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Original Investigation
September 9, 2020

Association of Race, Health Insurance Status, and Household Income With Location and Outcomes of Ambulatory Surgery Among Adult Patients in 2 US States

Author Affiliations
  • 1Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
  • 2Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts
  • 3Boston University School of Medicine, Boston, Massachusetts
  • 4Boston University School of Public Health, Boston, Massachusetts
JAMA Surg. Published online September 9, 2020. doi:10.1001/jamasurg.2020.3318
Key Points

Question  Are patient race, health insurance status, and household income associated with the location (freestanding ambulatory surgery center vs hospital-based outpatient department) in which ambulatory surgery is performed?

Findings  In this cohort study of 13 million patients who received ambulatory surgery in New York and Florida between 2011 and 2013, the likelihood of receiving surgery at a freestanding ambulatory surgery center compared with a hospital-based outpatient department was significantly lower among patients who were Black, had public health insurance, and resided in rural areas.

Meaning  The study’s findings indicated that Black patients and patients with public health insurance were less likely to receive surgery at freestanding ambulatory surgery centers.


Importance  The receipt of surgery in freestanding ambulatory surgery centers (ASCs) is often less costly compared with surgery in hospital-based outpatient departments. Although increasing numbers of surgical procedures are now being performed in freestanding ASCs, questions remain regarding the existence of disparities among patients receiving care at ASCs.

Objective  To examine the association of patient race, health insurance status, and household income with the location (ASC vs hospital-based outpatient department) of ambulatory surgery.

Design, Setting, and Participants  This cohort study used data from the State Ambulatory Surgery and Services Databases of the Healthcare Cost and Utilization Project to perform a secondary analysis of patients who received ambulatory surgery in New York and Florida between 2011 and 2013. Patients aged 18 to 89 years who underwent 12 different types of ambulatory surgical procedures were included. Data were analyzed from December 2018 to June 2019.

Main Outcomes and Measures  Receipt of surgery at a freestanding ASC and 30-day unplanned hospital visits after ambulatory surgery.

Results  A total of 5.6 million patients in New York (57.4% female; 68.9% aged ≥50 years; and 62.5% White) and 7.5 million patients in Florida (57.3% female; 77.4% aged ≥50 years; 74.3% White) who received ambulatory surgery were included in the analysis. After adjusting for age, comorbidities, health insurance status, household income, location of surgery, and type of surgical procedure, the likelihood of receiving ambulatory surgery at a freestanding ASC was significantly lower among Black patients (adjusted odds ratio [aOR], 0.82; 95% CI, 0.81-0.83; P < .001) and Hispanic patients (aOR, 0.78; 95% CI, 0.77-0.79; P < .001) compared with White patients in New York. This likelihood was also lower among Black patients (aOR, 0.65; 95% CI, 0.65-0.66; P < .001) compared with White patients in Florida. Public health insurance coverage was associated with a significantly lower likelihood of receiving ambulatory surgery at freestanding ASCs in both New York and Florida, particularly among patients with Medicaid (in New York, aOR, 0.22; 95% CI, 0.22-0.22; P < .001; in Florida, aOR, 0.40; 95% CI, 0.40-0.41; P < .001) and Medicare (in New York, aOR, 0.46; 95% CI, 0.46-0.46; P < .001; in Florida, aOR, 0.67; 95% CI, 0.66-0.67; P < .001).

Conclusions and Relevance  Differences in the use of freestanding ASCs were found among Black patients and patients with public health insurance. Further exploration of the factors underlying these differences will be important to ensure that all populations have access to the increasing number of freestanding ASCs.

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