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  • Effect of Insurance Status on Outcome of Intracranial Aneurysm Treatment

    Final Number:

    Pui Man Rosalind Lai BA; Hormuzdiyar H. Dasenbrock MD, BA; Ning Lin; Rose Du MD PhD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: Medicare and Medicaid coverage have been associated with inferior outcomes for patients with varied medical and surgical conditions. This is the first nationwide study to analyze the impact of primary payer on the outcomes of patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling or microsurgical clipping.

    Methods: Patients were identified using the Nationwide Inpatient Sample (2001-2010) by ICD-9 codes for subarachnoid hemorrhage or intracerebral hemorrhage and a procedural code for aneurysm repair. Mutivariate regression models were utilized to analyze the impact of primary payer on in-hospital mortality, non-routine discharge, and length of hospital stay. Models were adjusted for patient age, sex, race, comorbidities, socioeconomic status, hospital region and location, procedural volume, year of admission. Subsequent models were also adjusted for time to aneurysm repair and time to ventriculostomy.

    Results: A total of 15,557 hospitalizations (4096 Medicare, 2578 Medicaid, 2002 uninsured, 8883 private insurance) were included in this study. In the initial model, in-hospital mortality was increased in Medicaid (OR 1.28, 95% CI 1.02-1.60), and uninsured patients (OR 1.36, 95% CI 1.08-1.72). Adjusting for intervention accounted for the mortality associations observed. Length of stay remained significantly longer for Medicaid patients (by 12.5 days for surgical clipping, 95% CI 7.21-17.7, and 13 days for coiling, 95% CI 2.4-24.5) with a reduced adjusted odds of non-routine discharge (clipping OR 0.55, 95% CI 0.38-0.81; coiling OR 0.92, 95% CI 0.60-1.40). Reduced non-routine discharge was also observed in uninsured patients (clipping OR 0.32, 95% CI 0.15-0.69; coiling OR 0.61, 95% CI 0.34-1.09).

    Conclusions: Differences by primary payer were more pronounced for patients who underwent microsurgical clipping. The observed differences by primary payer are likely multifactorial, attributable to varied socioeconomic factors and complexities of the American healthcare delivery system.

    Patient Care: The association between socioeconomic disadvantage and poor health has been well-established. However, no study to date has analyzed the impact of insurance status on the outcomes after aneurysmal subarachnoid hemorrhage. We report the first nationwide study evaluating if those with government-sponsored insurance have differential outcomes after microsurgical clipping and endovascular coiling of ruptured intracranial aneurysms.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1)Describe the impact of insurance status on outcome of intracranial aneurysm treatment. 2) Discuss the use and limitations of the Nationwide Inpatient Sample database

    References: Boxer LK, Dimick JB, Wainess RM, Cowan JA, Henke PK, et al. (n.d.) Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States. Surgery 134: 142–145. doi:10.1067/msy.2003.214. El-Sayed AM, Ziewacz JE, Davis MC, Lau D, Siddiqi HK, et al. (2011) Insurance status and inequalities in outcomes after neurosurgery. World neurosurgery 76: 459–466. Available: Accessed 12 February 2013. Lin N, Popp AJ (2011) Insurance status and patient outcome after neurosurgery. World neurosurgery 76: 398–400. Available: Accessed 12 February 2013. Lemaire A, Cook C, Tackett S, Mendes DM, Shortell CK (2008) The impact of race and insurance type on the outcome of endovascular abdominal aortic aneurysm (AAA) repair. Journal of vascular surgery 47: 1172–1180. Available: Accessed 12 February 2013. LaPar DJ, Bhamidipati CM, Mery CM, Stukenborg GJ, Jones DR, et al. (2010) Primary payer status affects mortality for major surgical operations. Annals of surgery 252: 544–50; discussion 550–1. Available: Accessed 4 March 2013.

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