Disparities in Postoperative Outcomes by Insurance Status Following Elective Spine Surgery: a Systematic Review and Meta-Analysis

Introduction: With increasing evidence demonstrating adverse outcomes for government insured patients following spine surgery, the expanding disparity between the care of privately and government insured patients is concerning. However, no pooled analyses have previously characterized differences in post-operative outcomes among patients with varying insurance types. The purpose of our review is to use an AI-assisted review platform to assess the effects of insurance status on postoperative outcomes following elective spine surgery.

Methods: A comprehensive literature search of PUBMED, MEDLINE(R), ERIC, and EMBASE was performed using a semi-automated cloud-based platform. 25 meta-analyses were performed to calculate pooled incidence rates and odds ratios for each outcome: 90-day readmission, non-routine discharge (NRD), extended length of stay (LOS), any complication (surgical and medical), and all medical complications. For each of these five outcomes, meta-analyses of the following comparisons were performed: (1) private versus government (Medicaid, Medicare, Veterans Affairs, Managed Care, and Triwest) insurance; (2) sub-analysis comparing Medicaid to private insurance; (3) sub-analysis comparing Medicare to private insurance; (4) Medicare versus Medicaid; and (5) Medicare versus non-Medicare (private and other government).

Results: 38 studies (5,018,165 total patients) were included. Compared to private insurance, patients with government insurance had an increased incidence of 90-day readmissions (OR 1.84, p< 0.0001), NRD (OR 4.40, p< 0.0001), extended LOS (OR 1.82, p< 0.0001), post-operative complication (OR 1.61, p< 0.0001), and any medical complication (OR 1.93, p< 0.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared to non-Medicare patients. Compared to Medicaid patients, Medicare patients were only more likely to experience NRD (OR 2.68, p=0.0007).

Conclusion : Patients with government insurance have a greater likelihood of morbidity across several peri-operative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based factors. These results warrant further granular analyses evaluating clinical and socioeconomic factors associated with suboptimal outcomes for government-insured patients. Based on our results, directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.