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1.  An Official American Thoracic Society Systematic Review: The Association between Health Insurance Status and Access, Care Delivery, and Outcomes for Patients Who Are Critically Ill 
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likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46–13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12–7.02).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.
doi:10.1164/rccm.200902-0281ST
PMCID: PMC3269233  PMID: 20430926
insurance; disparities; payer; critical care; intensive care; access; outcome; Medicare; managed care; Medicaid
2.  An exploration of the complex relationship of socioecologic factors in the treatment and outcomes of acute myocardial infarction in disadvantaged populations. 
Health Services Research  2001;36(4):711-732.
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.
PMCID: PMC1089253  PMID: 11508636
3.  Post-Operative Mortality after Surgery for Brain Tumors Differs by Insurance Status in the United States 
Objective
Determine whether being uninsured is associated with higher in-hospital postoperative mortality when undergoing surgery in the United States for a brain tumor.
Hypothesis
Uninsured patients may experience poor surgical outcomes due to suboptimal care, poor overall health, or impaired healthcare access.
Design
Retrospective cohort study utilizing the Nationwide Inpatient Sample (NIS), 1999 to 2008.
Setting
The NIS contains all inpatient records from a stratified sample of 20% of hospitals in 37 states.
Patients
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.
Results
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).
Conclusions
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.
doi:10.1001/archsurg.2012.1459
PMCID: PMC3571758  PMID: 23165616
4.  Prognostic Importance of Hyponatremia in Patients with Acute Pulmonary Embolism 
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.
doi:10.1164/rccm.201003-0481OC
PMCID: PMC3001260  PMID: 20595225
hyponatremia; prognosis; pulmonary embolism
5.  Insurance Status, not Race, is Associated with Mortality After an Acute Cardiovascular Event in Maryland 
Journal of General Internal Medicine  2012;27(10):1368-1376.
ABSTRACT
BACKGROUND
It is unclear how lack of health insurance or otherwise being underinsured contributes to observed racial disparities in health outcomes related to cardiovascular disease.
OBJECTIVE
To determine the relative risk of death associated with insurance and race after hospital admission for an acute cardiovascular event.
DESIGN
Prospective cohort study in three hospitals in Maryland representing different demographics between 1993 and 2007.
PATIENTS
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.
MAIN MEASURES
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.
KEY RESULTS
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]).
CONCLUSIONS
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.
doi:10.1007/s11606-012-2147-9
PMCID: PMC3445670  PMID: 22821570
health disparities; insurance coverage; socioeconomic status; race; cardiovascular disease
6.  Hospital volume and surgical outcomes after elective hip/knee arthroplasty: A risk adjusted analysis of a large regional database 
Arthritis and rheumatism  2011;63(8):2531-2539.
Objective
Examine the relationship between hospital procedure volume and surgical outcomes following primary elective total hip or total knee arthroplasty (THA/TKA).
Methods
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.
Results
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).
Conclusions
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.
doi:10.1002/art.30390
PMCID: PMC3149786  PMID: 21656509
7.  The Effect of Cuts in Medicare Reimbursement on Hospital Mortality 
Health Services Research  2006;41(3 Pt 1):683-700.
Objective
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.
Data Source
Hospital discharge data from all general acute care hospitals in Pennsylvania from 1997 to 2001.
Study Design
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.
Data Collection
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.
Principal Findings
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.
Conclusions
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.
doi:10.1111/j.1475-6773.2006.00507.x
PMCID: PMC1713202  PMID: 16704507
Medicare; Balanced Budget Act; financial strain; hospital; quality of care
8.  Effects of being uninsured on ethnic minorities' management of chronic illness 
Western Journal of Medicine  2001;175(1):19-23.
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.
PMCID: PMC1071457  PMID: 11431394
9.  Treatment Differences by Health Insurance Among Outpatients with Coronary Artery Disease: Insights from the NCDR® 
Objectives
To compare treatment rates by insurance status for 5 quality-of-care indicators for coronary artery disease (CAD) care related to medication treatment.
