Impact of insurance status on urgency of presentation and perioperative outcomes following endovascular repair of abdominal aortic aneurysms: A vascular quality initiative analysis.

Abstract

Socioeconomic factors, including insurance status, have been implicated in disparities in surgical outcomes. This study evaluates whether insurance status influences urgency of presentation and postoperative outcomes following endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysms (AAA). Patients undergoing infrarenal EVAR for AAA were identified from the prospectively maintained Vascular Quality Initiative database encompassing centers across the United States and Canada, between January 2003 and February 2024. Patients were categorized by insurance status: Medicare, commercial, Medicaid, or uninsured, and stratified by intact vs ruptured AAA (rAAA). Subgroup analyses were performed for patients aged <65 and ≥65 years. The primary outcome was in-hospital mortality. Secondary outcomes included in-hospital major adverse cardiac events and unplanned reoperation. Multivariable logistic regression assessed the association of insurance status with acuity of presentation and postoperative outcomes. Of 76,806 patients undergoing EVAR, 44,555 (58.0%) had Medicare, 21,782 (28.4%) had commercial insurance, 9708 (12.6%) had Medicaid, and 761 (1.0%) were uninsured. Uninsured patients presented with larger aneurysms (mean ± standard deviation: 6.2 ± 1.7 vs 5.7 ± 1.3 cm; P < .001) and rupture (25.4% vs 5.9%; Medicare, 6.3% commercial insurance, and 7.0% Medicaid; P < .001). After risk adjustment, both uninsured [odds ratio (OR), 2.70; 95% confidence interval (CI), 2.05-3.18; P < .001] and Medicaid patients (OR, 1.12; 95% CI, 1.01-1.24; P = .030) were associated with significantly higher odds of rAAA presentation compared with Medicare beneficiaries. For intact AAA, insurance status was not associated with adverse perioperative outcomes in all age groups. In 4869 patients presenting with rAAA, uninsured status was associated with higher in-hospital mortality across all age groups (age <65 years: OR, 4.24; 95% CI, 1.95-9.23; P < .001; age ≥65 years: OR, 2.46; 95% CI, 1.27-4.75; P = .008). Among patients ≥65 years, Medicaid was also associated with increased mortality compared with Medicare (OR, 1.42; 95% CI, 1.10-1.82; P = .007). Among patients undergoing EVAR, uninsured and Medicaid patients were more likely to present with rAAA, whereas uninsured and older Medicaid patients were more likely to suffer from higher perioperative mortality after EVAR for rAAA. These disparities may reflect delayed detection and barriers to surveillance. Expanding AAA screening programs, improving insurance coverage, and enhancing perioperative management strategies are critical to addressing inequities and reducing preventable AAA-related deaths.