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

Abstract

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

Homeless Patients in the ICU

“…For example, a study in United States reported hospital mortality rates for critically ill patients significantly higher for the uninsured than for the insured (46), whereas in our study, homeless status had no impact on this outcome. Similarly, a systematic review reported that American uninsured patients benefited from fewer procedures in intensive care (47), as did a more recent study taking into account hospital-level effect and disease severity (48). Differences between our study results and the American situation may be due, at least in part, to the availability of a "universal healthcare guarantee" in the public French healthcare system.…”

Evolution of Critical Care Cardiology: Transformation of the Cardiovascular Intensive Care Unit and the Emerging Need for New Medical Staffing and Training Models

“…71 Other studies would also be useful to tease out the multiple factors that influence ICU outcomes and costs, including severity of illness, divergent therapeutic approaches, increasing physician workload, 72 and patient insurance status. 73 Despite the limitations to these data, the overall consistency of the available evidence and the rational basis for improved outcomes with enhanced experience, which is a central tenet of medical and procedural training, are compelling. Intensivists may improve outcomes through common practices, provision of urgent therapy, familiarity with acute conditions usually seen only in the critical care setting, facilitation of multidisciplinary care, increased use of evidence-based measures for prevention of complications, and provision of an ICU leadership role.…”

Satisfaction with care and decision making among parents/caregivers in the pediatric intensive care unit: A comparison between English-speaking whites and Latinos

“…In the pediatric population, both Lopez et al [9] and Epstein et al [9,10] found no difference in pediatric ICU mortality based on race/ethnicity but did find that severity of illness at the time of ICU admission was higher for the uninsured and government-insured patients. Although convincing evidence for disparities in ICU health care based on race/ethnicity is lacking, most inequities in health care in the ICU seem to be based on socioeconomic status and health insurance [11][12][13][14][15]. Another outcome measurement, such as satisfaction with care and decision making, may be necessary to identify disparities within the ICU setting.…”