Insurance status and hospital care for myocardial infarction, stroke, and pneumonia

Avoidance of care: how health-care affordability influenced COVID-19 disease severity and outcomes

In this study we examined the association between payor type, a proxy for health-care affordability, and presenting COVID-19 disease severity among 2108 polymerase chain reaction-positive nonelderly patients admitted to an acute-care hospital between March 1 and June 30, 2020. The adjacent-category logit model was used to fit pairwise odds of individuals' having (1) an asymptomatic-to-mild modified sequential organ failure assessment (mSOFA) score (0-3) versus a moderate-to-severe mSOFA score (4-7) and (2) a moderate-to-severe mSOFA score (4-7) versus a critical mSOFA score (>7). Despite representing the smallest population, Medicare recipients experienced the highest in-hospital death rate (19%), a rate twice that of the privately insured. The uninsured had the highest rate of critical mSOFA score on admission and had twice the odds of presenting with a critical illness when compared with the privately insured (odds ratio = 2.08, P =.03). Because payor type was statistically related to the most severe presentations of COVID-19, we question whether policy changes affecting health-care affordability might have prevented deaths and rationing of scarce resources, such as intensive care unit beds and ventilators.

Association between insurance type and suicide-related behavior among US adults: The impact of the Affordable Care Act

This study examined the association between insurance type and suicidal ideation and attempts among adults in the United States, incorporating a comparative analysis of the pre- and post-Affordable Care Act (ACA) periods. We used a nationally representative, cross-sectional, population-based survey of individuals aged 18 years and older from the 2010-2019 National Survey on Drug Use and Health. The higher rates of suicidal ideation and attempts among Medicaid and uninsured groups compared with those with private insurance. After implementation of the ACA policy, the difference-in-differences analysis showed a significantly reduced risk of suicide in the Medicare group compared with the privately insured group, with no significant differences observed in the other groups. These findings highlight the importance of improving access to mental health services, particularly for those with lower levels of insurance coverage, such as Medicaid and Medicare.

Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis

Background

Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types.

Methods

A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses.

Results

Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007).

Conclusions

Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals

BACKGROUND

International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).

METHODS

We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017-2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors.

RESULTS

Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45-0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients.

CONCLUSION

Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

An Exploratory Analysis of Differential Prescribing of High-Risk Opioids by Insurance Type Among Patients Seen by the Same Clinician

BACKGROUND

Insurance status may influence quality of opioid analgesic (OA) prescribing among patients seen by the same clinician.

OBJECTIVE

To explore how high-risk OA prescribing varies by payer type among patients seeing the same prescriber and identify clinician characteristics associated with variable prescribing DESIGN: Retrospective cohort study using the 2016-2018 IQVIA Real World Data - Longitudinal Prescription PARTICIPANTS: New OA treatment episodes for individuals ≥ 12 years, categorized by payer and prescriber. We created three dyads: prescribers with ≥ 10 commercial insurance episodes and ≥ 10 Medicaid episodes; ≥ 10 commercial insurance episodes and ≥ 10 self-pay episodes; and ≥ 10 Medicaid episodes and ≥ 10 self-pay episodes.

MAIN OUTCOME(S) AND MEASURE(S)

Rates of high-risk episodes (initial opioid episodes with > 7-days' supply or prescriptions with a morphine milliequivalent daily dose >90) and odds of being an unbalanced prescriber (prescribers with significantly higher percentage of high-risk episodes paid by one payer vs. the other payer) KEY RESULTS: There were 88,352 prescribers in the Medicaid/self-pay dyad, 172,392 in the Medicaid/commercial dyad, and 122,748 in the self-pay/commercial dyad. In the Medicaid/self-pay and the commercial-self-pay dyads, self-pay episodes had higher high-risk episode rates than Medicaid (16.1% and 18.4%) or commercial (22.7% vs. 22.4%). In the Medicaid/commercial dyad, Medicaid had higher high-risk episode rates (21.1% vs. 20.4%). The proportion of unbalanced prescribers was 11-12% across dyads. In adjusted analyses, surgeons and pain specialists were more likely to be unbalanced prescribers than adult primary care physicians (PCPs) in the Medicaid/self-paydyad (aOR 1.2, 95% CI 1.16-1.34 and aOR 1.2, 95% CI 1.03-1.34). For Medicaid/commercial and self-pay/commercial dyads, surgeons had lower odds of being unbalanced compared to PCPs (aOR 0.6, 95% CI 0.57-0.66 and aOR 0.6, 95% CI 0.61-0.68).

CONCLUSIONS

Clinicians prescribe high-risk OAs differently based on insurance type. The relationship between insurance and opioid prescribing quality goes beyond where patients receive care.

Adverse Childhood Experiences, health insurance status, and health care utilization in middle adulthood

RATIONALE

Adverse childhood experiences (ACEs) negatively impact health over the life-course. Yet, compared to the robust literature on the consequences for ACEs for health, substantially fewer studies assess the implications of exposure to ACEs for health insurance status and health care utilization in adulthood.

OBJECTIVE

To assess the association between accumulating ACEs and (1) an individual's health insurance status, and (2) usual source of care, as well as examine the mediating role of adult socioeconomic status.

METHODS

Data are from the National Longitudinal Study of Adolescent to Adult Health (N = 8,757). Multinomial logistic regression is used to assess the relationship between ACEs and health insurance status and the usual source of care.

RESULTS

Net of control and mediating variables, accumulating exposure to ACEs -particularly four or more ACEs- is associated with a higher likelihood of being uninsured and utilizing the emergency room as the usual source of care. Adult socioeconomic status including educational attainment, household income, employment status, and being uninsured-in the case of usual source of care-substantially mediates these associations.

CONCLUSION

ACEs carry negative repercussions for health insurance and patterns of healthcare utilization that spans into adulthood, and this is largely driven by poor adult socioeconomic status.

Goals of care changes after acute ischaemic stroke: decision frequency and predictors

OBJECTIVES

Little is known about the factors leading to a change in goals of care (CGC) in patients with an acute ischaemic stroke (AIS). Our aim was to analyse the proportion and outcome of such patients and identify medical predictors of a CGC during acute hospitalisation.

METHODS

We retrospectively reviewed all patients who had an AIS over a 13-year period from the prospectively constructed Acute Stroke Registry and Analysis of Lausanne. We compared patients with a CGC during the acute hospital phase to all other patients and identified associated clinical and radiological variables using logistic regression analysis.

RESULTS

A CGC decision was taken in 440/4264 (10.3%) consecutive patients who had an AIS. The most powerful acute phase predictors of a CGC were transit through the intensive care unit, older age, pre-existing disability, higher stroke severity and initial decreased level of consciousness. Adding subacute phase variables, we also identified active oncological disease, fever and poor recanalisation as predictors. 76.6% of the CGC patients died in the stroke unit and 1.0% of other patients, and 30.5% of patients with a CGC received a palliative care consultation. At 12 months, 93.6% of patients with CGC had died, compared with 10.1% of non-CGC patients.

CONCLUSIONS

Over three-quarters of AIS patients with CGC died in hospital, but less than a third received a palliative care consultation. The identified clinical and radiological predictors of a CGC may allow physicians to initiate timely the decision-making process for a possible CGC.

Payer-Related Sources of Variation in Febrile Infant Management Before and After a National Practice Standardization Initiative

OBJECTIVES

Sources of variation within febrile infant management are incompletely described. In 2016, a national standardization quality improvement initiative, Reducing Excessive Variation in Infant Sepsis Evaluations (REVISE) was implemented. We sought to: (1) describe sociodemographic factors influencing laboratory obtainment and hospitalization among febrile infants and (2) examine the association of REVISE on any identified sources of practice variation.

METHODS

We included febrile infants ≤60 days of age evaluated between December 1, 2015 and November 30, 2018 at Pediatric Health Information System-reporting hospitals. Patient demographics and hospital characteristics, including participation in REVISE, were identified. Factors associated with variation in febrile infant management were described in relation to the timing of the REVISE initiative.

RESULTS

We identified 32 572 febrile infants in our study period. Pre-REVISE, payer-type was associated with variation in laboratory obtainment and hospitalization. Compared with those with private insurance, infants with self-pay (adjusted odds ratio [aOR] 0.43, 95% confidence interval [95% CI] 0.22-0.5) or government insurance (aOR 0.67, 95% CI 0.60-0.75) had lower odds of receiving laboratories, and self-pay infants had lower odds of hospitalization (aOR 0.38, 95% CI 0.28-0.51). Post-REVISE, payer-related disparities in care remained. Disparities in care were not associated with REVISE participation, as the interaction of time and payer was not statistically different between non-REVISE and REVISE centers for either laboratory obtainment (P = .09) or hospitalization (P = .67).

CONCLUSIONS

Payer-related care inequalities exist for febrile infants. Patterns in disparities were similar over time for both non-REVISE and REVISE-participating hospitals. Further work is needed to better understand the role of standardization projects in reducing health disparities.