Method
Within the NCDR's PINNACLE Registry, we identified 60,814 outpatients with CAD from 30 U.S. practices. Hierarchical modified Poisson regression models with practice site as a random effect were used to study the association between health insurance (no insurance, public or private health insurance) and 5 CAD quality measures.
Results
Of 60,814 patients, 5716 (9.4%) patients were uninsured and 11,962 (19.7%) had public insurance, whereas 43,136 (70.9%) were privately insured. After accounting for exclusions, uninsured patients with CAD were 9%, 12%, and 6% less likely to receive treatment with beta-blocker, ACE-I/ARB, and lipid lowering therapy, respectively, than privately insured patients, whereas patients with public insurance were 9% less likely to be prescribed ACE-I/ARB therapy. Most differences by insurance status were attenuated after adjusting for the site providing care. For example, whereas uninsured patients with left ventricular dysfunction and CAD were less likely to receive ACE-I/ARB therapy (unadjusted RR=0.88; 95% CI 0.84-0.93), this difference was eliminated after adjustment for site (adjusted RR=0.95; 95% CI 0.88-1.03; P=0.18).
Conclusions
Within this national outpatient cardiac registry, uninsured patients were less likely to receive evidence-based medications for CAD. These disparities were explained by the site providing care. Efforts to reduce treatment differences by insurance status among cardiac outpatients may additionally need to focus on improving rates of evidence-based treatment at sites with high proportions of uninsured patients.
doi:10.1016/j.jacc.2012.11.058
PMCID: PMC3641586  PMID: 23375933
Quality of Care; Disparities; Cardiovascular; Outpatient Care
10.  The Impact of Health Insurance Status on the Survival of Patients With Head and Neck Cancer 
Cancer  2010;116(2):476-485.
BACKGROUND
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.
METHODS
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.
RESULTS
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.
CONCLUSIONS
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.
doi:10.1002/cncr.24774
PMCID: PMC3085979  PMID: 19937673
retrospective cohort; cancer outcome; risk factors; epidemiology
11.  Surgery Wait Times and Specialty Services for Insured and Uninsured Breast Cancer Patients: Does Hospital Safety Net Status Matter? 
Health Services Research  2011;47(2):677-697.
Objective
To determine whether safety net and non-safety net hospitals influence inpatient breast cancer care in insured and uninsured women and in white and African American women.
Data Sources
Six years of Virginia Cancer Registry and Virginia Health Information discharge data were linked and supplemented with American Hospital Association data.
Study Design
Hierarchical generalized linear models and linear probability regression models were used to estimate the relationship between hospital safety net status, the explanatory variables, and the days from diagnosis to mastectomy and the likelihood of breast reconstruction.
Principal Findings
The time between diagnosis and surgery was longer in safety net hospitals for all patients, regardless of insurance source. Medicaid insured and uninsured women were approximately 20 percent less likely to receive reconstruction than privately insured women. African American women were less likely to receive reconstruction than white women.
Conclusions
Following the implementation of health reform, disparities may potentially worsen if safety net hospitals’ burden of care increases without commensurate increases in reimbursement and staffing levels. This study also suggests that Medicaid expansions may not improve outcomes in inpatient breast cancer care within the safety net system.
doi:10.1111/j.1475-6773.2011.01328.x
PMCID: PMC3419883  PMID: 22092155
Safety net hospitals; disparities; breast cancer; outcomes
12.  Effectiveness of predicting in-hospital mortality in critically ill children by assessing blood lactate levels at admission 
BMC Pediatrics  2014;14:83.
Background
Hyperlactatemia upon admission is a documented risk factor for mortality in critically ill adult patients. However, the predictive significance of a single lactate measurement at admission for mortality in the general population of critically ill children remains uncertain. This study evaluated the predictive value of blood lactate levels at admission and determined the cut-off values for predicting in-hospital mortality in the critically ill pediatric population.
Methods
We enrolled 1109 critically ill children who were admitted to a pediatric intensive care unit between July 2008 and December 2010. Arterial blood samples were collected in the first 2 hours after admission, and the lactate levels were determined. The Pediatric Risk of Mortality III (PRISM III) scores were calculated during the first 24 hours after admission.
