Disparities in Postoperative Complications and Perioperative Events based on Insurance Status following Elective Spine Surgery: A Systematic Review and Meta-Analysis

Background Context Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in post-operative outcomes among patients with varying insurance types. Purpose To assess the effects of insurance status on post-operative outcomes and adverse events after elective spine surgery. Study Design Systematic Review and Meta-analysis. Methods A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing post-operative outcomes in patients with private insurance vs. government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for three peri-operative events and two types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses. Results 38 studies (5,018,165 total patients) were included. Compared to patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<0.0001), non-routine discharge (OR 4.40, p<0.0001), extended LOS (OR 1.82, p<0.0001), any post-operative complication (OR 1.61, p<0.0001), and any medical complication (OR 1.93, p<0.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared to non-Medicare patients. Compared to Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=0.0007). Conclusions Patients with government insurance experience greater likelihood of morbidity across several peri-operative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.