title: Primary payer status affects outcomes for cardiac valve operations.
abstract: BACKGROUND
  Disparities in health care have been reported among various patient populations, and the uninsured and Medicaid populations are a major focus of current health care reform. The objective of this study was to examine the influence of primary payer status on outcomes after cardiac valve operations in the United States.
  
  
  METHODS
  From 2003 to 2007, 477,932 patients undergoing cardiac valve operations were evaluated using discharge data from the Nationwide Inpatient Sample database. Records were stratified by primary payer status: Medicare (n = 57,249, age = 74.0 ± 0.02 years), Medicaid (n = 5,868, age = 41.2 ± 0.13 years), uninsured (n = 2,349, age = 49.7 ± 0.15 years), and private insurance (n = 31,808, age = 53.3 ± 0.04 years). Multivariate regression models were applied to assess the independent effect of payer status on in-hospital outcomes.
  
  
  RESULTS
  Preoperative patient risk factors were more common among Medicare and Medicaid populations. Unadjusted mortality and complication rates for Medicare (6.9%, 36.6%), Medicaid (5.7%, 31.4%) and uninsured (5.2%, 31.4%) patient groups were higher compared with private insurance groups (2.9%, 29.9%; p < 0.001). In addition, mortality was lowest for patients with private insurance for all types of valve operations. Medicaid patients accrued the longest unadjusted hospital length of stay and highest total hospital costs compared with other payer groups (p < 0.001). Importantly, after risk adjustment, uninsured and Medicaid payer status conferred the highest odds of risk-adjusted mortality and morbidity compared with private insurance status, which were higher than those for Medicare.
  
  
  CONCLUSIONS
  Uninsured and Medicaid payer status is associated with increased risk-adjusted in-hospital mortality and morbidity among patients undergoing cardiac valve operations compared with Medicare and private insurance. In addition, Medicaid patients accrued the longest hospital stays and highest total costs. Primary payer status should be considered as an independent risk factor during preoperative risk stratification and planning.
authors.affiliation: Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA.
authors.forename: Damien J
authors.initials: DJ
authors.lastname: Lapar
authors.forename: Castigliano M
authors.initials: CM
authors.lastname: Bhamidipati
authors.forename: Dustin M
authors.initials: DM
authors.lastname: Walters
authors.forename: George J
authors.initials: GJ
authors.lastname: Stukenborg
authors.forename: Christine L
authors.initials: CL
authors.lastname: Lau
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; D000704:Analysis of Variance; D016009:Chi-Square Distribution; D005260:Female; D018166:Health Care Reform; D054625:Healthcare Disparities; D019918:Heart Valve Prosthesis Implantation / Q000191:economics* / Q000401:mortality; D017721:Hospital Costs; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008484:Medicaid / Q000191:economics*; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012044:Regression Analysis; D012307:Risk Factors; D014481:United States