Comparison of the Yield of Colonoscopy among Uninsured Patients Who Benefitted from the Free DC Screen for Life Program and Privately Insured Patients

Abstract Introduction Post-discharge services, such as outpatient wound care, may affect long term health outcomes and post-recovery quality of life. Access to these services may vary according to insurance status and ability to withstand out-of-pocket expenses. Our objective was to compare discharge location between burn patients who were uninsured, publicly insured, or privately insured at the time of their burn unit admissions. We hypothesized that uninsured patients were more likely to be discharged to locations with fewer wound care resources. Methods A retrospective review from July 1, 2015 to November 1, 2019 was performed at an ABA-verified burn center. All inpatient burn admission patients were identified and categorized according to insurance payer type. Patient and burn characteristics were recorded. The primary outcome was discharge location, and secondary outcomes included readmission and outpatient burn care attendance. Results In total, 284 uninsured, 565 publicly insured and 293 privately insured patients were identified. There were no significant differences in TBSA (P=0.3), presence of full thickness burn (P=0.3), inhalation injury (P=0.3), ICU days (P=0.09), ventilator days (P=0.2), or need for grafting (P=0.1). Uninsured patients were found to be younger (P< 0.0001) and more likely to be male (P=0.03). For primary outcome, uninsured patients were more likely to be discharged without ancillary services (self-care) (80.3% vs. 66.7% vs. 66.9%, P< 0.0001). Publicly insured patients were more likely to receive skilled nursing care (1.1% vs. 6.6% vs. 2.4%, P=0.0007). Privately insured patients were more likely to receive homecare (3.2% vs. 5.8% vs. 10.9%, P=0.0005) or transfer to other institutions for ongoing inpatient care (2.5% vs. 5.1% vs. 11.6%, P< 0.0001). For secondary outcomes, there was no difference in burn unit readmission (P=0.5) while uninsured were more likely to follow up in the same institution’s outpatient burn clinic after discharge (82.4% vs. 72.0% vs. 75.4%, P=0.004). Conclusions Despite no differences in burn injury severity, uninsured patients were less likely to receive post-discharge resources. However, these patients were younger, which may partially explain their disproportionate discharge to self-care. Nevertheless, insured patients have greater access to non-emergent medical resources and a broader range of treatment options. Although there were no significant differences in hospital readmission, the long-term implication to differential post-discharge care is unknown. Additional studies are needed to better elucidate if discrepancies in long-term wound healing or perceived quality of life amongst these populations exist.

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Survival Outcomes for US and Canadian Patients Diagnosed with Hodgkin Lymphoma before and after Brentuximab Vedotin Approval for Relapsed/Refractory Disease: A Retrospective Cohort Study

Blood ◽

10.1182/blood-2020-136356 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 3-4

Author(s):

Gwynivere A Davies ◽

John E. Orav ◽

Kristen Brantley

Keyword(s):

