Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York

J Clin Anesth. 2017 Dec:43:24-32. doi: 10.1016/j.jclinane.2017.09.008. Epub 2017 Sep 30.


Study objective: To confirm the relationship between primary payer status as a predictor of increased perioperative risks and post-operative outcomes after total hip replacements.

Design: Retrospective cohort study.

Setting: Administrative database study using 2007-2011 data from California, Florida, and New York from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

Patients: 295,572 patients age≥18years old who underwent total hip replacement with non-missing insurance data were collected, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures code (ICD-9-CM code 81.51).

Interventions: Patients underwent total hip replacement.

Measurements: Patients were cohorted by insurance type as either Medicare, Medicaid, Uninsured, Other, and Private Insurance. Demographic characteristics and comorbidities were compared. Unadjusted rates of in-hospital mortality, postoperative complications, LOS, 30-day, and 90-day readmission status were compared. Adjusted odds ratios were calculated for our outcomes using multivariate linear and logistic regression models fitted to our data.

Main results: Medicaid patients incurred a 125% increase in the odds of in-hospital mortality compared to those with Private Insurance (OR 2.25, 99% CI 1.01-5.01). Medicaid payer status was associated with the highest statistically significant adjusted odds of mortality, any complication (OR, 1.26), cardiovascular complications (OR, 1.37), and infectious complications (OR, 1.66) when compared with Private Insurance. Medicaid patients had the highest statistically significant adjusted odds of 30-day (OR, 1.63) and 90-day readmission (OR, 1.58) and the longest adjusted LOS.

Conclusions: We found higher unadjusted rates and risk adjusted odds ratios of postoperative mortality, morbidity, LOS, and readmissions for patients with Medicaid insurance as compared to patients with Private Insurance. Our study shows that primary payer status serves as a predictor of perioperative risks and that primary payer status should be viewed as a peri-operative risk factor.

Keywords: Health care; administrative database research; health care disparities; health insurance; primary payer status; total hip replacement.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Arthroplasty, Replacement, Hip / adverse effects*
  • Arthroplasty, Replacement, Hip / economics
  • Female
  • Health Care Costs / statistics & numerical data*
  • Healthcare Disparities / economics
  • Healthcare Disparities / statistics & numerical data*
  • Hospital Mortality*
  • Hospitalization / economics
  • Hospitalization / statistics & numerical data
  • Humans
  • Male
  • Medicaid / statistics & numerical data
  • Medically Uninsured / statistics & numerical data
  • Medicare / statistics & numerical data
  • Middle Aged
  • Patient Acceptance of Health Care / statistics & numerical data
  • Perioperative Period
  • Postoperative Complications / economics
  • Postoperative Complications / epidemiology*
  • Postoperative Complications / etiology
  • Registries / statistics & numerical data*
  • Retrospective Studies
  • Risk Factors
  • Social Determinants of Health / economics
  • Social Determinants of Health / statistics & numerical data
  • Socioeconomic Factors
  • United States / epidemiology