Results
Of the 1109 children admitted, 115 (10.4%) died in the hospital. The median (interquartile range) blood lactate level in critically ill children was 3.2 mmol/l (2.2-4.8). Among the children, 859 (77.5%) had a lactate concentration >2.0 mmol/l. The blood lactate level upon admission was significantly associated with mortality (odds ratio [OR] = 1.38; 95% confidence interval [CI], 1.30-1.46; p <0.001), even after adjustment for age, gender, and illness severity assessed by PRISM III (OR = 1.27; p <0.001). Multivariate regression analysis showed that a high blood lactate level (OR = 1.17; 95% CI, 1.07-1.29; p = 0.001), a high PRISM III score (OR = 1.15; 95% CI, 1.11-1.20; p <0.001), and a low serum albumin (OR =0.92; 95% CI, 0.88-0.96; p <0.001) were independent risk factors for mortality in critically ill children. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (p <0.001) for predicting mortality that was similar to that of PRISM III (AUC = 0.82; p <0.001). The p-value for a comparison of both AUCs was 0.318. Blood lactate displayed a sensitivity of 61% and a specificity of 86% in predicting mortality at the optimal cut-off value of 5.55 mmol/l, and the positive and negative likelihood ratios were 4.5 and 0.45, respectively.
Conclusions
A high blood lactate level at admission is independently associated with and predictive of in-hospital mortality in the general population of critically ill children.
doi:10.1186/1471-2431-14-83
PMCID: PMC3976355  PMID: 24673817
Blood lactate; Critically ill children; Cut-off value; In-hospital mortality; Pediatric risk of mortality III (PRISM III); Predictive test
13.  Understanding the demographic characteristics and health of medically uninsured patients 
Canadian Family Physician  2013;59(6):e276-e281.
Abstract
Objective
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.
Design
Medical chart audit.
Setting
Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont.
Participants
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.
Results
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.
Conclusion
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.
PMCID: PMC3681470  PMID: 23766066
14.  Platelet counts and outcome in the pediatric intensive care unit 
Objectives:
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.
Study Design:
Prospective, observational cohort analysis.
Setting:
8- bedded pediatric intensive care unit of a tertiary care teaching hospital.
Patients:
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.
Conclusions:
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.
doi:10.4103/0972-5229.43678
PMCID: PMC2738316  PMID: 19742257
Coagulopathy; mortality; pediatric intensive care; platelets; prognosis; thrombocytopenia
15.  Reasons Why Patients Remain Uninsured after Massachusetts’ Health Care Reform: A Survey of Patients at a Safety-Net Hospital 
ABSTRACT
BACKGROUND
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.
OBJECTIVE
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.
MAIN MEASURES
Demographic and clinical characteristics, employment and insurance history, reasons for lacking insurance and views of the state’s new “individual mandate”.
KEY RESULTS
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.
CONCLUSIONS
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.
doi:10.1007/s11606-011-1868-5
PMCID: PMC3270239  PMID: 21922156
uninsured; health reform; health policy; safety-net institutions; health insurance
16.  Differences in Mortality for Surgical Cancer Patients by Insurance and Hospital Safety Net Status 
Recent research suggests hospitals serving low-income patients have poorer outcomes. However, safety net hospitals (SNHs) offering access to care regardless of insurance coverage may provide better care than low-income patients would otherwise receive. This study considers the association between insurance and mortality among surgical cancer patients and the role of SNHs. We estimate models of 1- and 5-year mortality on insurance, SNH status, patient characteristics, and hospital surgical volume for colorectal and breast cancer patients. Interaction terms between insurance and SNH status estimate how mortality differs by insurance source at SNHs. Medicaid and uninsurance are associated with significantly higher mortality for colorectal cancer patients. There is a statistically significant improvement in mortality for Medicaid colorectal cancer patients treated in SNHs relative to non-safety net hospitals, and a marginally significant improvement for uninsured breast cancer patients treated in SNHs. The results suggest a survival benefit for low-income patients treated in SNHs.
doi:10.1177/1077558712458158
PMCID: PMC3759968  PMID: 22951313
Cancer; Mortality; Insurance; Safety Net Hospitals
17.  Glucose variability and mortality in patients with sepsis* 
Critical care medicine  2008;36(8):2316-2321.