Brentuximab Vedotin ◽

Insurance Status ◽

Uninsured Patients ◽

Risk Of Death ◽

Period 2 ◽

Fda Approval ◽

The Us ◽

Insured Patients ◽

Privately Insured

Background: Insurance status impacts access and survival for cancer patients within mixed healthcare systems, such as the US (Walker et al., 2014). Universal healthcare, as in Canada, provides broad coverage, though new drug funding is delayed for financial evaluations given escalating costs of oncologic therapies. Brentuximab Vedotin (BV) was the first FDA approved medication (2011) for Hodgkin lymphoma (HL) since 1977, with a 75% response rate and median overall survival (OS) 40.5 months in patients relapsing post transplant, compared to OS 10.5 to 27.6 months with prior therapies (Chen et al., 2016). Approximately 20% of HL patients develop refractory/relapsed disease, and most proceed to transplant; a further 50% relapse however, thus effective therapy is critical. Given the cost ($232 320 CAD per course; pCODR, 2018), an extensive cost-efficacy analysis was completed in Canada prior to funding, leading to a 3 year delay compared to FDA approval and US funding. We therefore compared OS for US and Canadian patients diagnosed with HL pre/post FDA approval of BV for post-transplant relapse, hypothesizing that 1) survival differences within the US according to insurance would be present and widen after approval and 2) a survival gap would emerge between privately insured US vs. Canadian patients. Methods: A retrospective cohort study was performed of patients 16-64 years diagnosed with classical HL in 2007-2010 (period 1) or 2011-2014 (period 2) from the US SEER and Canadian Cancer Registry (CCR), with vital status updated to November 2016 and December 31, 2014 respectively. A surrogate date for access (FDA approval) was used as neither dataset captures chemotherapy. Exclusion criteria included missing histology, follow-up or insurance data, or post-mortem diagnosis. Log-rank test and Kaplan-Meier analysis compared OS (primary outcome) between groups: in period 2 vs. 1 by US insurance status (aim 1) and including a Canadian/universal category (aim 2). Analysis was performed within each dataset to allow for maximal adjustment utilizing Cox proportional hazards by covariates (age, gender, insurance status, stage, lymphoma subtype, race, ethnicity, marital status within SEER; age, gender, subtype within CCR), then merged using common variables. Secondary outcomes examined 36-month OS (longest calculable given censoring dates) to compare the direction and degree of change in survival between time periods. Results: 12,003 US and 4,210 Canadian patients were included. Demographics were similar, though follow up was shorter for the latter due to censoring date. US patients demonstrated improved survival (crude HR=0.90 (95%CI 0.80-1.02), adjusted HR=0.80 (95%CI 0.71-0.91)), between periods. Canadian patients had a similar reduced risk of death between periods, though this became statistically insignificant after adjustment (crude HR=0.72 (95%CI 0.54-0.95), adjusted HR=0.77 (95%CI 0.59-1.02)). Comparing all patients by country (periods combined) demonstrated a non-significant increased crude risk of death in US vs. Canadian patients (HR 1.13, p=0.059, 95% CI 1.00-1.27). Stratifying US patients by insurance demonstrated stable OS for privately insured, significantly improved OS for Medicaid and non-significantly worse survival for uninsured patients, demonstrating divergence by time likely not solely due to BV access. No difference in OS improvement occurred between periods for privately insured vs. universal patients. In an adjusted model including time period, compared with universal there was increased risk for both uninsured (HR 1.80, p<0.0001, 95% CI 1.46-2.20) and Medicaid patients (HR 2.36, p<0.0001, 95% CI 2.02-2.76), and reduced risk in privately insured patients (HR 0.87, p=0.044, 95% CI 0.77-1.00). Unadjusted 36-month OS quantified divergence according to insurance, with a large (+7.4%) and small (+2.4%) improvement in Medicaid and universal patients respectively, no change in privately insured and worse survival (-4.1%) for uninsured patients. Conclusions: HL survival was worse for Medicaid/uninsured compared to privately/universally insured patients, however all had stable or improved survival in period 2 except uninsured patients. No difference in change between periods for privately or universally insured patients occurred due to delayed access, however robust datasets capturing chemotherapy and comorbidities are needed. Disclosures Davies: Novartis: Honoraria; TEVA: Honoraria.

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Burn Patient Insurance Status Influences Hospital Discharge Disposition and Utilization of Post-Discharge Outpatient Care

Journal of Burn Care & Research ◽

10.1093/jbcr/irab124 ◽

2021 ◽

Author(s):

Ian F Hulsebos ◽

Zachary J Collier ◽

Leigh J Spera ◽

Maxwell B Johnson ◽

Elise M Hulsebos ◽

...

Keyword(s):

Primary Outcome ◽

Wound Care ◽

Post Discharge ◽

Uninsured Patients ◽

Discharge Location ◽

Publicly Insured ◽

Insured Patients ◽

To Receive ◽

Privately Insured

Abstract Post-discharge services, such as outpatient wound care, may affect long term health outcomes and post-recovery quality of life. Access to these services may vary according to insurance status and ability to withstand out-of-pocket expenses. Our objective was to compare discharge location between burn patients who were uninsured, publicly insured, or privately insured at the time of their burn unit admissions. A retrospective review from July 1, 2015 to November 1, 2019 was performed at an ABA-verified burn center. All inpatient burn admission patients were identified and categorized according to insurance payer type. The primary outcome was discharge location, and secondary outcomes included readmission and outpatient burn care attendance. In total, 284 uninsured, 565 publicly insured and 293 privately insured patients were identified. There were no significant differences in TBSA (P=0.3), inhalation injury (P=0.3), ICU days (P=0.09), or need for grafting (P=0.1). For primary outcome, uninsured patients were more likely to be discharged without ancillary services(P<0.0001). Publicly insured patients were more likely to receive skilled nursing care (P=0.0007). Privately insured patients were more likely to receive homecare (P=0.0005) or transfer for ongoing inpatient care (P<0.0001). There was no difference in burn unit readmission (P=0.5); uninsured were more likely to follow up with outpatient burn clinic after discharge (P=0.004). Uninsured patients were less likely to receive post-discharge resources. Uninsured patients receive fewer post-discharge wound care resources which could result in suboptimal long-term results, and diminished return to pre-injury functional status. Increased access to post-discharge resources will provide comprehensive care to more patients.

