Association of insurance status with inpatient treatment for coronary artery disease: findings from the Get With the Guidelines program

Insurance-based Disparities in Outcomes and Extracorporeal Membrane Oxygenation Utilization for Hospitalized COVID-19 Patients

BACKGROUND

The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19.

METHODS

Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased.

RESULTS

Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased.

CONCLUSIONS

Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.

EDITOR’S PERSPECTIVE

Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

BACKGROUND/PURPOSE

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.

METHODS

We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.

RESULTS

Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.

CONCLUSIONS

Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Disparities in the management of non-ST-segment elevation myocardial infarction in the United States

Guidelines recommend managing patients aged ≥75 with non-ST-segment elevation myocardial infarction (NSTEMI) similar to younger patients. We analyze disparities in NSTEMI management and compare those ≥80 years to those <80 years. This is a matched case-control study using the 2016 National Inpatient Sample data of adults with NSTEMI receiving percutaneous coronary intervention with drug-eluting stent (PCI-DES) - one artery or no intervention. We included the statistically significant variables in univariate analysis in exploratory multivariate logistic regression models. Total sample included 156,328 patients, out of which 43,265 were ≥ 80 years, and 113,048 were < 80 years. Patients ≥80 years were more likely to not have an intervention (73.3%) when compared to those <80 (44.1%), P < 0.0005. Regardless of age, PCI-DES-one artery improved survival compared to no intervention (Age < 80: OR 0.230, 95% CI 0.189-0.279, and ≥ 80: OR 0.265, 95% CI 0.195-0.361, P < 0.0005). Women (OR 0.785, 95% CI 0.766-0.804, P < 0.0005) and non-white race (OR 0.832, 95% CI 0.809-0.855, P < 0.0005) were less likely to receive an intervention. Non-Medicare/Medicaid insurance was associated with 40% lower likelihood of dying in <80 age group (OR 0.596, 95% CI 0.491-0.724, P < 0.0005), and 16% higher chance of intervention overall (OR 1.160, 95% CI 1.125-1.197, P < 0.0005). Patients aged ≥80 with NSTEMI were 29% less likely to receive an intervention compared to patients aged <80, even though patients >80 derived similar mortality benefits from the intervention. There were gender, payor, and race-based disparities in NSTEMI management in 2016.

Association of State Medicaid Expansion With Quality of Care and Outcomes for Low-Income Patients Hospitalized With Acute Myocardial Infarction

Importance

Lack of insurance is associated with worse care and outcomes among adults hospitalized for acute myocardial infarction (AMI). It is unclear whether states' decision to expand Medicaid eligibility under the Patient Protection and Affordable Care Act in 2014 were associated with improved quality of care and outcomes among low-income patients hospitalized with AMI.

Objective

To investigate whether rates of uninsurance, quality of care, and outcomes changed among patients hospitalized for AMI 3 years after states elected to expand Medicaid compared with nonexpansion states.

Design, Setting, and Participants

Retrospective cohort study completed at hospitals participating in National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry. Participants were patients younger than 65 years hospitalized for AMI from January 1, 2012, to December 31, 2016.

Exposures

State Medicaid expansion in 2014.

Main Outcomes and Measures

Rates of uninsured and Medicaid-insured hospitalizations for AMI in states that expanded Medicaid vs those that did not. Comparison of in-hospital care quality, procedure use, and mortality between expansion and nonexpansion states for the years prior to and after Medicaid expansion. Hierarchical logistic regressions models were used to assess the association between Medicaid expansion and outcomes.

