Payer Status and Access to Laparoscopic Subtotal Colectomy for Ulcerative Colitis

Abstract

Medicaid populations have been shown to have inferior surgical outcomes, but less is known about their access to advanced surgical procedures. The aim of this study was to evaluate if patients with Medicaid and ulcerative colitis who presented for subtotal colectomy would have reduced access to the laparoscopic approach in comparison with a similar population with private insurance. Using the Nationwide Inpatient Sample database from 2008 to 2010, we identified all patients who underwent subtotal colectomy for ulcerative colitis. The χ test and multivariable logistic regression were used to identify predictors for laparoscopic subtotal colectomy for ulcerative colitis. The primary end point was the use of open or laparoscopic subtotal colectomy. Secondary end points included hospital length of stay and surgical outcomes. We identified a total of 2589 subtotal colectomy hospitalizations for ulcerative colitis (435 with Medicaid and 2154 with private insurance). The private insurance and Medicaid groups did not have significantly different mean age, sex, or Charlson scores (p > 0.05). Although 43% of the private insurance cohort received laparoscopic subtotal colectomy during their hospitalization, only 23% of the Medicaid population received equivalent care (p < 0.001). In a multivariate analysis that included age, sex, emergency status, hospital location, hospital size, teaching status, income, and Charlson score, urban teaching hospital status (p < 0.01), emergency status (p = 0.045), age <40 (p < 0.01), northeast location (p = 0.01), and private insurance status (p < 0.01) were independent predictors of the laparoscopic approach. Administrative data have the potential for unrecognized miscoding or incomplete risk adjustment. Disease severity is not accounted for in the Nationwide Inpatient Sample database. Medicaid payer status was associated with reduced use of laparoscopic subtotal colectomy for ulcerative colitis. Although this finding may be due in part to physician preference or patient characteristics, health system factors appear to contribute to selection of the surgical approach.