Rationale: One in three Americans under 65 years of age does not have health insurance during some portion of each year. Patients who are critically ill and lack health insurance may be at particularly high risk of morbidity and mortality due to the high cost of intensive care.
Objectives: To systematically review the medical and nonmedical literature to determine whether differences in critical care access, delivery, and outcomes are associated with health insurance status.
Methods: Nine electronic databases (inception to 11 April 2008) were independently screened and abstracted in duplicate.
Measurements and Main Results: From 5,508 citations, 29 observational studies met eligibility criteria. Among the general U.S. population, patients who were uninsured were less likely to receive critical care services than those with insurance (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.55–0.56). Once admitted to the intensive care unit, patients who were uninsured had 8.5% (95% CI, 6.0–11.1) fewer procedures, were more likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46–13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12–7.02). Lack of insurance may confer an independent risk of death for patients who are critically ill (OR 1.16; 95% CI, 1.01–1.33). Patients in managed care systems had 14.3% (95% CI, 11.5–17.2) fewer procedures in intensive care, but were also less likely to receive “potentially ineffective” care. Differences in unmeasured confounding factors may contribute to these findings.
Conclusions: Patients in the United States who are critically ill and do not have health insurance receive fewer critical care services and may experience worse clinical outcomes. Improving preexisting health care coverage, as opposed to solely delivering more critical care services, may be one mechanism to reduce such disparities.
insurance; disparities; payer; critical care; intensive care; access; outcome; Medicare; managed care; Medicaid
OBJECTIVE: To examine the relationship of patients' socioeconomic status (SES) as measured by race, health insurance status, and median income by zip code to in-hospital mortality of acute myocardial infarction (AMI), paying special attention to patients with multiple unfavorable socioeconomic risk factors. DATA SOURCES/STUDY SETTING: The data set was abstracted from patient-level hospital discharges in the Nationwide Inpatient Sample, Release 3, 1994. A total of 95,971 AMI discharges in 11 states were extracted. STUDY DESIGN: The risk adjustment methodology was adapted from the California Hospital Outcomes Project. Risk factors included demographic and clinical characteristics. Patients in double jeopardy had inferior insurance status and lived in poorer neighborhoods. PRINCIPAL FINDINGS: Compared with patients with health care coverage under Medicare and private insurance uninsured AMI patients had the highest risk-adjusted mortality odds and Medicaid AMI patients had the second highest odds. Probably because of the modest association of median income by zip code areas with mortality odds, the double jeopardy phenomenon was not observed. However, compared to patients who had two favorable SES attributes, patients who carried two unfavorable SES attributes had much higher mortality risk, more comorbidities, longer length of stay, and higher total hospital charges, while they received fewer AMI specialized procedures. Race did not seem to be a significant factor after adjustment for other SES attributes. CONCLUSIONS: SES is significantly related to the mortality of AMI patients. The disadvantaged patients receive fewer specialized procedures, possibly because of their higher levels of severity and financial barriers. The variation in mortality between patients who had favorable and unfavorable SES becomes wider when multiple socioeconomic risks are borne by the latter.
Determine whether being uninsured is associated with higher in-hospital postoperative mortality when undergoing surgery in the United States for a brain tumor.
Uninsured patients may experience poor surgical outcomes due to suboptimal care, poor overall health, or impaired healthcare access.
Retrospective cohort study utilizing the Nationwide Inpatient Sample (NIS), 1999 to 2008.
The NIS contains all inpatient records from a stratified sample of 20% of hospitals in 37 states.
28,582 patients, ages 18 to 65 years, who underwent craniotomy for a brain tumor. Three groups were studied: privately insured, Medicaid recipients, and uninsured.
Main Outcome Measure
In-hospital postoperative death. Associations between this outcome and insurance status were examined within the full cohort and within the subset of patients with no co-morbidity using Cox proportional hazards models. These models were stratified by hospital to control for any clustering effects that could arise from differing access to care.
In the unadjusted analysis, the mortality rate for privately insured patients was 1.28% (95% confidence interval [CI], 1.13%-1.42%), compared to 2.60% for uninsured patients (CI, 1.87%-3.33%, P<.001), and 2.33% for Medicaid recipients (CI, 1.85%-2.82%, P<.001). After adjusting for patient characteristics and stratifying by hospital in patients with no co-morbidity, uninsured patients still had a higher risk of experiencing in-hospital death (hazard ratio 2.62, CI, 1.11-6.14, P=.027) compared with privately-insured patients. In this adjusted analysis, the disparity was not conclusively present in Medicaid recipients (hazard ratio 2.03, CI, 0.97-4.23, P=.06).
Uninsured patients who underwent craniotomy for a brain tumor experienced the highest in-hospital mortality. Differences in overall health or healthcare access do not fully account for this disparity.