Results

The initial cohort included 325 343 patients. Uninsured AMI hospitalizations declined in expansion states (18.0% [4395 of 24 358 hospitalizations] to 8.4% [2638 of 31 382 hospitalizations]) and more modestly in nonexpansion states (25.6% [7963 of 31 137 hospitalizations] to 21.1% [8668 of 41 120 hospitalizations]) from 2012 to 2016 (P < .001 difference in trend expansion vs nonexpansion). Medicaid coverage increased from 7.5% (1818 of 24 358 hospitalizations) to 14.4% (4502 of 31 382 hospitalizations) in expansion states and 6.2% (1924 of 31 137 hospitalizations) to 6.6% (2717 of 41 120 hospitalizations) in nonexpansion states (P < .001). The low-income cohort included 55 737 patients across 765 sites. In expansion states, low-income adults' odds of receipt of defect-free care increased (76.3% to 75.9%, adjusted odds ratio 1.11; 95% CI, 1.02-1.21) but to a lesser degree than in nonexpansion states (72.8% to 74.5%, adjusted odds ratio, 1.38; 95% CI, 1.30-1.47; P for interaction < .001). There was no change in use of most procedures (ie, percutaneous coronary intervention for non-ST-segment elevation myocardial infarction) in expansion compared with nonexpansion states. Improvement in in-hospital mortality was similar between expansion and nonexpansion states (3.2% to 2.8%, adjusted odds ratio, 0.93; 95% CI, 0.77-1.12 vs 3.3% to 3.0%, adjusted odds ratio, 0.85; 95% CI, 0.73-0.99; P for interaction = .48).

Conclusions and Relevance

Medicaid expansion was associated with a significant reduction in rates of uninsurance among patients hospitalized with AMI. Quality of care and outcomes did not improve among low-income adults in expansion compared with nonexpansion states. Hospital care for AMI may be less sensitive to insurance than has been recognized in the past.

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.

Global geographical variation in patient characteristics in percutaneous coronary intervention clinical trials: A systematic review and meta-analysis

BACKGROUND

We sought to determine whether there are differences in enrolled patients' risk factors in published percutaneous coronary intervention (PCI) trials between various continents.

METHODS

We systematically identified clinical trials evaluating PCI interventions through PubMed. We reviewed 701 studies between 1990 and 2014 from North America (N=135), Europe (N=403), and Asia (N=163), examining the prevalence of cardiovascular risk factors-hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HL), smoking, sex, and body mass index. We performed meta-regression with random- and mixed-effects models to compare patient baseline characteristics between continents and linear meta-regression analysis to test trends over time.

RESULTS

In meta-regression with random-effects model, North American trials recruited the lowest proportion of male participants (71.32%), followed by Asian (74.41%) and European trials (76.47%; P<.0001). North American trials enrolled the highest proportion of patients with HTN (63.17%, P=.0035) and HL (63.72%, P<.0001), whereas Asia enrolled the highest proportion of DM patients (29.64%, P<.0001) and smoking (38.41%, P=.0144). When adjusting for other moderators such as publication date, body mass index, and sex in meta-regression with mixed-effects model, age was significantly positively correlated with HTN, HL, DM, and smoking (P<.001). Body mass index was significantly higher in Europe and North America than in Asia. All enrollment risk factors demonstrated (β<0.02) statistically significant temporal trends over time, except for sex.

CONCLUSIONS

There are major continental differences in risk factors among patients enrolled in PCI trials from various continents. Clinical trial results may not be applicable to patient populations from another region.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY PROTOCOL FOR STANDARDIZED PRODUCTION OF CLINICAL PRACTICE GUIDELINES, ALGORITHMS, AND CHECKLISTS - 2017 UPDATE

Clinical practice guideline (CPG), clinical practice algorithm (CPA), and clinical checklist (CC, collectively CPGAC) development is a high priority of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). This 2017 update in CPG development consists of (1) a paradigm change wherein first, environmental scans identify important clinical issues and needs, second, CPA construction focuses on these clinical issues and needs, and third, CPG provide CPA node/edge-specific scientific substantiation and appended CC; (2) inclusion of new technical semantic and numerical descriptors for evidence types, subjective factors, and qualifiers; and (3) incorporation of patient-centered care components such as economics and transcultural adaptations, as well as implementation, validation, and evaluation strategies. This third point highlights the dominating factors of personal finances, governmental influences, and third-party payer dictates on CPGAC implementation, which ultimately impact CPGAC development. The AACE/ACE guidelines for the CPGAC program is a successful and ongoing iterative exercise to optimize endocrine care in a changing and challenging healthcare environment.

ABBREVIATIONS

AACE = American Association of Clinical Endocrinologists ACC = American College of Cardiology ACE = American College of Endocrinology ASeRT = ACE Scientific Referencing Team BEL = best evidence level CC = clinical checklist CPA = clinical practice algorithm CPG = clinical practice guideline CPGAC = clinical practice guideline, algorithm, and checklist EBM = evidence-based medicine EHR = electronic health record EL = evidence level G4GAC = Guidelines for Guidelines, Algorithms, and Checklists GAC = guidelines, algorithms, and checklists HCP = healthcare professional(s) POEMS = patient-oriented evidence that matters PRCT = prospective randomized controlled trial.

