Insurance Coverage Type Impacts Hospitalization Patterns Among Patients with Hepatopancreatic Malignancies



Disparities in health and healthcare access remain a major problem in the USA. The current study sought to investigate the relationship between patient insurance status and hospital selection for surgical care.


Patients who underwent liver or pancreatic resection for cancer between 2004 and 2014 were identified in the National Inpatient Sample. The association of insurance status and hospital type was examined.


In total, 22,254 patients were included in the study. Compared with patients with private insurance, Medicaid patients were less likely to undergo surgery at urban non-teaching hospitals (OR = 0.36, 95%CI 0.22–0.59) and urban teaching hospitals (OR = 0.54, 95%CI 0.34–0.84) than rural hospitals. Medicaid patients were less likely to undergo surgery at private investor-owned hospitals (OR = 0.53, 95%CI 0.38–0.73) than private non-profit hospitals. In contrast, uninsured patients were 2.2-fold more likely to go to government-funded hospitals rather than private non-profit hospitals (OR = 2.19, 95%CI 1.76–2.71).


Insurance status was strongly associated with the type of hospital in which patients underwent surgery for liver and pancreatic cancers. Addressing the reasons for inequitable access to different hospital settings relative to insurance status is essential to ensure that all patients undergoing pancreatic or liver surgery receive high-quality surgical care.

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

Fig. 1
Fig. 2


  1. 1.

    Smedley BD, Stith, A. Y, Nelson, A. R: Institute of Medicine Committee on, Understanding Eliminating, Racial Ethnic Disparities in Health, Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 2003.

  2. 2.

    Sommers BD, Mc MC, Blendon RJ, Benson JM, Sayde JM: Beyond Health Insurance: Remaining Disparities in US Health Care in the Post-ACA Era. The Milbank quarterly 2017, 95(1):43–69.

    PubMed  PubMed Central  Google Scholar 

  3. 3.

    Frieden TR, Centers for Disease C, Prevention: CDC Health Disparities and Inequalities Report - United States, 2013. Foreword. MMWR Suppl 2013, 62(3):1–2.

  4. 4.

    Niu X, Roche LM, Pawlish KS, Henry KA: Cancer survival disparities by health insurance status. Cancer medicine 2013, 2(3):403–411.

    PubMed  PubMed Central  Google Scholar 

  5. 5.

    Rosenberg AR, Kroon L, Chen L, Li CI, Jones B: Insurance status and risk of cancer mortality among adolescents and young adults. Cancer 2015, 121(8):1279–1286.

    PubMed  Google Scholar 

  6. 6.

    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. American journal of public health 2000, 90(11):1746–1754.

    CAS  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Chen AY, Schrag NM, Halpern M, Stewart A, Ward EM: Health insurance and stage at diagnosis of laryngeal cancer: does insurance type predict stage at diagnosis?Archives of otolaryngology--head & neck surgery 2007, 133(8):784–790.

    Google Scholar 

  8. 8.

    Chen AY, Schrag NM, Halpern MT, Ward EM: The impact of health insurance status on stage at diagnosis of oropharyngeal cancer. Cancer 2007, 110(2):395–402.

    PubMed  Google Scholar 

  9. 9.

    Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM: Unmet health needs of uninsured adults in the United States. Jama 2000, 284(16):2061–2069.

    CAS  PubMed  Google Scholar 

  10. 10.

    Lillie-Blanton M, Hoffman C: The role of health insurance coverage in reducing racial/ethnic disparities in health care. Health affairs (Project Hope) 2005, 24(2):398–408.

    Google Scholar 

  11. 11.

    Armenia SJ, Pentakota SR, Merchant AM: Socioeconomic factors and mortality in emergency general surgery: trends over a 20-year period. J Surg Res 2017, 212:178–186.

    PubMed  Google Scholar 

  12. 12.

    Ho VP, Nash GM, Feldman EN, Trencheva K, Milsom JW, Lee SW: Insurance But Not Race Is Associated With Diverticulitis Mortality in a Statewide Database. 2011, 54(5):559–565.

  13. 13.

    Cohen RA MM: Health insurance coverage: Early release of estimates from the National Health Interview Survey, 2014. National Center for Health Statistics June, 2015.

  14. 14.

    Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE: Hospital volume and surgical mortality in the United States. N Engl J Med 2002, 346(15):1128–1137.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Ghaferi AA, Birkmeyer JD, Dimick JB: Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009, 361(14):1368–1375.

    CAS  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Merath K, Bagante F, Chen Q, Beal EW, Akgul O, Idrees J, Dillhoff M, Cloyd J, Schmidt C, Pawlik TM: The Impact of Discharge Timing on Readmission Following Hepatopancreatobiliary Surgery: a Nationwide Readmission Database Analysis. J Gastrointest Surg 2018.

  17. 17.

