title: Access to Posthospitalization Acute Care Facilities is Associated with Payer Status for Open Abdominal Aortic Repair and Open Lower Extremity Revascularization in the Vascular Quality Initiative.
abstract: BACKGROUND
  Uninsured patients may not have access to postacute care facilities that play an important role in clinical recovery, and functional outcomes after vascular surgery. We sought to determine whether discharge disposition is associated with insurance status.
  
  
  METHODS
  We retrospectively reviewed data from the Vascular Quality Initiative®for patients who underwent open abdominal aortic repair, infrainguinal bypass, or suprainguinal bypass (SB) between January 2012 and July 2015. Mixed-effects logistic regression analysis with clustering at the surgeon and facility level was used to calculate 95% confidence intervals for discharge disposition to home, skilled nursing facility (SNF) or rehabilitation (Rehab) facility by payer status (Medicare, Medicaid, Commercial, Military/Veterans Affairs, Non-US Insurance, or Self-pay), with adjustment for patient, operative, and postoperative characteristics.
  
  
  RESULTS
  The study cohort comprised 18,478 procedures (open abdominal aortic repair = 2,817; infrainguinal bypass = 11,572; suprainguinal bypass = 4,089) after we excluded procedures with missing data and in-hospital deaths. Twenty-four percent of the cohort was discharged to an SNF or Rehab site. On univariate analysis, the odds ratio (OR) of discharge home was 4.38 (95% CI: 3.33-5.77) for self-pay as compared to Medicare. On mixed-effects analysis, the adjusted odds of discharge home for self-pay as compared to Medicare remained high (OR = 3.09; 95% CI: 2.23-4.26), after adjustment for age, gender, race/ethnicity, preoperative ambulatory status, number of comorbidities, case urgency, total operative time, presence of a postoperative complication, procedure type, and length of stay. Adjusted odds for discharge to SNF (OR = 0.26; 95% CI: 0.15-0.46) and Rehab (OR = 0.50; 95% CI: 0.35-0.72) were lowest for self-pay status.
  
  
  CONCLUSIONS
  Access to postacute care facilities is associated with insurance status. Self-pay (uninsured) patients are less likely to have access to discharge services that may aid clinical recovery, and functional outcomes after major vascular surgery.
authors.affiliation: Robert Wood Johnson Foundation, Clinical Scholars Program, University of California, Los Angeles, Los Angeles, CA; Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA. Electronic address: jesus.ulloa@ucsf.edu.
authors.forename: Jesus G
authors.initials: JG
authors.lastname: Ulloa
authors.affiliation: Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA; Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA.
authors.forename: Karen
authors.initials: K
authors.lastname: Woo
authors.affiliation: Robert Wood Johnson Foundation, Clinical Scholars Program, University of California, Los Angeles, Los Angeles, CA; Division of Health Services Research, Department of Internal Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA.
authors.forename: Chi-Hong
authors.initials: CH
authors.lastname: Tseng
authors.affiliation: Robert Wood Johnson Foundation, Clinical Scholars Program, University of California, Los Angeles, Los Angeles, CA; Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA.
authors.forename: Melinda
authors.initials: M
authors.lastname: Maggard-Gibbons
authors.affiliation: Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA; Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA.
authors.forename: David
authors.initials: D
authors.lastname: Rigberg
mesh_terms: D000368:Aged; D001012:Aorta, Abdominal / Q000601:surgery*; D005260:Female; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008484:Medicaid / Q000191:economics; D017057:Medically Uninsured; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D016017:Odds Ratio; D010351:Patient Discharge / Q000191:economics*; D058729:Peripheral Arterial Disease / Q000191:economics / Q000601:surgery*; D020127:Recovery of Function; D012047:Rehabilitation Centers / Q000191:economics*; D012189:Retrospective Studies; D012307:Risk Factors; D012866:Skilled Nursing Facilities / Q000191:economics*; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics*