The Effect Of Insurance Status and Comorbidities On Outcomes After Splenectomy Among Patients With ITP

Importance of individual’s insurance status in access and quality of health care has been well documented in published literature. Lack of or inadequate insurance may be associated with negative health consequences. Currently there are no studies that have examined the relation between the insurance status and splenectomy outcomes among patients with Immune thrombocytopenia (ITP)

Splenectomy has been the standard second-line treatment for adults with ITP for several decades. Recently published guidelines by American Society of Hematology for the management of ITP gave splenectomy a strong recommendation based on its sustained remission rates and long-term experience. Despite its effectiveness in achieving durable response, there has been a tendency among physicians to avoid or delay splenectomy due to the fear of removing a healthy organ, a long-term risk of sepsis and mortality associated with surgery.

Previously reported mortality rates for splenectomy in ITP were around 0.2 - 1%. However, the effect of insurance status and the prevalence of common comorbidities that can influence postoperative outcomes have not been explored in this population. The following study, representative of a national cohort of ITP patients who underwent splenectomy, assesses the effect of insurance type and comorbidities on postoperative mortality and length of stay in hospital following splenectomy.

We hypothesized that uninsured or federally funded health insurance and underlying comorbidities might have an unfavorable effect on the outcomes.

Within the Health Care Utilization Project Nationwide Inpatient Sample (NIS), we identified 9419 (n=9419) patients who underwent splenectomy for ITP between 2004-2009. The presence of comorbidities was assessed based on Elixhauser’s comorbid conditions and patients were categorized based on presence of ≥ 3, ≥2 or ≤1 comorbid conditions. Multiple logistic regression analyses was performed to evaluate the effect of insurance type on inpatient mortality rate after adjusting for age, sex, race, and number of comorbidities. Furthermore, the effect of comorbidities on inpatient mortality was analyzed after adjusting for other variables such as age, type of insurance and race. Hospital length of stay (LOS) was dichotomized as prolonged if LOS > 9 days (third quartile) or short if LOS< 9 days. The study protocol was approved by Case Western Reserve University Institutional Review Board.

During the six-year period between 2004-2009, a weighted estimate of 9419 patients were identified who underwent splenectomy for ITP. Inpatient postoperative mortality was 3.1% and overall median LOS was 9 days. Most patients were privately insured (47.6%), followed by Medicare (35.1%), Medicaid (8.6%) and uninsured (8.5%). 2% of Medicare, 0.2% of Medicaid, 0.7% of uninsured and 0.16% of privately insured patients died. On multivariable analysis there was no significant difference in mortality among Medicare, Medicaid and uninsured patients when compared to privately insured patients. Medicaid patients had prolonged length of stay as compared to privately insured patients (aOR 2.55, CI 1.71-3.79, P< 0.0001). Patients with higher comorbidities had higher mortality rates and length of stay after adjusting for age, race and insurance type. Patients with ≥ 3 comorbid conditions were three times more likely to die (aOR 3.03, CI 1.4-6.2, p<0.01) and six times more likely to have prolonged hospital stay (aOR 6.4, CI 4.8-8.6, p<0.001) as compared to patients with ≤1 comorbid condition.

Patients who are privately insured have similar mortality rates as compared to Medicare and Medicaid and uninsured population. Preoperative comorbidities are associated with increased risk of mortality, and risk adjustment is necessary while evaluating patients with ITP undergoing splenectomy.

No relevant conflicts of interest to declare.