R. Manzano-Nunez1, J. P. Herrera-Escobar1, C. K. Zogg2, N. Bhulani1, T. Andriotti1, J. C. McCarty1, T. Uribe-Leitz1, M. Jarman1, A. Salim1, A. H. Haider1, G. Ortega1 1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Yale University School Of Medicine,New Haven, CT, USA
Introduction: State decisions not to implement Medicaid expansion under the Affordable Care Act have the potential to leave many homeless individuals without an affordable insurance coverage option, which in turn could be associated with worse outcomes and higher costs. We hypothesize that by placing additional obstacles in the flow of care of homeless patients requiring emergency general surgery (EGS) operations, non-expansion states impact patient outcomes and their health-related decision-making process.
Methods: We used 2014 State Inpatient Database claims to identify homeless individuals admitted with a primary EGS diagnosis, as defined by the American Association for the Surgery of Trauma, who underwent a surgical procedure. Data related to homeless status was available for nine states (AZ, CO, FL, GA, MA, MD, NY, WA, and WI). States within this group were divided into those that did and did not implement Medicaid expansion. Multivariable quantile regression (MQR) models at the 50th, 75th and 90th quantiles accounting for variations in age, gender, race/ethnicity, insurance status and Charlson Comorbidity Index were used to examine associations between non-Medicaid expansion states and (1) LOS and (2) total index hospital charges within the homeless population. Multivariable logistic regression (MLR) models, adjusted for the same variables, were fitted to examine the associations between non-Medicaid expansion and discharge against medical advice, surgical complications, and mortality.
Results: A total of 6,930 homeless patients were identified. Of these, 435 (6.2%) were admitted in non-expansion states. Seventy-four percent (n=5,162) were insured through Medicaid (77.4% in Medicaid expansion states; 30.3% in non-expansion states). Homeless individuals living in non-expansion states had significantly higher total hospital charges and longer hospital stays (Table). After adjusting for confounders, MQR showed that non-Medicaid expansion was associated with longer LOS and higher charges (Table). The effect was observed in all quantiles examined. MLR showed no differences in mortality (OR=1.4, 95% CI, 0.8-2.6; p=0.1) or surgical complications (OR=1.1, 95% CI 0.7-1.8; p=0.4). However, homeless individuals living in non-expansion states did have higher risk-adjusted odds of being discharged against medical advice (OR= 2.1, 95% CI, 1.08-4.05 p=0.02).
Conclusion: Homeless patients living in Medicaid expansion states had reduced LOS, lower odds of being discharged against medical advice, and overall lower total index hospital charges. Not expanding Medicaid appears to result in the persistence of worse modifiable outcomes and increased hospital charges for an often-overlooked segment of the EGS population least equipped to handle them.
