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Does Insurance Type, Private Versus Public, Have a Correlation with MRSA Carrier Status In a Population Undergoing Orthopedic Surgery?

Jeremie M Axe, Jessie Osbourne Paull, Steven Vlad and John Richmond

Background: Preoperative nasal colonization with Staphylococcus aureus (SA) is a strong risk factor for surgical site infection (SSI). Methicillin-resistant SA (MRSA) positive carriers are at a much higher risk of SSI than MRSA negative patients. MRSA screening is expensive. Treatment of everyone with single dose antibiotic is very inexpensive, but has downstream negative consequences. This presents a conundrum. Surrogate measures for MRSA colonization may include insurance status in individuals below Medicare age. Massachusetts Health reform law mandates that Massachusetts residents obtain a state government-regulated minimum level of healthcare insurance coverage termed MassHealth. Questions/Purposes: We hypothesized that patients with government issued insurance would have higher rates of preoperative MRSA colonization compared to those who carry private insurance and that this information could be used to develop treatment algorithms for those undergoing orthopedic procedures that would cost less than screening all patients while avoiding the consequences of routine single dose antibiotic prescription for all.
Methods: We performed nasal MRSA screening on all adults undergoing elective inpatient or outpatient orthopaedic surgery at a single institution for the fiscal years 2007 through 2011. The variables of interest included insurance type, age and sex.
Results: The overall incidence of MRSA nasal colonization was 3.9%. For those under 65, the percentage of MRSA colonization in patients with government issued insurance (Medicaid and MassHealth) was more than 3 time that of those with private insurance.
Conclusion: Our observations suggest that institutions that do not institute MRSA screening programs, or in emergency situations, might consider government issued insurance, specifically Medicaid, as a risk factor for possible MRSA colonization and consider adjusting perioperative antibiotics accordingly. In many states, the Affordable Care Act will include an expansion of Medicaid to similar levels like Massachusetts, potentially making these results applicable nationwide. Level of Evidence III Cross-sectional Study