    Merath K, Chen Q, Bagante F, Sun S, Akgul O, Idrees JJ, Dillhoff M, Schmidt C, Cloyd J, Pawlik TM: Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery. HPB (Oxford) 2018.

  18. 18.

    Sheetz KH, Dimick JB, Ghaferi AA: Impact of Hospital Characteristics on Failure to Rescue Following Major Surgery. Ann Surg 2016, 263(4):692–697.

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Amini N, Kim Y, Hyder O, Spolverato G, Wu CL, Page AJ, Pawlik TM: A nationwide analysis of the use and outcomes of perioperative epidural analgesia in patients undergoing hepatic and pancreatic surgery. Am J Surg 2015, 210(3):483–491.

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    Cerullo M, Gani F, Chen SY, Canner JK, Dillhoff M, Cloyd J, Pawlik TM: Routine intensive care unit admission among patients undergoing major pancreatic surgery for cancer: No effect on failure to rescue. Surgery 2018.

  21. 21.

    Kneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY, Pawlik TM: Risk of morbidity and mortality following hepato-pancreato-biliary surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2012, 16(9):1727–1735.

    Google Scholar 

  22. 22.

    Merath K, Chen Q, Johnson M, Mehta R, Beal EW, Dillhoff M, Cloyd J, Pawlik TM: Hot spotting surgical patients undergoing hepatopancreatic procedures. HPB : the official journal of the International Hepato Pancreato Biliary Association 2018.

    Google Scholar 

  23. 23.

    Abraham A, Al-Refaie WB, Parsons HM, Dudeja V, Vickers SM, Habermann EB: Disparities in pancreas cancer care. Annals of surgical oncology 2013, 20(6):2078–2087.

    PubMed  Google Scholar 

  24. 24.

    Hoehn RS, Hanseman DJ, Jernigan PL, Wima K, Ertel AE, Abbott DE, Shah SA: Disparities in care for patients with curable hepatocellular carcinoma. HPB : the official journal of the International Hepato Pancreato Biliary Association 2015, 17(9):747–752.

    Google Scholar 

  25. 25.

    Nathan H, Frederick W, Choti MA, Schulick RD, Pawlik TM: Racial disparity in surgical mortality after major hepatectomy. Journal of the American College of Surgeons 2008, 207(3):312–319.

    PubMed  PubMed Central  Google Scholar 

  26. 26.

    Schneider EB, Ejaz A, Spolverato G, Hirose K, Makary MA, Wolfgang CL, Ahuja N, Weiss M, Pawlik TM: Hospital volume and patient outcomes in hepato-pancreatico-biliary surgery: is assessing differences in mortality enough?Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2014, 18(12):2105–2115.

    Google Scholar 

  27. 27.

    NIS Description of Data Elements [ accessed 2nd May, 2019.]

  28. 28.

    Baram D, Daroowalla F, Garcia R, Zhang G, Chen JJ, Healy E, Riaz SA, Richman P: Use of the All Patient Refined-Diagnosis Related Group (APR-DRG) Risk of Mortality Score as a Severity Adjustor in the Medical ICU. Clinical medicine Circulatory, respiratory and pulmonary medicine 2008, 2:19–25.

    PubMed  PubMed Central  Google Scholar 

  29. 29.

    Swords DS, Mulvihill SJ, Brooke BS, Skarda DE, Firpo MA, Scaife CL: Disparities in utilization of treatment for clinical stage I-II pancreatic adenocarcinoma by area socioeconomic status and race/ethnicity. Surgery 2018.

  30. 30.

    Wasif N, Etzioni D, Habermann EB, Mathur A, Pockaj BA, Gray RJ, Chang YH: Racial and Socioeconomic Differences in the Use of High-Volume Commission on Cancer-Accredited Hospitals for Cancer Surgery in the United States. Annals of surgical oncology 2018, 25(5):1116–1125.

    PubMed  Google Scholar 

  31. 31.

    Gupta A, Sonis ST, Schneider EB, Villa A: Impact of the insurance type of head and neck cancer patients on their hospitalization utilization patterns. Cancer 2018, 124(4):760–768.

    PubMed  Google Scholar 

  32. 32.

    Okunrintemi V, Khera R, Spatz ES, Salami JA, Valero-Elizondo J, Warraich HJ, Virani SS, Blankstein R, Blaha MJ, Pawlik TM et al: Association of Income Disparities with Patient-Reported Healthcare Experience. J Gen Intern Med 2019.

  33. 33.

    Schneider EB, Calkins KL, Weiss MJ, Herman JM, Wolfgang CL, Makary MA, Ahuja N, Haider AH, Pawlik TM: Race-based differences in length of stay among patients undergoing pancreatoduodenectomy. Surgery 2014, 156(3):528–537.

    PubMed  Google Scholar 

  34. 34.