Peeking into a black box, the fairness and generalizability of a MIMIC-III benchmarking model

As artificial intelligence (AI) makes continuous progress to improve quality of care for some patients by leveraging ever increasing amounts of digital health data, others are left behind. Empirical evaluation studies are required to keep biased AI models from reinforcing systemic health disparities faced by minority populations through dangerous feedback loops. The aim of this study is to raise broad awareness of the pervasive challenges around bias and fairness in risk prediction models. We performed a case study on a MIMIC-trained benchmarking model using a broadly applicable fairness and generalizability assessment framework. While open-science benchmarks are crucial to overcome many study limitations today, this case study revealed a strong class imbalance problem as well as fairness concerns for Black and publicly insured ICU patients. Therefore, we advocate for the widespread use of comprehensive fairness and performance assessment frameworks to effectively monitor and validate benchmark pipelines built on open data resources.

Evaluating Equity Through the Social Determinants of Hearing Health

Hearing loss in adults is a significant public health problem throughout the world. Undiagnosed and untreated hearing loss causes a measurable impact on health and social, occupational, and emotional well-being of those affected. In spite of a wide array of health care resources to identify and manage hearing loss, there exist vast disparities in outcomes, as well as access to and utilization of hearing healthcare. Hearing rehabilitation outcomes may vary widely among different populations and there is a pressing need to understand, in a broader sense, the factors that influence equitable outcomes, access, and utilization. These factors can be categorized according to the widely accepted framework of social determinants of health, which is defined by the World Health Organization as "the conditions in which people are born, grow, work, live, and age." According to Healthy People 2030, these determinants can be broken into the following domains: healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment. This article defines these domains and examines the published research and the gaps in research of each of these domains, as it pertains to hearing health and healthcare. Herein, we review foundational sources on the social determinants of health and hearing-related research focused on the topic. Further consideration is given to how these factors can be evaluated in a systematic fashion and be incorporated into translational research and hearing health care.

Racial and Socioeconomic Disparities in Out-Of-Hospital Cardiac Arrest Outcomes: Artificial Intelligence-Augmented Propensity Score and Geospatial Cohort Analysis of 3,952 Patients

Introduction

Social disparities in out-of-hospital cardiac arrest (OHCA) outcomes are preventable, costly, and unjust. We sought to perform the first large artificial intelligence- (AI-) guided statistical and geographic information system (GIS) analysis of a multiyear and multisite cohort for OHCA outcomes (incidence and poor neurological disposition).

Method

We conducted a retrospective cohort analysis of a prospectively collected multicenter dataset of adult patients who sequentially presented to Houston metro area hospitals from 01/01/07-01/01/16. Then AI-based machine learning (backward propagation neural network) augmented multivariable regression and GIS heat mapping were performed.

Results

Of 3,952 OHCA patients across 38 hospitals, African Americans were the most likely to suffer OHCA despite representing a significantly lower percentage of the population (42.6 versus 22.8%; p < 0.001). Compared to Caucasians, they were significantly more likely to have poor neurological disposition (OR 2.21, 95%CI 1.25–3.92; p=0.006) and be discharged to a facility instead of home (OR 1.39, 95%CI 1.05–1.85; p=0.023). Compared to the safety net hospital system primarily serving poorer African Americans, the university hospital serving primarily higher income commercially and Medicare insured patients had the lowest odds of death (OR 0.45, p < 0.001). Each additional $10,000 above median household income was associated with a decrease in the total number of cardiac arrests per zip code by 2.86 (95%CI -4.26- -1.46; p < 0.001); zip codes with a median income above $54,600 versus the federal poverty level had 14.62 fewer arrests (p < 0.001). GIS maps showed convergence of the greater density of poor neurologic outcome cases and greater density of poorer African American residences.

Conclusion

This large, longitudinal AI-guided analysis statistically and geographically identifies racial and socioeconomic disparities in OHCA outcomes in a way that may allow targeted medical and public health coordinated efforts to improve clinical, cost, and social equity outcomes.

Health-related behaviors and health insurance status among US adults: Findings from the 2017 behavioral risk factor surveillance system

Health insurance coverage has increased overtime in the US. This study examined the associations between health insurance status and adoption of health-related behaviors among US adults. Using data collected through the 2017 Behavioral Risk Factor Surveillance System on health insurance coverage and type of insurance, we examined four health-related behaviors (i.e., no tobacco use, nondrinking or moderate drinking, meeting aerobic physical activity recommendations, and having a healthy body weight) and their associations with health insurance status. We conducted log-linear regression analyses to assess the associations with adjustment for potential confounders. Results showed the percentages of adults who reported no tobacco use or meeting physical activity recommendations were significantly higher, and the percentages of adults with a healthy body weight were significantly lower among those who were insured versus uninsured, or among adults with private insurance versus uninsured. Adults with health insurance also had a higher prevalence of reporting all 4 health-related behaviors than those uninsured. These patterns persisted after multivariable adjustment for potential confounders including sociodemographics, routine checkup, and number of chronic diseases. Adults with public insurance were 7% more likely to report no tobacco use than adults who were uninsured. Additionally, adults with private insurance were 8% and 7% more likely to report no tobacco use and meeting physical activity recommendations, respectively, but 10% less likely to report nondrinking or moderate drinking than adults with public insurance. In conclusion, we found significant associations existed between having health insurance coverage and engaging in some health-related behaviors among US adults.

Effect of Insurance Status on Outcomes of Acute Ischemic Stroke Patients Receiving Intra-Arterial Treatment: Results from the Paul Coverdell National Acute Stroke Program

BACKGROUND

Stroke continues to be a leading cause of death and disability in the United States. Rates of intra-arterial reperfusion treatments (IAT) for acute ischemic stroke (AIS) are increasing, and these treatments are associated with more favorable outcomes. We sought to examine the effect of insurance status on outcomes for AIS patients receiving IAT within a multistate stroke registry.

METHODS

We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) from 2014 to 2019 to quantify rates of IAT (with or without intravenous thrombolysis) after AIS. We modeled outcomes based on insurance status: private, Medicare, Medicaid, or no insurance. Outcomes were defined as rates of discharge to home, in-hospital death, symptomatic intracranial hemorrhage (sICH), or life-threatening hemorrhage during hospitalization.

RESULTS

During the study period, there were 486,180 patients with a clinical diagnosis of AIS (mean age 70.6 years, 50.3% male) from 674 participating hospitals in PCNASP. Only 4.3% of patients received any IAT. As compared to private insurance, uninsured patients receiving any IAT were more likely to experience in-hospital death (AOR 1.36 [95% CI 1.07-1.73]). Medicare (AOR 0.78 [95% CI 0.71-0.85]) and Medicaid (AOR 0.85 [95% CI 0.75-0.96]) beneficiaries were less likely but uninsured patients were more likely (AOR 1.90 [95% CI 1.61-2.24]) to be discharged home. Insurance status was not found to be independently associated with rates of sICH.

CONCLUSIONS

Insurance status was independently associated with in-hospital death and discharge to home among AIS patients undergoing IAT.

Differences in High- and Low-Value Cardiovascular Testing by Health Insurance Provider

Background

Quality of care incentives and reimbursements for cardiovascular testing differ between insurance providers. We hypothesized that there are differences in the use of guideline‐concordant testing between Medicaid versus commercial insurance patients <65 years, and between Medicare Advantage versus Medicare fee‐for‐service patients ≥65 years.

Methods and Results

Using data from the Colorado All‐Payer Claims Database from 2015 to 2018, we identified patients eligible to receive a high‐value test recommended by guidelines: assessment of left ventricular function among patients hospitalized with acute myocardial infarction or incident heart failure, or a low‐value test that provides minimal patient benefit: stress testing prior to low‐risk surgery or routine stress testing within 2 years of percutaneous coronary intervention or coronary artery bypass graft surgery. Among 145 616 eligible patients, 37% had fee‐for‐service Medicare, 18% Medicare Advantage, 22% Medicaid, and 23% commercial insurance. Using multilevel logistic regression models adjusted for patient characteristics, Medicaid patients were less likely to receive high‐value testing for acute myocardial infarction (odds ratio [OR], 0.84 [0.73–0.98]; P=0.03) and heart failure (OR, 0.59 [0.51–0.70]; P<0.01) compared with commercially insured patients. Medicare Advantage patients were more likely to receive high‐value testing for acute myocardial infarction (OR, 1.35 [1.15–1.59]; P<0.01) and less likely to receive low‐value testing after percutaneous coronary intervention/ coronary artery bypass graft (OR, 0.63 [0.55–0.72]; P<0.01) compared with Medicare fee‐for‐service patients.

Conclusions

Guideline‐concordant testing was less likely to occur among patients with Medicaid compared with commercial insurance, and more likely to occur among patients with Medicare Advantage compared with fee‐for‐service Medicare. Insurance plan features may provide valuable targets to improve guideline‐concordant testing.

