CLINICAL ARTICLE J Neurosurg 134:801–806, 2021 Impact of Medicaid insurance on outcomes following endoscopic transsphenoidal pituitary surgery Iyan Younus, BS,1 Mina Gerges, MD,2 Theodore H. Schwartz, MD,2–4 and Rohan Ramakrishna, MD2 1Weill Cornell Medical College; and Departments of 2Neurosurgery, 3Otolaryngology, and 4Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York OBJECTIVE Despite the rise of studies in the neurosurgical literature suggesting that patients with Medicaid insurance have inferior outcomes, there remains a paucity of data on the impact of insurance on outcomes after endonasal endo- scopic transsphenoidal surgery (EETS). Given the increasing importance of complications in quality-based healthcare metrics, the objective of this study was to assess whether Medicaid insurance type influences outcomes in EETS for pituitary adenoma. METHODS The authors analyzed a prospectively acquired database of EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. All patients with Medicaid insurance were identified. As a con- trol group, the clinical, socioeconomic, and radiographic data of all other patients in the series with non-Medicaid insur- ance were reviewed. Statistical significance was determined with an alpha < 0.05 using Pearson chi-square and Fisher’s exact tests for categorical variables and the independent-samples t-test for continuous variables. RESULTS Of 584 patients undergoing EETS for pituitary adenoma, 57 (10%) had Medicaid insurance. The maximum tumor diameter was significantly larger for Medicaid patients (26.1 ± 12 vs 23.1 ± 11 mm for controls, p < 0.05). Baseline comorbidities including diabetes mellitus, hypertension, smoking history, and BMI were not significantly different be- tween Medicaid patients and controls. Patients with Medicaid insurance had a significantly higher rate of any complica- tion (14% vs 7% for controls, p < 0.05) and long-term cranial neuropathy (5% vs 1% for controls, p < 0.05). There were no statistically significant differences in endocrine outcome or vision outcome. The mean postoperative length of stay was significantly longer for Medicaid patients compared to the controls (9.4 ± 31 vs 3.6 ± 3 days, p < 0.05). This difference remained significant even when accounting for outliers (5.6 ± 2.5 vs 3.0 ± 2.7 days for controls, p < 0.05). The most common causes of extended length of stay greater than 1 standard deviation for Medicaid patients were management of perioperative complications and disposition challenges. The rate of 30-day readmission was 7% for Medicaid patients and 4.4% for controls, which was not a statistically significant difference. CONCLUSIONS The authors found that larger tumor diameter, longer postoperative length of stay, higher rate of complications, and long-term cranial neuropathy were significantly associated with Medicaid insurance. There were no statistically significant differences in baseline comorbidities, apoplexy, endocrine outcome, vision outcome, or 30-day readmission. https://thejns.org/doi/abs/10.3171/2020.1.JNS192707 KEYWORDS pituitary adenoma; endonasal; endoscopic; transsphenoidal; insurance; socioeconomic; complications; pituitary surgery EALTHCARE disparities have been reported in the Curry et al. analyzed a large nationwide sample of patients neurosurgical literature, with patients covered by undergoing craniotomy procedures and found that patients Medicaid experiencing significantly worse out- covered by Medicaid had significantly higher rates of post- Hcomes after surgery.1,2 It has also been reported that pa- operative in-hospital mortality.1 Furthermore, El-Sayed tients covered by Medicaid have significantly longer post- and colleagues reported that patients covered by Medicaid operative length of stay and total costs associated with had a significantly increased risk for postoperative compli- their care.3 Therefore, there has been increased interest in cations within 30 days of neurosurgery.4 analyzing socioeconomic disparities within neurosurgery. It has been theorized that these differences may be due ABBREVIATIONS ACTH = adrenocorticotropic hormone; EETS = endonasal endoscopic transsphenoidal surgery; GH = growth hormone; GTR = gross-total resection; PE = pulmonary embolism. SUBMITTED October 3, 2019. ACCEPTED January 16, 2020. INCLUDE WHEN CITING Published online March 20, 2020; DOI: 10.3171/2020.1.JNS192707. ©AANS 2021, except where prohibited by US copyright law J Neurosurg Volume 134 • March 2021 801 Unauthenticated | Downloaded 09/27/21 01:24 PM UTC Younus et al. to baseline health, access to primary care, and access to Statistical Analysis postoperative outpatient follow-up care and rehabilitation.5 The SPSS statistical software package (version 24, Despite