Rationale: Although associated with adverse outcomes in other cardiopulmonary conditions, the prognostic value of hyponatremia, a marker of neurohormonal activation, in patients with acute pulmonary embolism (PE) is unknown.
Objectives: To examine the associations between hyponatremia and mortality and hospital readmission rates for patients hospitalized with PE.
Methods: We evaluated 13,728 patient discharges with a primary diagnosis of PE from 185 hospitals in Pennsylvania (January 2000 to November 2002). We used random-intercept logistic regression to assess the independent association between serum sodium levels at the time of presentation and mortality and hospital readmission within 30 days, adjusting for patient (race, insurance, severity of illness, use of thrombolytic therapy) and hospital factors (region, size, teaching status).
Measurements and Main Results: Hyponatremia (sodium ≤135 mmol/L) was present in 2,907 patients (21.1%). Patients with a sodium level greater than 135, 130–135, and less than 130 mmol/L had a cumulative 30-day mortality of 8.0, 13.6, and 28.5% (P < 0.001), and a readmission rate of 11.8, 15.6, and 19.3% (P < 0.001), respectively. Compared with patients with a sodium greater than 135 mmol/L, the adjusted odds of dying were significantly greater for patients with a sodium 130–135 mmol/L (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.33–1.76) and a sodium less than 130 mmol/L (OR, 3.26; 95% CI, 2.48–4.29). The adjusted odds of readmission were also increased for patients with a sodium of 130–135 mmol/L (OR, 1.28; 95% CI, 1.12–1.46) and a sodium less than 130 mmol/L (OR, 1.44; 95% CI, 1.02–2.02).
Conclusions: Hyponatremia is common in patients presenting with PE, and is an independent predictor of short-term mortality and hospital readmission.
hyponatremia; prognosis; pulmonary embolism
To determine if patients treated at hospitals under different levels of financial strain from the Balanced Budget Act (BBA) of 1997 had differential changes in 30-day mortality, and whether vulnerable patient populations such as the uninsured were disproportionately affected.
Hospital discharge data from all general acute care hospitals in Pennsylvania from 1997 to 2001.
A multivariate regression analysis was performed retrospectively on 30-day mortality rates, using hospital discharge data, hospital financial data, and death certificate information from Pennsylvania.
We used 370,017 hospital episodes with one of four conditions identified by the Agency for Healthcare Research and Quality as inpatient quality indicators were extracted.
The average magnitude of Medicare payment reduction on overall net revenues was estimated at 1.8 percent for hospitals with low BBA impact and 3.6 percent for hospitals with a high impact in 1998, worsening to 2 and 4.8 percent, respectively, by 2001. Operating margins decreased significantly over the time period for all hospitals (p<.05). While unadjusted mortality rates demonstrated a disproportionate rise in mortality for patients from high impact hospitals from 1997 to 2000, adjusted analyses show no consistent, significant difference in the rate of change in mortality between high-impact and low-impact hospitals (p = .04–.94). Similarly, uninsured patients did not experience greater increases in mortality in high-impact hospitals relative to low-impact hospitals.
An analysis of hospitalizations in the Commonwealth of Pennsylvania did not find an adverse impact of increased financial strain from the BBA on patient mortality either among all patients or among the uninsured.
Medicare; Balanced Budget Act; financial strain; hospital; quality of care
Examine the relationship between hospital procedure volume and surgical outcomes following primary elective total hip or total knee arthroplasty (THA/TKA).
Using the Pennsylvania Health Care Cost Containment Council database, we identified all patients who underwent primary elective THA/TKA in Pennsylvania. Hospitals were categorized by annual procedure volume of THA/TKA into: ≤25, 26–100, 101–200 and >200. Logistic regression models assessed 30-day complications and 30-day and 1-year mortality, adjusted for age, gender, race, insurance type, hospital region, 3M™ All Patient Refined-Diagnosis Related Group Risk of Mortality score, hospital teaching status and bed count.
THA and TKA cohorts had mean age of 69 years each with 42.8% (n=10,187) and 35% men (n=19,418), respectively. Compared to high-volume hospitals (>200/year), patients who underwent elective primary THA at low-volume hospitals (≤25, 26–100, and 101–200 annually) had higher multivariable-adjusted odds ratios (95% confidence interval) for: venous thromboembolism: 2.0(0.2–16.0), 3.4(1.4–8.0) and 1.1(0.3–3.7), respectively, (p=0.02) (respective events were 3/814, 24/4,163, 7/2,246, 9/2,964); and one-year mortality: 2.1(1.2–3.6) -2.0(1.4–2.9) and 1.0(0.7–1.5) (respective events were 32/814, 147/4,163, 50/2,246, 25/2,964), respectively, (p<0.01). Patients ≥65 who underwent elective primary TKA at low-volume hospitals had significantly higher odds ratios (95% confidence interval) for one-year mortality: 0.6(0.2–2.1), 1.6(1.0–2.4) and 0.9(0.6–1.3), respectively, (p=0.02), compared to high volume hospitals (respective events were 3/309, 58/2,462, 59/3,966, 83/5,750).
