Association of Health Insurance Status with Outcomes of Sepsis in Adult Patients: A Retrospective Cohort Study.
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SUBMITTER: Wang GS
PROVIDER: S-EPMC8198413 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ImportanceThe receipt of surgery in freestanding ambulatory surgery centers (ASCs) is often less costly compared with surgery in hospital-based outpatient departments. Although increasing numbers of surgical procedures are now being performed in freestanding ASCs, questions remain regarding the existence of disparities among patients receiving care at ASCs.ObjectiveTo examine the association of patient race, health insurance status, and household income with the location (ASC vs hospital-based outpatient department) of ambulatory surgery.Design, setting, and participantsThis cohort study used data from the State Ambulatory Surgery and Services Databases of the Healthcare Cost and Utilization Project to perform a secondary analysis of patients who received ambulatory surgery in New York and Florida between 2011 and 2013. Patients aged 18 to 89 years who underwent 12 different types of ambulatory surgical procedures were included. Data were analyzed from December 2018 to June 2019.Main outcomes and measuresReceipt of surgery at a freestanding ASC and 30-day unplanned hospital visits after ambulatory surgery.ResultsA total of 5.6 million patients in New York (57.4% female; 68.9% aged ≥50 years; and 62.5% White) and 7.5 million patients in Florida (57.3% female; 77.4% aged ≥50 years; 74.3% White) who received ambulatory surgery were included in the analysis. After adjusting for age, comorbidities, health insurance status, household income, location of surgery, and type of surgical procedure, the likelihood of receiving ambulatory surgery at a freestanding ASC was significantly lower among Black patients (adjusted odds ratio [aOR], 0.82; 95% CI, 0.81-0.83; P < .001) and Hispanic patients (aOR, 0.78; 95% CI, 0.77-0.79; P < .001) compared with White patients in New York. This likelihood was also lower among Black patients (aOR, 0.65; 95% CI, 0.65-0.66; P < .001) compared with White patients in Florida. Public health insurance coverage was associated with a significantly lower likelihood of receiving ambulatory surgery at freestanding ASCs in both New York and Florida, particularly among patients with Medicaid (in New York, aOR, 0.22; 95% CI, 0.22-0.22; P < .001; in Florida, aOR, 0.40; 95% CI, 0.40-0.41; P < .001) and Medicare (in New York, aOR, 0.46; 95% CI, 0.46-0.46; P < .001; in Florida, aOR, 0.67; 95% CI, 0.66-0.67; P < .001).Conclusions and relevanceDifferences in the use of freestanding ASCs were found among Black patients and patients with public health insurance. Further exploration of the factors underlying these differences will be important to ensure that all populations have access to the increasing number of freestanding ASCs.
| S-EPMC7489412 | biostudies-literature
Project description:OBJECTIVES:Older adults frequently visit the emergency department (ED). Socioeconomic status (SES) has an important impact on health and ED utilisation; however, the association between SES and ED utilisation in elderly remains unclear. The aim of this study was to investigate the association between SES in older adult patients visiting the ED on outcomes. DESIGN:A retrospective study. PARTICIPANTS:Older adults (≥65 years) visiting the ED, in the Netherlands. SES was stratified into tertiles based on average household income at zip code level: low (<€1800/month), intermediate (€1800-€2300/month) and high (>€2300/month). PRIMARY OUTCOMES:Hospitalisation, inhospital mortality and 30-day ED return visits. Effect of SES on outcomes for all groups were assessed by logistic regression and adjusted for confounders. RESULTS:In total, 4828 older adults visited the ED during the study period. Low SES was associated with a higher risk of hospitalisation among community-dwelling patients compared with high SES (adjusted OR 1.3, 95% CI 1.1 to 1.7). This association was not present for intermediate SES (adjusted OR 1.1, 95% CI 0.95 to 1.4). Inhospital mortality was comparable between the low and high SES group, even after adjustment for age, comorbidity and triage level (low OR 1.4, 95% CI 0.8 to 2.6, intermediate OR 1.3, 95% CI 0.8 to 2.2). Thirty-day ED revisits among community-dwelling patients were also equal between the SES groups (low: adjusted OR 1.0, 95% CI 0.7 to 1.4, and intermediate: adjusted OR 0.8, 95% CI 0.6 to 1.1). CONCLUSION:In older adult ED patients, low SES was associated with a higher risk of hospitalisation than high SES. However, SES had no impact on inhospital mortality and 30-day ED revisits after adjustment for confounders.
