Top

Published in:

01-04-2020 | Cholecystitis | 2019 SSAT Quick Shot Presentation

Treatment of Acute Cholecystitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care?

Authors: Amanda Fazzalari, Natalie Pozzi, David Alfego, Qiming Shi, Nathaniel Erskine, Gary Tourony, Jomol Mathew, Demetrius Litwin, Mitchell A. Cahan

Published in: Journal of Gastrointestinal Surgery | Issue 4/2020

Abstract

Background

Nationally, Medicaid enrollees with emergency surgical conditions experience worse outcomes overall when compared with privately insured patients. The goal of this study is to investigate disparities in the treatment of cholecystitis based on insurance type and to identify contributing factors.

Methods

Adults with cholecystitis at a safety-net hospital in Central Massachusetts from 2017–2018 were included. Sociodemographic and clinical characteristics were compared based on Medicaid enrollment status (Medicare excluded). Univariate and multivariate analyses were used to compare the frequency of surgery, time to surgery (TTS), length of stay (LOS), and readmission rates between groups.

Results

The sample (n = 203) included 69 Medicaid enrollees (34%), with a mean age of 44.4 years. Medicaid enrollees were younger (p = 0.0006), had lower levels of formal education (high school diploma attainment, p < 0.0001), were more likely to be unmarried (p < 0.0001), Non-White (p = 0.0012), and require an interpreter (p < 0.0001). Patients in both groups experienced similar rates of laparoscopic cholecystectomy, TTS, and LOS; however, Medicaid enrollees experienced more readmissions within 30 days of discharge (30.4% vs 17.9%, p < 0.001).

Conclusion

Despite anticipated population differences, the treatment of acute cholecystitis was similar between Medicaid and Non-Medicaid enrollees, with the exception of readmission. Further research is needed to identify patient, provider, and/or population factors driving this disparity.

Smedley BD, Stith AY, Nelson AR. Unequal treatment: confronting racial and ethnic disparities in health care. Institute of Medicine; 2003.

Loehrer AP, Chang DC, Scott JW, Hutter MM, Patel VI, Lee JE et al. Association of the affordable care act Medicaid expansion with access to and quality of care for surgical conditions. JAMA Surg. 2018;153(3):e175568. doi:https://doi.org/10.1001/jamasurg.2017.5568.CrossRefPubMedPubMedCentral

U.S. Census Bureau. Income, poverty, and health insurance coverage in the United States: 2010. Health Insurance Coverage in the United States: 2016. 2017.

Khubchandani JA, Shen C, Ayturk D, Kiefe CI, Santry HP. Disparities in access to emergency general surgery care in the United States. Surgery. 2018;163(2):243-50. doi:https://doi.org/10.1016/j.surg.2017.07.026.CrossRefPubMed

Metcalfe D, Castillo-Angeles M, Olufajo OA, Rios-Diaz AJ, Salim A, Haider AH et al. Failure to rescue and disparities in emergency general surgery. J Surg Res. 2018;231:62-8. doi:https://doi.org/10.1016/j.jss.2018.04.047.CrossRefPubMed

Schwartz DA, Hui X, Schneider EB, Ali MT, Canner JK, Leeper WR et al. Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities? Surgery. 2014;156(2):345-51. doi:https://doi.org/10.1016/j.surg.2014.04.039.CrossRefPubMed

Coburn N, Fulton J, Pearlman DN, Law C, DiPaolo B, Cady B. Treatment variation by insurance status for breast cancer patients. The breast journal. 2008;14(2):128-34. doi:https://doi.org/10.1111/j.1524-4741.2007.00542.x.CrossRefPubMed

Kim LK, Swaminathan RV, Minutello RM, Gade CL, Yang DC, Charitakis K et al. Trends in hospital treatments for peripheral arterial disease in the United States and association between payer status and quality of care/outcomes, 2007-2011. Catheter Cardiovasc Interv. 2015;86(5):864-72. doi:https://doi.org/10.1002/ccd.26065.CrossRefPubMed

Yeh D, Jones M, Schulman C, Karmacharya J, Velazquez OC. Uninsured South Florida vascular surgery patients are less likely to receive optimal medical management than their insured counterparts. J Vasc Surg. 2010;51(4 Suppl):4S-8S. doi:https://doi.org/10.1016/j.jvs.2010.01.035.CrossRefPubMed

10.

Kumar G, Taneja A, Majumdar T, Jacobs ER, Whittle J, Nanchal R. The association of lacking insurance with outcomes of severe sepsis: retrospective analysis of an administrative database. Critical care medicine. 2014;42(3):583-91. doi:https://doi.org/10.1097/01.ccm.0000435667.15070.9c.CrossRefPubMedPubMedCentral

11.

Kakuturu J, Pozzi, N., Friedrich, A., Damle, R., Wyman, A., Litwin, D., Cahan, M. Disparities between Medicaid and privately-insured patients extend to emergency surgery: Medicaid patients can expect less surgery and more in-hospital morbidity submitted for publication 2018.

