TY - JOUR
T1 - Impact of Insurance Status on Outcomes and use of Rehabilitation Services in Acute Ischemic Stroke
T2 - Findings From Get With The Guidelines-Stroke
AU - Medford-Davis, Laura N.
AU - Fonarow, Gregg C.
AU - Bhatt, Deepak L.
AU - Xu, Haolin
AU - Smith, Eric E.
AU - Suter, Robert
AU - Peterson, Eric D.
AU - Xian, Ying
AU - Matsouaka, Roland A.
AU - Schwamm, Lee H.
N1 - Funding Information:
Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi Aventis, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, St. Jude Medical; Trustee: American College of Cardiology; Unfunded Research: FlowCo, PLx Pharma, Takeda. Dr Xu is employed by GWTG. Dr Smith is a member of the GWTG Steering Committee. Dr Suter discloses prior employment by the American Heart Association. Dr Peterson reports serving as principal investigator of the Data Analytic Center for AHA GWTG; receipt of research grants from Johnson & Johnson and Janssen Pharmaceuticals; and serving as a consultant to Bayer, Boehringer Ingelheim, Johnson & Johnson, Medscape, Merck, Novartis, Ortho-McNeil-Janssen, Pfizer, Valeant, Wes-tat, the Cardiovascular Research Foundation, WebMD, and United Healthcare. Dr Xian and Dr Matsouaka are employed by GWTG. Dr Schwamm receives research funding from Patient Centered Outcome Research Center and NINDS, is a member of the GWTG Steering Committee, and chair of the GTWTG stroke clinical workgroup.
Funding Information:
Dr Medford-Davis receives research funding through the Robert Wood Johnson Foundation Clinical Scholars Program. Dr Fonarow receives research funding from Patient Centers Outcome Research Center, is a member of the GWTG Steering Committee, is employed by UCLA, and holds a patent on an endovascular device. Dr Bhatt discloses the following relationships—Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/ Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Vice-Chair), VA CART Research and Publications Committee (Chair); Research Funding: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest
Funding Information:
The research analysis for this study was funded through a grant from the American Heart Association.
PY - 2016/11
Y1 - 2016/11
N2 - 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 inhospital mortality differ by patient insurance status.
AB - 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 inhospital mortality differ by patient insurance status.
KW - Health outcomes
KW - Health policy
KW - Health services research
KW - Insurance
KW - Stroke, ischemic
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U2 - 10.1161/JAHA.116.004282
DO - 10.1161/JAHA.116.004282
M3 - Article
C2 - 27930356
AN - SCOPUS:85032565901
SN - 2047-9980
VL - 5
JO - Journal of the American Heart Association
JF - Journal of the American Heart Association
IS - 11
M1 - e004282
ER -