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.

Impact of Insurance Status on Outcomes and Use of Rehabilitation Services in Acute Ischemic Stroke: Findings From Get With The Guidelines-Stroke

Background

Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government‐sponsored insurance had worse quality of care or in‐hospital outcomes in acute ischemic stroke.

Methods and Results

Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in‐hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines‐Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (<65 years, OR 1.33 [95% CI 1.22‐1.45]; ≥65 years OR 1.54 [95% CI 1.34‐1.75]), and among survivors, were less likely to go to inpatient rehab (<65 OR 0.63 [95% CI 0.6‐0.67]; ≥65 OR 0.56 [95% CI 0.5‐0.63]). In contrast, patients with Medicare and Medicaid were more likely to be discharged to a Skilled Nursing Facility (<65 years OR 2.08 [CI 1.96‐2.2]; OR 2.01 [95% CI 1.91‐2.13]; ≥65 years OR 1.1 [95% CI 1.07‐1.13]; OR 1.41 [95% CI 1.35‐1.46]).

Conclusions

Preventative care prior to ischemic stroke, time to presentation for acute treatment, access to rehabilitation, and in‐hospital mortality differ by patient insurance status.

The association of lacking insurance with outcomes of severe sepsis: retrospective analysis of an administrative database*

OBJECTIVE

Patients with severe sepsis have high mortality that is improved by timely, often expensive, treatments. Patients without insurance are more likely to delay seeking care; they may also receive less intense care.

DESIGN

We performed a retrospective analysis of administrative database-Healthcare Costs and Utilization Project's Nationwide Inpatient Sample-to test whether mortality is more likely among uninsured patients hospitalized for severe sepsis.

PATIENTS

None.

INTERVENTIONS

We used International Classification of Diseases-9th Revision, Clinical Modification, codes indicating sepsis and organ system failure to identify hospitalizations for severe sepsis among patients aged 18-64 between 2000 and 2008. We excluded patients with end-stage renal disease or solid organ transplants because very few are uninsured. We performed multivariate logistic regression modeling to examine the association of insurance status and in-hospital mortality, adjusted for patient and hospital characteristics. We performed subgroup analysis to examine whether the impact of insurance status varied by geographical region; by patient age, sex, or race; or by hospital characteristics such as teaching status, size, or ownership. We used similar methods to examine the impact of insurance status on the use of certain procedures, length of stay, and discharge destination.

MEASUREMENTS AND MAIN RESULTS

There were 1,600,269 discharges with severe sepsis from 2000 through 2008 in the age group 18-64 years. Uninsured people, who accounted for 7.5% of admissions with severe sepsis, had higher adjusted odds of mortality (odds ratio, 1.43; 95% CI, 1.37-1.47) than privately insured people. The higher mortality in uninsured was present in all subgroups and was similar in each year from 2000 to 2008. After adjustment, uninsured individuals had a slightly shorter length of stay than insured people and were less likely to receive five of the six interventions we examined. They were also less likely to be discharged to skilled nursing facilities or with home healthcare after discharge.

CONCLUSIONS

Uninsured are more likely to die following admission for severe sepsis than patients with insurance, even after adjusting for potential confounders. This was not due to a hospital effect or demographic or clinical factors available in our administrative database. Further research should examine the mechanisms that lead to this association.

US health care policy and reform: implications for cardiac electrophysiology

In response to unsustainably rising costs, variable quality and access to health care, and the projected insolvency of vital safety net insurance programs, the federal government has proposed important health policy and regulatory changes in the USA. The US Supreme Court's decision to uphold most of the major provisions of the Affordable Care Act will lead to some of the most sweeping government reforms on entitlements since the creation of Medicare. Furthermore, implementation of new organizational, reimbursement, and health care delivery models will strongly affect the practice of cardiac electrophysiology. In this brief review, we will provide background and context to the problem of rising health care costs and describe salient reforms and their projected impacts on the field and practice of cardiac electrophysiology.

Primary payer status is associated with mortality and resource utilization for coronary artery bypass grafting

BACKGROUND

Medicaid and uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes after coronary artery bypass grafting (CABG) in the United States is dependent on primary payer status.