12.

Ambur V, Taghavi S, Kadakia S, Jayarajan S, Gaughan J, Sjoholm LO et al. Does socioeconomic status predict outcomes after cholecystectomy? Am J Surg. 2017;213(1):100-4. doi:https://doi.org/10.1016/j.amjsurg.2016.04.012.CrossRefPubMed

13.

Stey AM, Greenstein AJ, Aufses A, Moskowitz AJ, Egorova NN. Managing acute cholecystitis among Medicaid insured in New York State: opportunities to optimize care. Surg Endosc. 2018. doi:https://doi.org/10.1007/s00464-017-5693-8.

14.

Greenstein AJ, Moskowitz A, Gelijns AC, Egorova NN. Payer status and treatment paradigm for acute cholecystitis. Arch Surg. 2012;147(5):453-8. doi:https://doi.org/10.1001/archsurg.2011.1702.CrossRefPubMed

15.

Loehrer AP, Song Z, Auchincloss HG, Hutter MM. Influence of health insurance expansion on disparities in the treatment of acute cholecystitis. Ann Surg. 2015;262(1):139-45. doi:https://doi.org/10.1097/sla.0000000000000970.CrossRefPubMedPubMedCentral

16.

Fazzalari A, Pozzi, N., Alfego, D., Qiming, S., Erskine, N., Tourony, G., Mathew, J., Litwin, D., Cahan, M.A. Treatment of appendicitis: do Medicaid and Non-Medicaid enrolled patients receive the same care?. SURGERY2019.

17.

Gahagan J, Hanna, M., Whealon, M., Maximus, S., Phelan, M., Lekawa, M., Barrios, C., Bernal, N. Racial disparities in access and outcomes of cholecystectomy in the United States. The American Surgeon. 2016;82:921-5.PubMed

18.

Lu P, Yang NP, Chang NT, Lai KR, Lin KB, Chan CL. Effect of socioeconomic inequalities on cholecystectomy outcomes: a 10-year population-based analysis. Int J Equity Health. 2018;17(1):22. doi:https://doi.org/10.1186/s12939-018-0739-7.CrossRefPubMedPubMedCentral

19.

Huang Y, Chua TC, Maddern GJ, Samra JS. Robotic cholecystectomy versus conventional laparoscopic cholecystectomy: a meta-analysis. Surgery. 2017;161(3):628-36. doi:https://doi.org/10.1016/j.surg.2016.08.061.CrossRefPubMed

20.

Haider AH, Scott VK, Rehman KA, Velopulos C, Bentley JM, Cornwell EE, 3rd et al. Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors. J Am Coll Surg. 2013;216(3):482-92 e12. doi:https://doi.org/10.1016/j.jamcollsurg.2012.11.014.CrossRefPubMedPubMedCentral

21.

Chaudhary MA, Sharma M, Scully RE, Sturgeon DJ, Koehlmoos T, Haider AH et al. Universal insurance and an equal access healthcare system eliminate disparities for Black patients after traumatic injury. Surgery. 2018;163(4):651-6. doi:https://doi.org/10.1016/j.surg.2017.09.045.CrossRefPubMed

22.

Armenia SJ, Pentakota SR, Merchant AM. Socioeconomic factors and mortality in emergency general surgery: trends over a 20-year period. J Surg Res. 2017;212:178-86. doi:https://doi.org/10.1016/j.jss.2017.01.015.CrossRefPubMed

23.

Schoenfeld AJ, Jiang W, Harris MB, Cooper Z, Koehlmoos T, Learn PA et al. Association between race and postoperative outcomes in a universally insured population versus patients in the State of California. Ann Surg. 2017;266(2):267-73. doi:https://doi.org/10.1097/SLA.0000000000001958.CrossRefPubMed

24.

Scott JW, Havens JM, Wolf LL, Zogg CK, Rose JA, Salim A et al. Insurance status is associated with complex presentation among emergency general surgery patients. Surgery. 2017;161(2):320-8. doi:https://doi.org/10.1016/j.surg.2016.08.038.CrossRefPubMed

25.

Guller U, Jain N, Curtis LH, Oertli D, Heberer M, Pietrobon R. Insurance status and race represent independent predictors of undergoing laparoscopic surgery for appendicitis: secondary data analysis of 145,546 patients. J Am Coll Surg. 2004;199(4):567-75; discussion 75-7. doi:https://doi.org/10.1016/j.jamcollsurg.2004.06.023.CrossRefPubMed

26.

Buchmueller TC, Levinson ZM, Levy HG, Wolfe BL. Effect of the affordable care act on racial and ethnic disparities in health insurance coverage. Am J Public Health. 2016;106(8):1416-21. doi:https://doi.org/10.2105/AJPH.2016.303155.CrossRefPubMedPubMedCentral

27.