the rise of studies in the neurosurgical literature IBM Corp.) was utilized for all analyses. Univariate analy- suggesting that patients with Medicaid insurance have in- sis was performed using Pearson chi-square and Fisher’s ferior outcomes, there remains a paucity of data on the exact tests for categorical variables and the independent- impact of Medicaid insurance on outcomes after endona- samples t-test for continuous variables. For all tests, sta- sal endoscopic transsphenoidal surgery (EETS). Given the tistical significance was determined with an alpha < 0.05. increasing importance of complications in quality-based healthcare metrics, the objective of this study is to assess Results whether Medicaid insurance type influences outcomes in EETS for pituitary adenoma. Patient Demographics and Clinical Characteristics Among 584 patients undergoing EETS for pituitary ad- Methods enoma, 10% had Medicaid insurance (Table 1). Females comprised 51% of Medicaid cases compared to 49% of Study Design controls. The mean age for Medicaid cases was 49 ± 14 The authors analyzed a prospectively acquired data- years compared to 52 ± 16 years for controls. Reoperations base of EETS for pituitary adenoma from 2005 to 2018 at accounted for 12% of Medicaid cases compared to 13% NewYork-Presbyterian Hospital, Weill Cornell Medicine. of controls. Mean follow-up days were similar for both We identified all patients with Medicaid insurance. As a Medicaid and control cases (702 ± 840 vs 711 ± 844 days, control group, we also reviewed clinical, socioeconomic, respectively). Race/ethnicity was not significantly differ- and radiographic data of all other patients in the series ent between Medicaid cases and controls. Among Medic- with non-Medicaid insurance. The study was approved by aid cases, 53% were white, 16% black, 14% Hispanic, 5% our IRB. Asian, and 12% classified as other, compared with 54% white, 19% black, 8.5% Hispanic, 7% Asian, and 11% oth- Tracking of Pre- and Perioperative Variables er for the controls. Preoperative clinical and radiographic data were col- lected and analyzed in both groups. Demographic param- Tumor Characteristics eters recorded for each case included sex, age, and postop- The maximum tumor diameter was significantly larger erative length of stay. Tumor characteristics recorded for for Medicaid patients compared to the controls (26.1 ± 12 each case included maximum tumor diameter, cavernous vs 23.1 ± 11 mm, p < 0.05). All other tumor characteristics sinus invasion determined by Knosp grade, radiographic were not significantly different between Medicaid cases extent of resection based on review of postoperative MRI compared to controls. Cavernous sinus invasion was pres- by a board-certified neuroradiologist performed within a ent in 26% of cases in the Medicaid group compared to week after surgery, reoperation, apoplexy, and breakdown 22% of the controls. Gross-total resection (GTR) was per- by functional adenoma subtype. Endocrine outcomes formed in 70% of cases in the Medicaid group compared were recorded for both nonfunctioning and functioning to 72% of the controls. Functioning pituitary adenomas ac- adenomas. Complete biochemical remission for prolacti- counted for 32% of cases in the Medicaid group (22% pro- nomas was determined by normalization of serum prolac- lactinomas, 61% GH-producing, and 17% ACTH-produc- tin levels < 20 μg/L; for growth hormone (GH)–producing ing) compared to 27% of the controls (40% prolactinomas, tumors by normalization of serum GH < 1 μg/L or nadir 34% GH-producing, and 26% ACTH-producing). Pituitary GH after an oral glucose tolerance test < 0.4 μg/L; and apoplexy was present in 7% of cases in the Medicaid group for adrenocorticotropic hormone (ACTH)–producing tu- and 6% in the control group. mors by morning serum cortisol < 3 μg/dl, 3–5 days after surgery. Clinical history recorded for each case included Baseline Comorbidities preoperative vision status, preoperative cranial neuropa- Baseline comorbidities were not significantly different thy, smoking status, BMI, history of diabetes mellitus, and between Medicaid cases compared to the controls. History history of hypertension. Socioeconomic factors assessed of diabetes mellitus and hypertension were present in 19% for each case included race/ethnicity (white, black, His- and 42% of Medicaid patients compared to 13% and 39% panic, Asian, or other) and health insurance (Medicare, of the controls. Active smoking history was reported in Medicaid, private, or self-pay). Imaging analysis was per- 9% of Medicaid cases versus 8% in controls. The mean formed on a GE Advantage Workstation (version 4.3) to BMI was 28.7 ± 6 kg/m2 for Medicaid patients compared determine preoperative maximum