A low hospital surgery volume was associated with higher risk of venous thromboembolism and mortality after primary elective THA/TKA. Confounding due to unmeasured variables is possible. Modifiable system-based factors/processes should be targeted to reduce complications.
To determine whether racial differences in hospital mortality worsened after implementation of a New Jersey law in 1993 that reduced subsidies for uninsured hospital care and changed hospital payment from rate regulation to price competition.
DATA SOURCES/STUDY SETTING
State discharge data for New Jersey and New York from 1990 to 1996.
We used an interrupted time series design to compare risk-adjusted in-hospital mortality rates between states over time. Adjusting for patient characteristics, baseline interstate differences, and common intertemporal trends, we compared the effect sizes for whites and blacks in the following 4 groups: overall, uninsured, insured under age 65, and Medicare patients.
DATA COLLECTION/EXTRACTION METHODS
The study sample included 1,357,394 patients admitted to New Jersey or New York hospitals between 1990 to 1996 with stroke, hip fracture, pneumonia, pulmonary embolism, congestive heart failure, or acute myocardial infarction (AMI).
The increase in mortality in New Jersey versus New York was significantly larger among blacks than among whites for AMI (2.4% points vs 0.1% points, P-value for difference .026) but not for the other 6 conditions. In groupings of conditions for which hospital admission is non-discretionary and conditions in which admission is discretionary, we found qualitatively larger increases in mortality for blacks but no statistically significant racial differences among patients overall, uninsured patients, insured patients under age 65, or Medicare patients.
Market-based reform and reductions in subsidies for hospital care for the uninsured in New Jersey were associated with worsening racial disparities in in-hospital mortality for AMI but not for 6 other common conditions.
quality of health care; economics; medical; financing; organized
Objective To compare the effectiveness with which insured and uninsured persons with chronic illnesses managed their health care. Design Recruited volunteers diagnosed with a variety of chronic illnesses who underwent 3 semistructured interviews in a 1-year period. Setting Volunteers were recruited through referrals, flyers, and face-to-face contacts from community health clinics, senior centers, acute care hospitals, and home care services in 2 urban counties in California between December 1997 and December 2000. Participants A total of 297 persons between the ages of 23 and 97 years (35% African American, 33% Latino, and 32% Filipino American), of whom 42 (14%) had no health insurance. Main outcome measures Qualitative analysis of interview data compared insured and uninsured respondents on a series of components of chronic illness management, including control over illness, frequency of health crises, procuring medication, use of medication, understanding of the illness, knowledge of self-care measures, and awareness of risk factors. Whether respondents were under the care of a regular physician was also assessed. Results Compared with insured respondents, uninsured respondents were much less effective at managing their illnesses. The uninsured had poorly controlled illnesses, frequent health crises, difficulty procuring medication, used medication incorrectly, demonstrated poor understanding of their illness, and displayed little knowledge of self-care measures or risk awareness. They rarely had a regular physician or attended a specific health clinic. Conclusions The findings suggest that not only did uninsured persons with chronic health conditions lack adequate health care, their illnesses were also poorly controlled. Inadequately educated about their health, uninsured persons lacked the information, insight, and tools that would have allowed them to manage their illnesses more effectively.
In 2006, it was estimated that 47 million people in the United States are without insurance. Studies have shown that patients who are uninsured or are insured by Medicaid are more likely to present with more advanced cancer. The objective of this study was to examine whether cancer recurrence and mortality of patients diagnosed with squamous cell carcinoma of the head and neck are associated with insurance status, after adjusting for known cancer risk factors. The main outcome measures were overall survival and relapse-free survival.
Retrospective cohort of patients with a biopsy-proven primary squamous cell carcinoma of the oral cavity, pharynx, or larynx diagnosed or treated at the University of Pittsburgh Medical Center between 1998 and 2007. Patients were stratified by their insurance status, including private insurance, uninsured/Medicaid, Medicare disability (Medicare under age 65), and Medicare 65 years +. Covariates included age, gender, race, smoking status, alcohol consumption, anatomic tumor site, treatment, stage at diagnosis, and occupational prestige score. Cox proportional hazards regression was used to estimate the effect of insurance status on overall survival, relapse-free survival, tumor stage, and lymph node involvement.
A total of 1231 patients were included in the analysis. Patients with Medicaid/uninsured (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.07-2.11) and Medicare disability (HR, 1.69; 95% CI, 1.16-2.48) had significantly lower overall survival compared with patients with private insurance; the result was independent of variables known to affect outcome, such as alcohol and tobacco use. For all squamous cell carcinoma of the head and neck (SCCHN) cancer sites, Medicaid and uninsured patients were significantly more likely to present with an advanced stage tumor at diagnosis (odds ratio [OR] = 2.94; 95% CI, 1.72-5.01) and to present with at least 1 positive lymph node (OR = 1.84; 95% CI, 1.16-2.90) compared with patients with private insurance.
