Introduction: Lumbar spinal stenosis is one of the most common reasons patients undergo spinal procedures. The association between insurance type and outcomes of surgery for lumbar spinal stenosis is unknown. We sought to describe the insurance disparities in the rate of complications, rate of reoperation, and health care resource usage after surgery for lumbar stenosis.
Methods: We analyzed the Medicaid, Medicare, and Commercial datasets of the Reuter's MarketScan database. We included all adult patients with a primary diagnosis of lumbar stenosis who underwent laminectomy or fusion between 2000 and 2009. We excluded those who lacked 2 years of pre- and post-operative follow-up. We used multivariate regression and general linear models to determine the association between the different insurance types and the rate of reoperation, amount of health care resource usage, and rate of complications. We controlled for age, sex, year of index operation, length of follow-up, and comorbidities.
Results: After applying our inclusion and exclusion criteria, our cohort contained 10,604 patients with commercial insurance, 12,959 with Medicare, and 1,523 with Medicaid. On average, the Medicaid population was slightly older, had longer follow-up, contained more females, and had more comorbidities than those with commercial insurance. After adjusting for covariates, Medicaid patients were 32% less likely to receive any reoperation than those with commercial insurance (aOR = 0.78, p < 0.01). Patients with Medicaid were at 21% increased risk of immediate post-operative complications (aOR = 1.21, p < 0.0001) and were prescribed more medications (130 vs. 70, p < 0.0001) than those with commercial insurance.
Conclusions: The results of our national, retrospective study suggest that patients with Medicare have worse outcomes after lumbar stenosis operations. Patients with Medicare have more complications, receive fewer reoperations, and use more health care resources than patients with commercial insurance.
Patient Care: As the nation considers health care reform, understanding the ways in which insurance type affect outcomes of surgeries is of utmost importance. Our study contributes to this endeavor in a number of ways. First, our study adds more evidence to the argument that simply having insurance does not guarantee optimal outcomes after surgery. As researchers continue to describe the phenomenon of insurance inequalities and elucidate the mechanisms through which one insurance type provides better outcomes, we will provide policymakers with more data with which they can craft health care reforms that ensure optimal results for all patients. Second, our study will stimulate thought and discussion among spine surgeons to help address these inequalities at the the local and institutional levels.
Learning Objectives: After this session, participants should be able to: 1) Describe the differences in lumbar stenosis surgery outcomes in the commercial and Medicaid populations, 2) Identify the possible mechanisms through which insurance type influences outcomes, 3) Create strategies to address these disparities at the local and national levels.