Variance in Complications After Oral Cancer Surgery Based on Insurance Status (7 Year Review)

Variance in complications following surgical resection for patients diagnosed with oral squamous cell carcinoma was investigated in a retrospective chart review in a tertiary care setting by the oral maxillofacial surgery department at NSU College of Dental Medicine. Patients were grouped into Medicaid/Uninsured (Medicaid) and privately Insured/Medicare (Insured). Medicaid population generally comprises lower educational and income groups, which have less access to screening and regular medical care¹. Due to their lack of preventive care and tobacco and alcohol abuse,^1,2 the majority of these patients have significant medical comorbidities. Co-morbidities have been found to be a major risk factor for complications and mortality in head and neck surgery. Medicaid patients are often diagnosed later, encounter delays with initiating treatment, and in some cases receive substandard care¹.

An exempt classification was granted by each hospital’s institutional review board. A retrospective review of patient charts from July 2007 to January 2014 was performed.  Lip and only oral cavity tumor sites were included.  Patients with previous head and neck surgery, adjunctive therapy, or recurrence were excluded. Patients were grouped into Medicaid or Insured then further stratified using initial staging, pre-existing comorbidities, surgical complications, and post-operative length of stay (LOS). A statistical analysis using odds ratio and chi square/student t-test was performed on collected data.

This study consisted of 89 surgically treated patients.  The Medicaid cohort comprised 31 patients, 30 males and 1 female. Average age was 54, and 42% were stage IV.  The Insured cohort had 58 patients, 33 males and 25 females, with an average age of 69, and 28% were stage IV. The mean stages of the Medicaid and Insured groups were III and II, respectively (p=0.07). The Medicaid group had increased predilection for poor healing (OR=6.7, CI_95%= 2.4-18.6), wound dehiscence (OR=2.7, CI₉₅%=1-7.2), respiratory failure (OR=7, CI_95%= 2.6-18.4), post-op delirium (OR=4.4, CI_95%=1-19), and need for PEG placement (OR=4, CI_95%= 1.5-10.5), when compared to Insured patients.  The Insured group had no cardiovascular complications, compared to 22.6% of Medicaid patients (P<0.001).  Medicaid patients had a higher percentage of surgical site infections, fistula, and recurrence, however, results were not significant.  Medicaid patients mean LOS was 15.5 days, compared to 9 days for Insured patients (p<0.05).

Medicaid patients are at increased odds for major and minor complications after head and neck cancer surgery. Overall, Medicaid patients have an increased length of hospital stay. Although findings were statistically significant for our 89 patients, a multicenter study would be indicated to further assess risk to this patient population and possible solutions to lowering these risks.

References:

1. Kwok, J., Langevin, S.M, Argiris, A., et al.  2010. The Impact of Health Insurance Status on the Survival of Patients with Head and Neck Cancer.  Cancer. 116:476-85.
2. Ferrier, M., Spuesens, E., Cessie, S., et al. Comorbitiy as a Major Risk Factor for Mortality and Complications in Head and Neck Surgery. Arch Otolaryngol Head Neck Surg. 131:27-32. 2005