Patients with Medicaid/uninsured and Medicare disability were at increased risk of death after a diagnosis of SCCHN when compared with patients with private insurance, after adjustment for age, gender, race, smoking, alcohol use, site, socioeconomic status, treatment, and cancer stage.
retrospective cohort; cancer outcome; risk factors; epidemiology
Optimal management of acute pulmonary embolism (PE) requires medical expertise, diagnostic testing and therapies, which may not be consistently available throughout the entire week. We sought to assess whether there are associations between weekday and weekend admission and mortality and length of hospital stay for patients hospitalized with PE.
Methods and Results
We evaluated patients discharged with a primary diagnosis of PE from 186 acute care hospitals in Pennsylvania (01/2000-11/2002). We used random-effect logistic models to study the association between weekend admission and 30-day mortality and used discrete survival models to study the association weekend admission and time to hospital discharge, adjusting for hospital (region, size, teaching status) and patient factors (race, insurance, severity of illness, use of thrombolytic therapy). Among 15,531 patient discharges with PE, 3286 (21.2%) were admitted on a weekend. Patients admitted on weekends had a higher unadjusted 30-day mortality (11.1% vs 8.8%) compared to patients admitted on weekdays, with no difference in length of stay. Patients admitted on weekends had a significantly greater adjusted odds of dying (odds ratio 1.17, 95% confidence interval: 1.03-1.34) compared to patients admitted on weekdays. The higher mortality among patients hospitalized on weekends was driven by the increased mortality rate among the most severely ill patients.
Patients with PE who are admitted on weekends have a significantly higher short-term mortality than patients admitted on weekdays. Quality improvement efforts should aim to ensure that there is a consistent approach to the management of PE 7 days a week.
lung embolism; prognosis; mortality
To determine demographic and diagnostic information about the medically uninsured patient population and compare it with that of the medically insured patient population at a primary care centre.
Medical chart audit.
Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont.
Medically uninsured patients who were treated in the Department of Family and Community Medicine at St Michael’s Hospital from 2005 to 2009, as well as randomly selected patients who were insured through the Ontario Health Insurance Program.
Main outcome measures
The following information was obtained from patients’ medical charts: patient’s age, sex, and household income; if the patient had a specific diagnosis (ie, hypertension, type 2 diabetes mellitus, HIV, tuberculosis, substance addiction, or mental health disorder); if the patient accessed a specific category of primary care (ie, prenatal care or routine pediatric care); and the reason for the patient’s uninsured status.
There was no significant difference in the mean age and sex distribution of insured and uninsured patients. The uninsured group had a significantly lower mean household income (P = .02). With the exception of HIV, there was no significant difference in the prevalence of the specific diagnoses studied or in the prevalence of accessing specific categories of primary care between insured and uninsured patients (P > .05). The prevalence of HIV was significantly greater in the uninsured group (24%) than in the insured group (4%) (P = .004). The largest proportion of uninsured patients lacked health insurance owing to the landed immigrant health insurance waiting period (27%), followed by individuals without permanent resident status in Canada (22%). A subgroup analysis of the uninsured, HIV-positive population revealed that the largest proportion of individuals (36%) lacked health insurance because they had no permanent resident status in Canada.
Uninsured and insured patients at the primary care centre did not differ significantly with respect to age and sex distribution; prevalence of hypertension, type 2 diabetes mellitus, tuberculosis, substance addiction, or mental health disorder; or the proportion who sought prenatal or routine pediatric care. The landed immigrant 3-month waiting period was the most common reason that uninsured patients lacked health insurance. Uninsured patients in this study lived in lower-income areas than insured patients did. This, combined with the increased prevalence of HIV in the uninsured group, might lead to a large number of uninsured, HIV-positive patients delaying seeking treatment and might have negative implications for public health.
It is unclear how lack of health insurance or otherwise being underinsured contributes to observed racial disparities in health outcomes related to cardiovascular disease.
To determine the relative risk of death associated with insurance and race after hospital admission for an acute cardiovascular event.
Prospective cohort study in three hospitals in Maryland representing different demographics between 1993 and 2007.
Patients with an incident admission who were either white or black, and had either private insurance, state-based insurance or were uninsured. 4,908 patients were diagnosed with acute myocardial infarction, 6,759 with coronary atherosclerosis, and 1,293 with stroke.
Demographic and clinical patient-level data were collected from an administrative billing database and neighborhood household income was collected from the 2000 US Census. The outcome of all-cause mortality was collected from the Social Security Death Master File.