    Sedney CL, Khan U, Dekeseredy P: Traumatic spinal cord injury in West Virginia: Disparities by insurance and discharge disposition from an acute care hospital. J Spinal Cord Med 2018:1–5.

  35. 35.

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

    PubMed  Google Scholar 

  36. 36.

    Bhattacharyya N, Abemayor E: Patterns of hospital utilization for head and neck cancer care: changing demographics. JAMA otolaryngology-- head & neck surgery 2015, 141(4):307–312; quiz 400.

    Google Scholar 

  37. 37.

    Dimick JB, Cowan JA, Colletti LM, Upchurch GR: Hospital teaching status and outcomes of complex surgical procedures in the United States. Arch Surg 2004, 139(2):137–141.

    PubMed  Google Scholar 

  38. 38.

    Gruber K, Soliman AS, Schmid K, Rettig B, Ryan J, Watanabe-Galloway S: Disparities in the Utilization of Laparoscopic Surgery for Colon Cancer in Rural Nebraska: A Call for Placement and Training of Rural General Surgeons. J Rural Health 2015, 31(4):392–400.

    PubMed  PubMed Central  Google Scholar 

  39. 39.

    Hocking C, Broadbridge VT, Karapetis C, Beeke C, Padbury R, Maddern GJ, Roder DM, Price TJ: Equivalence of outcomes for rural and metropolitan patients with metastatic colorectal cancer in South Australia. The Medical journal of Australia 2014, 201(8):462–466.

    PubMed  Google Scholar 

  40. 40.

    Avall Lundqvist E, Nordstrom L, Sjovall K, Eneroth P: Evaluation of seven different tumour markers for the establishment of tumour marker panels in gynecologic malignancies. European journal of gynaecological oncology 1989, 10(6):395–405.

    CAS  PubMed  Google Scholar 

  41. 41.

    Hyder O, Sachs T, Ejaz A, Spolverato G, Pawlik TM: Impact of hospital teaching status on length of stay and mortality among patients undergoing complex hepatopancreaticobiliary surgery in the USA. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2013, 17(12):2114–2122.

    Google Scholar 

  42. 42.

    Nathan H, de Jong MC, Pulitano C, Ribero D, Strub J, Mentha G, Gigot JF, Schulick RD, Choti MA, Aldrighetti L et al: Conditional survival after surgical resection of colorectal liver metastasis: an international multi-institutional analysis of 949 patients. Journal of the American College of Surgeons 2010, 210(5):755–764, 764-756.

  43. 43.

    Finks JF, Osborne NH, Birkmeyer JD: Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011, 364(22):2128–2137.

    CAS  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Idrees JJ, Merath K, Gani F, Bagante F, Mehta R, Beal E, Cloyd JM, Pawlik TM: Trends in centralization of surgical care and compliance with National Cancer Center Network guidelines for resected cholangiocarcinoma. HPB : the official journal of the International Hepato Pancreato Biliary Association 2018.

  45. 45.

    Harrington C, Woolhandler S, Mullan J, Carrillo H, Himmelstein DU: Does investor ownership of nursing homes compromise the quality of care?American journal of public health 2001, 91(9):1452–1455.

    CAS  PubMed  PubMed Central  Google Scholar 

  46. 46.

    Amini A, Jones BL, Ghosh D, Schefter TE, Goodman KA: Impact of facility volume on outcomes in patients with squamous cell carcinoma of the anal canal: Analysis of the National Cancer Data Base. Cancer 2017, 123(2):228–236.

    PubMed  Google Scholar 

  47. 47.

    Visser BC, Ma Y, Zak Y, Poultsides GA, Norton JA, Rhoads KF: Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes. HPB (Oxford) 2012, 14(8):539–547.

    Google Scholar 

  48. 48.

    Zak Y, Rhoads KF, Visser BC: Predictors of surgical intervention for hepatocellular carcinoma: race, socioeconomic status, and hospital type. Archives of surgery (Chicago, Ill : 1960) 2011, 146(7):778–784.

    Google Scholar 

  49. 49.

    Bilimoria KY, Bentrem DJ, Stewart AK, Winchester DP, Ko CY: Comparison of commission on cancer-approved and -nonapproved hospitals in the United States: implications for studies that use the National Cancer Data Base. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 2009, 27(25):4177–4181.

    Google Scholar 

  50. 50.

    Haut ER, Pronovost PJ, Schneider EB: Limitations of Administrative Databases. Jama 2012, 307(24):2589–2590.

    CAS  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Timothy M. Pawlik.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Mehta, R., Sahara, K., Merath, K. et al. Insurance Coverage Type Impacts Hospitalization Patterns Among Patients with Hepatopancreatic Malignancies. J Gastrointest Surg 24, 1320–1329 (2020).

Download citation


  • Insurance
  • Hospital utilization
  • Hepatopancreatic cancer
  • Medicaid