Undiagnosed medical comorbidities in the uninsured

Monaghan, Sean F.; Connolly, Michael D.; Gregg, Shea C.; Stephen, Andrew H.; Adams, Charles A.; Cioffi, William G.; Heffernan, Daithi S.

doi:10.1097/ta.0b013e31826fc844

Cited by 40 publications

(28 citation statements)

References 31 publications

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“…23 We found the uninsured had similar numbers of comorbidities compared to the insured, however, the uninsured may have more undiagnosed comorbidities that are not accounted for in our data. While the total number of comorbidities was not associated with mortality in our adjusted analysis, this says nothing about the potentially mortal physiological burden of undiagnosed comorbidities among the uninsured.…”

Section: Discussionmentioning

confidence: 45%

Uninsured status may be more predictive of outcomes among the severely injured than minority race

Gerry

Weiser

Spain

et al. 2016

Injury

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Aim Worse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers. Methods We performed a retrospective analysis of the 2010 to 2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18 to 64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care. Results There were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29 – 1.98, p<0.001) and black race (OR 1.24, 1.04 – 1.49, p=0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36 – 0.51, p<0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29 – 2.19, p<0.001) and decreased post-hospital care (OR 0.45, 0.32 – 0.63, p<0.001). Conclusion Uninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.

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Section: Discussionmentioning

confidence: 45%

Uninsured status may be more predictive of outcomes among the severely injured than minority race

Gerry

Weiser

Spain

et al. 2016

Injury

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“…One possible explanation is that black patients are known to have undiagnosed co-morbidities and be at risk for cardiovascular complications, 45 including VTE. Providers who were making clinical decisions entirely independently, without the use of a standardized mandatory decision support tool, may have chosen to prescribe more aggressive VTE prophylaxis regimens for these black patients to overcompensate for these issues.…”

Section: Discussionmentioning

confidence: 99%

Eliminating Health Care Disparities With Mandatory Clinical Decision Support

et al. 2015

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Background All hospitalized patients should be assessed for VTE risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacologic prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. Objectives To examine the effect of a quality improvement intervention on race- and gender-based healthcare disparities across two distinct clinical services. Research Design Retrospective cohort study of a quality improvement intervention Subjects 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients Measures Proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis Results Racial disparities existed in prescription of best-practice VTE prophylaxis in the pre-implementation period between black and white patients on both the trauma (70.1% vs. 56.6%, p=0.025) and medicine (69.5% vs. 61.7%, p=0.015) services. After implementation of the CCDS tool, compliance improved for all patients and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, p=0.99) and medicine (91.8% vs. 88.0%, p=0.082). Similar findings were noted for gender disparities in the trauma cohort. Conclusions Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and gender, practice varied widely prior to our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across two distinct clinical services. Health information technology approaches to care standardization are effective to eliminate healthcare disparities.

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“…This finding makes intuitive sense; if you are not be evaluated by a doctor, then you cannot be diagnosed with a comorbidity. 2 As a result, the Charlson Comorbidity Index, which the authors used in the multivariable analysis, is likely skewed toward a lower score (ie, fewer comorbidities) in the uninsured population. As a result, the data presented will not reflect the increased risk of complications including death and may be the reason why government-insured patients had poorer outcomes than the uninsured.…”

Section: To the Editorsmentioning

confidence: 99%