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Insurance status and hepatocellular carcinoma: A NCDB analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.4_suppl.240 ◽

2019 ◽

Vol 37 (4_suppl) ◽

pp. 240-240

Author(s):

Hibah Ahmed ◽

Aabra Ahmed ◽

Katrina Wolfe ◽

Peter T. Silberstein

Keyword(s):

Hepatocellular Carcinoma ◽

Median Survival ◽

Statistical Significance ◽

Private Insurance ◽

Stage I ◽

Uninsured Patients ◽

Kaplan Meier ◽

Insured Patients ◽

Survival Differences ◽

Privately Insured

240 Background: Typically occurring in patients with chronic liver disease, hepatocellular carcinoma is the most common liver cancer. Our goal was to compare survival of patients with differing insurance types diagnosed with hepatocellular carcinoma identified in the National Cancer Database (NCDB). Methods: We identified 113,159 patients with hepatocellular carcinoma in the NCDB diagnosed between 2004-2014. Patients included were categorized as having no insurance, private insurance, Medicaid, or Medicare were included. Between-insurance survival differences were estimated by the Kaplan-Meier method and associated log-rank tests; Tukey-Kramer adjusted p < .05 indicated statistical significance. Results: Statistically significant survival differences were indicated between all insurance groups (all adjusted p < 0.05), such that privately insured patients had the highest median survival. The discrepancy in survival between uninsured and privately insured patients was the largest (4.6 months vs. 16.9 months, respectively). Medicaid patients on average had a survival of 9.8 months, while Medicare patients had a median survival of 10.0 months. 19% of uninsured patients presented with stage I hepatocellular carcinoma, whereas 30.3% of privately insured patients presented with stage I hepatocellular carcinoma. More uninsured patients did not have surgery of the primary site compared to privately insured patients (87.7% vs. 70.0%, respectively). Likewise, more privately insured patients had a transplant compared to those with Medicaid, Medicare, or those who were uninsured (13.0% vs. 5.7% vs. 5.0% vs. 1.6%, respectively). Conclusions: Our study shows the discrepancies in survival between patients with differing insurance statuses. Of all insurances, those privately insured had the largest median survival. Median survival and percentage surviving. [Table: see text]

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Health insurance status and cancer stage at diagnosis and survival in the United States.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.7026 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 7026-7026

Author(s):

Jingxuan Zhao ◽

Xuesong Han ◽

Leticia Nogueira ◽

Ahmedin Jemal ◽

Michael T. Halpern ◽

...

Keyword(s):

Health Insurance ◽

Cancer Site ◽

Insurance Status ◽

Advanced Stage ◽

Stage At Diagnosis ◽

Uninsured Patients ◽

Health Insurance Status ◽

Access To Health ◽

Insured Patients ◽

Privately Insured

7026 Background: While previous studies demonstrated associations between Medicaid coverage or no health insurance with both advanced stage at cancer diagnosis and worse survival, access to health care in the U.S. has changed substantially in the past decade. This study examined associations of health insurance status with stage at diagnosis and survival among 17 common cancers using recent national data. Methods: We identified 1,427,532 cancer patients aged 18-64 years newly diagnosed with 17 common cancers from the 2010-2013 National Cancer Database. Multivariable logistic regression models were used to examine the distribution of stage at diagnosis by health insurance status (private, Medicare, Medicaid, dual Medicare/Medicaid, and uninsured) overall and for each cancer site. Cox models compared stage-specific survival by health insurance for each site. Results: Compared to privately insured patients, Medicaid and uninsured patients were significantly more likely to be diagnosed with advanced-stage cancer (III/IV) for all the 17 cancers combined (adjusted odds ratio [AOR]: 2.27, 95% confidence interval [95CI]: 2.24-2.29; AOR: 2.39, 95CI: 2.36-2.42, respectively) and for all included cancer sites separately. Medicare and Medicare-Medicaid patients were also more likely to be diagnosed at advanced-stage for all the 17 cancers combined, but results varied by cancer site. Compared to the privately insured patients, worse survival was observed for patients with all other insurance types and uninsured at each stage for all the 17 cancers combined and most cancer sites. For example, among patients diagnosed at stage I, adjusted mortality hazard ratios for Medicare, Medicaid, Medicare-Medicaid, and uninsured patients were 1.72 (95CI: 1.70-1.75), 1.73 (95CI: 1.71-1.76), 2.07 (95CI: 2.02-2.17) and 1.56 (95CI: 1.53-1.58), respectively, compared with privately-insured patients. Conclusions: Patients with non-private insurance were more likely to be diagnosed with cancer at advanced stage and have worse survival. Improving access to health insurance with adequate coverage is crucial for receiving appropriate cancer screening, diagnosis, and quality care.