| S-EPMC5770947 | biostudies-literature
Project description:Patients with severe sepsis have high mortality that is improved by timely, often expensive, treatments. Patients without insurance are more likely to delay seeking care; they may also receive less intense care.We performed a retrospective analysis of administrative database-Healthcare Costs and Utilization Project's Nationwide Inpatient Sample-to test whether mortality is more likely among uninsured patients hospitalized for severe sepsis.None.We used International Classification of Diseases-9th Revision, Clinical Modification, codes indicating sepsis and organ system failure to identify hospitalizations for severe sepsis among patients aged 18-64 between 2000 and 2008. We excluded patients with end-stage renal disease or solid organ transplants because very few are uninsured. We performed multivariate logistic regression modeling to examine the association of insurance status and in-hospital mortality, adjusted for patient and hospital characteristics. We performed subgroup analysis to examine whether the impact of insurance status varied by geographical region; by patient age, sex, or race; or by hospital characteristics such as teaching status, size, or ownership. We used similar methods to examine the impact of insurance status on the use of certain procedures, length of stay, and discharge destination.There were 1,600,269 discharges with severe sepsis from 2000 through 2008 in the age group 18-64 years. Uninsured people, who accounted for 7.5% of admissions with severe sepsis, had higher adjusted odds of mortality (odds ratio, 1.43; 95% CI, 1.37-1.47) than privately insured people. The higher mortality in uninsured was present in all subgroups and was similar in each year from 2000 to 2008. After adjustment, uninsured individuals had a slightly shorter length of stay than insured people and were less likely to receive five of the six interventions we examined. They were also less likely to be discharged to skilled nursing facilities or with home healthcare after discharge.Uninsured are more likely to die following admission for severe sepsis than patients with insurance, even after adjusting for potential confounders. This was not due to a hospital effect or demographic or clinical factors available in our administrative database. Further research should examine the mechanisms that lead to this association.
| S-EPMC4990450 | biostudies-literature
Project description:BackgroundWe hypothesized that lower socioeconomic status (SES) was associated with higher all-cause mortality in patients newly diagnosed with cancer, particularly in the elderly population.MethodsWe collected study patients from the stratified random sample of Korean National Health Insurance Elderly Cohort (2002-2015). The Cox's proportional hazards model was used to investigate the risk factors for mortality. Income level and composite deprivation index (CDI) 2010 were used to define the SES: low, intermediate, and high SES groups. The comorbidities were measured using Charlson Comorbidity Index score. After a wash-out period (2002), the final study population was 108 626 (2003-2015).ResultsIn multivariate analysis, low SES was associated with poor overall survival (OS) (HR = 1.08, 95% CI: 1.05-1.12, P < 0.001) and cancer-specific survival (CSS) (HR = 1.11, 95% CI: 1.06-1.16, P < 0.001) particularly for patients aged 70-79 years. High SES was favorable prognostic factor of OS in patients aged 60-69 years (HR = 0.85, 95% CI: 0.81-0.89, P < 0.001), 70-79 years (HR = 0.90, 95% CI: 0.87-0.93, P < 0.001), and ≥80 years (HR = 0.91, 95% CI: 0.87-0.96, P < 0.001). However, SES was not associated with CSS in advanced age patients (≥80 years). Patients with low SES manifesting colorectal, urinary, liver, gastric, melanoma, and esophageal cancers demonstrated worse OS, compared to patients with intermediate SES. Also, low SES patients with urinary, liver, or colorectal cancers or melanoma demonstrated worse CSS compared to those with intermediate SES.ConclusionLow SES at the time of cancer diagnosis is associated with increased risk of OS and CSS in elderly patients. Depending on cancer sites, different patterns of OS and CSS were observed according to SES. Further elucidation of the causes underlying these phenomena is needed along with appropriate support for elderly cancer patients with low SES.