In an analysis adjusted for race, disease severity, location, neighborhood household income among other confounders, being underinsured was associated with an increased risk of death after myocardial infarction (relative hazard, 1.31 [95 % CI: 1.09, 1.59]), coronary atherosclerosis (relative hazard, 1.50 [95 % CI: 1.26, 1.80]) or stroke (relative hazard, 1.25 [95 % CI: 0.91, 1.72]). Black race was not associated with an increased risk of death after myocardial infarction (relative hazard, 1.03 [95 % CI: 0.85, 1.24]), or after stroke (relative hazard, 1.18 [95 % CI: 0.86, 1.61]) and was associated with a decreased risk of death after coronary atherosclerosis (relative hazard, 0.82 [95 % CI: 0.69, 0.98]).
Race was not associated with an increased risk of death, before or after adjustment. Being underinsured was strongly associated with death among those admitted with myocardial infarction, or a coronary atherosclerosis event. Our results support growing evidence implicating insurance status and socioeconomic factors as important drivers of health disparities, and potentially racial disparities.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2147-9) contains supplementary material, which is available to authorized users.
health disparities; insurance coverage; socioeconomic status; race; cardiovascular disease
To examine the effects of safety net hospital (SNH) closure and for-profit conversion on uninsured, Medicaid, and racial/ethnic minorities.
Data Sources/Extraction Methods
Hospital discharge data for selected states merged with other sources.
We examined travel distance for patients treated in urban hospitals for five diagnosis categories: ambulatory care sensitive conditions, referral sensitive conditions, marker conditions, births, and mental health and substance abuse. We assess how travel was affected for patients after SNH events. Our multivariate models controlled for patient, hospital, health system, and neighborhood characteristics.
Our results suggested that certain groups of uninsured and Medicaid patients experienced greater disruption in patterns of care, especially Hispanic uninsured and Medicaid women hospitalized for births. In addition, relative to privately insured individuals in SNH event communities, greater travel for mental health and substance abuse care was present for the uninsured.
Closure or for-profit conversions of SNHs appear to have detrimental access effects on particular subgroups of disadvantaged populations, although our results are somewhat inconclusive due to potential power issues. Policymakers may need to pay special attention to these patient subgroups and also to easing transportation barriers when dealing with disruptions resulting from reductions in SNH resources.
safety net hospitals; access to care; racial/ethnic disparities
Following the 2006 Massachusetts health care reform, an estimated 316,492 residents remain uninsured. However, there have been no published studies that examine why Massachusetts residents remain uninsured four years into health reform.
To describe the characteristics of uninsured patients seeking acute medical care in Massachusetts after implementation of health care reform and reasons for lacking insurance.
DESIGN AND PARTICIPANTS
We performed an in-person survey of a convenience sample of patients visiting the emergency department of the state’s second largest safety net hospital between July 25, 2009 and March 20, 2010. We interviewed 431 patients age 18–64, 189 of whom were uninsured.
Demographic and clinical characteristics, employment and insurance history, reasons for lacking insurance and views of the state’s new “individual mandate”.
The uninsured were largely employed (65.9%), but only a quarter (25.1%) of the employed uninsured had access to employer-sponsored insurance. The majority qualified for subsidized insurance (85.7% earned ≤300% of the federal poverty level), yet many reported being unable to find affordable insurance (32.7%). Over a third (35.2%) were uninsured because they had lost insurance due predominantly to job loss or policy cancellation. For nearly half of the uninsured (48.6%), the individual mandate had motivated them to try to find insurance, but they were unable to find insurance they could afford.
After full implementation of the Massachusetts health reform, those remaining without insurance are largely the working poor who do not have access to, or cannot afford, either employer sponsored insurance or state subsidized insurance.
uninsured; health reform; health policy; safety-net institutions; health insurance
Thrombocytopenia is commonly observed in critically ill patients. This study was undertaken to evaluate the variation in platelet counts and the risk factors associated with thrombocytopenia and mortality in pediatric intensive care patients. In addition, prognostic value of platelet counts for outcome in pediatric intensive care unit was studied.
Prospective, observational cohort analysis.
8- bedded pediatric intensive care unit of a tertiary care teaching hospital.
All consecutively admitted patients (n=138) staying in the pediatric intensive care unit (PICU) for at least 48h over a 7 months period were studied.
