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Increased Morbidity and Mortality of Total Hip Replacements for the Uninsured and Underinsured
Thurs, April 6, 8:15-9:45 am
Salon 5

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Increased Morbidity and Mortality of Total Hip Replacements for the Uninsured and Underinsured

Hannah Xu1, Robert S. White1, Dahniel Sastow1, Michael Andreae2,

Licia Gaber-Baylis1, Zachary Turnbull1

1. New York-Presbyterian Hospital Weill Cornell Medicine, 2. Penn State Health Milton S. Hershey Medical Center

Introduction

Insurance status is a marker of socioeconomic standing, and studies show that uninsured and underinsured patients have worse outcomes following medical and surgical care.

Our study examined how insurance status affects healthcare outcomes of one of the most commonly performed procedures in the United States: total hip replacements.

Given the current political climate surrounding healthcare reform, our work brings awareness of ongoing obstacles in bringing quality healthcare to all. 

Methods

We conducted a retrospective study of adults age > 18yrs old   from 2007-2011 using the State Inpatient Database (SID) of CA, FL, and NY, Healthcare Cost and Utilization Project (HCUP), and Agency for Healthcare Research and Quality (AHRQ).

We identified those who underwent a total hip replacement using ICD-9-CM code 8151. Patients were cohorted by insurance type (Medicare, Medicaid, Uninsured, Other, Private).

Primary outcomes were the rates of in-hospital mortality, postoperative complications, and 30- and 90-day readmission rates.

Postoperative complications included pulmonary, wound, infectious, urinary, gastrointestinal, cardiovascular, systemic, and intraoperative/ procedural. 

Results

295,572 patients age >18 yrs old underwent total hip replacements in CA, FL, and NY from 2007-2011.
Medicaid and other non-Private insurance patients had higher unadjusted rates and risk-adjusted odds of in-hospital mortality, postoperative complications, and 30-day and 90-day readmission rates when compared to patients with Private insurance. 

Discussion

Medicaid (and having non-Private insurance in general) was associated with worse postoperative outcomes.

There is a strong association between insurance status and race when investigating healthcare disparities.

Healthcare outcomes can be secondary to pre, intra, and postoperative factors:

Preoperatively, Medicaid and Uninsured patients have more comorbidities and worse health.

Intraoperatively, neuraxial anesthesia was used in 17% of Blacks undergoing total knee arthroplasty or total hip arthroplasty compared to 25% of Whites, and in 17% of Medicare patients compared to 22% of Private insurance patients.

Postoperatively, minorities have longer wait times to receive analgesia, are more likely to have worse Pain Management Index (PMI) scores, and receive fewer days’ supply of opioids than Whites.

Not only do most surgeons fail to recognize disparities across healthcare, but they are even worse at recognizing it in their own specialty and practices.

Our study represents the most up-to-date analysis of insurance status vs. postoperative outcomes after total hip replacements.

Study strength include our ability to analyze a large number of patient records and control for potentially confounding patient and non-patient variables. 

Study limitations include use of administrative datasets with the potential for coding errors, including missing data and misclassified data. 

Conclusions

Our study suggests that insurance status is predictive of perioperative risks.

With ongoing discussion of healthcare reform, our analysis highlights larger socioeconomic and health system-related issues to be addressed to improve surgical outcomes for all patients.

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