| S-EPMC6601595 | biostudies-literature
Project description:BackgroundNumerous studies across a variety of malignancies have demonstrated that health insurance status is associated with differences in clinical presentation, type of treatments received, and survival. The effect of insurance status on the management of soft tissue sarcoma is unknown. We assessed the association of insurance on (a) stage at diagnosis, (b) receipt of neoadjuvant/adjuvant radiation therapy, and (c) overall survival (OS) in patients with soft tissue sarcoma.MethodsThe study cohort was identified from the National Cancer Database (NCDB) and consisted of patients with stage I-IV soft tissue sarcoma of various histologies diagnosed from 2004 to 2015. The patients were stratified by age (<65 and ≥65 years) and by insurance status (commercial, Medicare, Medicaid and uninsured). Using multivariable logistic regression analysis, we evaluated the association between insurance status and (a) stage at diagnosis (Stage I-III vs IV), and (b) receipt of neoadjuvant/adjuvant radiation therapy in patients with locally advanced disease. The association of insurance status on OS was assessed using Kaplan-Meier and multivariable Cox proportional hazards analyses. A propensity score matched survival analysis was performed to account for measured confounders.Results49 754 patients were identified of whom 23 677 (48%) had commercial insurance, 20 867 (42%) had Medicare, 3229 (6%) had Medicaid, and 1981 (4%) were uninsured. In patients <65 years, those with Medicaid (OR = 1.74, 95% CI: 1.57-1.93, P < .001) and the uninsured (OR = 1.71, 95% CI: 1.51-1.94, P < .001) were more likely to present with stage IV vs Stage I-III disease. Furthermore, among patients with locally advanced disease treated with limb sparing surgery, those with Medicaid (OR = 0.87, 95% CI: 0.77- 0.98, P = .021) and the uninsured (OR = 0.73, 95% CI: 0.63-0.85, P < .001) were less likely to receive neoadjuvant or adjuvant radiotherapy as compared to those with commercial insurance. Lastly, having Medicaid (HR = 1.26, 95% CI: 1.17-1.34, P < .001) and no insurance (HR = 1.30, 95% CI: 1.20-1.41, P < .001) was associated with worse OS compared to having commercial insurance, a finding which remained significant after propensity score matching. In contrast, in patients ≥65 years, there were no statistically significant differences between those with Medicare and commercial insurance with regards to disease presentation, receipt of radiotherapy, or survival.ConclusionsIn a large modern cohort identified from the NCDB, commercial insurance status in patients <65 years was associated early diagnosis, receipt of neoadjuvant/adjuvant radiation therapy, and overall survival for patients with soft tissue sarcoma. Further efforts are warranted to understand disparities in care based on health insurance in the United States.
| S-EPMC6797574 | biostudies-literature
Project description:BackgroundRacial/ethnic disparities in prognosis have been reported in patients with hepatocellular carcinoma (HCC); however, few studies have evaluated racial/ethnic disparities in the context of insurance status.AimsCharacterize racial/ethnic and insurance status in early tumor detection, receipt of curative therapy and overall survival in a multicenter diverse cohort of HCC patients from the USA.StudyWe included patients with HCC diagnosed between June 2012 and May 2013 at four centers in the USA. Generalized linear mixed effects models were used to compare early tumor detection (defined using Milan Criteria) and curative treatment receipt (liver transplantation, surgical resection, or local ablation) as a function of patient race/ethnicity and insurance status. A multivariable frailty survival model was used to compare risk of death between patient groups.ResultsOf 379 HCC patients (52.8% non-Hispanic White, 19.5% Hispanic White, 19.8% Black), 46.4% and 48.0% were found at an early stage and underwent curative therapy, respectively, and median overall survival of the cohort was 25.7 months. Early detection of HCC was associated with gastroenterology subspecialty care and receipt of HCC surveillance but not race/ethnicity or insurance status in adjusted models. However, commercial insurance was significantly associated with higher odds of curative treatment receipt, which in turn was the strongest correlate for overall survival. After adjusting for health system and insurance status, race/ethnicity was not associated with curative treatment receipt or overall survival.ConclusionsInsurance status and access to gastroenterology subspecialty care may be important drivers of racial/ethnic disparities in prognosis among HCC patients.