Loehrer AP, Song Z, Auchincloss HG, Hutter MM. Massachusetts health care reform and reduced racial disparities in minimally invasive surgery. JAMA Surg. 2013;148(12):1116-22. doi:https://doi.org/10.1001/jamasurg.2013.2750.CrossRefPubMedPubMedCentral

28.

Scott JW, Rose, J.A., Tsai, T.C., Kogg, C.K., Shrime, M.G., Sommers, B.D., Salim, A. & Haider, A.H. Impact of ACA insurance coverage expansion on perforated appendix rates among young adults. Med Care. 2016;54(9):818-26.CrossRef

29.

Loehrer AP, Hawkins AT, Auchincloss HG, Song Z, Hutter MM, Patel VI. Impact of expanded insurance coverage on racial disparities in vascular disease: insights from Massachusetts. Ann Surg. 2016;263(4):705-11. doi:https://doi.org/10.1097/SLA.0000000000001310.CrossRefPubMedPubMedCentral

30.

Ku L, Jones, E., Shin, P., Rothenberg Byrne, F., Long, S.K. Safety-net providers after health care reform lessons from Massachusetts. Archives of internal medicine. 2011;171(15):1379-84.

31.

Dhar VK, Kim Y, Wima K, Hoehn RS, Shah SA. The importance of safety-net hospitals in emergency general surgery. J Gastrointest Surg. 2018;22(12):2064-71. doi:https://doi.org/10.1007/s11605-018-3885-8.CrossRefPubMed

32.

Hoehn RS, Wima K, Vestal MA, Weilage DJ, Hanseman DJ, Abbott DE et al. Effect of hospital safety-net burden on cost and outcomes after surgery. JAMA Surg. 2016;151(2):120-8. doi:https://doi.org/10.1001/jamasurg.2015.3209.CrossRefPubMed

33.

Hall EC, Zheng C, Langan RC, Johnson LB, Shara N, Al-Refaie WB. Medicaid beneficiaries undergoing complex surgery at quality care centers: insights into the Affordable Care Act. Am J Surg. 2016;211(4):750-4. doi:https://doi.org/10.1016/j.amjsurg.2015.11.026.CrossRefPubMedPubMedCentral

34.

Schaetzel S, Dirks R, Davis J. Comparison of outcomes of patients with acute appendicitis between an acute care surgery model and traditional call coverage model in the same community. Am J Surg. 2016;212(6):1083-9. doi:https://doi.org/10.1016/j.amjsurg.2016.09.006.CrossRefPubMed

35.

Bandy NL, DeShields SC, Cunningham TD, Britt RC. Statewide assessment of surgical outcomes and the acute care surgery model. J Surg Res. 2017;220:25-9. doi:https://doi.org/10.1016/j.jss.2017.06.027.CrossRefPubMed

36.

Havens JM, Olufajo OA, Cooper ZR, Haider AH, Shah AA, Salim A. Defining rates and risk factors for readmissions following emergency general surgery. JAMA Surg. 2016;151(4):330-6. doi:https://doi.org/10.1001/jamasurg.2015.4056.CrossRefPubMed

37.

Muthuvel G, Tevis SE, Liepert AE, Agarwal SK, Kennedy GD. A composite index for predicting readmission following emergency general surgery. J Trauma Acute Care Surg. 2014;76(6):1467-72. doi:https://doi.org/10.1097/TA.0000000000000223.CrossRefPubMedPubMedCentral

38.

Rana G, Bhullar JS, Subhas G, Kolachalam RB, Mittal VK. Thirty-day readmissions after inpatient laparoscopic cholecystectomy: factors and outcomes. Am J Surg. 2016;211(3):626-30. doi:https://doi.org/10.1016/j.amjsurg.2015.12.007.CrossRefPubMed

Title: Treatment of Acute Cholecystitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care?
Authors: Amanda Fazzalari
Natalie Pozzi
David Alfego
Qiming Shi
Nathaniel Erskine
Gary Tourony
Jomol Mathew
Demetrius Litwin
Mitchell A. Cahan
Publication date: 01-04-2020
Publisher: Springer US
Keywords: Cholecystitis
Basic Surgery
Cholangiography
Cholecystectomy
Published in: Journal of Gastrointestinal Surgery / Issue 4/2020
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-019-04471-y

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Treatment of Acute Cholecystitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care?

Abstract

Background

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 4/2020

Three-Dimensional Visualization Technology Used in Pancreatic Surgery: a Valuable Tool for Surgical Trainees

Plexiform Fibromyxoma of the Stomach

Comparison of FIB-4 Index and Child-Pugh Score in Predicting the Outcome of Hepatic Resection for Hepatocellular Carcinoma

Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis

The Evaluation of the Eighth Edition of the AJCC/UICC Staging System for Intrahepatic Cholangiocarcinoma: a Proposal of a Modified New Staging System

Analysis of Outcomes by Extraction Site following Subtotal Colectomy in Ulcerative Colitis: A Retrospective Cohort Study