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

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