive increased complications odds and higher costs compared to private patients, suggesting lack of access to outpatient care. SNH care for higher cost populations, receive lower reimbursements, and are penalized by value-based programs. Increasing healthcare access for Medicaid/uninsured patients could reduce urgent/emergent surgeries, resulting in fewer complications, EDOS/readmissions, and costs.
背景/目的：医疗保险的住院患者再入院率降低计划不成比例地惩罚了为弱势群体服务的安全网医院（SNH）。本研究评估了保险类型与 30 天内急诊就诊/观察停留（EDOS）、再入院和结直肠手术患者累计费用之间的关联。
使用国家手术质量改进计划（2013-2019 年）对 SNH 中的成本数据进行回顾性住院队列研究。使用脆弱性、病例状态、造口存在以及开放与腹腔镜手术，对 EDOS 和再入院以及累计变量（索引住院和所有 30 天 EDOS 和再入院）的费用进行建模，以调整 EDOS 和再入院的可能性和累积变量（索引住院和所有 30 天 EDOS 和再入院）的费用。
该队列包括 245 例私人保险、195 例医疗保险和 590 例医疗补助/无保险病例，平均年龄 55.0 岁（SD=13.3），52.9%的病例为男性。大多数手术为开放性手术（58.7%）。并发症发生率为 41.8%，EDOS 为 12.0%，再入院率为 20.1%。医疗补助/无保险患者接受紧急/紧急手术的可能性（aOR=2.15，CI=1.56-2.98，p<0.001）和并发症（aOR=1.43，CI=1.02-2.03，p=0.042）的可能性高于私人患者。与私人患者相比，医疗补助/无保险患者的 EDOS（16.6%比 4.1%）和再入院率（22.9%比 14.3%）更高，EDOS（aOR=4.81，CI=2.57-10.06，p<0.001）和再入院（aOR=1.62，CI=1.07-2.50，p=0.025）的可能性更高，而医疗保险患者与私人患者的可能性相似。医疗保险和医疗补助/无保险患者的累计变量成本百分比变化增加，但在调整紧急/紧急病例后，医疗补助/无保险患者与私人患者相似。
医疗补助/无保险人群中紧急/紧急病例的增加导致并发症发生率和成本增加高于私人患者，这表明他们缺乏获得门诊护理的机会。SNH 为高成本人群提供护理，获得的报销较少，并受到基于价值的计划的惩罚。增加医疗补助/无保险患者的医疗保健机会可以减少紧急/紧急手术，从而减少并发症、EDOS/再入院和费用。
