Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States

Abstract

Purpose Current healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative morbidity, mortality, and resource utilization in pediatric surgical patients within the United States. Methods A weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids’ Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloroplasty, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung’s disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51, 862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes. Results Overall median patient age was 12 years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.001). Importantly, these results were dependent on operation type. Conclusions Primary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.

The effect of race and gender on pediatric surgical outcomes within the United States

“…Third, the present study provides an association between race and gender to the primary outcomes of mortality and morbidity in addition to hospital length of stay and total charge and does not support conclusive causality within these relationships. Fourth, this study does not directly examine the effect of payer status on risk-adjusted outcomes as this has recently been demonstrated within pediatric surgery[6]. Fifth, interinstitutional transfers cannot be tracked through patient identifiers, introducing the potential confounding effect of multiple entries for a single patient.…”

“…Procedural codes as classified by the ICD-9 procedure coding system were matched to diagnoses and included: small bowel resection, air contrast enema, appendectomy, decortication, pyloromyotomy, diaphragm repair, and colonic resection[5]. The selected operations modeled prior analyses on primary payer status and were chosen to achieve a representative spectrum of morbidity and mortality for both infant and childhood illness [6]. Patients were stratified according to gender and race for comparison: white, black, Hispanic, Asian or Pacific Islander, Native American, and other.…”

Hospital survival of aortic dissection in children

“…Additionally, we found no association with survival rates in teaching or nonteaching hospitals. Other studies have found the KID database to be an excellent source for examining how outcomes are affected by socioeconomic and payer status [11,12].…”

“…Nevertheless, the KID database remains an excellent source of outcomes information for the pediatric population, especially given its large sample size and information about socioeconomic, epidemiologic, and payer status. Several retrospective reviews of pediatric surgical conditions have used this database to analyze outcomes [11,12,14,15].…”

Disparities in Reportable Quality Metrics by Insurance Status in the Primary Spine Neoplasm Population

“…[1][2][3][4][5][6][7][8][9] Although acquiring health insurance may play a role in reducing disparities across socioeconomic groups, [10][11][12] expanding health insurance access does not guarantee that patients receive high quality care. [9,13,14] The Hospital Value Based Purchasing Program, implemented by the Centers for Medicare and Medicaid Services (CMS) as part of the Affordable Care Act (ACA), links healthcare quality with healthcare reimbursements to improve the quality of care received by all patients, regardless of socioeconomic or insurance status.…”