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596. Clinical outcomes and healthcare utilization in uninsured patients requiring long-term antibiotic therapy

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.790 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S360-S361

Author(s):

Daniel Vo ◽

Yasir Hamad

Keyword(s):

Length Of Stay ◽

Clinical Outcomes ◽

Bacterial Infections ◽

Clinical Characteristics ◽

Joint Infection ◽

Composite Outcome ◽

Oral Antibiotics ◽

Uninsured Patients ◽

Insured Patients ◽

Privately Insured

Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) is frequently indicated in the management of severe bacterial infections. Uninsured patients may more have difficulties accessing OPAT services (compared to those with a payer source) which can lead to prolonged hospitalizations or early discharge with potentially suboptimal therapy. We sought to assess disparities in the care of hospitalized, uninsured patients who had an OPAT indication and to examine subsequent clinical outcomes. Methods We performed a retrospective analysis of consecutive patients admitted to an academic hospital from 09/01/2018-12/31/2018 who received an infectious diseases consultation and had an index diagnosis of endocarditis (IE), Staphylococcus aureus BSI, or bone and joint infection including osteomyelitis, prosthetic joint infection, and septic arthritis identified by ICD-10 code. Clinical data were collected during index admission; outcomes were followed for up to 30 days after discharge. We examined differences in length of stay (LOS), discharge against medical advice (AMA), and composite outcome of death and readmission at 30 days in uninsured and privately insured patients. Results Of 104 patients, 66 (63.5%) were privately insured and 38 (36.5%) were uninsured. Baseline clinical characteristics are presented in Table 1. Uninsured patients were younger (40.9 versus 51.4 years, p< 0.001) and more likely to be African American (55.3% versus 19.7%, p< 0.001). Uninsured patients were more likely to leave AMA (18.4% versus 0%, p=0.001), complete shorter duration of IV antibiotics (p=0.001), and receive oral antibiotics at discharge (15.8% versus 3.0%, p=0.049). Length of stay was numerically longer in this group although not significant (15.5 days versus 10 days, p=0.053). Composite outcome of readmission or death from all cause at 30 days was lower in the uninsured group; however, after adjusting for age, the results were not significant (aOR 0.372, 95% CI 0.106-1.297, p=0.121). Table 1. Demographic and clinical characteristics of privately insured and uninsured patients Conclusion Uninsured patients were more likely to leave AMA, complete shorter duration of IV antibiotics, and receive oral antibiotics at discharge compared with privately insured patients. Thirty-day readmission and death rates were not significantly different among the two groups. Disclosures All Authors: No reported disclosures

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623. Self-Administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) in Uninsured Patients

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.817 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S371-S371

Author(s):

Yasir Hamad ◽

Jaspur Min ◽

Yvonne Burnett

Keyword(s):

Antimicrobial Therapy ◽

Adverse Drug Events ◽

Hospital Length ◽

Clinic Visit ◽

Hospital Length Of Stay ◽

Uninsured Patients ◽

Outpatient Parenteral Antimicrobial Therapy ◽

Joint Infections ◽

Insured Patients ◽

Hospital Days

Abstract Background Uninsured patients requiring long-term intravenous (IV) antimicrobials do not have access to outpatient parenteral antimicrobial therapy (OPAT) and often remain hospitalized for the duration of their treatment, transition to inferior oral antimicrobials, or leave against medical advice. A hospital-supported self-administered OPAT (S-OPAT) program was piloted in uninsured patients to decrease hospital length of stay and improve access to care. Methods Uninsured adult patients requiring IV antimicrobials were enrolled in an S-OPAT pilot study from July 2019 to April 2020. Patients with drug use history or documented non-adherence were excluded. S-OPAT patients attended weekly clinic visits for blood draws, dressing changes, and medication supply. The measured outcomes were hospital days saved, and potential income generated by earlier discharges. The latter was calculated by multiplying the number of hospital days saved by the daily charge for a hospital bed to insured patients. Results Seventeen patients were enrolled in S-OPAT, 14 (82%) were males, 8 (47%) were black, and the mean age was 39 years. The most common indication for OPAT was bone and joint infections in 12 (71%), and most commonly used antibiotic was ceftriaxone in 12 (71%) patients (Table). Early discontinuation occurred in 3 (17%) patients due to clinic visit non-adherence resulted in 2 (12%) and adverse drug events in 1 (6%). Only one (6%) patient had unplanned hospital readmission during OPAT. Transition to S-OPAT resulted in 533 hospital days avoided, and a net saving of approximately $900,000. Conclusion S-OPAT model is safe and can enhance care for uninsured patients while optimizing health-system resources. Table Disclosures All Authors: No reported disclosures

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