Measurements and Main Results:
Thrombocytopenia was defined as platelet counts <150.0/nL. Median 1st day Pediatric Risk of Mortality Score (PRISM) was 5 (range 0-30) and median ICU stay was 4 days (range 2-98 days). Twenty five percent patients had at least one episode of thrombocytopenia during the stay. Twenty percent of these patients had thrombocytopenia on admission and rest (80%) developed it during the PICU stay. Seventy one percent (19) of the patients developed thrombocytopenia by fourth day of admission. Patients with PICU acquired thrombocytopenia had statistically significant lower baseline, nadir and 4th day platelet counts and a significantly higher drop in platelet counts (56% vs. 6% P<0.001) as compared to non thrombocytopenic patients. PRISM score, long PICU stay, sepsis, coagulopathy, and creatinine levels were significantly associated with occurrence of thrombocytopenia. Patients with thrombocytopenia had higher probability of bleeding (34% vs. 15%, P=0.01). Higher platelet counts on admission were associated with significantly reduced risk of thrombocytopenia (P=0.00) Baseline, nadir and day-4 platelet counts, presence of thrombocytopenia on admission, sepsis, coagulopathy and a higher mean PRISM score on univariate analysis were significantly associated with mortality. Leucopenia or leucocytosis, thrombocytopenia and coagulopathy were found to significantly affect outcome. Drop in platelet counts was found to have slightly higher discriminative value for mortality prediction than PRISM on the ROC curve. The survivors had higher platelet counts throughout the PICU stay and after an initial fall in platelet counts in the PICU showed a significantly higher rise in the platelet counts in the following days than the non-survivors.
Thrombocytopenia is common in PICU. Patients requiring cardiopulmonary resuscitation or with circulatory shock, coagulopathy, sepsis and with more severe disease have higher risk of developing thrombocytopenia. Thrombocytopenic patients have a higher risk of bleeding. Drop in platelet counts >27% and thrombocytopenia were independently related to mortality. Serial measurements of platelet counts are better predictors of pediatric intensive care outcome than one-time values. Any drop in platelet counts even without thrombocytopenia needs an urgent and extensive evaluation.
Coagulopathy; mortality; pediatric intensive care; platelets; prognosis; thrombocytopenia
The relationship between health care insurance and quality of medical care remains incompletely studied. We sought to determine whether type of patient insurance is related to quality of care and subsequent outcomes for patients who arrive in the emergency department (ED) for acute asthma.
Using prospectively collected data from the Multicenter Airway Research Collaboration, we compared measures of quality of pre-ED care, acute severity, and short-term outcomes across 4 insurance categories: managed care, indemnity, Medicaid, and uninsured.
SETTING AND PARTICIPANTS
Emergency departments at 57 academic medical centers enrolled 1,019 adults with acute asthma.
Patients with managed care ranked first and uninsured patients ranked last on all 7 unadjusted quality measures. After controlling for covariates, uninsured patients had significantly lower quality of care than indemnity patients for 5 of 7 measures and had lower initial peak expiratory flow rates than indemnity insured patients. Patients with managed care insurance were more likely than indemnity-insured patients to identify a primary care physician and report using inhaled steroids in the month prior to arrival in the ED. Patients with Medicaid insurance were more likely than indemnity-insured patients to use the ED as their usual source of care for problems with asthma. We found no differences in patient outcomes among the insurance categories we studied.
Uninsured patients had consistently poorer quality of care and than insured patients. Despite differences in indicators of quality of care between types of insurance, we found no differences in short-term patient outcomes by type of insurance.
asthma; acute asthma; emergency department; primary care; quality; insurance; managed care; length of stay; uninsured; Medicaid
Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefit from management by critical care physicians, but evidence of this benefit is scant.
To examine the association between hospital mortality in critically ill patients and management by critical care physicians.
Retrospective analysis of a large, prospectively collected database of critically ill patients.
123 ICUs in 100 U.S. hospitals.
101 832 critically ill adults.
Through use of a random-effects logistic regression, investigators compared hospital mortality between patients cared for entirely by critical care physicians and patients cared for entirely by non–critical care physicians. An expanded Simplified Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for differences in the probability of selective referral of patients to critical care physicians.
Patients who received critical care management (CCM) were generally sicker, received more procedures, and had higher hospital mortality rates than those who did not receive CCM. After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not. The difference in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM.
Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized.
In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.
To compare process of care and outcome after acute myocardial infarction, for patients with and without mental illness, cared for in the Veterans Health Administration (VA) health care system.
Primary clinical data from 81 VA hospitals.
This was a retrospective cohort study of 4,340 veterans discharged with clinically confirmed acute myocardial infarction. Of these, 859 (19.8 percent) met the definition of mental illness. Measures were age-adjusted in-hospital and 90-day cardiac procedure use; age-adjusted relative risks (RR) of use of thrombolytic therapy, beta-blockers, angiotensin converting enzyme (ACE) inhibitors, or aspirin at discharge; risk-adjusted 30-day and one-year mortality.
