Brain tumor resection may be a riskier proposition for uninsured patients and possibly those with public insurance as well, a national analysis suggested.
In-hospital mortality after the procedure was 2.62 times more likely without insurance even after adjusting for patient characteristics and stratifying by hospital in patients with no comorbidity (P=0.03), Alfredo Quiñones-Hinojosa, MD, of Johns Hopkins University, and colleagues found.
Medicaid recipients showed a strong trend for poorer survival in the adjusted analysis as well, with a hazard ratio of 2.03 compared with privately insured patients (P=0.06).
"This variation in postoperative outcomes remains unexplained by hospital characteristics, including clustering effects, comorbid disease, or socioeconomic variations," the group reported in the November issue of the Archives of Surgery.
However, their results couldn't exclude underdiagnosed comorbid conditions or presentation with more advanced stages of disease among the uninsured as an explanation, they noted.
Since more of the uninsured patients were admitted through the emergency department, that strong potential for confounding limits the strength of any conclusions that could be drawn from the retrospective analysis, an accompanying invited critique warned.
Another concern was crossover, as an unknown proportion of patients were enrolled in Medicaid only during their hospitalization and thus would have been better categorized as uninsured, Shawn Hervey-Jumper, MD, and Cormac Maher, MD, both of the University of Michigan in Ann Arbor, noted in the critique.
Nevertheless, the study is important for drawing attention to inequalities in neurosurgery, similar to other areas of medicine, they acknowledged.
"As surgeon scientists, much of our attention has focused on tumor biology and surgical technique," they wrote. "It is time that other socioeconomic considerations receive the same attention."
Anything that can be done to provide even a small boost to survival would be an advance, given the 5-year survival rate of only about 35% with malignant brain tumors and the modest effect of existing treatments, Quiñones-Hinojosa's group noted.
They retrospectively analyzed the Nationwide Inpatient Sample ("the largest all-payer inpatient database") for insurance status of all 28,581 patients, ages 18 to 65, who had a craniotomy for a brain tumor.
Among them, 81% had private insurance, 13% had Medicaid, and 6.5% were uninsured.
The raw in-hospital postoperative mortality rates were higher for those without private insurance, at 2.3% with Medicaid and 2.6% with no insurance compared with 1.3% among the privately insured (both P<0.001).
The same was true in the subset of patients without any known comorbidity, with in-hospital mortality rates of 1.6% and 1.8%, respectively, versus 0.7% with private insurance (P=0.004 and P=0.005).
Within that otherwise healthy group, the disparity persisted when looking just at procedures done at teaching hospitals, which accounted for 79% of the cases.
Uninsured patients had 3.55-fold higher risk of dying in the hospital after craniotomy than the privately insured (95% CI 1.41 to 8.95).
The 63% higher hazard ratio of in-hospital mortality among patients on Medicaid didn't reach statistical significance.
It's possible that the population cared for at teaching hospitals is skewed by greater likelihood of transfer for patients with operative brain tumors and lack of insurance, Quiñones-Hinojosa and colleagues noted.
The researchers also acknowledged the questionable reliability of comorbidity data for uninsured patients and lack of data on severity of comorbidity.
"Uninsured patients are less likely to see a physician regularly, and there is probably a tendency for medical conditions to be undiagnosed in this group. These data may be problematic because hospital records often depend on what patients know and say when asked about their medical history," they wrote.
"Furthermore, diagnosing some comorbidities in the acute care setting is not always straightforward; for example, high-dose corticosteroids interfere with blood glucose levels, and blood pressure values are routinely labile after craniotomy," they added.
Other limitations were lack of data on tumor histology, grade, location, and stage as well as the heterogeneity within Medicaid and private insurances with regard to what procedures they cover.
The study couldn't determine whether care provided to uninsured patients differed from that of privately insured patients, Quiñones-Hinojosa's group added.
Yet, "it is important to mention this possibility because it might prompt healthcare professionals to reflect on this question of the quality of care that we provide to our patients," they wrote.
The researchers reported no conflicts of interest. Study authors reported support from the Doris Duke Charitable Foundation, VSBfonds, Prins Bernhard Cultuurfonds, NIH, and the Robert Wood Johnson Foundation.
Hervey-Jumper and Maher reported no conflicts of interest.
- Reviewed by Zalman S. Agus, MD Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
Archives of SurgerySource Reference: Momin EN, et al "Postoperative mortality after surgery for brain tumors by patient insurance status in the United States" Arch Surg 2012; 147: 1017-1024.
Archives of SurgerySource Reference: Hervey-Jumper SL, Maher CO "Is insurance status a modifiable factor in brain tumor treatment outcomes?" Arch Surg 2012; 147: 1025.