Longitudinal, multidisciplinary, resident-driven intervention to increase immunisation rates for Medicaid, low-income and uninsured patients

Introduction

More payers are closely linking reimbursement to high-value care outcomes such as immunisation rates. Despite this, there remain high rates of pneumonia and influenza-related hospitalisations generating hospital expenditures as high as $11 000 per hospitalisation. Vaccinating the public is an integral part of preventing poor health and utilisation outcomes and is particularly relevant to high-risk patients. As part of a multidisciplinary effort between family and internal medicine residency programmes, our goal was to improve vaccination rates to an average of 76% of eligible Medicaid, low-income and uninsured (MLIU) patients at an academic primary care practice.

Methods

The quality improvement project was completed over 3 months by three primary care resident groups. The setting was a suburban academic primary care practice and eligible patients were 18 years of age or older. Our aim was to increase immunisation rates of pneumococcal, influenza, varicella, herpes zoster virus and tetanus and diphtheria vaccination. There were 1690 patients eligible for the vaccination composite metric. Data were derived from the electronic health record and administrative data.

Interventions

Cohort 1 developed an initial intervention that consisted of a vaccine questionnaire for patients to complete while in the waiting room. Cohort 2 modified questionnaire after reviewing results from initial intervention. Cohort 3 recommended elimination of questionnaire and implementation of a bundled intervention approach.

Results

There were minimal improvements in patient immunisation rates after using a patient-directed paper questionnaire. After implementation of multiple interventions via an improvement bundle, there were improvements in immunisation rates which were sustained and the result of special cause variation.

Conclusion

A key to improving immunisation rates for MLIU patients in this clinic was developing relationships with faculty and staff stakeholders. We received feedback from all the medical staff and then applied it to the interventions and made an impact in the average of vaccinations.

Ethnicity and insurance status predict metastatic disease presentation in prostate, breast, and non-small cell lung cancer

Background

Ethnicity and insurance status have been shown to impact odds of presenting with metastatic cancer, however, the interaction of these two predictors is not well understood. We evaluate the difference in odds of presenting with metastatic disease in minorities compared to white patients despite access to the same insurance across three common cancer types.

Methods

Using the National Cancer Database, a multilevel logistic regression model that estimated the odds of metastatic disease was fit, adjusting for covariates including year of diagnosis, ethnicity, insurance, income, and region. We included adults diagnosed with metastatic prostate, non–small cell lung cancer (NSCLC), and breast cancer from 2004 to 2015.

Results

The study cohort consisted of 1 191 241 prostate cancer (PCa), 1 310 986 breast cancer (BCa), and 1 183 029 NSCLC patients. Private insurance was the most protective factor against metastatic presentation. Odds of presenting with metastatic disease were 0.190 [95% CI, 0.182‐0.198], 0.616 [95% CI, 0.602‐0.630], and 0.270 [95% CI, 0.260‐0.279] for PCa, NSCLC, and BCa compared to uninsured patients, respectively. Private insurance provided the most significant benefit to non‐Hispanic White PCa patients with 81% reduction in odds of metastatic presentation and conferred the least benefit to African‐American NSCLC patients at 30.4% reduction in odds of metastatic presentation.

Conclusions

Insurance status provided the single most protective effect against metastatic presentation. This benefit varied for minorities despite similar insurance. Reducing metastatic disease presentation rates requires addressing social barriers to care independent of insurance.

Effects of Medicaid expansion on access, treatment and outcomes for patients with acute myocardial infarction

INTRODUCTION

Uninsured patients have decreased access to care, lower rates of percutaneous coronary intervention (PCI), and worse outcomes after acute myocardial infarction (AMI). The aim of this study was to determine whether expanding insurance coverage through the Affordable Care Act's expansion of Medicaid eligibility affected access to PCI hospitals, rates of PCI, 30-day readmissions, and in-hospital mortality after AMI.

METHODS

Quasi-experimental, difference-in-differences analysis of Medicaid and uninsured patients with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act, and Florida, which did not, from 2010-2015. This study accounts for the early expansion of Medicaid in certain California counties that began as early as July 2011. Main outcomes included rates of admission to PCI hospitals, rates of transfer for patients who initially presented to non-PCI hospitals, rates of PCI, rates of early PCI defined as within 48 hours of hospital admission, in-hospital mortality, and 30-day readmission.

RESULTS

55,991 hospital admissions between 2010-2015 met inclusion criteria. Of these, 32,540 were in California, which expanded Medicaid, and 23,451 were in Florida, which did not. 30-day readmission rates after AMI decreased by an absolute difference of 1.22 percentage points after the Medicaid expansion (95% CI -2.14 to -0.30, P < 0.01). This represented a relative decrease in readmission rates of 9.5% after AMI. No relationship between the Medicaid expansion and admission to PCI hospitals, transfer to PCI hospitals, rates of PCI, rates of early PCI, or in-hospital mortality were observed.

CONCLUSIONS

Hospital readmissions decreased by 9.5% after the Affordable Care Act expanded Medicaid eligibility, although there was no association found between Medicaid expansion and access to PCI hospitals or treatment with PCI. Better understanding the ways that Medicaid expansion might affect care for vulnerable populations with AMI is important for policymakers considering whether to expand Medicaid eligibility in their state.

Prediction of Chronic Disease-Related Inpatient Prolonged Length of Stay Using Machine Learning Algorithms

Objectives

The study aimed to develop and compare predictive models based on supervised machine learning algorithms for predicting the prolonged length of stay (LOS) of hospitalized patients diagnosed with five different chronic conditions.

Methods

An administrative claim dataset (2008-2012) of a regional network of nine hospitals in the Tampa Bay area, Florida, USA, was used to develop the prediction models. Features were extracted from the dataset using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Five learning algorithms, namely, decision tree C5.0, linear support vector machine (LSVM), k-nearest neighbors, random forest, and multi-layered artificial neural networks, were used to build the model with semi-supervised anomaly detection and two feature selection methods. Issues with the unbalanced nature of the dataset were resolved using the Synthetic Minority Over-sampling Technique (SMOTE).

Results

LSVM with wrapper feature selection performed moderately well for all patient cohorts. Using SMOTE to counter data imbalances triggered a tradeoff between the model's sensitivity and specificity, which can be masked under a similar area under the curve. The proposed aggregate rank selection approach resulted in a balanced performing model compared to other criteria. Finally, factors such as comorbidity conditions, source of admission, and payer types were associated with the increased risk of a prolonged LOS.

Conclusions

Prolonged LOS is mostly associated with pre-intraoperative clinical and patient socioeconomic factors. Accurate patient identification with the risk of prolonged LOS using the selected model can provide hospitals a better tool for planning early discharge and resource allocation, thus reducing avoidable hospitalization costs.

The Effect of the Breast Cancer Provider Discussion Law on Breast Reconstruction Rates in New York State

BACKGROUND

New York State passed the Breast Cancer Provider Discussion Law in 2010, mandating discussion of insurance coverage for reconstruction and expedient plastic surgical referral, two significant factors found to affect reconstruction rates. This study examines the impact of this law.

METHODS

A retrospective cohort study of the New York State Planning and Research Cooperative System database to examine breast reconstruction rates 3 years before and 3 years after law enactment was performed. Difference-interrupted time series models were used to compare trends in the reconstruction rates by sociodemographic factors and provider types.

RESULTS

The study included 32,452 patients. The number of mastectomies decreased from 6479 in 2008 to 5235 in 2013; the rate of reconstruction increased from 49 percent in 2008 to 62 percent in 2013. This rise was seen across all median income brackets, races, and age groups. When comparing before to after law enactment, the increase in risk-adjusted reconstruction rates was significantly higher for African Americans and elderly patients, but the disparity in reconstruction rates did not change for other races, different income levels, or insurance types. Reconstruction rates were also not significantly different between those treated in various hospital settings.

CONCLUSIONS

The aim of the Breast Cancer Provider Discussion Law is to improve reconstruction rates through provider-driven patient education. The authors' data show significant change following law passage in African American and elderly populations, suggesting effectiveness of the law. The New York State Provider Discussion Law may provide a template for other states to model legislation geared toward patient-centered improvement of health outcomes.

"We get double slammed!": Healthcare experiences of perceived discrimination among low-income African-American women

BACKGROUND

On account of their racial/ethnic minority status, class, and gender, African-American women of low socioeconomic status are among the least privileged, underserved, and most marginalized groups in the United States. Generally, African Americans continue to experience poorer health outcomes, in which disparities have been attributed to socioeconomic inequities and structural racism. This objective of this study was to explore the lived experiences of low-income African-American women in interacting with the healthcare system and healthcare providers.

METHODS

Twenty-two in-depth one-on-one interviews were conducted with low-income African-American women. The audio-recorded interviews were transcribed verbatim. An inductive content analysis was performed, using an analytical software, Dedoose® to enabled hierarchical coding. Codes were grouped into categories which were further analyzed for similarities that led to the emergence of themes.

RESULTS

A key finding was the experience of discriminatory treatment. The three themes that emerged relevant to this category were (1) perceived discrimination based on race/ethnicity, (2) perceived discrimination based on socioeconomic status, and (3) stereotypical assumptions such as drug-seeking and having sexually transmitted diseases.

