How does lack of insurance affect use of intensive care? A population-based study*

Danis, Marion; Linde-Zwirble, Walter T.; Astor, Avi; Lidicker, Jeffrey; Angus, Derek C.

doi:10.1097/01.ccm.0000227657.75270.c4

Cited by 46 publications

(36 citation statements)

References 20 publications

(19 reference statements)

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“…Danis and colleagues showed that uninsured patients had an increased mortality and were less likely to receive ICU services on a population level (36). An important limitation of this study is a lack of adjustment for severity of illness.…”

Section: Discussionmentioning

confidence: 89%

The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients

Lyon

Benson

Cooke

et al. 2011

Am J Respir Crit Care Med

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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. 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.Keywords: insurance; intensive care unit; critical care; mortality There is known variation in mortality and intensity of care among patients with critical illness across hospitals in the United States (1). One determinant of that variation may be whether the patient has health insurance (2). With approximately 50.9 million Americans uninsured in 2009 (3), understanding how insurance status impacts health care outcomes and use is crucial to improving disparities in critical illness. Previous studies generally show that lack of health insurance is associated with an increased risk of death in the intensive care unit (ICU), but inconsistently adjust for severity of illness and typically use a single-center design (4-9). Determining whether uninsured patients experience poor outcomes because they tend to receive care in low performance hospitals, or because they receive differential care within hospitals, will help focus efforts to improve health care delivery to this patient population. With the implementation of the health care reform, we anticipate the transition of millions of Americans from no insurance to Medicaid and private insurance. Previous work has yet to distinguish whether poorly insured patients have worse outcomes because

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Section: Discussionmentioning

confidence: 89%

The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients

Lyon

Benson

Cooke

et al. 2011

Am J Respir Crit Care Med

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“…61 The implications of differences and similarities must be carefully considered because the structure and context of ICUs affects the process of care. Differences in availability of critical care services influences the ICU patient profile, 62 access to ICU beds, overall case mix ,and clinician workload. 61 Bed availability may influence adoption of clinical practices that may reduce ICU length of stay, such as weaning protocols and daily spontaneous breathing trials, enabling provision of services to more patients.…”

Section: Discussionmentioning

confidence: 99%

International Perspectives on the Influence of Structure and Process of Weaning From Mechanical Ventilation

Rose

Blackwood²,

Burns³

et al. 2010

American Journal of Critical Care

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“…For one study the author provided us with original data and we used the same models developed in their study to obtain estimates for the specific variables analyzed in this review (11). For a second study that examined mortality, we adjusted the reported OR for age, by combining the log-ORs for different age groups weighted by the inverse of their variance (12). For a third study that compared hospital mortality for managed care to nonmanaged care, we based our estimate of the log-OR on adjusted proportions derived from the survival curves for the two groups (13).…”

Section: Discussionmentioning

confidence: 99%

“…Five studies reported hospital mortality in relation to insurance status (12,18,20,31,39,43), but one of these did not adjust for potential confounders (18). Among studies that adjusted for potential confounding variables, patients who were critically ill and without health insurance had a higher hospital mortality (OR, 1.16; 95% CI 1.01-1.33) (12,18,31,39,43) (Figure 3).…”

Section: The Association Between Insurance and Care For Patients Who mentioning

confidence: 99%

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

Fowler¹,

Noyahr²,

Thornton³

et al. 2010

Am J Respir Crit Care Med

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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.

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How does lack of insurance affect use of intensive care? A population-based study*

Abstract: Americans without insurance use ICU services less often than those with insurance, primarily because of decreased likelihood of hospital admission in the first place. Outcome is worse for those who are admitted to the ICU, possibly because they are sicker when they seek care.

Cited by 46 publications

References 20 publications

The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients

The Effect of Insurance Status on Mortality and Procedural Use in Critically Ill Patients

International Perspectives on the Influence of Structure and Process of Weaning From Mechanical Ventilation

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

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