title: Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States.
abstract: BACKGROUND
  The hypothesis of this study was that differences exist among patients with private insurance compared with patients with Medicaid or no insurance, regarding access to the timely treatment of abdominal aortic aneurysms (AAAs) and the outcomes of AAA repair.
  
  
  METHODS
  The study comprised 5363 patients aged less than 65 years (mean age, 59 years) with a diagnostic code for intact or ruptured AAA and a procedure code for AAA repair in the National Inpatient Sample for 1995 to 2000. Dependent variables included ruptured AAA, intact AAA, and in-hospital postoperative mortality rates. Independent variables included payer status, median income, race, gender, age, and comorbid disease. Risk-adjusted analyses were performed with the use of binary logistic regression.
  
  
  RESULTS
  AAA rupture was most likely (P <.001) to affect patients with no insurance (36%) or Medicaid (18%), compared with patients with private insurance (13%). After an adjustment for case-mix had been made, data showed that patients without insurance had an increased risk of rupture compared with patients with private insurance (odds ratio, 2.3; 95% CI, 1.5-3.5; P <.001). Operative mortality rates after elective AAA repair were greater (P =.04) for patients with no insurance (2.6%) or Medicaid (2.7%), compared with patients with private insurance (1.2%). Similarly, operative mortality rates for AAA repair after rupture were greater (P =.001) in patients without insurance (45.3%) or Medicaid (31.3%), compared with patients with private insurance (26.2%).
  
  
  CONCLUSIONS
  Uninsured patients more often seek treatment of ruptured AAAs compared with patients with private insurance. Operative mortality rates in uninsured patients are greater for elective and emergent AAA repair. These data support the tenet that payer status is associated with mortality rates after AAA repair.
authors.affiliation: Department of Surgery, Section of Vascular Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
authors.forename: Leslie K
authors.initials: LK
authors.lastname: Boxer
authors.forename: Justin B
authors.initials: JB
authors.lastname: Dimick
authors.forename: Reid M
authors.initials: RM
authors.lastname: Wainess
authors.forename: John A
authors.initials: JA
authors.lastname: Cowan
authors.forename: Peter K
authors.initials: PK
authors.lastname: Henke
authors.forename: James C
authors.initials: JC
authors.lastname: Stanley
authors.forename: Gilbert R
authors.initials: GR
authors.lastname: Upchurch
mesh_terms: D017542:Aneurysm, Ruptured / Q000209:etiology; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000706:statistics & numerical data; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D016017:Odds Ratio; D018570:Risk Assessment; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000401:mortality