Examining Insurance-Related Disparities in Postsurgery Mortality During Pandemic

The pandemic’s first wave was associated with a higher risk of mortality after major surgery in hospitals where at least 1 in 4 patients had COVID-19, but no worsening disparities were found among patients with no insurance or Medicaid vs those with commercial insurance. Researchers published their findings in JAMA Network Open.

“The COVID-19 pandemic caused significant disruptions in surgical care,” researchers said. “Our goal in this study was to examine whether the pandemic was associated with a widening of the gap in health outcomes between insured and uninsured individuals undergoing major surgery.”

The cross-sectional study included 2,950,147 adult patients who had major surgery at 677 US hospitals. Data spanning January 2018 through May 2020 was collected from the Vizient Clinical Database.

Authors reported 48.4% of participants had Medicare, 33.9% had commercial insurance, 10.9% had Medicaid, 4.8% had coverage through another payer, and 2% had no insurance.

Hospitals’ COVID-19 burden was calculated as the proportion of infected patients during the first wave of cases. Researchers ranked burden as low (≤5%), medium (5.1%-10%), high (10.1%-25%), or very high (>25%).

There was a greater increase in mortality rates for patients undergoing surgery at hospitals with a high (adjusted odds ratio [AOR], 1.13; 95% CI, 1.03-1.24; P=0.01) or very high COVID-19 burden (AOR, 1.38; 95% CI, 1.24-1.53; P<0.001), as compared to patients in facilities with a low burden.

“These odds were greater among patients requiring urgent and emergency surgery than among those requiring elective surgery,” researchers noted.

Compared to patients with commercial insurance, those with Medicaid and no insurance had 29% (AOR, 1.29; 95% CI, 1.22-1.36; P<0.001) and 75% (AOR, 1.75; 95% CI, 1.55-1.98; P<0.001) higher odds of death, respectively.

However, when comparing hospitals with high vs low COVID-19 burdens, mortality rates did not increase disproportionately for patients with Medicaid (AOR, 1.03; 95% CI, 0.82-1.30; P=0.79) or no insurance (AOR, 0.85; 95% CI, 0.47-1.54; P=0.60). These findings suggest the first wave of the pandemic was not associated with a widening disparity between payer types, researchers said.

“Our study supports extensive and longstanding evidence that uninsured individuals or individuals with Medicaid have worse health outcomes than patients with commercial insurance. However, it is difficult to disentangle the extent to which these worse outcomes are associated with lower-quality medical care or whether the lack of insurance or Medicaid serves as a proxy for worse health status,” authors concluded.

“It will be important to track the long-term effects of delays and disruptions to surgical care among disadvantaged groups even after the COVID-19 pandemic has waned,” they added.

Reference:
Glance LG, Dick AW, Shippey E, et al. Association between the COVID-19 pandemic and insurance-based disparities in mortality after major surgery among US adults. JAMA Netw Open. 2022;5(7):e2222360. doi:10.1001/jamanetworkopen.2022.22360