| S-EPMC7603399 | biostudies-literature
Project description:ObjectivesObservational studies suggest obesity is associated with sepsis survival, but these studies are small, fail to adjust for key confounders, measure body mass index at inconsistent time points, and/or use administrative data to define sepsis. To estimate the relationship between body mass index and sepsis mortality using detailed clinical data for case detection and risk adjustment.DesignRetrospective cohort analysis of a large clinical data repository.SettingOne-hundred thirty-nine hospitals in the United States.PatientsAdult inpatients with sepsis meeting Sepsis-3 criteria.ExposureBody mass index in six categories: underweight (body mass index < 18.5 kg/m), normal weight (body mass index = 18.5-24.9 kg/m), overweight (body mass index = 25.0-29.9 kg/m), obese class I (body mass index = 30.0-34.9 kg/m), obese class II (body mass index = 35.0-39.9 kg/m), and obese class III (body mass index ≥ 40 kg/m).MeasurementsMultivariate logistic regression with generalized estimating equations to estimate the effect of body mass index category on short-term mortality (in-hospital death or discharge to hospice) adjusting for patient, infection, and hospital-level factors. Sensitivity analyses were conducted in subgroups of age, gender, Elixhauser comorbidity index, Sequential Organ Failure Assessment quartiles, bacteremic sepsis, and ICU admission.Main resultsFrom 2009 to 2015, we identified 55,038 adults with sepsis and assessable body mass index measurements: 6% underweight, 33% normal weight, 28% overweight, and 33% obese. Crude mortality was inversely proportional to body mass index category: underweight (31%), normal weight (24%), overweight (19%), obese class I (16%), obese class II (16%), and obese class III (14%). Compared with normal weight, the adjusted odds ratio (95% CI) of mortality was 1.62 (1.50-1.74) for underweight, 0.73 (0.70-0.77) for overweight, 0.61 (0.57-0.66) for obese class I, 0.61 (0.55-0.67) for obese class II, and 0.65 (0.59-0.71) for obese class III. Results were consistent in sensitivity analyses.ConclusionsIn adults with clinically defined sepsis, we demonstrate lower short-term mortality in patients with higher body mass indices compared with those with normal body mass indices (both unadjusted and adjusted analyses) and higher short-term mortality in those with low body mass indices. Understanding how obesity improves survival in sepsis would inform prognostic and therapeutic strategies.
| S-EPMC6465121 | biostudies-literature
Project description:BACKGROUND:The Affordable Care Act has provided health insurance to a large portion of the uninsured in the United States. However, different types of health insurance provide varying amounts of reimbursements to providers, which may lead to different types of treatment, potentially worsening health outcomes in patients covered by low-reimbursement insurance plans, such as Medicaid. The objective was to determine differences in access, treatment, and health outcomes by insurance type, using hospital fixed effects. METHODS AND RESULTS:We conducted a multivariate regression analysis using patient-level data for nonelderly adult patients with acute myocardial infarction in California from January 1, 2001, to December 31, 2014, as well as hospital-level information to control for differences between hospitals. The probability of Medicaid-insured and uninsured patients having access to catheterization laboratory was higher by 4.50 and 3.75 percentage points, respectively, relative to privately insured patients. When controlling for access to percutaneous coronary intervention facilities, however, Medicaid-insured and uninsured patients had a 4.24- and 0.85-percentage point lower probability, respectively, in receiving percutaneous coronary intervention treatment compared with privately insured patients. They also had higher mortality and readmission rates relative to privately insured patients. CONCLUSIONS:Although Medicaid-insured and uninsured patients with acute myocardial infarction had better access to catheterization laboratories, they had significantly lower probabilities of receiving percutaneous coronary intervention treatment and a higher likelihood of death and readmission compared with privately insured patients. This provides empirical evidence that treatment received and health outcomes strongly vary between Medicaid-insured, uninsured, and privately insured patients, with Medicaid-insured patients most disproportionately affected, despite having better access to cardiac technology.
