title: Primary payer status affects mortality for major surgical operations.
abstract: OBJECTIVE
  Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following major surgical operations in the United States is dependent on primary payer status.
  
  
  METHODS
  From 2003 to 2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n = 491,829), Medicaid (n = 40,259), Private Insurance (n = 337,535), and Uninsured (n = 24,035). Multivariate regression models were applied to assess outcomes.
  
  
  RESULTS
  Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality.
  
  
  CONCLUSIONS
  Medicaid and Uninsured payer status confers increased risk-adjusted mortality. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors or operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US Patients.
authors.affiliation: Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908-0679, USA.
authors.forename: Damien J
authors.initials: DJ
authors.lastname: LaPar
authors.forename: Castigliano M
authors.initials: CM
authors.lastname: Bhamidipati
authors.forename: Carlos M
authors.initials: CM
authors.lastname: Mery
authors.forename: George J
authors.initials: GJ
authors.lastname: Stukenborg
authors.forename: David R
authors.initials: DR
authors.lastname: Jones
authors.forename: Bruce D
authors.initials: BD
authors.lastname: Schirmer
authors.forename: Irving L
authors.initials: IL
authors.lastname: Kron
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D003627:Data Interpretation, Statistical; D005260:Female; D018166:Health Care Reform; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data*; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality*; D012307:Risk Factors; D012959:Socioeconomic Factors; D013514:Surgical Procedures, Operative / Q000401:mortality*; D014481:United States / Q000453:epidemiology