CONCLUSION AND RECOMMENDATIONS

Low-income African-American women experience less than satisfactory patient care, where participants attribute to their experience of being stereotyped and their perception of discrimination in the healthcare system and from providers. Patients' experiences within the healthcare system have implications for their healthcare-seeking behaviors and treatment outcomes. Healthcare personnel and providers need to be more aware of the potential for implicit bias toward this population. Healthcare workforce training on culturally responsive patient care approaches and more community engagement will help providers better understand the context of patients from this population and more effectively meet their healthcare needs.

Sex Differences in Acute Myocardial Infarction Hospital Management and Outcomes: Update From Facilities With Comparable Standards of Quality Care

Supplemental digital content is available in the text.

Background:

Acute myocardial infarction (AMI) sex disparities in management and outcomes have long been attributed to multiple factors, although questions regarding their relevance have not been fully addressed.

Objective:

The aim of this study was to identify current factors associated with sex-related AMI management and outcomes disparities in hospitals with comparable quality care standards.

Methods:

This is a cross-sectional study of 299 women and 540 men with AMI discharged in 2013 from 3 southern California hospitals with tertiary cardiac care. Outcomes (adjusted by demographic/clinical variables using multiple logistic regression) included mortality (in-hospital, 30 days), 30-day readmissions, invasive/revascularization procedures, and quality medication performance measures (aspirin, statins/antilipids, β-blockers, angiotensin-converting enzyme inhibitors, <90-minute door-balloon time).

Results:

Performance was similar to the top 10% National Inpatient Quality AMI Measures. Women had similar mortality, 30-day readmission rates, and performance on medication quality measures compared with men; readmissions were higher in patients with County Services/Medicaid or no medical insurance regardless of sex. Women had similar cardiac catheterization and ST-segment elevation myocardial infarction percutaneous coronary intervention rates but significantly less percutaneous coronary intervention for non–ST-segment elevation myocardial infarction (39.1% vs 52.1%, P = .008) and coronary artery bypass graft (6.7% vs 14.1%, P < .001) than men.

Conclusions:

Women with AMI had similar early mortality, 30-day readmissions and quality performance measures compared with men across hospitals with current quality care standards. Type of medical insurance influenced readmission rates for both sexes. Sex disparities in coronary revascularization procedures were likely determined by differences in AMI type and coronary disease vascular expression.

Association of Hospital Racial Composition and Payer Mix With Mortality in Acute Coronary Syndrome

Background Patient characteristics insufficiently explain disparities in cardiovascular outcomes among hospitalized patients, suggesting a role for community or hospital-level factors. Here, we evaluate the association of hospital racial composition and payer mix with all-cause inpatient mortality for patients hospitalized with acute coronary syndrome (ACS). Methods and Results Using the National Inpatient Sample, we identified adult hospitalizations from 2014 with a primary diagnosis of ACS (n=550 005). We divided National Inpatient Sample hospitals into quartiles based on percent of minority (black, Hispanic, Asian or Pacific Islander, Native American race/ethnicity) and low-income payer (Medicaid or uninsured) discharges in 2014. We utilized logistic regression to determine whether hospital minority or low-income payer makeup associated with all-cause inpatient mortality among those admitted for ACS . In adjusted models, ACS patients admitted to hospitals with >12.4% to 25.4% (Quartile 2), >25.4% to 44.3% (Q3), and >44.3% (Q4) minority discharges experienced a 14% (OR 1.14, 95% CI 1.06-1.23), 13% (OR 1.13, 95% CI 1.04-1.23), and 15% (OR 1.15, 95% CI 1.04-1.26) increased odds of all-cause inpatient mortality compared with hospitals with ≤12.4% (Q1) minority discharges. ACS patients admitted to hospitals with >18.7% to 25.7% (Q2) and >34.0% (Q4) low-income payer discharges experienced a 9% (OR 1.09, 1.01-1.17) and 9% (OR 1.09, 1.00-1.19) increased odds of all-cause inpatient mortality when compared with hospitals with ≤18.7% (Q1) low-income payer discharges. Conclusions Hospital minority and low-income payer makeup positively associate with odds of all-cause inpatient mortality among patients admitted for acute coronary syndrome.

Risk of health morbidity for the uninsured: 10-year evidence from a large hospital center in Boston, Massachusetts

OBJECTIVE

To investigate the independent contribution of insurance status toward the risk of diagnosis of specific clinical comorbidities for individuals admitted to intensive care unit (ICU).

DESIGN

Retrospective analysis of secondary database.

SETTING

Ten years of public de-identified ICU electronic medical records from a large hospital in USA.

PARTICIPANTS

Patients (18-65 years old) who had private insurance or no insurance were extracted from the database.

MAIN OUTCOME MEASURES

Independent association of insurance status (uninsured vs. privately insured) with the risk of diagnosis of specific clinical comorbidities.

RESULTS

Among 14 268 (from 11 753 patients) admissions to ICU between 2001 and 2012, 96% of them were covered by private insurance. Patients with private insurance had higher proportion of females, married, White race, longer ICU stay and more procedures during stay, and fewer deaths. A lower CCI was observed in uninsured patients. At multivariable analysis, uninsured patients had higher odds of death and of admissions for accidental falls, substance or alcohol abuse.

CONCLUSIONS

Patients with no insurance coverage were at higher risk of death and of admission for physical and substance-related injury. We did not observe a higher risk for acute life-threatening diseases such as myocardial infarction or kidney failure. The lower CCI observed in the uninsured may be explained by under diagnosis or voluntary withdrawal from coverage in the pre-Affordable Care Act era. Replication of findings is warranted in other populations, among those with government-subsidized insurance and in the procedure/prescription domains.

Prevalence, trends, outcomes, and disparities in hospitalizations for nonalcoholic fatty liver disease in the United States

Background

As the frequency of nonalcoholic fatty liver disease (NAFLD) continues to rise in the United States (US) community, more patients are hospitalized with NAFLD. However, data on the prevalence and outcomes of hospitalizations with NAFLD are lacking. We investigated the prevalence, trends and outcomes of NAFLD hospitalizations in the US.

Methods

Hospitalizations with NAFLD were identified in the National Inpatient Sample (2007-2014) by their ICD-9-CM codes, and the prevalence and trends over an 8-year period were calculated among different demographic groups. After excluding other causes of liver disease among the NAFLD cohorts (n=210,660), the impact of sex, race and region on outcomes (mortality, discharge disposition, length of stay [LOS], and cost) were computed using generalized estimating equations (SAS 9.4).

Results

Admissions with NAFLD tripled from 2007-2014 at an average rate of 79/100,000 hospitalizations/year (P<0.0001), with a larger rate of increase among males vs. females (83/100,000 vs. 75/100,000), Hispanics vs. Whites vs. Blacks (107/100,000 vs. 80/100,000 vs. 48/100,000), and government-insured or uninsured patients vs. privately-insured (94/100,000 vs. 74/100,000). Males had higher mortality, LOS, and cost than females. Blacks had longer LOS and poorer discharge destination than Whites; while Hispanics and Asians incurred higher cost than Whites. Uninsured patients had higher mortality, longer LOS, and poorer discharge disposition than the privately-insured.

Conclusions

Hospitalizations with NAFLD are rapidly increasing in the US, with a disproportionately higher burden among certain demographic groups. Measures are required to arrest this ominous trend and to eliminate the disparities in outcome among patients hospitalized with NAFLD.

Association Between State Medicaid Eligibility Thresholds and Deaths Due to Substance Use Disorders

IMPORTANCE

The United States is currently facing an epidemic of deaths related to substance use disorder (SUD), with totals exceeding those due to motor vehicle crashes and gun violence. The epidemic has led to decreased life expectancy in some populations. In recent years, Medicaid eligibility has expanded in some states, and the association of this expansion with SUD-related deaths is yet to be examined.

OBJECTIVE

To examine the association between eligibility thresholds for state Medicaid coverage and SUD-related deaths.

DESIGN, SETTING, AND PARTICIPANTS

Economic evaluation study using a retrospective analysis of state-level data between 2002 and 2015 to determine the association between the Medicaid eligibility threshold and SUD-related deaths, controlling for other relevant policies, state socioeconomic characteristics, fixed effects, and a time trend. Policy variables were lagged by 1 year to allow time for associations to materialize. Data were collected and analyzed from 2016 to 2017.

EXPOSURES

The policy of interest was the state Medicaid eligibility threshold, ie, the highest allowed income that qualifies a person for Medicaid, expressed as a percentage of the federal poverty level. State policies related to mental health, overdose treatment, and law enforcement of drug crimes were included as controls.

MAIN OUTCOMES AND MEASURES

The primary outcome was number of SUD-related deaths, obtained from data provided by the Centers for Disease Control and Prevention.

