Payer Status and Treatment Paradigm for Acute Cholecystitis

Hypothesis: Medicaid recipients who present to the emergency department with acute cholecystitis (AC) would have reduced access to cholecystectomy compared with a similar population of private insurance carriers. Design: The Nationwide Inpatient Sample (NIS) database from 1998 to 2008. Participants: Emergent hospitalizations (843 179) with AC as a primary diagnosis. Interventions: Insurance type was analyzed against cholecystectomy in propensity score-matched cohorts. Main Outcome Measures: Surgical intervention and surgical outcomes. Results: Approximately 200 000 patients were in each matched cohort. The median age of the matched patients was 43.9 years, 76% were women, and the mean Charlson Comorbidity Index was 0.5. While 89% of the private insurance cohort underwent cholecystectomy during their hospitalization, only 83% of the Medicaid population received equivalent care (P <.001). The Medicaid cohort also had reduced rates of laparoscopic surgery (78% vs 69%; P <.001) and an increased conversion rate from laparoscopic to open surgery (3.9% vs 3.0%; P <.001). While disparities in the rates of laparoscopic surgery between the 2 groups sequentially narrowed during the 10-year period, overall disparities in surgical treatment remained constant over time. Conclusions: Medicaid payer status confers inferior access to surgical treatment for AC. While this finding may be due in part to patients' health beliefs and physician preferences, the magnitude of difference suggests that health systems factors may provide a significant contribution toward clinical decision making in this entity.