Disparities in Outcomes by Insurance Payer Groups for Patients Undergoing Anterior Cervical Discectomy and Fusion

Abstract

Study Design. Retrospective, observational study of clinical outcomes at a single institution. Objective. To compare postoperative complication and readmission rates of payer groups in a cohort of patients undergoing anterior cervical discectomy and fusion (ACDF). Summary of Background Data. Studies examining associations between primary payer and outcomes in spine surgery have been equivocal. Methods. Patients at Mount Sinai having undergone ACDF from 2008 to 2016 were queried and assigned to one of five insurance categories: uninsured, managed care, commercial indemnity insurance, Medicare, and Medicaid, with patients in the commercial indemnity group serving as the reference cohort. Multivariable logistic regression equations for various outcomes with the exposure of payer were created, controlling for age, sex, American Society of Anesthesiology Physical Status Classification (ASA Class), the Elixhauser Comorbidity Index, and number of segments fused. A Bonferroni correction was utilized, such that alpha = 0.0125. Results. Two thousand three hundred eighty seven patients underwent ACDF during the time period. Both Medicare (P < 0.0001) and Medicaid (P < 0.0001) patients had higher comorbidity burdens than commercial patients when examining ASA Class. Managed care (2.86 vs. 2.72, P = 0.0009) and Medicare patients (2.99 vs. 2.72, P < 0.0001) had more segments fused on average than commercial patients. Medicaid patients had higher rates of prolonged extubation (odds ratio [OR]: 4.99; 95% confidence interval [CI]: 1.13–22.0; P = 0.007), and Medicare patients had higher rates of prolonged length of stay (LOS) (OR: 2.44, 95% CI: 1.13–5.27%, P = 0.004) than the commercial patients. Medicaid patients had higher rates of 30- (OR: 4.12; 95% CI: 1.43–11.93; P = 0.0009) and 90-day (OR: 3.28; 95% CI: 1.34–8.03; P = 0.0009) Emergency Department (ED) visits than the commercial patients, and managed care patients had higher rates of 30-day readmission (OR: 3.41; 95% CI: 1.00–11.57; P = 0.0123). Conclusion. Medicare and Medicaid patients had higher rates of prolonged LOS and postoperative ED visits, respectively, compared with commercial patients. Level of Evidence: 3

Quantifying the collective influence of social determinants of health using conditional and cluster modeling

“…Five pre-operative SDoH variables were selected based on the Commission on Social Determinants of Health Final Report published by World Health Organization [22]. The variables included race/ethnicity, educational attainment, employment status, insurance payer, and gender, which were dichotomized based on previous research findings [4,17,[23][24][25][26] to improve interpretability of findings.…”

Racial Differences in Patients Undergoing Anterior Cervical Discectomy and Fusion

“…As a result, the smaller patient cohort size and single health care system setting limits the generalizability of our findings to other locations. In addition, variables important to spine surgery disparities, such as socioeconomic and insurance status, were not included within the analysis 22,23. However, although these variables have been independent predictors of increased LOS and cost, they likely reflect lower preoperative health status and postoperative support 24.…”

“…In addition, variables important to spine surgery disparities, such as socioeconomic and insurance status, were not included within the analysis. 22,23 However, although these variables have been independent predictors of increased LOS and cost, they likely reflect lower preoperative health status and postoperative support. 24 This idea fits with our previously mentioned finding that AA patients required higher rates of discharge to subacute rehabilitation facilities following ACDF, which has also been shown in other studies.…”

Establishing the Socio-Economic Impact of Degenerative Cervical Myelopathy Is Fundamental to Improving Outcomes [AO Spine RECODE-DCM Research Priority Number 8]

“… 6 In a recent evaluation of patients undergoing ACDF (all indications) from a single US center over 8 years (N = 2387), state-funded (Medicare / Medicaid) patients had more co-morbidities, longer hospitalization, and more frequently returned for reassessment within 90 days than insurance funded patients. 37 Taken together, this suggests that SES is likely an important determining factor of treatment costs and outcomes as well as a potential sources of unconsciousness bias during the decision making process for the individual’s treatment.…”