Cost of Failure to Achieve Textbook Outcomes: Association of Insurance Type with Outcomes and Cumulative Cost for Inpatient Surgery

Authors

Michael A Jacobs
Jeongsoo Kim
Jasmine C Tetley
Susanne Schmidt
Bradley B Brimhall
Virginia Mika
Chen-Pin Wang
Laura S Manuel
Paul Damien
Paula K Shireman

Language

English

Publication Date

2-1-2023

Journal

Journal of the American College of Surgeons

DOI

10.1097/XCS.0000000000000468

PMID

36648264

PMCID

PMC11549895

PubMedCentral® Posted Date

11-9-2024

PubMedCentral® Full Text Version

Author MSS

Abstract

Background: Surgical outcome/cost analyses typically focus on single outcomes and do not include encounters beyond the index hospitalization.

Study design: This cohort study used NSQIP (2013-2019) data with electronic health record and cost data risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status, and operative stress assessing cumulative costs of failure to achieve textbook outcomes defined as absence of 30-day Clavien-Dindo level III and IV complications, emergency department visits/observation stays (EDOS), and readmissions across insurance types (private, Medicare, Medicaid, uninsured). Return costs were defined as costs of all 30-day emergency department visits/observation stays and readmissions.

Results: Cases were performed on patients (private 1,506; Medicare 1,218; Medicaid 1,420; uninsured 2,178) with a mean age 52.3 years (SD 14.7) and 47.5% male. Medicaid and uninsured patients had higher odds of presenting with preoperative acute serious conditions (adjusted odds ratios 1.89 and 1.81, respectively) and undergoing urgent/emergent surgeries (adjusted odds ratios 2.23 and 3.02, respectively) vs private. Medicaid and uninsured patients had lower odds of textbook outcomes (adjusted odds ratios 0.53 and 0.78, respectively) and higher odds of emergency department visits/observation stays and readmissions vs private. Not achieving textbook outcomes was associated with a greater than 95.1% increase in cumulative costs. Medicaid patients had a relative increase of 23.1% in cumulative costs vs private, which was 18.2% after adjusting for urgent/emergent cases. Return costs were 37.5% and 65.8% higher for Medicaid and uninsured patients, respectively, vs private.

Concusions: Higher costs for Medicaid patients were partially driven by increased presentation acuity (increased rates/odds of preoperative acute serious conditions and urgent/emergent surgeries) and higher rates of multiple emergency department visits/observation stays and readmission occurrences. Decreasing surgical costs/improving outcomes should focus on reducing urgent/emergent surgeries and improving postoperative care coordination, especially for Medicaid and uninsured populations.

Keywords

Humans, Male, Aged, United States, Middle Aged, Female, Medicare, Inpatients, Cohort Studies, Medicaid, Hospitalization, Medically Uninsured, Retrospective Studies

Published Open-Access

yes

Recommended Citation

Jacobs, Michael A; Kim, Jeongsoo; Tetley, Jasmine C; et al., "Cost of Failure to Achieve Textbook Outcomes: Association of Insurance Type with Outcomes and Cumulative Cost for Inpatient Surgery" (2023). Faculty, Staff and Student Publications. 5898.
https://digitalcommons.library.tmc.edu/uthgsbs_docs/5898