Rationale: Lack of health insurance may be an independent risk factor for mortality and differential treatment in critical illness.

Objectives: To determine whether uninsured critically ill patients had differences in 30-day mortality and critical care service use compared with those with private insurance and to determine if outcome variability could be attributed to patient-level or hospital-level effects.

Methods: Retrospective cohort study using Pennsylvania hospital discharge data with detailed clinical risk adjustment, from fiscal years 2005 and 2006, consisting of 167 general acute care hospitals, with 138,720 critically ill adult patients 64 years of age or younger.

Measurements and Main Results: Measurements were 30-day mortality and receipt of five critical care procedures. Uninsured patients had an absolute 30-day mortality of 5.7%, compared with 4.6% for those with private insurance and 6.4% for those with Medicaid. Increased 30-day mortality among uninsured patients persisted after adjustment for patient characteristics (odds ratio [OR], 1.25 for uninsured vs. insured; 95% confidence interval [CI], 1.04–1.50) and hospital-level effects (OR, 1.26; 95% CI, 1.05–1.51). Compared with insured patients, uninsured patients had decreased risk-adjusted odds of receiving a central venous catheter (OR, 0.84; 95% CI, 0.72–0.97), acute hemodialysis (OR, 0.59; 95% CI, 0.39–0.91), and tracheostomy (OR, 0.43; 95% CI, 0.29–0.64).

Conclusions: Lack of health insurance is associated with increased 30-day mortality and decreased use of common procedures for the critically ill in Pennsylvania. Differences were not attributable to hospital-level effects, suggesting that the uninsured have a higher mortality and receive fewer procedures when compared with privately insured patients treated at the same hospitals.

Context

Long-term acute care hospitals have emerged as a novel approach for the care of patients recovering from severe acute illness, but the extent and growth of their activity at the national level is unknown.

Objective

To examine temporal trends in long-term acute care hospital utilization after an episode of critical illness among fee-for-service Medicare beneficiaries ≥ 65 years of age.

Design, Setting and Patients

Retrospective cohort study using the Medicare Provider Analysis and Review files from 1997 to 2006. We included all Medicare hospitalizations involving admission to an intensive care unit of an acute-care, non-federal hospital within the continental United States.

Main outcome measures

Overall long-term acute care utilization, associated costs, and survival following transfer.

Results

The number of long-term acute care hospitals in the United States increased at a mean rate of 8.8% per year, from 192 in 1997 to 408 in 2006. During that time, the annual number of long-term acute care admissions after critical illness increased from 13,732 to 40,353, with annual costs increasing from $484 million to $1.325 billion. The age-standardized population incidence of long-term acute care utilization after critical illness increased from 38.1/100,000 in 1997 to 99.7/100,000 in 2006, with greater use among male individuals and black individuals in all time periods. Over time, transferred patients had higher numbers of comorbidities (5.0 in 1997–2000 versus 5.8 in 2004–2006, p<0.001), and were more likely to receive mechanical ventilation at the long-term acute care hospital (16.4% in 1997–2000 versus 29.8% in 2004–2006, p<0.001). One-year mortality after long-term acute care hospital admission was high throughout the study period: 50.7% in 1997–2000 and 52.2% in 2004–2006.

Conclusions

Long-term acute care hospital utilization after critical illness is common and increasing. Survival among Medicare beneficiaries transferred to long-term acute care after critical illness is poor.