Skip to main content

Advertisement

Log in

Insurance status does not affect short-term outcomes after oncological colorectal surgery in Europe, but influences the use of minimally invasive techniques: a propensity score-matched analysis

  • ORIGINAL ARTICLE
  • Published:
Langenbeck's Archives of Surgery Aims and scope Submit manuscript

Abstract

Background and Purpose

Controversy exists whether surgical treatment is influenced by insurance status. American studies suggest higher morbidity and decreased survival in uninsured patients with colorectal cancer (CRC). It remains elusive, however, whether these findings apply to European countries with mandatory, government-driven insurance systems. We aimed to analyze whether operative techniques, quality of surgery, and complication rates differ among patients covered by statutory (SI) versus private (PI) healthcare insurance.

Methods

Based on a prospective national surgical quality database, patients undergoing elective resection for CRC during 2007–2015 were identified. A propensity score match of eligible patients with SI and PI yielded 765 patients per group.

Results

Hierarchical status of the operating surgeon differed substantially (p = 0.001): junior surgeons operated on > 50% of patients with SI, whereas over 80% of patients with PI were operated by senior surgeons. Minimally invasive techniques were used more frequently in patients with PI (p = 0.001) and patients with SI undergoing colonic resection showed an increased conversion rate (OR 2.44). Median duration of surgery (p = 0.001) and blood loss (p = 0.002) were higher in patients with SI; however, length of hospital stay was equal. Neither the rate of positive resection margins nor the number of resected lymph nodes differed among groups. Complications and mortality occurred with similar frequencies for patients undergoing colon (p = 0.140) and rectal (p = 0.335) resection.

Conclusion

The use of minimally invasive techniques was favored in patients with PI; however, the quality of oncological resection was not affected by insurance status and only minor differences in perioperative complications observed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

CRC:

Colorectal carcinoma

SI:

Statutory insurance

PI:

Private insurance

Supp. Info.:

Supplementary information

MIS:

Minimally invasive surgery

IQR:

Interquartile range

NA:

Not available

References

  1. WHO: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx

  2. Schmoll HJ, Van Cutsem E, Stein A et al (2012) ESMO consensus guidelines for management of patients with colon and rectal cancer. A personalized approach to clinical decision making. Ann Oncol 23(10):2479–2516

    Article  CAS  Google Scholar 

  3. Van Cutsem E, Cervantes A, Adam R et al (2016) ESMO consensus guidelines for the management of patients with metastatic colorectal cancer. Ann Oncol 27(8):1386–1422

    Article  Google Scholar 

  4. Amato L, Fusco D, Acampora A et al (2017) Volume and health outcomes: evidence from systematic reviews and from evaluation of Italian hospital data. Epidemiologia e prevenzione 41(5–6 (Suppl 2)):1–128

    PubMed  Google Scholar 

  5. Robbins AS, Pavluck AL, Fedewa SA, Chen AY, Ward EM (2009) Insurance status, comorbidity level, and survival among colorectal cancer patients age 18 to 64 years in the National Cancer Data Base from 2003 to 2005. J Clin Oncol 27(22):3627–3633

    Article  Google Scholar 

  6. Roetzheim RG, Pal N, Tennant C, Voti L, Ayanian JZ, Schwabe A, Krischer JP (1999) Effects of health insurance and race on early detection of cancer. JNCI: J Natl Cancer Inst 91(16):1409–1415

    Article  CAS  Google Scholar 

  7. Kelz RR, Gimotty PA, Polsky D, Norman S, Fraker D, DeMichele A (2004) Morbidity and mortality of colorectal carcinoma surgery differs by insurance status. Cancer 101(10):2187–2194

    Article  Google Scholar 

  8. Halpern MT, Ward EM, Pavluck AL, Schrag NM, Bian J, Chen AY (2008) Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncol 9(3):222–231

    Article  Google Scholar 

  9. Scott JW, Havens JM, Wolf LL, Zogg CK, Rose JA, Salim A, Haider AH (2017) Insurance status is associated with complex presentation among emergency general surgery patients. Surgery 161(2):320–328

    Article  Google Scholar 

  10. Schwartz DA, Hui X, Schneider EB, Ali MT, Canner JK, Leeper WR, Efron DT, Haut ER, Velopulos CG, Pawlik TM, Haider AH (2014) Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities? Surgery 156(2):345–351

    Article  Google Scholar 

  11. Lapar DJ, Bhamidipati CM, Mery CM et al (2010) Primary payer status affects mortality for major surgical operations. Ann Surg 252(3):544–550 discussion 550–541

    PubMed  PubMed Central  Google Scholar 

  12. Bisig B, Gutzwiller F, Domenighetti G. [Incidence of operations in Switzerland related to insurance status]. Swiss Surg 1998;4(3):109–116; discussion 116-107

  13. Borsky M, Gutzwiller F (1994) Does insurance status have an effect on frequency of appendectomies? Schweiz Med Wochenschr 124(37):1619–1625

    CAS  PubMed  Google Scholar 

  14. von Holzen U, Gehrz A, Meier L, Zuber M (2012) The AQC database represents a useful tool for quality control and scientific analysis of acute appendicitis. Swiss Med Wkly 142:w13617

    Google Scholar 

  15. Rageth JC, Häner C, Hess P, Laffer U, Inderbitzi R (1999) Systematic scientific quality improvement in surgical specialties. The AQS mode. Swiss Surg 5(2):62–72

    Article  CAS  Google Scholar 

  16. CHOP Codes: https://www.bfs.admin.ch/bfs/de/home/statistiken/gesundheit/nomenklaturen/medkk.html

  17. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196

    Article  Google Scholar 

  18. Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications. Ann Surg 240(2):205–213

    Article  Google Scholar 

  19. Roetzheim RG, Pal N, Gonzalez EC, Ferrante JM, Van Durme DJ, Krischer JP. Effects of health insurance and race on colorectal cancer treatments and outcomes. Am J Public Health 2000;90(11):1746–1754

  20. McDavid K, Tucker TC, Sloggett A, Coleman MP (2003) Cancer survival in Kentucky and health insurance coverage. Arch Intern Med 163(18):2135–2144

    Article  Google Scholar 

  21. Ellis L, Canchola AJ, Spiegel D, Ladabaum U, Haile R, Gomez S Trends in cancer survival by health insurance status in California from 1997 to 2014. JAMA Oncol 2017

  22. Alnasser M, Schneider EB, Gearhart SL et al (2014) National disparities in laparoscopic colorectal procedures for colon cancer. Surg Endosc 28(1):49–57

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank Luzi Rageth and the whole team of the AQC database for providing support during analysis of the extracted data.

Author information

Authors and Affiliations

Authors

Contributions

Study conception and design: Marcel André Schneider and Matthias Turina; acquisition of data: Marcel André Schneider, Andreas Rickenbacher, Lukas Frick, Daniela Cabalzar-Wondberg, Samuel Käser, and Matthias Turina; analysis and interpretation of data: all authors; drafting of manuscript: Marcel André Schneider, Andreas Rickenbacher, Pierre-Alain Clavien, and Matthias Turina; and critical revision of the manuscript: all authors.

Corresponding author

Correspondence to Matthias Turina.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Electronic supplementary material

ESM 1

(PDF 151 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schneider, M.A., Rickenbacher, A., Frick, L. et al. Insurance status does not affect short-term outcomes after oncological colorectal surgery in Europe, but influences the use of minimally invasive techniques: a propensity score-matched analysis. Langenbecks Arch Surg 403, 863–872 (2018). https://doi.org/10.1007/s00423-018-1716-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00423-018-1716-8

Keywords

Navigation