Health Insurance Payer Status Is Associated With Frailty in a Surgical Patient Population: A Retrospective Case Series

Abstract

Background and Aims

Frailty is an age-related syndrome associated with poor surgical outcomes, but the impact of insurance payer status on frailty is not fully understood. We sought to evaluate the association between insurance payer status and frailty among thoracic surgery patients.

Methods

This retrospective study included all patients undergoing routine frailty screening in a general thoracic surgery clinic at a single center from December 2020 to December 2022. Insurance payers were collected (Medicare, Medicaid, or private). Frailty was measured using the Fried's Frailty Phenotype (FFP) (0: not frail, 1–2: prefrail, 3–5: frail) and the Modified 5-Item Frailty Index (mFI-5) (≥ 2 vs. 0–1). Fisher's Exact and Kruskal–Wallis tests and multivariable logistic regressions were performed. A final sensitivity analysis was conducted to examine the association of insurance and frailty in patients who underwent surgery.

Results

Of the 430 screened patients, 41% (183) were female, median age was 68 (IQR: 62–74), and 48% (207) were non-White. Insurance coverage was 63% (271) Medicare, 15% (64) Medicaid, and 22% (95) private insurance. Of the cohort, 44% (189) of patients underwent subsequent surgery. After adjusting for age, sex, BMI, race/ethnicity, income, smoking status, medications, cancer history, and healthcare utilization, patients with Medicare were more likely to be frail than those with private insurance (FFP: Medicare—OR: 3.17, CI: [1.14–9.72], p < 0.05 | mFI-5: OR: 3.40, CI: [1.45–8.55], p < 0.01). This association was seen in patients with Medicaid by mFI-5 (OR: 3.35, CI: [1.24–9.51], p < 0.05). Furthermore, these findings were consistent with our sensitivity analysis.

Conclusion

Publicly insured surgical patients are more likely to be frail than those privately insured. The etiology of this disparity is multifactorial and may be a result of healthcare inaccessibility, limitations of coverage, and lower socioeconomic status. Future policy-based interventions to address social determinants of health may reduce insurance disparities.