Insurance status is associated with acuity of presentation and outcomes for thoracic aortic operations.
BACKGROUND
Nonelective procedure status is the greatest risk factor for postoperative morbidity and mortality in patients undergoing thoracic aortic operations. We hypothesized that uninsured patients were more likely to require nonelective thoracic aortic operation due to decreased access to preventative care and elective surgical services.


RESULTS
An observational study of the Society of Thoracic Surgeons Database identified 51 282 patients who underwent thoracic aortic surgery between 2007 and 2011 at 940 North American centers. Patients were stratified by insurance status (private insurance, Medicare, Medicaid, other insurance, or uninsured) as well as age <65 or ≥65 years to account for differences in Medicare eligibility. The need for nonelective thoracic aortic operation was highest for uninsured patients (71.7%) and lowest for privately insured patients (36.6%). The adjusted risks of nonelective operation were increased for uninsured patients (adjusted risk ratio, 1.77; 95% confidence interval, 1.70-1.83 for age <65 years; adjusted risk ratio, 1.46; 95% confidence interval, 1.29-1.62 for age ≥65 years) as well as Medicaid patients aged <65 years (adjusted risk ratio, 1.18; 95% confidence interval, 1.10-1.26) when compared with patients with private insurance. The adjusted risks of major morbidity or mortality were further increased for all patients aged <65 years without private insurance (adjusted risk ratios between 1.13 and 1.27).


CONCLUSIONS
Insurance status was associated with acuity of presentation and major morbidity and mortality for thoracic aortic operations. Efforts to reduce insurance-based disparities in the care of patients with thoracic aortic disease seem warranted and may reduce the incidence of aortic emergencies and improve outcomes after thoracic aortic surgery.
From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.).
Nicholas D
ND
Andersen
From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.).
J Matthew
JM
Brennan
From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.).
Yue
Y
Zhao
From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.).
Judson B
JB
Williams
From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.).
Matthew L
ML
Williams
From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.).
Peter K
PK
Smith
From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.).
John E
JE
Scarborough
From the Departments of Surgery (N.D.A., J.B.W., P.K.S., J.E.S., G.C.H.) and Medicine (J.M.B.), and the Duke Clinical Research Institute (J.M.B., Y.Z., J.B.W.), Duke University Medical Center, Durham, NC; and Department of Surgery, University of Louisville, Louisville, KY (M.L.W.). gchad.hughes@duke.edu.
G Chad
GC
Hughes
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic / Q000601:surgery; D018450:Disease Progression; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D006278:Medicare; D008875:Middle Aged; D016896:Treatment Outcome; D014481:United States; D014652:Vascular Diseases / Q000453:epidemiology* / Q000601:surgery; D014656:Vascular Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data*
aorta; surgery