"Our most significant finding was that poor older adults with Medicaid insurance who receive treatment for a critical illness in the ICU are more likely to die after hospital discharge when compared to those with commercial insurance," said lead author Yoland Philpotts, MD, of the Columbia University College of Physicians & Surgeons. "This was true even after taking into account differences in pre-existing health conditions and the severity of critical illness."
Dr. Philpotts and colleagues found this disparity to be greatest among survivors of critical illness with Medicaid who are discharged from the hospital to a nursing home. "These patients have a 15 percent increased risk of death compared to those with commercial insurance," he said.
The researchers used the New York Statewide Planning and Research Cooperative System (SPARCS) database and American Hospital Association Annual Survey to examine post-discharge mortality of New Yorkers age 65 and older who had their first hospitalization in intensive care, and survived while in the hospital. They looked at 339,261 New York State cases between 2010 and 2014.
Dr. Philpotts found that 20 percent of those who survived while in the ICU died within one year of hospital discharge.
In addition to looking at whether there were differences in death rates for patients with co-existing health conditions or who had more severe critical illness, the team examined if differences in age, race or household income affected patients' post-hospital one-year mortality. They also separated out teaching hospitals from non-teaching hospitals, and urban from rural hospitals. None of these factors made a significant difference in patient mortality rates.
"Our findings did not surprise us since they are consistent with a body of research that has demonstrated deficiencies in outpatient and nursing home care for older Americans with Medicaid insurance," Dr. Philpotts said. "Our work is novel because we show that these disparities may be associated with a substantial risk for death among older survivors of critical illness."
He added, "The implications of our findings are important: to improve the long-term survival and quality-of-life of critical illness survivors, we may have to improve care not only within the hospital and ICU, but also after hospital discharge."
"We now need further studies aimed at identifying the factors that mediate the higher mortality among ICU survivors who lack commercial insurance," said Dr. Philpotts. "Our team will study insurance status and readmission to the hospital after critical illness for this vulnerable patient population. A readmission to the hospital after critical illness is a potential marker of a barrier to high-quality care after discharge."
Abstract Number: 13612
Title: Health Insurance and Disparities in Mortality Among Older Survivors of Critical Illness
Authors: Y. F. Philpotts1, X. Ma2, M. R. Anderson1, M. Hua2, M. R. Baldwin1; 1Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY, United States, 2Division of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, NY, United States.
Rationale: Access to care and outcomes for several diseases have been shown to differ by whether older (age ?65 years) American patients have additional commercial or Medicaid insurance coverage. It is unknown whether mortality differs by type of insurance coverage for the approximate 1.5 million older Americans who annually survive a hospitalization necessitating intensive care.
Objective: To determine whether different types of insurance status are independently associated with a higher 1-year mortality rate among older survivors of critical illness.
Methods: We used the New York Statewide Planning and Research Cooperative System and American Hospital Association Annual Survey to conduct a retrospective cohort study of older (age ?65 years) adults who had their first hospitalization with intensive care and who survived to discharge between January 1, 2010 and December 31, 2014 in New York State.
Measurements and Main Results: The primary outcome was mortality in the first year after hospital discharge. Of the 339,261 survivors of critical illness, 20% died within 1 year of hospital discharge. Compared to those with Medicare and commercial insurance, those with Medicare alone had no difference in 1-year mortality (adjusted hazard ratio [aHR], 1.01; 95% CI, 0.99-1.03), and those with Medicaid had a 7% higher 1-year mortality rate (aHR, 1.07; 95% CI, 1.05-1.09). Compared to whites, blacks had a similar 1-year mortality rate, and Hispanic ethnicity was associated with better 1-year survival (aHR 0.87; 95% CI 0.84-0.89). The association between insurance status and mortality only varied among whites when the analysis was stratified by race. Whites with Medicaid had a 9% higher 1-year mortality rate when compared to those with Medicare and commercial insurance (aHR 1.09; 95% CI, 1.07-1.12). Analyses stratified on discharge location showed that the 1-year adjusted mortality rate did not vary by insurance status, Medicare alone and Medicaid, for those discharged home (aHR 0.99, 95% CI 0.96-1.02 and 0.99, 0.96-1.02), but was substantially greater for Medicaid recipients discharged to skilled-care facilities (aHR 1.18; 95% CI,1.15-1.21).
Conclusions: Mortality in the first year after critical illness is higher among older adults with Medicaid insurance compared to those with Medicare and additional commercial insurance, especially among those discharged to skilled-care facilities. Our findings should prompt future investigations into care disparities at skilled-care facilities that may mediate the higher mortality rates observed among these poor older survivors of critical illness.