Association of Cost Sharing With Delayed and Complicated Presentation of Acute Appendicitis or Diverticulitis

Importance Treatment delays are associated with increased morbidity and cost of disease, although the extent to which cost sharing influences timely presentation and management of acute surgical disease remains unknown. Given recent policy changes using cost sharing to modify health care behavior, this study examines the association of cost sharing with the health of the patient at presentation and with receipt of optimal or minimally invasive surgery. Objective To assess whether cost sharing is associated with the likelihood of early, uncomplicated patient presentation or with surgical management of 2 representative emergency general surgery diagnoses: acute appendicitis and acute diverticulitis. Design, Setting, and Participants This cohort study used Health Care Cost Institute claims from January 1, 2013, through December 31, 2017, to analyze data of commercially insured individuals hospitalized for acute appendicitis or diverticulitis. In total, 151 852 patients in the data set aged 18 to 64 years and presenting with acute appendicitis or diverticulitis were included as identified using the International Classification of Diseases, Ninth Revision and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Data were analyzed from January 2020 through February 2021. Exposures The primary exposure was patient total cost sharing incurred for the index hospitalization, defined as their summed deductible, copayments, and coinsurance. Main Outcomes and Measures The primary outcome was early, uncomplicated disease presentation. Secondary outcomes were receipt of optimal surgical care and minimally invasive surgery if undergoing an operation. Analyses were conducted with multivariable logistic regression models to adjust for patient characteristics and community-level socioeconomic and geographic factors. High cost sharing was defined as quartile 4 (>$3082), and low cost sharing as quartile 1 ($0-$502). Results Among 151 852 patients, 52.4% were men, and the total cost-sharing median was $1725 (interquartile range, $503-$3082). Higher cost sharing was associated with lower odds of early, uncomplicated disease presentation (odds ratio, 0.63; 95% CI, 0.61-0.65). Patients with higher cost sharing were less likely to receive optimal surgical care (odds ratio, 0.96; 95% CI, 0.93-0.99) or minimally invasive surgery (odds ratio, 0.89; 95% CI, 0.84-0.95). Conclusions and Relevance The findings of this cohort study suggest that, as policymakers debate the degree of cost sharing in public and private insurance plans, attention should be given to the clinical and financial implications associated with care delays. Question Does an association exist between high cost-sharing insurance plans and patient presentation with and surgical management of acute appendicitis or acute diverticulitis? Findings In this cohort study of 151 852 patients, higher patient cost sharing was associated with lower odds of presenting with early, uncomplicated disease, receiving optimal surgical care, and receiving minimally invasive surgery. Meaning Policymakers should be aware of the clinical and financial implications of patient health care behaviors associated with increased cost sharing. This cohort study uses commercial claims data to assess whether increased patient cost sharing is associated with the likelihood of early, uncomplicated presentation or surgical management of emergency general surgery diagnoses.