Objective
Treatment and prevention of hyperglycemia has been advocated for subjects with sepsis. Glucose variability, rather than the glucose level, has also been shown to be an important factor associated with in-hospital mortality, in general, critically ill patients. Our objective was to determine the association between glucose variability and hospital mortality in septic patients and the expression of glucose variability that best reflects this risk.
Design
Retrospective, single-center cohort study.
Setting
Academic, tertiary care hospital.
Patients
Adult subjects hospitalized for >1 day, with a diagnosis of sepsis were included.
Interventions
None.
Measurements
Glucose variability was calculated for all subjects as the average and standard deviation of glucose, the mean amplitude of glycemic excursions, and the glycemic lability index. Hospital mortality was the primary outcome variable. Logistic regression was used to determine the odds of hospital death in relation to measures of glucose variability after adjustment for important covariates.
Main results
Of the methods used to measure glucose variability, the glycemic lability index had the best discrimination for mortality (area under the curve = 0.67, p < 0.001). After adjustment for confounders, including the number of organ failures and the occurrence of hypoglycemia, there was a significant interaction between glycemic lability index and average glucose level, and the odds of hospital mortality. Higher glycemic lability index was not independently associated with mortality among subjects with average glucose levels above the median for the cohort. However, subjects with increased glycemic lability index, but lower average glucose values had almost five-fold increased odds of hospital mortality (odds ratio = 4.73, 95% confidence interval = 2.6 – 8.7) compared with those with lower glycemic lability index.
Conclusions
Glucose variability is independently associated with hospital mortality in septic patients. Strategies to reduce glucose variability should be studied to determine whether they improve the outcomes of septic patients.
doi:10.1097/CCM.0b013e3181810378
PMCID: PMC3176449  PMID: 18596625
sepsis; hyperglycemia; insulin therapy; mortality
18.  Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit 
Annals of internal medicine  2008;148(11):801-809.
Background
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.
Objective
To examine the association between hospital mortality in critically ill patients and management by critical care physicians.
Design
Retrospective analysis of a large, prospectively collected database of critically ill patients.
Setting
123 ICUs in 100 U.S. hospitals.
Patients
101 832 critically ill adults.
Measurements
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.
Results
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.
Limitation
Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized.
Conclusion
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.
PMCID: PMC2925263  PMID: 18519926
19.  Insurance coverage and access: implications for health policy. 
Health Services Research  1978;13(4):369-377.
Data are presented from a recent survey of the United States population comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.
PMCID: PMC1072079  PMID: 738895
20.  Insurance and Quality of Care for Adults with Acute Asthma 
OBJECTIVE
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.
DESIGN
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.
RESULTS
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.
CONCLUSIONS
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.
doi:10.1046/j.1525-1497.2002.20230.x
PMCID: PMC1495135  PMID: 12472926
asthma; acute asthma; emergency department; primary care; quality; insurance; managed care; length of stay; uninsured; Medicaid
21.  Community health insurance schemes & patient satisfaction - evidence from India 
Background & objectives:
Quality of care is an important determinant for utilizing health services. In India, the quality of care in most health services is poor. The government recognizes this and has been working on both supply and demand aspects. In particular, it is promoting community health insurance (CHI) schemes, so that patients can access quality services. This observational study was undertaken to measure the level of satisfaction among insured and uninsured patients in two CHI schemes in India.
Methods:
Patient satisfaction was measured, which is an outcome of good quality care. Two CHI schemes, Action for Community Organisation, Rehabilitation and Development (ACCORD) and Kadamalai Kalanjiam Vattara Sangam (KKVS), were chosen. Randomly selected, insured and uninsured households were interviewed. The household where a patient was admitted to a hospital was interviewed in depth about the health seeking behaviour, the cost of treatment and the satisfaction levels.
