Health Insurance Status and Clinical Outcomes Among Patients

1. Health Insurance Status and Clinical Outcomes Among Patients Hospitalized in the Intensive Care Unit Matthew Woodford1, Karim El Kersh1, Udit Sudhir Chaddha1, Rahul Siddhartha Sinha1, Rodrigo Cavallazzi1, Rafael Perez1, Timothy L. Wiemken2 Division of Pulmonary, Critical Care, and Sleep Disorders Medicine, University of Louisville, Louisville. Division of Infectious Diseases, University of Louisville, Louisville. ABSTRACT RESULTS INTRODUCTION CONCLUSIONS Background: One in three United States citizens under 65 years old does not have health insurance during portions of the year.  Patients without insurance have decreased access to primary care, and may have worse clinical outcomes compared to insured patients. However, the impact of insurance status on clinical outcomes of critically ill patients is still unclear.  The objective of this study is to evaluate the impact of insurance status on the outcomes of patients in the intensive care unit. Methods:  This was a retrospective cohort study conducted at the University of Louisville Hospital from January 2008 to June 2011.  A logistic regression model was used to evaluate the impact of insurance status on in-hospital mortality.  Cox Proportional Hazards Regression Models were used to evaluate the impact of insurance status on ICU and total hospital length of stay. Results:  Data on 1890 hospitalized patients in the intensive care unit were collected.  After adjusting for confounding variables, we were not able to identify a significant difference in in-hospital mortality between patients with and without health insurance (OR = 0.88, 95% CI, 0.7-1.1, P=0.278).  However, ICU length of stay and total hospital length of stay were significantly shorter in uninsured patients (Hazard Ratio=1.25, 95% CI, 1.19-1.31, P<0.001, and Hazard Ratio =1.26, 95% CI, 1.2-1.33, P=0.011, respectively).  Conclusion:  We were unable to identify a difference in in-hospital mortality between insured and uninsured patients.  ICU and total hospital length of stays in patients without health insurance were significantly shorter. These findings may reflect the ready availability of diagnostic tests and therapeutics for all patients in the ICU. One in three United States citizens under 65 years of age does not have health insurance during some portion of each year. Patients without insurance have decreased access to primary and ambulatory care, and may have worse clinical outcomes compared to insured patients. However, the impact of insurance status on clinical outcomes of critically ill patients is still unclear. The objective of this study is to evaluate the impact of insurance status on the clinical outcomes of hospitalized patients in the intensive care unit. • We were unable to identify a difference in in-hospital mortality between insured and uninsured patients. Furthermore, there were significantly shorter ICU and total hospital length of stays in patients without health insurance. • In a prior meta-analysis of 4 observational studies, being uninsured was associated with a 1.16 (95% CI: 1.01 to 1.33) higher risk of death after adjustment for confounders. However, there was heterogeneity in the analysis, and not all the studies pointed to the same direction. • A potential explanation for our findings is that in the hospital--and particularly in the ICU–diagnostic tests and therapeutics are for the most part readily available for all patients regardless of insurance status. Thus, the harm of lack of health insurance may not be reflected in the ICU care. Once discharged from the hospital, these patients are again at risk due to the lack of health insurance. • Our findings should give further impetus to guarantee that all patients have health insurance. Figures 1 and 2 depict Kaplan-Meier Survival curves comparing uninsured and insured patients on the basis of length of stay in the ICU and length of stay in the hospital, respectively. After adjusting for confounding variables, we were not able to identify a significant difference in in-hospital mortality between patients with and without health insurance (OR = 0.88, 95% CI, 0.7-1.1, P=0.278). ICU length of stay and total hospital length of stay were significantly shorter in uninsured patients (Hazard Ratio=1.25, 95% CI, 1.19-1.31, P<0.001, and Hazard Ratio =1.26, 95% CI, 1.2-1.33, P=0.011, respectively). METHODS This was a retrospective cohort study conducted at the University of Louisville Hospital, Louisville, KY from January 2008 to June 2011. Data were extracted from the electronic medical record. Information collected included age, gender, diagnosis, date of admission, admission severity of disease, expected mortality, length of stay, and in-hospital mortality. A logistic regression model was used to evaluate the impact of insurance status on in-hospital mortality. Cox Proportional Hazards Regression Models were used to evaluate the impact of insurance status on ICU and total hospital length of stay. Figure 1: Kaplan-Meier curve for length of stay in the ICU REFERENCES Fowler RA, Noyahr LA, Thornton JD et al. 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. Am J RespirCrit Care Med..2010 May 1;181(9):1003-11. RESULTS Data on 1890 hospitalized patients in the intensive care unit were collected. Uninsured patients were younger than insured patients (42 years (SD: 12.9) and 55 years (SD: 18.1) respectively, P<0.001). There were more males in the uninsured group than the insured group (73% vs. 59%, respectively, P<0.001). Figure 2: Kaplan-Meier curve for length of stay in the Hospital