Inequalities in accessing quality healthcare, does insurance play a role? retrospective analysis of aortic emergencies from national inpatient sample 2019
Authors: Watts A , Park K , Vohra S , Raj K , Toquica C C , Jalal A , Shah M , Patel K V 
Published: October 2022

Abstract

Background
Aortic emergencies, dissection and rupture, are rare but catastrophic entities, with the cornerstone to survival being prompt diagnosis and treatment. Insurance status often limits access to healthcare, and our study aims to determine if it plays a role in the outcomes of aortic emergencies.

Method
A retrospective analysis of the 2019 Nationwide Inpatient Sample was conducted to identify hospitalization (Age ≥18 & non-elective) with aortic dissection and ruptured aortic aneurysms using ICD-10 codes. Discharge-level weight analysis was used to produce a national estimate. Variables were screened with univariate regression, and intermediate and co-linear variables were screened-out before a multivariable regression analysis model was built and performed to calculate the odds ratio.

Results
A total of 19,685 (0.06%) hospitalizations are identified for aortic emergencies (14965 dissections & 4720 ruptured aneurysms). The mean age was 58.56, 62.7% were males, and ethnic distribution was 65.1% white, 19.5% blacks, 7.6% Hispanics, and others.
11.4% of the hospitalizations underwent diagnostic imaging with either CTA/MRA/TEE/Aortography within 24 hours. Hypotension/shock was present in 32% of these hospitalizations and was a risk factor for mortality OR 3.21 (p&lt;0.00), increasing LOS by an average of 5.1 days and resource utilization by 156,000$. Another risk factor for mortality was stroke/TIA (OR-1.76, p&lt;0.00), increasing LOS and resource utilization by 3.1 days and 80,662$, respectively.
3220 hospitalizations (16.4%) did not survive the course, and the mortality rate in uninsured, Medicare, and Medicaid was 17%, 20%,9% compared with 12% in privately insured. On crude analysis, uninsured and medicare patients appeared to have higher odds of mortality [OR 1.50, p&lt;0.04, and OR 1.83 p-value &lt;0.002 respectively], however upon adjusting for confounders, only uninsured patients showed statistically significant difference (OR 2.13, p&lt;0.002). Similar results were corroborated on analyzing hospitalizations for aortic dissection; however, insurance status did not influence mortality in a ruptured aneurysm.
When comparing hospitalization of median household income of ≥79,000$ with household of median income of 59,000–78,999 $, 46,000–58,999 $ and &lt;46,000$ had higher odds of mortality (OR-1.38, p&lt;0.04), (OR-1.44, p&lt;0.02) and (OR-1.44, p&lt;0.03) respectively. Of all the insurance types, a statistically significant difference compared with private insurance, Medicaid on average, had 2.8 more days and incurred an additional 62,912$ in resource utilization (p&lt;0.00).

Conclusion
Inequalities in accessing healthcare, median household income, and insurance status are risk factors for mortality in aortic emergencies. Efforts are needed to bridge the gap in this particular facet of social determinants of health to find a sustainable and equitable solution for quality healthcare for aall regardless of their insurance status.

Funding Acknowledgement
Type of funding sources: None.