title: Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?
abstract: BACKGROUND
  We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation.
  
  
  METHODS
  A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005-2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled.
  
  
  RESULTS
  The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage.
  
  
  CONCLUSIONS
  Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD. Electronic address: dschwa37@jhmi.edu.
authors: Diane A
authors: DA
authors: Schwartz
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: Xuan
authors: X
authors: Hui
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: Eric B
authors: EB
authors: Schneider
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: Mays T
authors: MT
authors: Ali
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: Joseph K
authors: JK
authors: Canner
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: William R
authors: WR
authors: Leeper
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: David T
authors: DT
authors: Efron
authors: Elliot
authors: E
authors: Haut
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: Elliot R
authors: ER
authors: Haut
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: Catherine G
authors: CG
authors: Velopulos
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: Timothy M
authors: TM
authors: Pawlik
authors: Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD.
authors: Adil H
authors: AH
authors: Haider
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D004638:Emergency Treatment; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured; D006278:Medicare; D008875:Middle Aged; D016017:Odds Ratio; D058991:Patient Protection and Affordable Care Act; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000191:economics; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult