MedWire News: Medicaid patients attending the emergency department with acute cholecystitis (AC) are less likely to receive definitive treatment than patients with private insurance (PI), US researchers have found.
"While this finding may be due in part to patients' health beliefs and physician preferences, the magnitude of difference suggests that health systems factors may provide a significant contribution toward clinical decision making in this entity," say Alexander Greenstein and co-workers, from The Mount Sinai Medical Center in New York.
The team used the Nationwide Inpatient Sample database for 1998 through 2008 to determine whether Medicaid patients have reduced access to cholecystectomy compared with their PI patient counterparts.
Overall, 291,326 Medicaid and 623,853 PI patients, aged an average of 46.4 years, were admitted to the emergency department with a primary diagnosis of AC. Medicaid patients were younger than those with PI, had a higher level of comorbidity, and were more likely to have a major co-existing condition.
The researchers propensity matched approximately 200,000 Medicaid patients with 200,000 PI patients using age, gender, comorbidity, year of surgery, and hospital characteristics. Matched patients were aged a median of 43.9 years with a Charlson Comorbidity Index of 0.5, and 76% were female.
Medicaid patients were significantly less likely to undergo cholecystectomy during their hospital stay than PI patients (83 vs 89%), the researchers report in the Archives of Surgery.
Medicaid patients who underwent cholecystectomy were less likely to undergo laparoscopic surgery - "the approach of choice" - than PI patients (69 vs 78%). Furthermore, Medicaid patients treated laparoscopically were significantly more likely to have conversion to open surgery than PI patients (3.9 vs 3.0%).
Of concern, Medicaid patients had a significant 2.15-fold higher rate of mortality than PI patients, after adjusting for confounding factors such as age and comorbidity (0.33 vs 0.16%). Rates of nonfatal complications, wound complications, infections, acute renal failure, and conversion to open surgery over the 10-year period also remained significantly higher among Medicaid than PI patients after adjustment.
Greenstein et al note that, although there was a narrowing of the disparity in the use of laparoscopic surgery between the two populations over the study period, the overall inequity in receipt of surgery continued.
"In an atmosphere of increasing cutbacks in both federal and state support for Medicaid, the gap in medical care for patients dependent on the Medicaid program will most likely widen," the researchers say.
"Further studies in health disparities are needed to monitor the impact of reduced support on this vulnerable population and to delineate interventions to help eliminate the gap."
In an accompanying critique, Paul Rosenthal (Bariatic Institute, Weston, Florida, USA) says that PI status could mean patients are offered surgery unnecessarily, noting that the study lacks "clinical and pathologic evidence" to show that only PI patients who required urgent cholecystectomy underwent surgery, or that Medicaid AC patients who required urgent surgery did not receive it.
Nevertheless, he adds: "I also concur that in this atmosphere of increasing cutbacks in both federal and state support for Medicaid, the gap in medical care for patients dependent on the Medicaid program will most likely widen and further put this already vulnerable population at higher risk."
MedWire (www.medwire-news.md) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012
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