Is Insurance Status a Modifiable Factor in Brain Tumor Treatment Outcomes? Comment on “Postoperative Mortality After Surgery for Brain Tumors by Patient Insurance Status in the United States” Insurance Status

Hervey-Jumper SL, Maher CO. — Thu, 01 Nov 2012 00:00:00 GMT

Despite advancements in surgical technique and in our understanding of tumor biology, the survival of patients with brain tumors has not vastly improved during the past 2 decades. Exploration of factors that can be changed in individual patients deserves attention. Inequalities in the delivery and implementation of health care in the United States have been well documented. Using the Nationwide Inpatient Sample (NIS), Momin et al provide an excellent analysis of uninsured, Medicaid, and privately insured adult patients who underwent craniotomy for a brain tumor. They analyzed International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes collected for 10 years for the surgical treatment of brain tumors from 28 582 patients in 37 states. Their aim was to determine whether insurance status was associated with a higher early in-hospital postoperative mortality rate. They concluded that uninsured (as opposed to Medicaid and privately insured) patients experienced the highest mortality even after exclusion of patients with comorbid illness.

Postoperative Mortality After Surgery for Brain Tumors by Patient Insurance Status in the United States Insurance Status and Craniotomy

Momin EN, Adams H, Shinohara RT, et al. — Thu, 01 Nov 2012 00:00:00 GMT

Objective

To examine whether being uninsured is associated with higher in-hospital postoperative mortality when undergoing surgery in the United States for a brain tumor.

Design

Retrospective cohort study using the Nationwide Inpatient Sample, January 1, 1999, through December 31, 2008.

Setting

The Nationwide Inpatient Sample contains all inpatient records from a stratified sample of 20% of hospitals in 37 states.

Patients

A total of 28 581 patients, aged 18 to 65 years, who underwent craniotomy for a brain tumor. Three groups were studied: Medicaid recipients and privately insured and uninsured patients.

Main Outcome Measure

The main outcome measure was in-hospital postoperative death. Associations between this outcome and insurance status were examined within the full cohort and within the subset of patients with no comorbidity using Cox proportional hazards models. These models were stratified by hospital to control for any clustering effects that could arise from differing access to care.

Results

In the unadjusted analysis, the mortality rate for privately insured patients was 1.3% (95% CI, 1.1%-1.4%) compared with 2.6% for uninsured patients (95% CI, 1.9%-3.3%; P < .001) and 2.3% for Medicaid recipients (95% CI, 1.8%-2.8%; P < .001). After adjusting for patient characteristics and stratifying by hospital in patients with no comorbidity, uninsured patients still had a higher risk of experiencing in-hospital death (hazard ratio, 2.62; 95% CI, 1.11-6.14; P = .03) compared with privately insured patients. In this adjusted analysis, the disparity was not conclusively present in Medicaid recipients (hazard ratio, 2.03; 95% CI, 0.97-4.23; P = .06).

Conclusions

Uninsured patients who underwent craniotomy for a brain tumor experienced the highest in-hospital mortality. Differences in overall health do not fully account for this disparity.

JAMA Surgery: Brain Cancer Topic Collection

Is Insurance Status a Modifiable Factor in Brain Tumor Treatment Outcomes? Comment on “Postoperative Mortality After Surgery for Brain Tumors by Patient Insurance Status in the United States” Insurance Status

Postoperative Mortality After Surgery for Brain Tumors by Patient Insurance Status in the United States Insurance Status and Craniotomy