RESULTS

Across 700 state-year observations, the mean (SD) number of SUD-related deaths was 21.15 (6.05) per 100 000 population. Between 2002 and 2015, the national SUD-related death rate increased from 16.0 to 27.5 per 100 000, while the average Medicaid eligibility threshold increased from 87.2% to 97.1% of the federal poverty level. Over this period, every 100-percentage point increase in the Medicaid eligibility threshold (eg, from 50% to 150% of the federal poverty level) was associated with 1.373 (95% CI, -2.732 to -0.014) fewer SUD-related deaths per 100 000 residents, a reduction of 6.50%. In the 22 states with net contractions in eligibility thresholds between 2005 and 2015, an estimated increase of 570 SUD-related deaths (95% CI, -143 to 1283) occurred. In the 28 states that increased eligibility thresholds, an estimated 1045 SUD-related deaths (95% CI, -209 to 2299) may have been prevented.

CONCLUSIONS AND RELEVANCE

These findings suggest that the overall increase in SUD-related deaths between 2002 and 2015 may have been greater had the average eligibility threshold for Medicaid not increased over this period. Broader eligibility for Medicaid coverage may be one tool to help reduce SUD-related deaths.

Association of health insurance with post-resuscitation care and neurological outcomes after return of spontaneous circulation in out-of-hospital cardiac arrest patients in Korea

BACKGROUND

We investigated the association of health insurance status with post-resuscitation care and neurological recovery in out-of-hospital cardiac arrest (OHCA) and whether the effects changed with age or gender.

METHODS

Adult OHCAs with presumed cardiac etiology who had sustained ROSC from 2013 to 2016 were enrolled from the nationwide OHCA registry of Korea. Insurance status was categorized into 2 groups: National Health Insurance (NHI) and Medical Aid (MA). The endpoints were post-resuscitation coronary reperfusion therapy (CRT), targeted temperature management (TTM), and good neurological recovery (cerebral performance category of 1 or 2). Multivariable logistic regression models and interaction analyses (insurance × age and insurance × gender) were conducted for adjusted odds ratios (aORs) and 95% confidence intervals (CI).

RESULTS

Of a total of 19,865 eligible OHCA patients, 18,119 (91.2%) were covered by NHI and 1746 (8.8%) by MA. The MA group was less likely to receive post-resuscitation CRT and TTM (aOR (95% CI): 0.75 (0.59-0.96) for CRT; 0.71 (0.57-0.89) for TTM) and had worse neurological outcomes (0.71 (0.57-0.89)) compared with the NHI group. In the interaction analyses, MA was associated with less CRT and good neurological recovery in the 45-64 year old group (0.54 (0.37-0.77) for CRT; 0.70 (0.51-0.95) for neurological outcome) and in the male group (0.69 (0.52-0.91) for CRT; 0.77 (0.61-0.97) for TTM; 0.70 (0.53-0.92)) for neurological outcome).

CONCLUSIONS

There were disparities in post-resuscitation care and substantial neurological recovery by health insurance status, and the disparities were prominent in middle-aged adults and males. Increasing health insurance coverage for post-resuscitation care should be considered.

Vertebral Osteomyelitis: A Comparison of Associated Outcomes in Early Versus Delayed Surgical Treatment

Background

The recommended timing of surgical intervention for vertebral osteomyelitis (VO) is controversial; however, most studies are not sufficiently powered. Our goal was to investigate the associated effects of delaying surgery in VO patients on in-hospital complications, neurologic deficits, and mortality.

Methods

Retrospective review of the National Inpatient Sample. Patients who underwent surgery for VO from 1998 to 2013 were identified using codes from the International Classification of Disease, Ninth Revision, Clinical Modification. Patients were stratified into groups based on incremental delay of surgery: 0-day delay (same-day surgery), 1-day delay, 2-day delay, 3- to 6-day delay, 7- to 14-day delay, and 14- to 30-day delay. Univariate analysis compared demographics and outcomes between groups. Multivariate logistic regression models calculated independent predictors of any complication, mortality, and neurologic deficits. A 0-day delay was the reference group.

Results

A total of 34 465 patients were identified. Delayed groups were older (same day: 53.5 vs. 7-14-day delay: 61.1) and had a higher Deyo-Charlson score (same day: 0.4901 vs. 14-30-day delay: 1.66), length of stay (same day: 4.2 vs. 14-30-day delay: 34.04 days), and total charges (same day: $63,390.78 vs. 14-30-day delay: $245,752.4), all P < .001. Delayed groups had higher surgical combined-approach rates (same day: 9.1% vs. 14-30-day delay: 31.5%) and lower anterior-approach rates (same day: 42.4% vs. 14-30-day delay: 24.2%). Delayed groups had increased mortality and complication rates. Regressions showed delayed groups as the strongest independent indicators of any complication (14-30-day delay: odds ratio [OR] 3.384), mortality (14-30-day delay: OR 10.658), and neurologic deficits (14-30-day delay: OR 3.464), all P < .001.

Conclusion

VO patients who operate within 24 hours of admission are more likely to have desirable outcomes. Patients with delayed surgery had a significantly increased risk of developing any complication, mortality, and discharging with neurologic deficits.

Level of Evidence

III.

Clinical Relevance

Medically fit patients may benefit from earlier surgical management in order to reduce risk of postoperative complications, improve outcomes, and reduce overall hospital costs.

Racial/Ethnic Disparities in Readmissions in US Hospitals: The Role of Insurance Coverage

We examine differences in rates of 30-day readmissions across patients by race/ethnicity and the extent to which these differences were moderated by insurance coverage. We use hospital discharge data of patients in the 18 years and above age group for 5 US states, California, Florida, Missouri, New York, and Tennessee for 2009, the latest year prior to the start of Centers for Medicare & Medicaid Services’ Hospital Compare program of public reporting of hospital performance on 30-day readmissions. We use logistic regression models by state to estimate the association between insurance status, race, and the likelihood of a readmission within 30 days of an index hospital admission for any cause. Overall in 5 states, non-Hispanic blacks had a slightly higher risk of 30-day readmissions relative to non-Hispanic whites, although this pattern varied by state and insurance coverage. We found higher readmission risk for non-Hispanic blacks, compared with non-Hispanic whites, among those covered by Medicare and private insurance, but lower risk among uninsured and similar risk among Medicaid. Hispanics had lower risk of readmissions relative to non-Hispanic whites, and this pattern was common across subgroups with private, Medicaid, and no insurance coverage. Uninsurance was associated with lower risk of readmissions among minorities but higher risk of readmissions among non-Hispanic whites relative to private insurance. The study found that risk of readmissions by racial ethnic groups varies by insurance status, with lower readmission rates among minorities who were uninsured compared with those with private insurance or Medicare, suggesting that lower readmission rates may not always be construed as a good outcome, because it could result from a lack of insurance coverage and poor access to care, particularly among the minorities.

Racial and Socioeconomic Disparities in Hysterectomy Route for Benign Conditions

BACKGROUND

The aim of this paper was to explore disparities associated with the route of hysterectomy in the University of Pittsburgh Medical Center (UPMC) health system and to evaluate whether the hysterectomy clinical pathway implementation impacted disparities in the utilization of minimally invasive hysterectomy (MIH).

METHODS

We performed a retrospective medical record review of all the patients who have undergone hysterectomy for benign indications at UPMC-affiliated hospitals between fiscal years (FY) 2012 and 2014.

RESULTS

A total number of 6373 hysterectomy patient cases were included in this study: 88.7% (5653) were European American (EA), 11.02% (702) were African American (AA), and the remaining 0.28% (18) were of other ethnicities. We found that non-EA, women aged 45-60, traditional Medicaid, and traditional Medicare enrollees were more likely to have a total abdominal hysterectomy (TAH). Residence in higher median income zip code (> $61,000) was associated with 60% lower odds of undergoing TAH. Both FY 2013 and 2014 were associated with significantly lower odds of TAH. Logistic regression results from the model for non-EA patients for FY 2012 and FY 2014 demonstrated that FY and zip code income group were not significant predictors of surgery type in this subgroup. Pathway implementation did not reduce racial disparity in MIH utilization.

CONCLUSION

This study demonstrated that there is a significant disparity in MIH utilization, where non-EA and Medicaid/Medicare recipients had higher odds of undergoing TAH. Further research is needed to investigate how care standardization may alleviate healthcare disparities.

Insurance status and 1-year outcomes of stroke and transient ischaemic attack: a registry-based cohort study in China

OBJECTIVE

Although more than 95% of the population is insured by urban or rural insurance programmes in China, little research has been done on insurance-related outcome disparities for patients with acute stroke and transient ischaemic attack (TIA). This study aimed to examine the relationship between insurance status and 1-year outcomes for patients with stroke and TIA.

METHODS

We abstracted 24 941 patients with acute stroke and TIA from the China National Stroke Registry II. Insurance status was categorised as Urban Basic Medical Insurance Scheme (UBMIS), New Rural Cooperative Medical Scheme (NRCMS) and self-payment. The relationship between insurance status and 1-year outcomes, including all-cause death, stroke recurrence and disability, was analysed using the shared frailty model in the Cox model or generalised estimating equation with consideration of the hospital's cluster effect.

