Critical Care Outcomes Tied to Insurance Status

http://www.sciencedaily.com/releases/2010/04/100428110814.htm

ScienceDaily (Apr. 29, 2010) — Among the general U.S. population, people who are uninsured are about half as likely to receive critical care services as those with insurance, according to systematic review of the literature by the American Thoracic Society's Health Disparities Group. They also found that once admitted to the hospital intensive care unit, uninsured patients are less likely to have invasive procedures or pulmonary artery catheterizations and more likely to have life support withdrawn.

"Patients in the United States who do not have health insurance and become critically ill receive fewer critical care services and may experience worse clinical outcomes," said J. Randall Curtis, M.D., M.P.H., president of the ATS, and an investigator for the review. "Improving preexisting health care coverage may be one mechanism to reduce such disparities."



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Currently, one-third of the population under the age of 65 is uninsured for a portion of any given year, and the costs of critical care is approaching one percent of the U.S. gross domestic product.

In addition to reduced services and greater discharge delays among uninsured, the review found that while uninsured patients were slightly more likely to be admitted overall, the difference was not statistically significant, those with traumatic injuries were 63 percent as likely to be admitted as those with insurance.

"The finding that the uninsured were more likely to be admitted to the ICU after arriving at the hospital could occur if the uninsured delayed going to a hospital until experiencing a more advanced stage of illness," wrote Robert Fowler, M.D., associate professor of medicine at Sunnybrook Hospital, the University of Toronto, and lead author of the systematic review. "That the uninsured were perhaps less likely to use an ambulance to get to the hospital provides some support for this concept."

Finally, uninsured patients were more likely to face discharge delays.

"Although U.S. hospitals are legally obligated to care for patients who are emergently ill, they are not obligated to be the continuing provider for medically stabilized uninsured patients," Dr. Fowler noted. The increase in discharge delay may be due to the "difficulty in finding healthcare providers or facilities to accept these patients."

Overall, lack of insurance is independently associated with reduced access to care and poorer outcomes. "We found evidence that patients who are critically ill with lesser degrees of insurance coverage receive fewer critical care services compared with those who have more insurance. Developing more comprehensive programs and legislation to improve health coverage for patients who are acutely ill would therefore seem a logical avenue for investigation," the authors conclude.

While increasing access to insurance inevitable raises concerns about costs, the costs of underinsurance are already borne by society at large, as uninsured patients rely more heavily on emergent care, and the ultimate responsibility for unpaid bills falls to the states and ultimately the tax payers. Furthermore, concerns about possible over-usage are not substantiated by research. Recent evidence shows that individuals who move from no insurance to more comprehensive coverage do not use more resources than the consistently and long-term insured.

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