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Impact Of Insurance Type On Urgency Of Presentation And Perioperative Outcomes Following Endovascular Repair Of Abdominal Aortic Aneurysms
Neil Feste, MD
1, Caron B. Rockman, MD
1, Karan Garg, MD
2, Frank J. Veith, MD
2, Jae S. Cho, MD
3, Thomas S. Maldonado, MD
2, Daniel J. Ventarola, MD
4, Peter Kagan, MD
1, Katherine Teter, MD
1, Romeo B. Mateo, MD
5,
Heepeel Chang, MD1.
1Hackensack University Medical Center / Hackensack Meridian School of Medicine, Hackensack, NJ, USA,
2NYU Langone Medical Center, New York, NY, USA,
3Case Western Reserve University School of Medicine / UH Harrington Heart & Vascular Institute, Cleveland, OH, USA,
4Morristown Medical Center, Morristown, NJ, USA,
5Westchester Medical Center, Westchester, NY, USA.
OBJECTIVES:Socioeconomic factors, including insurance status, have been implicated in disparities in surgical outcomes. This study evaluates whether insurance type influences urgency of presentation and postoperative outcomes following endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysms (AAA).
METHODS: Patients undergoing standard EVAR for infrarenal AAA were identified from the prospectively maintained Vascular Quality Initiative database (2003-2024). Patients were categorized by insurance type: Medicare, commercial, Medicaid, or uninsured, and stratified by intact versus ruptured AAA (rAAA). Subgroup analyses were performed for patients aged <65 and ≥65 years. Outcomes included in-hospital mortality, major adverse cardiac events, and unplanned reoperation. Multivariable logistic regression assessed the association between insurance status and outcomes.
RESULTS: Of 76,806 patients, 44,555 (58%) had Medicare, 21,782 (28%) commercial insurance, 9,708 (13%) Medicaid, and 761 (1%) were uninsured (Table). Uninsured patients presented with larger aneurysms (mean ± standard deviation: 6.2 ± 1.7 cm vs 5.7 ± 1.3 cm; p<.001) and rupture (25.4% vs Medicare 5.9%, commercial 6.3%, Medicaid 7%; p<.001). After risk adjustment, Medicaid and uninsured patients had increased odds of rAAA presentation compared with Medicare and commercial groups. For intact AAA, insurance type was not associated with adverse perioperative outcomes. In 4,869 patients presenting with rAAA, uninsured status independently predicted higher in-hospital mortality across all age groups (age < 65 years: odds ratio [OR] 4.24, 95% confidence interval [CI] 1.95-9.23; p<.001; age ≥ 65 years: OR 2.46, 95% CI 1.27-4.75; p=.008; Figure). Among patients ≥ 65 years, Medicaid was also associated with increased mortality compared to Medicare (OR 1.42, 95% CI 1.10-1.82; p=.007).
CONCLUSIONS:Uninsured patients were more likely to present with rupture, while uninsured and older Medicaid patients faced significantly higher perioperative mortality after rAAA repair. These disparities likely reflect delayed detection, barriers to surveillance, and differences in perioperative care. Expanding AAA screening programs, improving insurance coverage, and enhancing perioperative management strategies are critical to addressing inequities and reducing preventable AAA-related deaths.
Table. Baseline characteristics of patients undergoing endovascular aortic aneurysm repair| Characteristic | Medicare / N=44 555 (58%) | Commercial / N=21 782 (28.4%) | Medicaid / N=9 708 (12.6%) | Uninsured / N=761 (1.0%) | p-value |
| Age, years (mean ± SD) | 75.5 ± 7.7 | 69.9 ± 9.4 | 72.6 ± 9.3 | 63.4 ± 10.1 | <.001 |
| Male | 35301 (79.2) | 18049 (82.9) | 7529 (77.6) | 629 (82.7) | <.001 |
| Caucasian | 40185 (90.2) | 19325 (88.7) | 8081 (83.2) | 580 (76.2) | <.001 |
| Hypertension | 36995 (84.2) | 17715 (82.7) | 8266 (85.5) | 564 (75.2) | <.001 |
| Diabetes | 7087 (15.9) | 3499 (16.1) | 1589 (16.4) | 89 (11.8) | <.001 |
| Congestive heart failure | 6366 (14.3) | 2501 (11.5) | 1500 (15.5) | 65 (8.6) | <.001 |
| Smoker | 12718 (28.6) | 8156 (37.5) | 3683 (38) | 471 (62.3) | <.001 |
| AAA diameter, cm (mean ± SD) | 5.7 ± 1.3 | 5.7 ± 1.3 | 5.7 ± 1.3 | 6.2 ± 1.7 | <.001 |
| Ruptured AAA | 2621 (5.9) | 1380 (6.3) | 675 (7.0) | 193 (25.4) | <.001 |
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