RESULTS

About 50% of patients were covered by UBMIS, 41.2% by NRCMS and 8.9% by self-payment. Compared with patients covered by UBMIS, patients covered by NRCMS had a significantly higher risk of all-cause death (9.7% vs 8.6%, adjusted HR: 1.32 (95% CI 1.17 to 1.48), p<0.001), stroke recurrence (7.2% vs 6.5%, adjusted HR: 1.12 (95% CI 1.11 to 1.37), p<0.001) and disability (32.0% vs 26.3%, adjusted OR: 1.29 (95% CI 1.21 to 1.39), p<0.001). Compared with patients covered by UBMIS, self-payment patients had a similar risk of death and stroke recurrence but a higher risk of disability.

CONCLUSIONS

Patients with stroke and TIA demonstrated differences in 1-year mortality, stroke recurrence and disability between urban and rural insurance groups in China.

Sex, race, and insurance status differences in hospital treatment and outcomes following out-of-hospital cardiac arrest

BACKGROUND

Sex, race, and insurance status are associated with treatment and outcomes in several cardiovascular diseases. These disparities, however, have not been well-studied in out-of-hospital cardiac arrest (OHCA).

OBJECTIVE

Our objective was to evaluate the association of patient sex, race, and insurance status with hospital treatments and outcomes following OHCA.

METHODS

We studied adult patients in the 2011-2015 California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database with a "present on admission" diagnosis of cardiac arrest (ICD-9-CM 427.5). Insurance status was classified as private, Medicare, and Medi-Cal/government/self-pay. Our primary outcome was good neurologic recovery at hospital discharge, which was determined by discharge disposition. Secondary outcomes were survival to hospital discharge, treatment at a 24/7 percutaneous coronary intervention (PCI) center, "do not resuscitate" orders within 24 h of admission, and cardiac catheterization during hospitalization. Data were analyzed with hierarchical multiple logistic regression models.

RESULTS

We studied 38,163 patients in the OSHPD database. Female sex, non-white race, and Medicare insurance status were independently associated with worse neurologic recovery [OR 0.94 (0.89-0.98), 0.93 (0.88-0.98), and 0.85 (0.79-0.91), respectively], lower rates of treatment at a 24/7 PCI center [OR 0.89 (0.85-0.93), 0.88 (0.85-0.93), and 0.87 (0.82-0.94), respectively], and lower rates of cardiac catheterization [OR 0.61 (0.57-0.65), 0.90 (0.84-0.97), and 0.44 (0.40-0.48), respectively]. Female sex, white race, and Medicare insurance were associated with DNR orders within 24 h of admission [OR 1.16 (1.10-1.23), 1.14 (1.07-1.21), and 1.25 (1.15-1.36), respectively].

CONCLUSIONS

Sex, race, and insurance status were independently associated with post-arrest care interventions, patient outcomes and treatment at a 24/7 PCI center. More studies are needed to fully understand the causes and implications of these disparities.

Health Insurance and the Use of Peritoneal Dialysis in the United States

BACKGROUND

Many patients in the United States have limited or no health insurance at the time they develop end-stage renal disease (ESRD). We examined whether health insurance limitations affected the likelihood of peritoneal dialysis (PD) use.

STUDY DESIGN

Retrospective cohort analysis of patients from the US Renal Data System initiating dialysis therapy in 2006 through 2012.

SETTING & PARTICIPANTS

We identified socioeconomically similar groups of patients to examine the association between health insurance and PD use. Patients aged 60 to 64 years with "limited insurance" (defined as having Medicaid or no insurance) at ESRD onset were compared with patients aged 66 to 70 years who were dually eligible for Medicare and Medicaid at ESRD onset.

PREDICTOR

Type of insurance coverage at ESRD onset.

OUTCOMES

The likelihoods of receiving PD before dialysis month 4, when all patients qualified for Medicare due to ESRD, and of switching to PD therapy following receipt of Medicare.

RESULTS

After adjusting for observable patient and geographic differences, patients with limited insurance had an absolute 2.4% (95% CI, 1.1%-3.7%) lower probability of PD use by dialysis month 4 compared with patients with Medicare at ESRD onset. The association between insurance and PD use reversed when patients became Medicare eligible; patients with limited insurance had a 3-fold higher rate of switching to PD therapy between months 4 and 12 of dialysis (HR, 2.9; 95% CI, 1.8-4.6) compared with patients with Medicare at ESRD onset.

LIMITATIONS

Because this study was observational, there is a potential for bias from unmeasured patient-level factors.

CONCLUSIONS

Despite Medicare's policy of covering patients in the month that they initiate PD therapy, insurance limitations remain a barrier to PD use for many patients. Educating providers about Medicare reimbursement policy and expanding access to pre-ESRD education and training may help overcome these barriers.

Disparities in Outcomes and Resource Use After Hospitalization for Cardiac Surgery by Neighborhood Income

BACKGROUND

Significant disparities exist between patients of different races and with different family incomes; less is understood regarding community-level factors on outcomes.

METHODS

In this study, we used linked data from the Pediatric Health Information System database and the US Census Bureau to examine associations between median annual household income by zip code and mortality, length of stay, inpatient standardized costs, and costs per day, over and above the effects of race and payer, first for children undergoing cardiac surgery (2005-2015) and then for all pediatric discharges (2012-2015). Median community-level income was examined as continuous and categorical (by quartile) predictors. Hierarchical logistic and censored linear regression models were constructed. To these models, patient and surgical characteristics, year, race, payer, state, urban or rural designation, and center fixed effects were added.

RESULTS

We identified 101 013 cardiac surgical (and 857 833 total) hospitalizations from 46 institutions. Children from the lowest-income neighborhoods who were undergoing cardiac surgery had 1.18 times the odds of mortality (95% confidence interval [CI]: 1.03 to 1.35), 7% longer lengths of stay (CI: 1% to 14%), and 7% higher standardized costs (CI: 1% to 14%) than children from the highest-income neighborhoods. Results for all children were similar, both with and without any major chronic conditions. The effects of neighborhood were only partially explained by differences in race, payer, or the centers at which patients received care. There were no differences in costs per day.

CONCLUSIONS

Children from lower-income neighborhoods are at increased risk of mortality and use more resource intensive care than children from higher-income communities, even after accounting for disparities between races, payers, and centers.

Health Literacy and Hospital Length of Stay: An Inpatient Cohort Study

BACKGROUND

Associations between low health literacy (HL) and adverse health outcomes have been well documented in the outpatient setting; however, few studies have examined associations between low HL and in-hospital outcomes.

OBJECTIVE

To compare hospital length of stay (LOS) among patients with low HL and those with adequate HL.

DESIGN

Hospital-based cohort study.

SETTING

Academic urban tertiary-care hospital.

PATIENTS

Hospitalized general medicine patients.

MEASUREMENTS

We measured HL using the Brief Health Literacy Screen. Severity of illness and LOS were obtained from administrative data. Multivariable linear regression controlling for illness severity and sociodemographic variables was employed to measure the association between HL and LOS.

RESULTS

Among 5540 participants, 20% (1104/5540) had low HL. Participants with low HL had a longer average LOS (6.0 vs 5.4 days, P < 0.001). Low HL was associated with an 11.1% longer LOS (95% confidence interval [CI], 6.1%-16.1%; P < 0.001) in multivariate analysis. This effect was significantly modified by gender (P = 0.02). Low HL was associated with a 17.8% longer LOS among men (95% CI, 10.0%-25.7%; P < 0.001), but only a 7.7% longer LOS among women (95% CI, 1.9%-13.5%; P = 0.009).

CONCLUSIONS

In this single-center cohort study, low HL was associated with a longer hospital LOS. The findings suggest that the adverse effects of low HL may extend into the inpatient setting, indicating that targeted interventions may be needed for patients with low HL. Further work is needed to explore these negative consequences and potential mitigating factors.

Nationwide trends of clinical characteristics and economic burden of emergency department visits due to acute ischemic stroke

We aimed to provide estimates of the volume and associated charges of acute ischemic stroke (AIS) visits in the US, as well as to assess predictors of patient disposition following an emergency department (ED) visit for AIS. Our study was conducted using the 2010–2013 data from the Nationwide Emergency Department Sample. We identified adult visits with AIS as the primary diagnosis. A generalized linear model was used to calculate mean charges per visit after adjusting for covariates. Multinomial logistic regression was used to assess predictors of patient disposition following an ED visit for AIS. The national incidence did not appreciably change over time, increasing from 26.4 to 27.0 visits per 10,000 adults. Adjusted mean charges per event were highest in the West, increasing from $3,761 in 2010 to $4,575 in 2013. Multinomial logistic regression showed that older age was associated with increased likelihood of both hospital admission and mortality in the ED, while male sex was associated with lower odds of mortality in the ED. Despite improvements in primary and secondary prevention of cardiovascular disease, AIS remains a significant burden on the health care system with a high volume of ED visits and increasing charges for care.

Insurance status, inhospital mortality and length of stay in hospitalised patients in Shanxi, China: a cross-sectional study

OBJECTIVES

To determine insurance-related disparities in hospital care for patients with acute myocardial infarction (AMI), heart failure (HF) and pneumonia.

