title: Insurance status predicts acuity of thoracic aortic operations.
abstract: OBJECTIVE
  Nonelective case status is the strongest predictor of mortality for thoracic aortic operations. We hypothesized that underinsured patients were more likely to require nonelective thoracic aortic surgery because of reduced access to preventative cardiovascular care and elective surgical services.
  
  
  METHODS
  Between June 2005 and August 2011, 826 patients were admitted to a single aortic referral center and underwent 1 or more thoracic aortic operations. Patients with private insurance or Medicare (insured group, n=736; 89%) were compared with those with Medicaid or no insurance (underinsured group, n=90; 11%).
  
  
  RESULTS
  The proportion of patients requiring nonelective surgery was higher for underinsured than insured patients (56% vs 26%, P<.0001). Multivariable analysis revealed underinsurance to be the strongest independent predictor of nonelective case status (odds ratio [OR], 2.67; P<.0001). Preoperative use of lipid-lowering medications (OR, 0.63; P<.009) or a history of aortic surgery (OR, 0.48; P<.001) was associated with a decreased risk of nonelective operation. However, after adjustment for differences in preoperative characteristics and case status, underinsurance did not confer an increased risk of procedural morbidity or mortality (adjusted OR, 0.94; P=.83) or late death (adjusted hazard ratio, 0.83, P=.58) when compared with insured patients.
  
  
  CONCLUSIONS
  Underinsured patients were at the greatest risk of requiring nonelective thoracic aortic operation, possibly because of decreased use of lipid-lowering therapies and aortic surveillance. These data imply that greater access to preventative cardiovascular care may reduce the need for nonelective thoracic aortic surgery and lead to improved survival from thoracic aortic disease.
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Nicholas D
authors.initials: ND
authors.lastname: Andersen
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Hanna
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Asvin M
authors.initials: AM
authors.lastname: Ganapathi
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Syamal D
authors.initials: SD
authors.lastname: Bhattacharya
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Judson B
authors.initials: JB
authors.lastname: Williams
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Gaca
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Richard L
authors.initials: RL
authors.lastname: McCann
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address: gchad.hughes@duke.edu.
authors.forename: G Chad
authors.initials: GC
authors.lastname: Hughes
mesh_terms: D000328:Adult; D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D001018:Aortic Diseases / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000601:surgery*; D017558:Elective Surgical Procedures; D004630:Emergencies; D005260:Female; D006801:Humans; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D019458:Insurance Coverage / Q000191:economics; D007348:Insurance, Health / Q000191:economics; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured; D006278:Medicare; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D017149:Private Sector; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000401:mortality
chemical_list: D000960:Hypolipidemic Agents
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