Does Patient Insurance Affect Readmission for Skull Base Tumors after Craniotomy?

Introduction: Readmission after surgery places a significant financial burden on patients and the healthcare system alike. Socioeconomic disparities are known to exacerbate the risk of readmission. We hypothesize that while insurance is inextricable with socioeconomic status, we hypothesized that patient insurance be a partially modifiable risk factor for patient readmission.

Methods: We queried the 2014–2015 Nationwide Readmission Databases, which include half of all annual inpatient hospitalizations, for adult patients who received craniotomy for meningioma or intracranial schwannoma. We selected these two lesions as they represent common and often complex tumors encountered by skull base surgeons that require open procedures. The primary outcome of interest was 90-day all-cause readmissions. Secondary outcomes included 30-day readmission and hospital charges during index readmission. Interaction terms were applied to query effect modification by demographic.

Results: A total of 11,997 patients were included in analysis. The average age in the cohort was 59 years (IQR: 49–69), and 68% of patients were female. Patients were either insured through private insurance (46%), Medicaid (11%), Medicare (38%), or other schemes and self-pay (5%). Relative to patients with private insurance, patients on Medicaid or Medicare were more likely to be diagnosed with hypertension, diabetes, chronic lung disease, chronic heart failure, and depression (all p < 0.001).

The overall 90-day readmission rate was 5.9%. This rate was 4.6% for privately insured, 6.0% for Medicaid, and 7.5% for Medicare patients. After adjustment for demographic characteristics, chronic co-morbidities, and treating hospital characteristics, Medicaid and Medicare insurance were associated with 90-day readmission compared with private insurance (adjusted odds ratio (OR) 1.3 and 1.5, respectively; both p < 0.05). Medicare was also associated with 30-day readmission (OR: 1.4, p = 0.02). The average hospital charge was $143,463; the charges for Medicaid patients were $32,024 higher (p < 0.001) and for Medicare patients were $12,522 higher (p = 0.01).

Age was found to modify the effect of Medicaid insurance on 90-day readmission (β = −0.022, p = 0.042). For example, the adjusted ORs for 90-day readmission for 30 and 65 year old patients on Medicaid relative to privately insured patients are 2.1 and 1.0, respectively, indicating that being on Medicaid become more strongly associated with readmission for younger patients. This effect was not seen for 30-day Medicaid readmission or any Medicare readmissions.

Conclusion: Medicaid and Medicare patients who undergo craniotomy for skull base tumors are at increased risk of 90-day readmission after accounting for their higher medical complexity. This risk is more pronounced in young Medicaid patients, which may reflect poorer social support, medical understanding of their disease, and access to primary care. Surgeons may work with ancillary staff to flag young Medicaid patients to consult counseling and social work services prior to discharge to discuss postdischarge follow-up and access to care.

No conflict of interest has been declared by the author(s).