Comparing Outcomes after Transnasal Pituitary Surgery Based on Socioeconomic Status

Background Health care exists in a state where the demand is to deliver cost conscious care without compromising quality. The expansion of insurance coverage and need for controlling costs presents new challenges in health care, particularly in public health institutions. Pituitary tumors represent around 10% of all brain tumors and in our institution, which includes both private and public hospital settings, accounts for more than 100 cases per year. Important differences in outcomes based on socioeconomic status have been demonstrated in multiple surgical disciplines. The goal of this study was to determine differences in outcomes following pituitary surgery based on socioeconomic status and better understand reasons behind those differences in an attempt to improve both quality and cost effectiveness of care delivered in a tertiary care center.

Methods A retrospective review of a tertiary care center’s pituitary surgery database was performed. All patients older than the age of 18 years who underwent either endoscopic or microscopic pituitary surgery between the years 2009 and 2015 were included. Patients were divided based on primary payer status (PPS) into privately insured (PI) versus government health care coverage and uninsured (GHC/U). Demographic data including age, gender, and body mass index (BMI) were collected. Tumor-specific information including tumor size, maximum diameter, volume, secretory status, and pathology, as well as surgical approach and postoperative outcomes including length of hospitalization, presence of a lumbar drain, development of transient diabetes insipidus (DI), chronic DI, hypopituitarism, cerebrospinal fluid (CSF) leak, and meningitis were also collected.

Results Seventy-three patients (47 females and 26 males) were included in the GHC/U group and 49 (26 females and 23 males) were included in the PI group. There were no significant differences between the PI and GHC/U groups for age (means 52.9 and 51.7 years, respectively, p = 0.61) or BMI (means 32.8 and 31.3, respectively, p = 0.205). The GHC/U group had a significantly higher average maximum tumor diameter compared with the PI group (3.02 vs. 2.54 mm, p = 0.0148, 95% CI: 0.096–0.868) and a greater mean volume (11.6 vs. 7.06 mm³, respectively) although this did not quite meet statistical significance (p = 0.0683). The GHC/U group had significantly longer hospital stays (6.19 vs. 4.12 days, p = 0.001, 95% CI: 0.85–3.29). There was a significantly increased rate of transient DI in the GHC/U group compared with the PI group (p = 0.012) and a higher rate of postoperative CSF leak that did not quite reach statistical significance (p = 0.06). Age, gender, and BMI matched rates of medical comorbidities did not significantly differ between the groups (p = 0.91).

Conclusion Compared with patients with PI, those with GHC/U had larger tumors at the time of surgery. There was an increase in postoperative complications including transient DI, which could have contributed to a significantly longer hospital stay in the GHC/U group. Interestingly, overall health status was not significantly different between the groups. Therefore, it appears that issues associated with lower socioeconomic status such as social support and access to resources may also contribute to longer hospital stays in this patient population.