METHODS AND RESULTS

From 2003 to 2007, 1,250,619 isolated CABG operations were evaluated using the Nationwide Inpatient Sample (NIS) database. Patients were stratified by primary payer status: Medicare, Medicaid, uninsured, and private insurance. Hierarchical multiple regression models were applied to assess the effect of primary payer status on postoperative outcomes. Unadjusted mortality for Medicare (3.3%), Medicaid (2.4%), and uninsured (1.9%) patients were higher compared with private insurance patients (1.1%, P<0.001). Unadjusted length of stay was longest for Medicaid patients (10.9 ± 0.04 days) and shortest for private insurance patients (8.0 ± 0.01 days, P<0.001). Medicaid patients accrued the highest unadjusted total costs ($113 380 ± 386, P<0.001). Importantly, after controlling for patient risk factors, income, hospital features, and operative volume, Medicaid (odds ratio, 1.82; P<0.001) and uninsured (odds ratio, 1.62; P<0.001) payer status independently conferred the highest adjusted odds of in-hospital mortality. In addition, Medicaid payer status was associated with the longest adjusted length of stay and highest adjusted total costs (P<0.001).

CONCLUSIONS

Medicaid and uninsured payer status confers increased risk adjusted in-hospital mortality for patients undergoing coronary artery bypass grafting operations. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors. Possible explanations include delays in access to care or disparate differences in health maintenance.

Effect of Joint National Committee VII report on hospitalizations for hypertensive emergencies in the United States

Approximately 1% to 2% of patients with hypertension will have a hypertensive emergency at some time in their life. However, no data are available on the frequency of hospitalizations for a hypertensive emergency after the publication of the Seventh Joint National Committee (JNC7) on the prevention, detection, evaluation, and treatment of high blood pressure. We sought to explore the changes in the frequency of hospitalizations and in-hospital mortality for hypertensive emergencies before and after the JNC7 report. Using the Nationwide Inpatient Sample from 2000 to 2007, adult patients (aged ≥18 years) who were hospitalized with a diagnosis of a hypertensive emergency were identified through appropriate "International Classification of Diseases, 9th revision, Clinical Modification" codes. A total of 456,259 hospitalizations with the diagnosis of hypertensive emergency occurred from the start of calendar year 2000 to the end of calendar year 2007. After adjusting for the United States census for 2000 and American Community Survey estimates for 2007 for adults, the frequency of hospitalizations with a hypertensive emergency increased in United States adults from 101/100,000 in 2000 to 111/100,000 in 2007, an average increase of about 1.11%. Despite the increase in hospitalizations, the all-cause in-hospital mortality rate decreased from 2.8% in the pre-JNC7 era to 2.6% in the post-JNC7 era (odds ratio 0.91, 95% confidence interval 0.86 to 0.96). In conclusion, the results of the present study have shown that although the number of patients with hypertensive emergency increased from 2000 to 2007, the mortality rates decreased significantly after the JNC7 guidelines.

Impact of insurance and hospital ownership on hospital length of stay among patients with ambulatory care-sensitive conditions

PURPOSE Some studies suggest proprietary (for-profit) hospitals are maximizing financial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines the role of insurance related to length of stay once the patient is in the hospital and risk for mortality, particularly in a for-profit environment. METHODS We undertook an analysis of hospitalizations in the National Hospital Discharge Survey (NHDS) of the 5-year period of 2003 to 2007 for patients aged 18 to 64 years (unweighted n = 849,866; weighted n = 90 million). The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), hospitalizations considered to be preventable, and non-ACSCs. We analyzed the transformed mean length of stay between individuals who had Medicaid or all other insurance types while hospitalized and those who were hospitalized without insurance. This analysis was stratified by hospital ownership. We also examined the relationship between in-hospital mortality and insurance status. RESULTS After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay. Across all hospital types, the mean length of stay for ACSCs was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P <.01). Among hospitalizations for ACSCs, in-hospital mortality rate for individuals with either private insurance or Medicaid was not significantly different from the mortality rate for those without insurance. CONCLUSIONS Patients without insurance have shorter lengths of stay for both ACSCs and non-ACSCs. Future research should examine whether patients without insurance are being discharged prematurely.