Dataset Information

Use of intensive care services and associated hospital mortality after Massachusetts healthcare reform*.

ABSTRACT: To use the natural experiment of health insurance reform in Massachusetts to study the impact of increased insurance coverage on ICU utilization and mortality.Population-based cohort study.Massachusetts and four states (New York, Washington, Nebraska, and North Carolina) that did not enact reform.All nonpregnant nonelderly adults (age 18-64 yr) admitted to nonfederal acute care hospitals in one of the five states of interest were eligible, excluding patients who were not residents of a respective state at the time of admission.We used a difference-in-differences approach to compare trends in ICU admissions and outcomes of in-hospital mortality and discharge destination for ICU patients.Healthcare reform in Massachusetts was associated with a decrease in ICU patients without insurance from 9.3% to 5.1%. There were no significant changes in adjusted ICU admission rates, mortality, or discharge destination. In a sensitivity analysis excluding a state that enacted Medicaid reform prior to the study period, our difference-in-differences analysis demonstrated a significant increase in mortality of 0.38% per year (95% CI, 0.12-0.64%) in Massachusetts, attributable to a greater per-year decrease in mortality postreform in comparison states (-0.37%; 95% CI, -0.52% to -0.21%) compared with Massachusetts (0.01%; 95% CI, -0.20% to 0.11%).Massachusetts healthcare reform increased the number of ICU patients with insurance but was not associated with significant changes in ICU use or discharge destination among ICU patients. Reform was also not associated with changed in-hospital mortality for ICU patients; however, this association was dependent on the comparison states chosen in the analysis.

SUBMITTER: Lyon SM

PROVIDER: S-EPMC4845959 | biostudies-literature | 2014 Apr

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Use of intensive care services and associated hospital mortality after Massachusetts healthcare reform*.

Lyon Sarah M SM Wunsch Hannah H Asch David A DA Carr Brendan G BG Kahn Jeremy M JM Cooke Colin R CR

Critical care medicine 20140401 4

<h4>Objective</h4>To use the natural experiment of health insurance reform in Massachusetts to study the impact of increased insurance coverage on ICU utilization and mortality.<h4>Design</h4>Population-based cohort study.<h4>Setting</h4>Massachusetts and four states (New York, Washington, Nebraska, and North Carolina) that did not enact reform.<h4>Patients</h4>All nonpregnant nonelderly adults (age 18-64 yr) admitted to nonfederal acute care hospitals in one of the five states of interest were ...[more]

PMID: 24275512

Similar Datasets

Project description:Massachusetts' health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts' second largest safety net hospital between July 25, 2009 and March 20, 2010.Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.Access to care improved less than access to insurance following Massachusetts' health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.

Project description:ObjectivesTo examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states.DesignDifference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform.SettingHospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States.ParticipantsAdults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007).Main outcome measuresAdmission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs.ResultsAfter adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval -1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (-1.9%, -8.5% to 5.1%) or white and Hispanic people (2.0%, -7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, -2.3% to 5.3%).ConclusionsMassachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions.

Project description:The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform's impact on actual health care utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral.Using discharge data on Massachusetts hospitalizations for 21 months before and after health reform implementation (7/1/2006-12/31/2007), we identified all nonobstetrical major therapeutic procedures for patients aged 40 or older and for which ?70% of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated prereform and postreform procedure rates, and their changes, for those aged 40-64 (nonelderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged 70 years and above (elderly), whose coverage (Medicare) was not affected by reform.Overall increases in procedure rates (among 17 procedures identified) between prereform and postreform periods were higher for nonelderly low area income (8%, P=0.04) and medium area income (8%, P<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and blacks (23% and 21%, respectively; P<0.001) than for whites (7%). Adjusting for secular changes unrelated to reform, postreform increases in procedure utilization among nonelderly were: by area income, low=13% (95% confidence interval (CI)=[9%, 17%]), medium=15% (95% CI [6%, 24%]), and high=2% (95% CI [-3%, 8%]); and by race/ethnicity, Hispanics=22% (95% CI [5%, 38%]), blacks=5% (95% CI [-20%, 30%]), and whites=7% (95% CI [5%, 10%]).Postreform use of major inpatient procedures increased more among nonelderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.