Results:
It was found that at both ACCORD and KKVS, there was no significant difference in the levels of satisfaction between the insured and uninsured patients. The main reasons for satisfaction were the availability of doctors and medicines and the recovery by the patient.
Interpretation & conclusions:
Our study showed that insured hospitalized patients did not have significantly higher levels of satisfaction compared to uninsured hospitalized patients. If CHI schemes want to improve the quality of care for their clients, so that they adhere to the scheme, the scheme managers need to negotiate actively for better quality of care with empanelled providers.
PMCID: PMC3100144  PMID: 21321418
Community health insurance; India; micro health insurance; patient satisfaction; quality of care
22.  The Effect of Market Reform on Racial Differences in Hospital Mortality 
Journal of General Internal Medicine  2006;21(11):1198-1202.
OBJECTIVE
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.
STUDY DESIGN
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).
PRINCIPAL FINDINGS
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.
CONCLUSIONS
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.
doi:10.1111/j.1525-1497.2006.00484.x
PMCID: PMC1831664  PMID: 17026731
quality of health care; economics; medical; financing; organized
23.  Morbidity and severity of illness during interhospital transfer: impact of a specialised paediatric retrieval team. 
BMJ : British Medical Journal  1995;311(7009):836-839.
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.
PMCID: PMC2550851  PMID: 7580489
24.  THE STRUCTURE OF CRITICAL CARE TRANSFER NETWORKS 
Medical care  2009;47(7):787-793.
Rationale
Moving patients from low performing hospitals to high performing hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival.
Objective
To characterize the existing critical care network in terms of the pattern of transfers.
Methods
In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations.
Measurements
We measured the characteristics of the interhospital transfer network and the extent to which ICU patients are referred towards each hospital in that network, a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical and radiologic capabilities.
Results
There were 47,820 transfers of critically ill patients among 3,308 hospitals. 4.5% of all critical care stays of any length involved an inter-hospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital position was associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals’ centrality.
Conclusions
Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.
doi:10.1097/MLR.0b013e318197b1f5
PMCID: PMC2760433  PMID: 19536030
25.  Statin therapy as prevention against development of acute respiratory distress syndrome: An observational study* 
Critical care medicine  2012;40(5):1470-1477.
Objectives
The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (“statins”) have anti-inflammatory properties and are associated with improved outcomes in critically ill patients. We investigated whether previous statin therapy affects outcomes in patients at risk for acute respiratory distress syndrome.
Design
Patients were followed-up for the primary outcome of acute respiratory distress syndrome and secondary outcomes of intensive care unit and 60-day mortality, organ dysfunction, and ventilator-free days in a secondary analysis of a prospective cohort study. Receipt of statin therapy was recorded. Propensity score matching was used to adjust for confounding by indication.
Setting
Intensive care units at a tertiary care academic medical center.
Patients
Critically ill patients (2,743) with acute respiratory distress syndrome risk factors.
Interventions
None.
Measurements and Main Results
Acute respiratory distress syndrome developed in 738 (26%) patients; 413 patients (15%) received a statin within 24 hrs of intensive care unit admission. Those who had received a statin within 24 hrs had a lower rate of development of acute respiratory distress syndrome (odds ratio 0.56; 95% confidence interval 0.43–0.73; p < .0001). After multivariate adjustment for potential confounders, this association remained significant (odds ratio 0.69; 95% confidence interval 0.51–0.92; p = .01). However, after propensity score matching, the association was not statistically significant (odds ratio 0.79; 95% confidence interval 0.57–1.10; p = .16). Statin use was not associated with reduced acute respiratory distress syndrome mortality, organ dysfunction, or ventilator-free days. Results of the study were presented in accordance with STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.
Conclusions
Statin therapy at the time of intensive care unit admission was not associated with a lower rate of development of acute respiratory distress syndrome after matching for patient propensity to receive statins. Statin therapy was not associated with improvements in acute respiratory distress syndrome mortality, organ failure, or days free from mechanical ventilation.
doi:10.1097/CCM.0b013e3182416d7a
PMCID: PMC3939937  PMID: 22430234
ALI/ARDS; critical illness; statin

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