Impact of the Affordable Care Act on Disparities in Pituitary Surgery

Objective: Pituitary lesions account for nearly 10 to 15% of all intracranial tumors. When medically refractory, they often require surgical intervention and management by multidisciplinary teams within specialized medical centers. However, access to surgery may be limited based on socioeconomic factors such as race/ethnicity, income, insurance status, and geography. The Affordable Care Act (ACA) was enacted to mitigate disparate access to care. While a few studies on access to pituitary surgery have identified health disparities, it is unclear whether the ACA has impacted disparities in pituitary surgery. We evaluated the impact of the ACA on pituitary surgery volume and examined multilevel (patient, hospital, and sociodemographic) factors associated with pituitary surgery post-ACA.

Methods: Cross-sectional data from the National Inpatient Sample (NIS) was analyzed over a 7-year period (2011–2017). All patients admitted to the hospital with ICD9 and ICD10 procedures codes for pituitary surgery were identified. With 2014 used as the reference time point for implementation of the ACA, the frequency of pituitary surgeries was compared between the pre-ACA (2011–2013) and post-ACA (2015–2017) periods (we excluded 2014 as a wash-out period). In addition, we performed interrupted time series (ITS) to model the impact of the ACA stratified by variables of interests such as race/ethnicity, gender, income, payer status, hospital location, and region ([Figs. 1]–[3]).

Results: There were 6,348 (56.2% White) patients and 6,211 (53.3% White) patients who received pituitary surgery pre- and post-ACA, respectively. Overall, there was a significant lasting effect with an increasing trend in the number of pituitary surgeries post-ACA 11.14 (95% CI: [3.51, 18.78], p = 0.01). More patients underwent surgery at urban teaching hospitals in the post-ACA period (93.8%) compared to the pre-ACA period (87.1%), p < 0.0001. ITS modeling revealed that the following patient characteristics were associated with lasting effects of the ACA with an increase in the number of pituitary surgeries over time in the post-ACA period: Hispanic 2.20 (95% CI: 0.07, 4.33, p = 0.04); 1st income quartile 4.07 (95% CI: 1.50, 6.65, p = 0.004), Medicaid insurance 2.27 (95% CI: 0.59, 3.95, p = 0.01; living in non-metro areas 1.98 (95% CI: 0.66, 3.30, p = 0.01). In addition, hospital characteristics associated with an increase in pituitary surgery post-ACA were: large bed size 9.74 (95% CI: 3.59, 15.90, p = 0.004); urban teaching centers 10.19 (95% CI: 3.25, 17.13, p = 0.01) and Midwest location 4.12 (95% CI: 2.49, 5.76, p < 0.0001).

Fig. 1 Number of pituitary surgeries over time. Pre-ACA period is from quarter 1 of 2011 to quarter 4 of 2013. Post-ACA period is from quarter 1 of 2015 to quarter 4 of 2017. Each point represents a discharge quarter.

Fig. 2 Number of pituitary surgeries over time stratified by patient location and hospital location/teaching status.

Fig. 3 Number of pituitary surgeries over time stratified by income quartile.

Conclusion: The ACA has had a multilevel impact on access to pituitary surgery in the United States, particularly for underserved, lower-income populations through the expansion of Medicaid and the private insurance exchange. Monitoring the NIS database will ensure continued progress in eliminating health disparities related to pituitary surgery. Future studies will need to evaluate surgery outcomes.

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Artikel online veröffentlicht:
05. Februar 2024