title: Insurance status is associated with complex presentation among emergency general surgery patients.
abstract: The Affordable Care Act has the potential to significantly affect access to care for previously uninsured patients in need of emergency general surgical care. Our objective was to determine the relationship between insurance status and disease complexity at presentation among a national sample of emergency general surgical patients.
  
  
  
  Data from the National Emergency Department Sample from 2006-2009 were queried to identify all patients aged 18-64 years old admitted through the emergency department with a primary diagnosis of appendicitis, diverticulitis, inguinal hernia, or bowel obstruction. Primary outcome of complex presentation was defined as also presenting with generalized peritonitis, intra-abdominal abscess, perforated bowel, intestinal gangrene, or other disease-specific measures of complexity. We used multivariable logistic regression to determine the independent association between insurance status and complex presentation. Models accounted for patient- and hospital-level covariates. Counterfactual models were used to estimate the risk of complex presentation attributable to lack of insurance.
  
  
  
  A total of 1,373,659 patients were included, with an overall uninsured rate of 12.3%. Uninsured patients had significantly higher, unadjusted rates of complex presentation, and uninsured payer status was independently associated with complex presentation (odds ratio 1.38, 95% confidence interval: 1.34-1.42). Counterfactual models suggest that having insurance would result in a 22.37% (95% confidence interval: 22.35-22.39%) relative decline in risk of complex emergency general surgical presentation among the uninsured population.
  
  
  
  Insurance status is independently associated with severity of disease at presentation among emergency general surgical conditions nationally. In light of recently reaffirmed Affordable Care Act insurance expansion provisions, these results anticipate increased timely access to operative care for newly insured patients and a corresponding decline in complex, emergency general surgical presentations.
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA. Electronic address: jwscott@partners.org.
authors.forename: John W
authors.initials: JW
authors.lastname: Scott
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: Joaquim M
authors.initials: JM
authors.lastname: Havens
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: Lindsey L
authors.initials: LL
authors.lastname: Wolf
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: Cheryl K
authors.initials: CK
authors.lastname: Zogg
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: John A
authors.initials: JA
authors.lastname: Rose
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: Ali
authors.initials: A
authors.lastname: Salim
authors.affiliation: Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, MA; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
mesh_terms: D000328:Adult; D016208:Databases, Factual; D004636:Emergency Service, Hospital / Q000191:economics / Q000706:statistics & numerical data; D004638:Emergency Treatment / Q000191:economics; D005260:Female; D013502:General Surgery / Q000191:economics* / Q000379:methods; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage; D016015:Logistic Models; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D058991:Patient Protection and Affordable Care Act / Q000191:economics; D061214:Patient Safety; D012189:Retrospective Studies; D018570:Risk Assessment; D012959:Socioeconomic Factors; D014481:United States; D055815:Young Adult