Presentation Authors: David F. Friedlander*, Brighton, MA, Marieke J. Krimphove, Alexander P. Cole, Maya Marchese, Gezzer Ortega, George E. Haleblian, Quoc-Dien Trinh, Boston, MA
Introduction: Medicaid expansion is a key provision by which the Affordable Care Act seeks to improve access to health insurance. However, there is concern over the quality and cost of care received by Medicaid beneficiaries. Urinary stone disease is a condition uniquely suited to address the aforementioned quality/cost concerns: the disease incurs high population-level costs with multiple treatment options and large variation in practice and care setting. We investigated the role of payer status in predicting perioperative outcomes and cost associated with elective definitive surgery for nephroureterolithiasis.
Methods: All-payer data from the 2014 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify all index elective definitive surgical interventions for nephroureterolithiasis in the form of ureteroscopy (URS) or shockwave lithotripsy (SWL). Patient demographics, regional data, 30-day revisit rates, and total charges (converted to costs) were determined. Multivariate logistic regression adjusted for facility clustering was utilized to identify predictors of index care setting.
Results: We identified a total of 27,527 unique patients undergoing either an elective index URS (n=16,572) or SWL (n=10,955). Inpatient procedures accounted for 30.1% of index cases compared to 69.9% performed in the ambulatory setting, at a median cost per case of $7,686.77 vs. $4,349.55 (P < 0.001), respectively. Predictors of undergoing surgery in the ambulatory setting included fewer comorbidities (Charlson Comorbidity Index â‰¥2 vs. 0: OR 0.33, 95% CI 0.27-0.41; P < 0.001), payer status (Medicaid vs. Medicare: OR 0.66, 95% CI 0.55-0.79; P < 0.001), race (black vs. white: OR 0.75, 95% CI 0.61-0.91; P=0.003), higher education level (median county-level rate of less than high school education quintiles â‰¥13% vs. < 9.7%: OR 0.52, 95% CI 0.37-0.74; P < 0.001), and procedure type (URS vs. SWL: OR 0.16, 95% CI 0.14-0.19; P < 0.001). Patients receiving care in the ambulatory care setting experienced slightly higher 30-day revisit rates relative to inpatient cases (9.1% vs. 7.2%, P < 0.001).
Conclusions: We demonstrated that payer status is an independent predictor of where patients undergo elective definitive stone surgery, with Medicaid beneficiaries experiencing greater odds of receiving more costly inpatient care. Our findings have important policy implications in the setting of recent value-based purchasing efforts.
Source of Funding: Quoc-Dien Trinh is supported by the Brigham Research Institute Fund to Sustain Research Excellence, the Bruce A. Beal and Robert L. Beal Surgical Fellowship, the Genentech Bio-Oncology Career Development Award from the Conquer Cancer Foundation of the Ame