Authors: Daniel J Snyder; Daniel Snyder, BS; Jonathan Rasouli, MD; Sean Neifert, BS; Jonathan Gal, MD; Brian Deutsch, BS; Robert Rothrock, MD; John Caridi, MD (New York, NY)
Posterior cervical decompression and fusion (PCDF) is the treatment of choice for degenerative cervical radiculopathy and myelopathy refractory to medical management. Despite numerous studies examining patient-specific risk factors for outcomes after PCDF, questions remain about whether socioeconomic differences are risk factors themselves. Our goal was to investigate the effect of insurance status on episode-based outcomes for patients undergoing PCDF.
All PCDF cases between 2008-2016 were obtained from a single institution. Demographic, comorbidity, and outcomes data were collected. Five cohorts were created by insurance status: commercial, Medicare, Medicaid, managed care, and uninsured. Groups were compared using bivariate analysis. Multivariate models were also created including age, sex, ASA status, and Elixhauser score for the following outcomes: in-hospital complication, LOS, ICU stay, post-acute care (PAC) discharge, unplanned readmission and ER visit within 30- and 90-days.
A total of 1,137 patients underwent PCDF during the study period: commercial (n=217), managed care (n=492), Medicaid (n=63), Medicare (n=360), and uninsured (n=5). Patients in the Medicaid cohort had higher ASA designations than those in the commercial cohort. When compared to the commercial cohort, Medicaid patients were more likely to have an ICU stay (25.4% vs. 12.4%, p=0.01) and an ER visit within 90 days (14.3% vs. 4.2%, p=0.004); these differences failed to retain significance in multivariate analyses. Patients with Medicaid had a higher frequency of PAC discharge (38.1% vs. 18.0%, p=0.0008), and a higher likelihood of PAC discharge (OR=2.4, 95% CI: 1.1 – 5.7; p=0.009). No other outcomes differed significantly between cohorts.
Our findings show an association between Medicaid insurance status and PAC facility discharge after PCDF, even after adjusting for clinical characteristics. Recent literature suggests that PAC facility discharge may predispose patients to adverse events postdischarge, and future literature should investigate the reasons behind differential rates of PAC discharge for Medicaid patients.