Project description:RationaleSurvivors of critical illness experience significant morbidity, but the impact of surviving the intensive care unit (ICU) has not been quantified comprehensively at a population level.ObjectivesTo identify factors associated with increased hospital resource use and to ascertain whether ICU admission was associated with increased mortality and resource use.MethodsMatched cohort study and pre/post-analysis using national linked data registries with complete population coverage. The population consisted of patients admitted to all adult general ICUs during 2005 and surviving to hospital discharge, identified from the Scottish Intensive Care Society Audit Group registry, matched (1:1) with similar hospital control subjects. Five-year outcomes included mortality and hospital resource use. Confounder adjustment was based on multivariable regression and pre/post within-individual analyses.Measurements and main resultsOf 7,656 ICU patients, 5,259 survived to hospital discharge (5,215 [99.2%] matched to hospital control subjects). Factors present before ICU admission (comorbidities/pre-ICU hospitalizations) were stronger predictors of hospital resource use than acute illness factors. In the 5 years after the initial hospital discharge, compared with hospital control subjects, the ICU cohort had higher mortality (32.3% vs. 22.7%; hazard ratio, 1.33; 95% confidence interval, 1.22-1.46; P < 0.001), used more hospital resources (mean hospital admission rate, 4.8 vs. 3.3/person/5 yr), and had 51% higher mean 5-year hospital costs ($25,608 vs. $16,913/patient). Increased resource use persisted after confounder adjustment (P < 0.001) and using pre/post-analyses (P < 0.001). Excess resource use and mortality were greatest for younger patients without significant comorbidity.ConclusionsThis complete, national study demonstrates that ICU survivorship is associated with higher 5-year mortality and hospital resource use than hospital control subjects, representing a substantial burden on individuals, caregivers, and society.

Project description:Racial disparities in receipt of minimally invasive surgery (MIS) persist in the United States and have been shown to also be associated with a number of driving factors, including insurance status. However, little is known as to how expanding insurance coverage across a population influences disparities in surgical care.To evaluate the impact of Massachusetts health care reform on racial disparities in MIS.A retrospective cohort study assessed the probability of undergoing MIS vs an open operation for nonwhite patients in Massachusetts compared with 6 control states. All discharges (n?=?167,560) of nonelderly white, black, or Latino patients with government insurance (Medicaid or Commonwealth Care insurance) or no insurance who underwent a procedure for acute appendicitis or acute cholecystitis at inpatient hospitals between January 1, 2001, and December 31, 2009, were assessed. Data are from the Hospital Cost and Utilization Project State Inpatient Databases.The 2006 Massachusetts health care reform, which expanded insurance coverage for government-subsidized, self-pay, and uninsured individuals in Massachusetts.Adjusted probability of undergoing MIS and difference-in-difference estimates.Prior to the 2006 reform, Massachusetts nonwhite patients had a 5.21-percentage point lower probability of MIS relative to white patients (P?<?.001). Nonwhite patients in control states had a 1.39-percentage point lower probability of MIS (P?=?.007). After reform, nonwhite patients in Massachusetts had a 3.71-percentage point increase in the probability of MIS relative to concurrent trends in control states (P?=?.01). After 2006, measured racial disparities in MIS resolved in Massachusetts, with nonwhite patients having equal probability of MIS relative to white patients (0.06 percentage point greater; P?=?.96). However, nonwhite patients in control states without health care reform have a persistently lower probability of MIS relative to white patients (3.19 percentage points lower; P?<?.001).The 2006 Massachusetts insurance expansion was associated with an increased probability of nonwhite patients undergoing MIS and resolution of measured racial disparities in MIS.

Project description:ObjectiveTo estimate the impact of the insurance expansion in 2006 on use of knee and hip replacement procedures by race/ethnicity, area income, and the use of hospitals that predominantly serve poor people ("safety net hospitals").DesignQuasi-experimental difference in differences study examining change after reform in the share of procedures performed in safety net hospitals by race/ethnicity and area income, with adjustment for patients' residence, demographics, and comorbidity.SettingState of Massachusetts, United States.ParticipantsMassachusetts residents aged 40-64 as the target beneficiaries of reform and similarly aged residents of New Jersey, New York, and Pennsylvania as the comparison (control) population.Main outcomes measuresNumber of knee and hip replacement procedures per 10 000 population and use of safety net hospitals. Procedure counts from state discharge data for 2.5 years before and after reform, and multivariate difference in differences. Poisson regression was used to adjust for demographics, economic conditions, secular time, and geographic factors to estimate the change in procedure rate associated with health reform by race/ethnicity and area income.ResultsBefore reform, the number of procedures (/10 000) in Massachusetts was lower among Hispanic people (12.9, P<0.001) than black people (28.1) and white people (30.1). Overall, procedure use increased 22.4% during the 2.5 years after insurance expansion; reform in Massachusetts was associated with a 4.7% increase. The increase associated with reform was significantly higher among Hispanic people (37.9%, P<0.001) and black people (11.4%, P<0.05) than among white people (2.8%). Lower income was not associated with larger increases in procedure use. The share of knee and hip replacement procedures performed in safety net hospitals in Massachusetts decreased by 1.0% from a level of 12.7% before reform. The reduction was larger among Hispanic people (-6.4%, P<0.001) than white people (-1.0%), and among low income residents (-3.9%, p<0.001) than high income residents (0%).ConclusionsInsurance expansion can help reduce disparities by race/ethnicity but not by income in access to elective surgical care and could shift some elective surgical care away from safety net hospitals.

Dataset Information

Use of intensive care services and associated hospital mortality after Massachusetts healthcare reform*.

Publications

Use of intensive care services and associated hospital mortality after Massachusetts healthcare reform*.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets