Public Release:  Uninsured patients undergoing craniotomy for brain tumor have higher in-hospital mortality

The JAMA Network Journals

CHICAGO - Compared to insured patients, uninsured patients have higher in-hospital mortality following surgery for brain tumors, according to a report published in the November issue of Archives of Surgery, a JAMA Network publication.

Research examining insurance-related disparities in patients undergoing surgery for brain tumors has been limited. About 612,000 people in the United States have a diagnosis of a primary brain or central nervous system tumor. Malignant brain tumors cause 13,000 deaths annually and have a five-year survival rate about 35 percent, the authors write in the study background.

Eric N. Momin, M.D., of the Johns Hopkins University School of Medicine, Baltimore, and colleagues used the Nationwide Inpatient Sample from January 1999 through December 2008 to examine whether being uninsured was associated with higher in-hospital postoperative mortality when undergoing surgery. The study included 28,581 patients (ages 18 to 65 years) who underwent a craniotomy and they were studied in three groups: Medicaid recipients, privately insured and uninsured patients.

"Among patients with brain tumors with no other major medical condition, uninsured patients (but not necessarily Medicaid recipients) have higher in-hospital mortality than privately insured patients, a disparity that was pronounced in teaching hospitals. These findings further reinforce prior data indicating insurance-related disparities in medical and surgical settings," the authors comment.

The mortality rate for privately insured patients was 1.3 percent compared with 2.6 percent for uninsured patients and 2.3 percent for Medicaid recipients in an unadjusted statistical analysis. After adjusting for patient characteristics and stratifying (classifying) by hospital in patients with no co-existing illnesses, uninsured patients still had a higher risk of in-hospital death (hazard ratio, 2.62) compared with privately insured patients. In the adjusted analysis, being a Medicaid recipient was "not definitively" associated with higher in-hospital mortality compared with private insurance, according to the study results.

"Uninsured patients undergoing craniotomy for a brain tumor experience worse outcomes than privately insured patients, and this difference is pronounced in teaching hospitals. This variation in postoperative outcomes remains unexplained by hospital characteristics, including clustering effects, comorbid disease, or socioeconomic variations," the authors conclude. "This study did not exclude the possibilities that comorbid conditions are underdiagnosed in uninsured patients or that uninsured patients are presenting with more advanced stages of the disease." (

Arch Surg. 2012; 147[11]:1017-1024.)

Editor's Note: Several authors disclosed funding sources. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Critique: Is Insurance Status Modifiable Factor in Brain Tumor Outcomes?

In an invited critique, Shawn L. Hervey-Jumper, M.D., and Cormac O. Maher, M.D., of the University of Michigan, Ann Arbor, write: "Although the recognition of differing survival and complication outcomes in the postoperative period based on insurance status is not new, it has not been rigorously studied in neurosurgery patients."

"We commend the authors for shedding light on this difficult problem. As surgeon scientists, much of our attention has focused on tumor biology and surgical technique. It is time that other socioeconomic considerations receive the same attention," they conclude.

(Arch Surg. 2012;147[11]:1025.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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To contact Alfredo Quiñones-Hinojosa, M.D., call Stephanie Desmon at 410-955-8665 or email sdesmon1@jhmi.edu. To contact critique corresponding author Shawn L. Hervey-Jumper, M.D., call Kara Gavin 734-764-2220 or email kegavin@umich.edu.

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