| S-EPMC6015377 | biostudies-literature
Project description:The prognostic value of health status metrics in patients with adult congenital heart disease (ACHD) and atrial arrhythmias is unclear. In this retrospective cohort study of an ongoing national, multicenter registry (PROTECT-AR, NCT03854149), ACHD patients with atrial arrhythmias on apixaban are included. At baseline, health metrics were assessed using the physical component summary (PCS), the mental component summary (MCS) of the Short-Form-36 (SF-36) Health Survey, and the modified European Heart Rhythm Association (mEHRA) score. Patients were divided into groups according to their SF-36 PCS and MCS scores, using the normalized population mean of 50 on the PCS and MCS as a threshold. The primary outcome was the composite of mortality from any cause, major thromboembolic events, major/clinically relevant non-major bleedings, or hospitalizations. Multivariable Cox-regression analyses using clinically relevant parameters (age greater than 60 years, anatomic complexity, ejection fraction of the systemic ventricle, and CHA₂DS₂-VASc and HAS-BLED scores) were performed to examine the association of health metrics with the composite outcome. Over a median follow-up period of 20 months, the composite outcome occurred in 50 of 158 (32%) patients. The risk of the outcome was significantly higher in patients with SF-36 PCS ≤ 50 compared with those with PCS > 50 (adjusted hazard ratio (aHR), 1.98; 95% confidence interval [CI], 1.02−3.84; p = 0.04) after adjusting for possible confounders. The SF-36 MCS ≤ 50 was not associated with the outcome. The mEHRA score was incrementally associated with a higher risk of the composite outcome (aHR = 1.44 per 1 unit increase in score; 95% CI, 1.03−2.00; p = 0.03) in multivariable analysis. In ACHD patients with atrial arrhythmias, the SF-36 PCS ≤ 50 and mEHRA scores predicted an increased risk of adverse events.
| S-EPMC9605619 | biostudies-literature
Project description:BackgroundJapanese employers are obligated to offer employees annual health checkups and guidance programs for their health promotion and maintenance to prevent cardiovascular (CV) and lifestyle-related diseases. Under these programs, checkup recipients are notified of the checkup results, and in case of abnormal findings, employers are expected to provide employees with follow-up encouragement to change their behavior; for example, with medical consultations or lifestyle modifications. However, the effect of these programs on behavioral changes and their subsequent clinical outcomes has not been clearly assessed.ObjectiveThe aim of this study was to investigate changes in CV risk management behaviors after receiving unfavorable health checkup results on serum lipid levels among subjects without antidyslipidemic drug prescription and uncontrolled lipid levels and at elevated risk of CV events in a real-world setting.Patients and methodsThis retrospective cohort study used a Japanese employment-based health insurance database managed by MinaCare Co., Ltd. This study analyzed the data from the annual health checkups of recipients aged 20-74 years with data on their low-density lipoprotein-cholesterol (LDL-c), high-density lipoprotein-cholesterol (HDL-c), and triglyceride (TG) values from 2015 to 2017, who had uncontrolled lipid levels based on their checkup results at baseline in 2015, and without prescription records of antidyslipidemic drugs. Lipid status was considered uncontrolled if any of the following were detected: LDL-c ≥ 140 mg/dL, HDL-c < 40 mg/dL, or TG ≥ 150 mg/dL. Changes in antidyslipidemic drug prescription, as a primary CV risk management behavior measure, and in lipid control status in 2016 and 2017 were investigated. Potential factors associated with lipid control were also explored using logistic regression analysis.ResultsAmong 154,421 subjects without antidyslipidemic drug prescription and with uncontrolled lipid levels in 2015, 93.6% remained without antidyslipidemic drug prescription in both 2016 and 2017. Of these subjects, 76.8% and 76.4% continued having uncontrolled lipid levels in 2016 and 2017, respectively. Fewer subjects without prescription achieved lipid control than those with prescription. Various factors were associated with lipid control, with high LDL-c as the greatest risk factor for uncontrolled lipid levels.ConclusionsThese results suggest that most health checkup recipients may not have changed their behaviors; that is, they may have not sought medical treatment and continued having uncontrolled lipid levels in the years following the unfavorable health checkup results. To encourage subjects to initiate desirable behavioral changes, more practical support may be essential.
| S-EPMC8128960 | biostudies-literature