Matthew W Mell1, Laurence C Baker2. 1. Division of Vascular Surgery, Stanford University, Stanford, CA. Electronic address: mwmell@stanford.edu. 2. Department of Health Research and Policy, Stanford University, Stanford, CA; National Bureau of Economic Research, Cambridge, MA.
Abstract
BACKGROUND: To determine the factors contributing to increased rate of ruptured abdominal aortic aneurysms (AAAs) for elderly poor patients. METHODS: Medicare claims were analyzed for patients who underwent AAA repair from 2006 to 2009 with preoperative abdominal imaging. Repair for ruptured versus intact AAAs was our primary outcome measure. We used logistic regression to determine the relationship between Medicaid eligibility and the risk of rupture, sequentially adding variables related to patient characteristics, socioeconomic status, receipt of preoperative AAA surveillance, and hospital AAA volume. We then estimated the proportional effect of each factor. RESULTS: No differences in rupture were observed in women based on payer status. Medicaid-eligible men were more likely to present with ruptured AAA (odds ratio [OR] 2.42, 95% confidence interval [CI] 1.65-3.52). After adjusting for patient and hospital factors, the poor remained at higher risk for rupture (OR 1.5, 95% CI 1.10-2.26). This disparate risk of rupture was more commonly observed in hospitals treating a higher proportion of Medicaid-eligible patients. We estimate that 36% of the observed disparity in rupture for the elderly poor is explained by patient factors, 27% by gaps in surveillance, 9% by hospital factors, and <1% by socioeconomic factors. CONCLUSIONS: Incomplete preoperative surveillance is a key contributor to increased rupture of AAA in the elderly poor. Efforts aimed at improving disparities must include consistent access to medical care.
BACKGROUND: To determine the factors contributing to increased rate of ruptured abdominal aortic aneurysms (AAAs) for elderly poor patients. METHODS: Medicare claims were analyzed for patients who underwent AAA repair from 2006 to 2009 with preoperative abdominal imaging. Repair for ruptured versus intact AAAs was our primary outcome measure. We used logistic regression to determine the relationship between Medicaid eligibility and the risk of rupture, sequentially adding variables related to patient characteristics, socioeconomic status, receipt of preoperative AAA surveillance, and hospital AAA volume. We then estimated the proportional effect of each factor. RESULTS: No differences in rupture were observed in women based on payer status. Medicaid-eligible men were more likely to present with ruptured AAA (odds ratio [OR] 2.42, 95% confidence interval [CI] 1.65-3.52). After adjusting for patient and hospital factors, the poor remained at higher risk for rupture (OR 1.5, 95% CI 1.10-2.26). This disparate risk of rupture was more commonly observed in hospitals treating a higher proportion of Medicaid-eligible patients. We estimate that 36% of the observed disparity in rupture for the elderly poor is explained by patient factors, 27% by gaps in surveillance, 9% by hospital factors, and <1% by socioeconomic factors. CONCLUSIONS: Incomplete preoperative surveillance is a key contributor to increased rupture of AAA in the elderly poor. Efforts aimed at improving disparities must include consistent access to medical care.
Authors: Eric J Charles; Lily E Johnston; Morley A Herbert; J Hunter Mehaffey; Kenan W Yount; Donald S Likosky; Patricia F Theurer; Clifford E Fonner; Jeffrey B Rich; Alan M Speir; Gorav Ailawadi; Richard L Prager; Irving L Kron Journal: Ann Thorac Surg Date: 2017-05-26 Impact factor: 4.330