Patients with mental illness were marginally less likely than those without mental illness to undergo in-hospital angiography (age-adjusted RR 0.90 [95 percent confidence interval: 0.83, 0.98]), but there was no significant difference in the age-adjusted RR of coronary artery bypass graft surgery in the 90 days after admission (0.85 [0.69,1.05]), or in the receipt of medications of known benefit. For example, ideal candidates with and without mental illness were equally likely to receive beta-blockers at the time of discharge (age-adjusted RR 0.92 [0.82, 1.02]). The risk-adjusted odds ratio (OR) for death in patients with mental illness versus those without mental illness within 30 days was 1.00 (0.75,1.32), and for death within one year was 1.25 (1.00,1.53).
Veterans Health Administration patients with mental illness were marginally less likely than those without mental illness to receive diagnostic angiography, and no less likely to receive revascularization or medications of known benefit after acute myocardial infarction. Mortality at one year may have been higher, although this finding did not reach statistical significance. These findings are consistent with other studies showing reduced health care disparities in the VA for other vulnerable groups, and suggest that an integrated health care system with few financial barriers to health care access may attenuate some health care disparities. Further work should address how health care organizational features might narrow disparities in health care for vulnerable groups.
Acute myocardial infarction; mental disorders; outcome assessment (health care); health services accessibility; physicians’ practice patterns
To determine the association between body mass index (BMI) and hospital mortality for critically ill adults.
Retrospective cohort study.
One-hundred six intensive care units (ICUs) in 84 hospitals.
Mechanically ventilated adults (n = 1,488) with acute lung injury (ALI) included in the Project IMPACT database between December 1995 and September 2001.
Measurements and Main Results
Over half of the cohort had a BMI above the normal range. Unadjusted analyses showed that BMI was higher among subjects who survived to hospital discharge vs. those who did not (p < .0001). ICU and hospital mortality rates were lower in higher BMI categories. After risk-adjustment, BMI was independently associated with hospital mortality (p < .0001) when modeled as a continuous variable. The adjusted odds were highest at the lowest BMIs and then declined to a minimum between 35 and 40 kg/m2. Odds increased after the nadir but remained below those seen at low BMIs. With use of a categorical designation, BMI was also independently associated with hospital mortality (p = .0055). The adjusted odds were highest for the underweight BMI group (adjusted odds ratio [OR], 1.94; 95% confidence interval [CI], 1.05–3.60) relative to the normal BMI group. As in the analysis using the continuous BMI variable, the odds of hospital mortality were decreased for the groups with higher BMIs (overweight adjusted OR, 0.72; 95% CI, 0.51–1.02; obese adjusted OR, 0.67; 95% CI, 0.46 – 0.97; severely obese adjusted OR, 0.78; 95% CI, 0.44–1.38). Differences in the use of heparin prophylaxis mediated some of the protective effect of severe obesity.
BMI was associated with risk-adjusted hospital mortality among mechanically ventilated adults with ALI. Lower BMIs were associated with higher odds of death, whereas overweight and obese BMIs were associated with lower odds.
obesity; adult respiratory distress syndrome; outcome assessment (health care); artificial respiration; critical care; body mass index
Hospital readmissions among patients with diabetes are substantial and costly. Although prior studies have shown that receipt of outpatient quality of care significantly reduces the risk of hospitalization among patients with diabetes, little is known about its impact on hospital readmission. The objective of this study is to assess the impact of outpatient quality of care on 30-day readmission among patients with diabetes.
We used deidentified administrative claims data from the IMS LifeLink and included commercially insured diabetes patients ≥ 19 years old discharged from hospitals in the United States in 2009 and 2010 (n = 30,139). The outcome was readmission within 2–30 days of discharge. The main independent variables were receipt of outpatient quality-of-care measures (i.e., two hemoglobin A1c tests, low-density lipoprotein (LDL) test, 90-day supply of statin, and 90-day supply of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers). Multivariate logistic regression was used to examine the impact of outpatient quality of care on hospital readmission while controlling for demographics, clinical characteristics, health care utilization, and insurance type in the year prior to admission.
Overall 30-day readmission rates among patients with diabetes were 18.9%. Patients who received at least one LDL test [odds ratio (OR) = 0.918, 95% confidence interval (CI; 0.852 0.989), p < .025] and ≥90-day supply of statins (OR = 0.91, 95% CI [0.85 0.97], p < .01) were less likely to be readmitted to the hospital.
