The Relationship Between Payer and Risk of Surgical Site Infection Following Cesarean Delivery

Abstract

BackgroundBoth Medicaid and private health insurance support important access to care for many pregnant women in the United States. The role of health insurance on many outcomes, such as surgical site infection (SSI) following Cesarean delivery (CD), has not been adequately investigated.MethodsThis retrospective cohort study investigated SSI risk following CDs performed in California hospitals in 2011 among women covered by Medicaid or private health insurance. All CDs were obtained from identifiable state inpatient discharge (SID) data and linked with National Healthcare Safety Network (NHSN) data to ascertain post-delivery SSI. Characteristics including age, race/ethnicity, BMI, prior CD planned admission, emergency CD, active labor and labor duration, ASA physical status, general anesthesia, wound class, hospital ownership, hospital annual CD count, intern/resident-to-bed ratio, case mix index, disproportionate share adjustment, urban location, and area wage index were obtained from CMS facility, NHSN, and SID data. Potential effect modification of the payer-SSI relationship was assessed using a multivariable logistic regression model.Results90% of eligible NHSN records linked with a SID record. The analytic dataset consisted of 387 SSIs following 57,143 CDs performed in 196 hospitals. Payer distribution across CDs was 49% Medicaid, 51% private insurer. SSIs were reported following 0.74% of CDs among Medicaid recipients and 0.62% among those privately insured (unadjusted risk ratio: 1.2, 95% confidence interval: 1.0–1.5, P = 0.09). In for-profit hospitals women with Medicaid had a 2.6-fold (95% CI: 1.2–5.4, P = 0.01) increase in adjusted SSI risk compared with women with private insurance. There were no differences in adjusted SSI risk by payer in government (RR: 1.1, 95% CI 0.7–1.8, P = 0.92) or not-for-profit hospitals (RR: 0.9, 95% CI 0.7–1.2, P = 0.52).ConclusionDespite accounting for various patient and facility-level factors, Medicaid-insured women experienced higher SSI risk than privately-insured women in for-profit hospitals, but not in government owned or not-for-profit hospitals. Additional studies to understand underlying causes may help target efforts to prevent SSIs following CDs among vulnerable patients.Disclosures All authors: No reported disclosures.