SETTING AND PARTICIPANTS

A total of 22 392 patients with AMI, 8056 patients with HF and 17 161 patients with pneumonia were selected from 31 tertiary hospitals in Shanxi, China, from 2014 to 2015 using the International Classification of Diseases, Tenth Revision codes. Patients were stratified by health insurance status, namely, urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), new cooperative medical scheme (NCMS) and self-payment.

OUTCOME MEASURES

Inhospital mortality and length of stay (LOS).

RESULTS

The highest unadjusted inhospital mortality rate was detected in NCMS patients independent of medical conditions (4.7%, 4.4% and 11.1% for AMI, HF and pneumonia, respectively). The lowest unadjusted inhospital mortality rate and the longest LOS were observed in UEBMI patients. After controlling patient-level and hospital-level covariates, the adjusted inhospital mortality was significantly higher for NCMS and self-payment among patients with AMI, for NCMS among patients with HF and for URBMI, NCMS and self-payment among patients with pneumonia compared with UEBMI. The LOS of the URBMI, NCMS and self-payment groups was significantly shorter than that of the UEBMI group.

CONCLUSION

Insurance-related disparities in hospital care for patients with three common medical conditions were observed in this study. NCMS patients had significantly higher adjusted inhospital mortality and shorter LOS compared with UEBMI patients. Policies on minimising the disparities among different insurance schemes should be established by the government.

Update on quality of care in Hispanics and other racial-ethnic groups in the United States discharged with the diagnosis of Acute Myocardial Infarction in 2013

BACKGROUND

Disparities in Acute Myocardial Infarction (AMI) care and outcomes have been frequently reported in racial-ethnic minorities in the U.S. Some studies have attributed disparities in Hispanics and other minorities to lower quality of services at hospitals where they seek care. Current information from hospitals with large Hispanic representations and updated quality resources is needed.

METHODS

Retrospective observational study of 839 AMI patients discharged in 2013 from three Southern California Hospitals (A, B, C) with tertiary cardiac care level. Non-Hispanic Whites (NHW) and Hispanics (H) were the larger racial-ethnic groups (68.3%), and the comparison of these two groups constitutes the focus of the study. Mortality, 30day readmissions, medication/performance measures (PRx); aspirin, statins/anti-lipids, beta-blockers, ACEI/ARB for LV systolic dysfunction, <90min door-balloon time, and revascularization procedures were compared between hospitals, NHW and H, using Chi-squared tests (χ²), Odds Ratios (OR) with 95% confidence intervals (CI), and Z tests for proportions - independent groups.

RESULTS

No significant differences in hospital, 30day mortality, PRx or procedures were observed between NHW, H and other racial-ethnic minority groups, or hospitals. Hospital C had 47.3% H and Hospitals A+B 14.6% (p<0.001, effect size=0.430). AMI performance measures exceeded 2013 national rates across all facilities. NHW had more private/commercial insurance (52.5% vs. 25.4%, OR 3.24, 95% CI 2.19-4.80, p<0.001) than H.

CONCLUSIONS

Equitable access to quality hospital services in three Southern California hospitals offset previously reported disparities in AMI management in Hispanics. These results may not necessarily reflect the reality of AMI care for Hispanics in other U.S. regions.

Differences in Use of High-quality and Low-quality Hospitals Among Working-age Individuals by Insurance Type

BACKGROUND

Research suggests that individuals with Medicaid or no insurance receive fewer evidence-based treatments and have worse outcomes than those with private insurance for a broad range of conditions. These differences may be due to patients' receiving care in hospitals of different quality.

RESEARCH DESIGN

We used the Healthcare Cost and Utilization Project State Inpatient Databases 2009-2010 data to identify patients aged 18-64 years with private insurance, Medicaid, or no insurance who were hospitalized with acute myocardial infarction, heart failure, pneumonia, stroke, or gastrointestinal hemorrhage. Multinomial logit regressions estimated the probability of admissions to hospitals classified as high, medium, or low quality on the basis of risk-adjusted, in-hospital mortality.

RESULTS

Compared with patients who have private insurance, those with Medicaid or no insurance were more likely to be minorities and to reside in areas with low-socioeconomic status. The probability of admission to high-quality hospitals was similar for patients with Medicaid (23.3%) and private insurance (23.0%) but was significantly lower for patients without insurance (19.8%, P<0.01) compared with the other 2 insurance groups. Accounting for demographic, socioeconomic, and clinical characteristics did not influence the results.

CONCLUSIONS

Previously noted disparities in hospital quality of care for Medicaid recipients are not explained by differences in the quality of hospitals they use. Patients without insurance have lower use of high-quality hospitals, a finding that needs exploration with data after 2013 in light of the Affordable Care Act, which is designed to improve access to medical care for patients without insurance.

Impact of state medicaid expansion status on length of stay and in-hospital mortality for general medicine patients at US academic medical centers

BACKGROUND

Medicaid is often associated with longer hospitalizations and higher in-hospital mortality than other insurance types.

OBJECTIVE

To characterize the impact of state Medicaid expansion status under the Affordable Care Act (ACA) on payer mix, length of stay (LOS), and in-hospital mortality.

DESIGN/SETTING/PATIENTS

Retrospective cohort study of general medicine patients discharged from academic medical centers (AMCs) within the University HealthSystem Consortium from October 1, 2012 to September 30, 2015.

INTERVENTION/MEASUREMENTS

Hospitals were stratified according to state Medicaid expansion status. The proportion of discharges by primary payer, LOS index, and mortality index were compared between Medicaid-expansion and nonexpansion hospitals before and after ACA implementation. ACA implementation was defined as January 1, 2014, for all states except Michigan, New Hampshire, Pennsylvania, and Indiana, which had unique dates of Medicaid expansion.

RESULTS

We identified 3,144,488 discharges from 156 hospitals in 24 Medicaid-expansion states and Washington, DC, and 1,114,464 discharges from 55 hospitals in 14 nonexpansion states during the study period. Hospitals in Medicaid-expansion states experienced a significant 3.7% increase in Medicaid discharges (P = 0.013) and a 2.9% decrease in uninsured discharges (P < 0.001) after ACA implementation, whereas hospitals in nonexpansion states saw no significant change in payer mix. In a difference-in-differences analysis, the changes in LOS and mortality indices pre- to post-ACA implementation did not differ significantly between hospitals in Medicaid-expansion versus nonexpansion states.

CONCLUSIONS

The differential shift in payer mix between Medicaid-expansion and nonexpansion states under the ACA did not influence LOS or in-hospital mortality for general medicine patients at AMCs in the United States. Journal of Hospital Medicine 2015;11:847-852. © 2015 Society of Hospital Medicine.

Evaluation of the predictors of readmission in Korean patients with heart failure

WHAT IS KNOWN AND OBJECTIVE

Various factors contribute to the high rate of readmission among patients hospitalized with heart failure (HF). Determination of these factors is fundamental to identify potential targets for intervention in hospitalized patients.

METHODS

The retrospective cohort study used a large national insurance database to identify episodes of HF. Clinical information up to 12 months from the index hospitalization was obtained. Depending on their outcome, eligible patients were classified into a 30-day readmission group after discharge or a non-readmission group. Potential predictors of 30-day readmission were categorized by patient, drug therapy and health system utilization factors.

RESULTS AND DISCUSSION

Heart failure was identified in 19 128 inpatients. Of these, 27·6% were readmitted within 30 days after discharge. The mean Charlson comorbidity index (CCI) score was 5·2 ± 2·9 for the readmission group and 4·3 ± 2·5 for the non-readmission group. The strongest predictors included paralysis [adjusted odds ratio (AOR) 2·27, 95% confidence interval (CI) 1·97-2·62], followed by metastatic cancer (AOR 2·22, 95% CI 1·81-2·72) and loop diuretic therapy (AOR 1·52, 95% CI 1·29-1·79). A prescription of ACE inhibitor or angiotensin receptor blocker at discharge was associated with a 17% decreased risk (AOR 0·83, 95% CI 0·77-0·89).

WHAT IS NEW AND CONCLUSIONS

Hospitalized patients with HF have a 30-day all-cause readmission rate exceeding a quarter. Post-discharge care should focus on patients with advanced age, acuity of admission, enrolled medical aid, hospitalization exceeding 14 days, higher CCI score, more than 10 prescription drugs at discharge, presence of several comorbidities and loop diuretic therapy, which are independent predictors for 30-day readmission.

Patient-level costs of major cardiovascular conditions: a review of the international literature

OBJECTIVE

Robust cost estimates of cardiovascular (CV) events are required for assessing health care interventions aimed at reducing the economic burden of major adverse CV events. This review synthesizes international cost estimates of CV events.

METHODS

MEDLINE database was searched electronically for English language studies published during 2007-2012, with cost estimates for CV events of interest - unstable angina, myocardial infarction, heart failure, stroke, and CV revascularization. Included studies provided at least one estimate of patient-level direct costs in adults for any identified country. Information on study characteristics and cost estimates were collected. All costs were adjusted for inflation to 2013 values.

