There are disproportionately higher rates of in-hospital mortality, postoperative complications and hospital readmission rates after isolated coronary artery bypass graft (CABG) surgery in patients on Medicare, Medicaid and those without insurance, compared with those with private insurance.
“Our anesthesiology department wants to know how anesthesia care impacts patient outcomes,” said Zachary A. Turnbull, MD, an instructor in anesthesiology at NewYork-Presbyterian/Weill Cornell Medicine, in New York City. “We’ve started by looking at the cardiac population and how insurance status affects outcomes, and are using ‘Big Data’ to help answer this question.”
As Dr. Turnbull noted, Americans lacking private health insurance have been shown to suffer disproportionately higher rates of morbidity and mortality after major surgical procedures. The authors sought to find out whether the same relationship exists after CABG surgery.
To do so, they turned to the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, and State Inpatient Databases for California, Florida and New York.
“We used these states because they’re fairly diverse and can be reasonably generalized to the rest of the country, which will help us understand what really might be at play,” Dr. Turnbull said.
Analyzing Insurance Differences
The investigators reviewed isolated CABG surgeries reported between 2007 and 2011 in all patients aged 18 years or older who met the inclusion criteria. The patients’ primary payor status was divided into five subgroups: Medicaid, Medicare, private insurance, uninsured and other. The relative rates of in-hospital mortality, postoperative complications, and 30- or 90-day readmission rates were queried. A total of 194,920 isolated CABG surgical patients were identified.
As reported at the 2017 annual meeting of the Society of Cardiovascular Anesthesiologists (abstract SCA16), both Medicaid patients (odds ratio [OR], 1.74; 95% CI, 1.51-2.01) and Medicare patients (OR, 1.23; 95% CI, 1.11-1.437) were found to have significantly greater inpatient mortality than their counterparts with private health insurance. Perhaps not surprisingly, socioeconomic disparities also were observed, as individuals within the highest state income quartile had a lower mortality rate (OR, 0.74; 95% CI, 0.64-0.81).
Black patients also had a higher mortality rate than white patients after CABG surgery (OR, 1.30; 95% CI, 1.12-1.49). Although overall 30- and 90-day readmission rates were found to be 16.1% and 24.0%, respectively, patients on Medicaid and Medicare—as well as uninsured patients—were readmitted significantly more frequently than those privately insured, at both time points. Black and Hispanic patients also exhibited disproportionately higher readmission rates than white patients at both 30 and 90 days. In addition, Medicaid and Medicare patients demonstrated significantly higher postoperative complication rates.
“This is obviously a multifactorial problem, but there is clearly a tendency toward poorer outcomes in those patient populations,” Dr. Turnbull told Anesthesiology News. “Unfortunately, that’s not too surprising. We contribute that to a variety of factors, including access to care, financial constraints on those patient populations, potential difficulty in postoperative disease management outside the hospital and access to resources, and all the potential socioeconomic disparities that may come into play.”
“It would be disingenuous to deny that health care disparities are part of the fabric of contemporary life in our country, as the gap between the poor and the wealthy has developed into a chasm,” said Kathryn E. McGoldrick, MD, professor and chair emeritus of anesthesiology, New York Medical College, in Valhalla. “Clearly, the social determinants of health are real and not easily mitigated,” she told Anesthesiology News.
“Let’s focus on cancer. Research suggests that up to 50% of cancers are preventable if one does not smoke, eats a healthy diet rich in fruits and vegetables, minimizes sun exposure, and exercises regularly. Unfortunately, a healthy diet can be considerably more expensive than junk food. Obesity as a result of eating too much of the wrong foods is highly carcinogenic. Breast cancer, for example, has a strong association with obesity, presumably because macrophages in fat tissue can infiltrate tumors and not only promote tumor growth and metastasis, but also suppress tumor-killing cells. In addition, the role of genetics in cancer is indisputable. How many poor people undergo testing for BRCA1 or BRCA2 genetic mutations and then undergo prophylactic mastectomy or oophorectomy?
“The Angelina Jolie–like ‘previvors’ are not well represented amongst the economically disadvantaged, who often have to choose between paying the rent or purchasing their medication. Poverty is a deadly behemoth, and we as a nation must find the will and the means to address the complex, multifactorial reasons for the unacceptable health care disparities that are so pervasive in our ‘land of plenty.’”
Facing and Fixing The Disparity
Ameliorating health care disparities divided along insurance lines will take a coordinated effort by a host of related parties to rectify. These disparities are so multifaceted that no easy solution can be expected.
“We’re trying to brainstorm solutions as we speak,” Dr. Turnbull said. “I think the first part of all of this is to be aware that these implicit biases or patient situations are real and that they do exist.
“I think as anesthesiologists we’re all about metrics, and we’re lucky to have such rich databases available to us,” he added. “At Weill Cornell we’re implementing best practices and instituting provider feedback, and we hope with this we’ll be able to optimize the intraoperative portion of patient care. There are so many confounders and so many things outside the hospital walls that we can’t necessarily account for, but if we can optimize our care intraoperatively, then I hope we can tilt the balance toward better outcomes for all patients.”