Medicaid payer status is associated with increased mortality and morbidity after inpatient shoulder arthroplasty: a multistate analysis, 2007–2014

Abstract

Background and objectivesInpatient shoulder arthroplasty is widely performed around the USA at an increasing rate. Medicaid insurance has been identified as a risk factor for inferior surgical outcomes. We sought to identify the impact of being Medicaid-insured on in-hospital mortality, readmission, complications, and length of stay (LOS) in patients who underwent inpatient shoulder arthroplasty.MethodsWe analyzed 89 460 patient discharge records for inpatient total, partial, and reverse shoulder arthroplasties using data from the Healthcare Cost and Utilization Project’s State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky from 2007 through 2014. We compared patient demographics, present-on-admission comorbidities, and hospital characteristics by insurance payer. We estimated multilevel mixed-effect multivariate logistic regression models and generalized linear models to assess insurance’s effect on in-hospital mortality, readmission, infectious complications, cardiac complications, and LOS; models controlled for patient and hospital characteristics.ResultsMedicaid-insured patients had greater odds than patients with private insurance, other insurance, and Medicare of inpatient mortality (OR: 4.61, 95% CI 2.18 to 9.73, p<0.001) and 30-day and 90-day readmissions (OR: 1.94, 95% CI 1.57 to 2.38, p<0.001; OR: 1.65, 95% CI 1.42 to 2.38, p<0.001, respectively). Compared with private insurance, other insurance, and Medicare patients, Medicaid patients had increased likelihood of developing infectious complications and were expected to have longer LOS.ConclusionsOur study supports our hypothesis that among inpatient shoulder arthroplasty patients, those with Medicaid insurance have worse outcomes than patients with private insurance, other insurance, and Medicare. These results are relatively consistent with previous findings in the literature.

Hospital safety net burden is associated with increased inpatient mortality and postoperative morbidity after total hip arthroplasty: a retrospective multistate review, 2007–2014

“…6 Evidence supports the association between THA outcomes and multifactorial patient-level, provider-level and hospital-level racial and socioeconomic disparities. [7][8][9][10][11][12][13][14][15][16] Hospital safety net burden is defined as the proportion of cases at an individual hospital with the primary insurance payer being Medicaid or uninsured; safety net hospitals operate with a mandate or adopted mission to deliver care to patients regardless of their ability to pay. 17 18 Research shows higher rates of mortality, hospitalacquired infection, perioperative complications and poorer markers of surgical quality (timeliness, patient centeredness and equity of treatment) at high safety net burden hospitals.…”

Patients With Medicaid Insurance Undergoing Anterior Cruciate Ligament Reconstruction have Lower Postoperative International Knee Documentation Committee Scores and are Less Likely to Return to Sport Than Privately Insured Patients

“… 22 , 23 , 24 , 25 More specifically, recent investigations have demonstrated that in those undergoing total joint arthroplasty of the hip, knee, or shoulder, patients with Medicaid have greater resource use, greater complication rates, and poorer postoperative outcomes. 8 , 10 , 13 , 14 , 23 , 26 , 27 With the expansion of Medicaid through the Affordable Care Act in 2014, the investigation of these disparities in one of the most common orthopaedic sports medicine procedures performed, ACL reconstruction, is critical. 23 …”

“…[22][23][24][25] More specifically, recent investigations have demonstrated that in those undergoing total joint arthroplasty of the hip, knee, or shoulder, patients with Medicaid have greater resource use, greater complication rates, and poorer postoperative outcomes. 8,10,13,14,23,26,27 With the expansion of Medicaid through the Affordable Care Act in 2014, the investigation of these disparities in one of the most common orthopaedic sports medicine procedures performed, ACL reconstruction, is critical. 23 When assessing our primary outcome, despite similar preoperative IKDC scores (53.65 vs 53.95; P ¼ .978) between the 2 cohorts, we found significantly lower postoperative IKDC scores (P ¼ .005) at final follow-up in patients with Medicaid insurance compared with those with private insurance (74.68 vs 90.45, respectively; P ¼ .005).…”

Contemporary treatment utilization among women diagnosed with symptomatic uterine fibroids in the United States

“…Medicaid provides healthcare for millions of the poorest and most vulnerable people in the US, including many with complex and costly needs; the elderly and people with disabilities account for one in four Medicaid enrollees [25]. Many studies have observed poorer outcomes and higher mortality rates in Medicaid enrollees compared to those with private healthcare insurance [26][27][28] 9.73; P < 0.001) and 30-day readmissions (OR 1.94; 95% CI 1.57, 2.38; P < 0.001) in Medicaid-insured patients compared to those with private, other, or Medicare insurance [29]. A large study of 295,572 patients who underwent total hip replacement found that Medicaid patients had a 125% increase in the odds of in-hospital mortality compared to those with private insurance (OR 2.25; 99% CI 1.01, 5.01) [27].…”

“…Many studies have observed poorer outcomes and higher mortality rates in Medicaid enrollees compared to those with private healthcare insurance [ 26 – 28 ]. For example, an analysis of 89,460 patient-discharge records for inpatient shoulder arthroplasties from 2007 to 2014 found an increased probability of inpatient mortality (odds ratio [OR] 4.61; 95% confidence interval [CI] 2.18, 9.73; P < 0.001) and 30-day readmissions (OR 1.94; 95% CI 1.57, 2.38; P < 0.001) in Medicaid-insured patients compared to those with private, other, or Medicare insurance [ 29 ]. A large study of 295,572 patients who underwent total hip replacement found that Medicaid patients had a 125% increase in the odds of in-hospital mortality compared to those with private insurance (OR 2.25; 99% CI 1.01, 5.01) [ 27 ].…”