A. Fazzalari1,2, N. Pozzi2, D. Alfego1, N. Erskine1, S. Qiming1, J. Mathew1, G. Tourony1, D. Litwin1, M. Cahan1 1University Of Massachusetts Medical School,Surgery,Worcester, MA, USA 2Saint Mary’s Hospital,Surgery,Waterbury, CT, USA
Introduction:
Previous studies using national datasets have suggested that insurance type drives a disparity in care delivered to emergency surgery patients. These large databases lack the granularity that smaller single institution series may provide. The goal of this study is to identify socioeconomic and geographic factors that may account for disparities in care between Medicaid and Non-Medicaid enrollees with acute appendicitis in Central Massachusetts.
Methods:
This retrospective cohort study included all adult patients with acute appendicitis at two campuses of an academic medical center in Central Massachusetts between 2010-2017. Baseline sociodemographic and clinical characteristics were compared according to Medicaid enrollment status and univariate and multivariate analyses were performed to assess differences in the frequency of surgery performed, time to surgery (TTS), length of stay (LOS), and rates of readmission between those with and without Medicaid.
Results:
The sample consisted of 1,257 patients, with a mean age of 39.4 years old, 46.4% were female and 135 (10.7%) were enrolled in Medicaid. Medicaid enrollees were significantly younger (33.5 vs 40.1 years, p<0.0001), and more likely to be unmarried (73% vs 48.1%, p<0.0001) or Non-White (54.1% vs 24.4%, p<0.0001) when compared to Non-Medicaid enrollees. Medicaid enrollees were more likely to live in a neighborhood that was closer to the hospital (4.0 miles vs 8.3 miles, p<0.0009), had a lower median annual income ($40,400.00 vs $67,700.00, p<0.0001), had a lower level of formal education (82.9% vs 91.6% with high school diploma, p<0.0001) and were more likely to belong to a racial/ethnic minority (31.0% vs 17.1%, p<0.0001). Medicaid enrollees were also less likely to have diabetes mellitus, hyperlipidemia, or hypertension. There were no significant differences between the number of Medicaid and Non-Medicaid enrollees who presented with perforated appendicitis (28.9% vs 31.2%, p=0.857) or who underwent laparoscopic appendectomy (96.3% vs 90.7%, p=0.081). While LOS (20h:30m vs 22h:38m, p=0.109) and 30-day readmission rates (17.8% vs 14.5%, p=0.683) were similar between the two groups, there was a significant difference in the median TTS, with Medicaid patients waiting longer, even after adjusting for social and clinical characteristics (6h:47m vs 4h:49m, p<0.001).
Conclusion:
This study underscores the importance of local data in understanding delivery of care at the individual level. Despite anticipated population differences between patients with and without Medicaid, locally the treatment of appendicitis did not differ substantially. While Medicaid enrollees did experience longer TTS, the explanation for this is unclear. Further studies are needed to investigate factors that may account for insurance-based discrimination, racial or unconscious bias, or other unanticipated factors which may account for delays to surgery among Medicaid enrollees.