Association of Insurance Status with Severity and Management in ED Patients with Asthma Exacerbation

Abstract

IntroductionPrevious studies have demonstrated an association of low socioeconomic status with frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine the relationship of insurance status – a proxy for socioeconomic status – with asthma severity and management in adults. The objective is to investigate chronic and acute asthma management disparities by insurance status among adults requiring emergency department (ED) treatment in the United States.MethodsWe conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients, aged 18–54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture, practice charts, certification) before reviewing randomly selected charts. We categorized patients into three groups based on their primary health insurance: private, public, and no insurance. Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period) and management prior to the index ED visit, acute asthma management in the ED, and prescription at ED discharge.ResultsThe analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits during the preceding year (35%, 49%, and 45%, respectively; p<0.001). Despite the higher chronic severity, those with no insurance were less likely to have guideline-recommended chronic asthma care – i.e., lower use of inhaled corticosteroids (ICS [41%, 41%, and 29%; p<0.001]) and asthma specialist care (9%, 10%, and 4%; p<0.001). By contrast, there were no significant differences in acute asthma management in the ED – e.g., use of systemic corticosteroids (75%, 79%, and 78%; p=0.08) or initiation of ICS at ED discharge (12%, 12%, and 14%; p=0.57) – by insurance status.ConclusionIn this multicenter observational study of ED patients with acute asthma, we found significant discrepancies in chronic asthma severity and management by insurance status. By contrast, there were no differences in acute asthma management among the insurance groups.

Discharge disposition as an independent predictor of readmission among patients hospitalised for community-acquired pneumonia

“…6,32 Similar to prior studies, we attempted to control for social factors using insurance status and demographic characteristics as surrogate markers. 33,34 While this is a limited marker of socioeconomic status, we did not observe a significant relationship between insurance type and risk of readmission.…”

“…Other social factors that have been shown to affect readmission, for which we were not able to fully account, such as employment status, education level and socioeconomic status, may have influenced readmission rates in our patient population . Similar to prior studies, we attempted to control for social factors using insurance status and demographic characteristics as surrogate markers . While this is a limited marker of socioeconomic status, we did not observe a significant relationship between insurance type and risk of readmission.…”

Cost barriers to asthma care by health insurance type among children with asthma

“…Access to a doctor for asthma care because of high out-of-pocket costs was disproportionately lower for children who were uninsured, had public health insurance, or partial year coverage compared with insured, private insurance, and full year insurance coverage, respectively. This finding is not unexpected and supported by literature because uninsured children are less likely to have specialist care and medication use compared with insured children [19]. Hasegawa et al [19] found that patients with no insurance used fewer asthma control medications and were less likely to have asthma specialist care.…”

Barriers to medication adherence in asthma

“…Some research has evaluated whether public insurance coverage, commonly associated with minority status, is associated with lower rates of controller medication prescription and use than private insurance coverage. In 2 studies that assessed prescription patterns, 1 through chart review of emergency department records adults with asthma 57 and the other by evaluation of electronic medical record among children with asthma, 58 there were no differences in prescription rates of controller medication by insurance status (public vs private). In contrast, there are data to suggest differential patterns of controller medication prescription upon hospital discharge by insurance status.…”

“…27,32 Health care provider biases and communication patterns with culturally diverse patients, particularly those with LEP, likely affect providers' skill in communicating about controller medication use in a culturally sensitive manner. 49,50 Systems factors, such as health care coverage, 57,58 cost, 61 and features of the community environment such as exposure to violence, 59 also present challenges to effective disease management and consistent medication use. What then, can be done to address these disparities in medication use and subsequent outcomes?…”