Receipt of LDL testing and adherence to statin medications were effective in decreasing the likelihood of 30-day hospital readmission and may be considered as elements of a quality focused incentive-based health care delivery package for diabetes patients.
diabetes; quality of care; readmission; statins
OBJECTIVE--To evaluate the morbidity and severity of illness during interhospital transfer of critically ill children by a specialised paediatric retrieval team. DESIGN--Prospective, descriptive study. SETTING--Hospitals without paediatric intensive care facilities in and around the London area, and a paediatric intensive care unit at a tertiary centre. SUBJECTS--51 critically ill children transferred to the paediatric intensive care unit. MAIN OUTCOME MEASURES--Adverse events related to equipment and physiological deterioration during transfer. Paediatric risk of mortality score before and after retrieval. Therapeutic intervention score before and after arrival of retrieval team. RESULTS--Two (4%) patients had preventable physiological deterioration during transport. There were no adverse events related to equipment. Severity of illness decreased during stabilisation and transport by the retrieval team, suggested by the difference between risk of mortality scores before and after retrieval (P < 0.001). The median (range) difference between the two scores was 3.0 (-6 to 17). Interventions during stabilisation by the retrieval team increased, demonstrated by the difference between intervention scores before and after retrieval, median (range) difference between the two scores being 6 (-8 to 38) (P < 0.001). CONCLUSIONS--Our study indicates that a specialised paediatric retrieval team can rapidly deliver intensive care to critically ill children awaiting transfer. Such children can be transferred to a paediatric intensive care unit with minimal morbidity and mortality related to transport. There was no deterioration in the clinical condition of most patients during transfer.
To examine the relationship between hospital volume and mortality for non-surgical patients receiving mechanical ventilation.
Pennsylvania state discharge records from July 1, 2004 to June 30, 2006, linked to the Pennsylvania Department of Health death records and the 2000 United States Census.
We categorized all general acute care hospitals in Pennsylvania (n=169) by the annual number of non-surgical, mechanically ventilated discharges according to previous criteria. To estimate the relationship between annual volume and 30-day mortality we fit linear probability models using administrative risk adjustment, clinical risk adjustment and an instrumental variable approach.
Using a clinical measure of risk adjustment we observed a significant reduction in the probability of 30-day mortality at higher volume hospitals (≥300 admissions per year) compared to lower volume hospitals (<300 patients per year), (absolute risk reduction: 3.4%, p=0.04). No significant volume-outcome relationship was observed using only administrative risk adjustment. Using the distance from the patient’s home to the nearest higher volume hospital as an instrument, the volume-outcome relationship was greater than observed using clinical risk adjustment (absolute risk reduction: 7.0%, p=0.01).
Care in higher volume hospitals is independently associated with a reduction in mortality for patients receiving mechanical ventilation. Adequate risk adjustment is essential in order to obtained unbiased estimates of the volume-outcome relationship.
critical care; intensive care; respiratory failure; risk adjustment; mortality
To examine the relationship between hospital volume and mortality for nonsurgical patients receiving mechanical ventilation.
Pennsylvania state discharge records from July 1, 2004, to June 30, 2006, linked to the Pennsylvania Department of Health death records and the 2000 United States Census.
We categorized all general acute care hospitals in Pennsylvania (n=169) by the annual number of nonsurgical, mechanically ventilated discharges according to previous criteria. To estimate the relationship between annual volume and 30-day mortality, we fit linear probability models using administrative risk adjustment, clinical risk adjustment, and an instrumental variable approach.
Using a clinical measure of risk adjustment, we observed a significant reduction in the probability of 30-day mortality at higher volume hospitals (≥300 admissions per year) compared with lower volume hospitals (<300 patients per year; absolute risk reduction: 3.4%, p=.04). No significant volume–outcome relationship was observed using only administrative risk adjustment. Using the distance from the patient's home to the nearest higher volume hospital as an instrument, the volume–outcome relationship was greater than observed using clinical risk adjustment (absolute risk reduction: 7.0%, p=.01).
Care in higher volume hospitals is independently associated with a reduction in mortality for patients receiving mechanical ventilation. Adequate risk adjustment is essential in order to obtained unbiased estimates of the volume–outcome relationship.
Critical care; intensive care; respiratory failure; risk adjustment; mortality
The aim of this study was to estimate the occupational risks in relation to multiple sclerosis (MS). The immediate background for this research was our finding that there had been a high number of critical illness insurance claims by patients diagnosed with MS within the agricultural segment of a Danish pension fund.
An open insurance cohort. All payouts for the critical illness insurance from 2002 to 2011 were continuously registered.
PensionDanmark; one of Denmark's largest pension funds.
PensionDanmark insures more than 300 000 members of the Danish Confederation of Trade Unions against critical illness. All members are insured, and all policies are identical. The total exposure is 3.3 million person-years.
Primary outcome measures
The incidence of MS.
During the 10-year period, 389 persons were diagnosed with MS. The crude incidence rate for men was 10.2/100 000; the corresponding figure for women was 16.1/100 000. We found signs of an overall effect of occupation on the risk of developing MS, and the high frequency found within the agricultural segment was attributed to dairy operators, who had an incidence of MS 2.0 times higher than the rest of the study's population (95% CI=1.2 to 3.0).
Our results indicate some occupational risk factors in MS, and this should be investigated further.
Epidemiology; Occupational & Industrial Medicine
To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States.
The 2000 Behavioral Risk Factor Surveillance System.
Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use.
Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance.
Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.
Quality of care; health insurance; diabetes