RESULTS

Across the 114 studies included, the average cost was US $6,466 for unstable angina, $11,664 for acute myocardial infarction, $11,686 for acute heart failure, $11,635 for acute ischemic stroke, $37,611 for coronary artery bypass graft, and $13,501 for percutaneous coronary intervention. The ranges for cost estimates varied widely across countries with US cost estimate being at least twice as high as European Union costs for some conditions. Few studies were found on populations outside the US and European Union.

CONCLUSION

This review showed wide variation in the cost of CV events within and across countries, while showcasing the continuing economic burden of CV disease. The variability in costs was primarily attributable to differences in study population, costing methodologies, and reporting differences. Reliable cost estimates for assessing economic value of interventions in CV disease are needed.

Public versus Private Healthcare Systems following Discharge from the ICU: A Propensity Score-Matched Comparison of Outcomes

Purpose. The long-term outcomes of patients after discharge from tertiary ICUs as they relate to the public versus private healthcare systems in Brazil have not yet been evaluated. Materials and Methods. A multicenter prospective cohort study was conducted to compare the all-cause mortality and the physical functional status (PFS) 24 months after discharge from the ICU between adult patients treated in the public and private healthcare systems. A propensity score- (PS-) matched comparison of all causes of mortality and PFS 24 months after discharge from the ICU was performed. Results. In total, 928 patients were discharged from the ICU including 172 (18.6%) patients in the public and 756 (81.4%) patients in the private healthcare system. The results of the PS-matched comparison of all-cause mortality revealed higher mortality rates among the patients of the public healthcare system compared to those of the private healthcare system (47.3% versus 27.6%, P = 0.003). The comparison of the PS-matched Karnofsky performance and Lawton activities of daily living scores between the ICU survivors of the public and private healthcare systems revealed no significant differences. Conclusions. The patients of private healthcare system exhibited significantly greater survival rates than the patients of the public healthcare system with similar PFS following ICU discharge.

Does Using Complementary Health Insurance Affect Hospital Length of Stay? Evidence from Acute Coronary Syndrome Patients

BACKGROUND

Length of stay (LOS) is used as an indicator to show the efficacy of hospitals. An increase in hospitalized days is not cost effective and decreases the efficacy of hospitals. Using insurance has some side effects. One of these side effects is increasing the LOS. In this study we attempt to discover the effects of complementary health insurance (CHI) on LOS in patients with acute coronary syndrome (ACS).

METHODS

In this cross-sectional study, 260 patients were surveyed. By using Poisson regression, the effects of using complementary health insurance on LOS were examined. The effects of confounders were also controlled in the model.

RESULTS

The results of this study demonstrated that the relationship between use of CHI and LOS is direct. In addition, an increase in age and income also increases the LOS. The average LOS was 4.13 days, while it was 5.31 for CHI users, and 3.81 for CHI nonusers.

CONCLUSION

Government budget is restricted and ACS treatments are costly. Decreasing LOS in ACS patients can help to spend the budget more effectively.

Disparity in reimbursement for tuberculosis care among different health insurance schemes: evidence from three counties in central China

Background

Health inequity is an important issue all around the world. The Chinese basic medical security system comprises three major insurance schemes, namely the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Cooperative Medical Scheme (NCMS). Little research has been conducted to look into the disparity in payments among the health insurance schemes in China. In this study, we aimed to evaluate the disparity in reimbursements for tuberculosis (TB) care among the abovementioned health insurance schemes.

Methods

This study uses a World Health Organization (WHO) framework to analyze the disparities and equity relating to the three dimensions of health insurance: population coverage, the range of services covered, and the extent to which costs are covered. Each of the health insurance scheme’s policies were categorized and analyzed. An analysis of the claims database of all hospitalizations reimbursed from 2010 to 2012 in three counties of Yichang city (YC), which included 1506 discharges, was conducted to identify the differences in reimbursement rates and out-of-pocket (OOP) expenses among the health insurance schemes.

Results

Tuberculosis patients had various inpatient expenses depending on which scheme they were covered by (TB patients covered by the NCMS have less inpatient expenses than those who were covered by the URBMI, who have less inpatient expenses than those covered by the UEBMI). We found a significant horizontal inequity of healthcare utilization among the lower socioeconomic groups. In terms of financial inequity, TB patients who earned less paid more. The NCMS provides modest financial protection, based on income. Overall, TB patients from lower socioeconomic groups were the most vulnerable.

Conclusion

There are large disparities in reimbursement for TB care among the three health insurance schemes and this, in turn, hampers TB control. Reducing the gap in health outcomes between the three health insurance schemes in China should be a focus of TB care and control. Achieving equity through integrated policies that avoid discrimination is likely to be effective.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0102-4) contains supplementary material, which is available to authorized users.

Insurance Status and Differences in Treatment and Survival of Testicular Cancer Patients

OBJECTIVE

To explore the relationship between insurance status and differences in treatment and survival of testicular cancer patients. The Surveillance, Epidemiology, and End Results (SEER) database was utilized for this study.

MATERIALS AND METHODS

Between 2007 and 2011, 5986 testicular cancer patients were included in the SEER database. Patients were classified into nonseminoma and seminoma groups. We compared mortality rates, metastasis (M+) at diagnosis, and rates of adjuvant treatments between the uninsured (UI) and insured (I) populations.

RESULTS

Overall, 2.64% of UI vs 1.36% of I died from testicular cancer (P = .025) and 16.73% of UI vs 10.52% of I had M+ at diagnosis (P <.0001). In the nonseminoma group, 4.19% of UI vs 2.79% of I died from testicular cancer (P = .326) and 25.92% of UI vs 18.46% of I had M+ at diagnosis (P = .0007). Also 17.28% of UI vs 20.88% of I had retroperitoneal lymph node dissection (RPLND; P = .1). In the seminoma group, 1.06% of UI vs 0.33% of I died from testicular cancer (P = .030) and 7.43% of UI vs 4.81% of I had M+ at diagnosis (P = .029). Also 34.75% of UI vs 48.4% of I received adjuvant radiation (P = .0083). The lack of health insurance predicted poor survival after adjusting for tumor stage, receiving adjuvant radiation or RPLND.

CONCLUSION

UI testicular cancer patients present with more advanced cancer stages and have higher mortality rates than I patients. UI seminoma patients received less adjuvant radiation. This may be related to lack of access to care or more advanced cancer stage at diagnosis.

Differences in the rates of patient safety events by payer: implications for providers and policymakers

BACKGROUND

The reduction of adverse patient safety events and the equitable treatment of patients in hospitals are clinical and policy priorities. Health services researchers have identified disparities in the quality of care provided to patients, both by demographic characteristics and insurance status. However, less is known about the extent to which disparities reflect differences in the places where patients obtain care, versus disparities in the quality of care provided to different groups of patients in the same hospital.

OBJECTIVE

In this study, we examine whether the rate of adverse patient safety events differs by the insurance status of patients within the same hospital.

METHODS

Using discharge data from hospitals in 11 states, we compared risk-adjusted rates for 13 AHRQ Patient Safety Indicators by Medicare, Medicaid, and Private payer insurance status, within the same hospitals. We used multivariate regression to assess the relationship between insurance status and rates of adverse patient safety events within hospitals.

RESULTS

Medicare and Medicaid patients experienced significantly more adverse safety events than private pay patients for 12 and 7 Patient Safety Indicators, respectively (at P < 0.05 or better). However, Medicaid patients had significantly lower event rates than private payers on 2 Patient Safety Indicators.

CONCLUSIONS

Risk-adjusted Patient Safety Indicator rates varied with patients' insurance within the same hospital. More research is needed to determine the cause of differences in care quality received by patients at the same hospital, especially if quality measures are to be used for payment.

Association of Insurance Status with Stroke-Related Mortality and Long-term Survival after Stroke

BACKGROUND

Lack of insurance is a barrier to optimal stroke risk factor control but data on its long-term impact on stroke outcomes are sparse. We assessed the association between health insurance and long-term mortality after stroke.

METHODS

Using data from the National Health and Nutrition Examination Surveys 1999-2004 with follow-up mortality assessment through 2006, we examined the independent effect of health insurance on (1) stroke mortality among all adult participants (n = 15,049) and (2) vascular and all-cause mortality rates among participants with self-reported stroke (n = 563).

RESULTS

Among individuals without a previous stroke, uninsured individuals aged less than 65 years were more likely to die of stroke than those with insurance (adjusted hazard ratio [HR], 3.13; 95% confidence interval [CI], .96-10.23); however, among those aged 65 years or older, those with private insurance, private plus Medicare, or Medicare plus Medicaid had similar risk of stroke mortality when compared to those with Medicare alone. Stroke survivors aged 65 years or older with private insurance were less likely to die from vascular causes (adjusted HR, .38; 95% CI, .23-.63) compared to those with Medicare alone. For stroke survivors aged less than 65 years, uninsured individuals had similar all-cause mortality rates compared to their counterparts with insurance.

CONCLUSIONS

Insurance status influences risk of dying from a stroke in the general population, as well as long-term mortality rates among stroke survivors in the United States, but these relationships vary by age.