The Insurance Coverage Paradox- Characterizing Outcomes Among Dual-Eligible Hemorrhagic Stroke Patients

Abstract Background: Socioeconomic factors, such as insurance status, have been shown to affect outcomes following emergency injuries. Dual-eligible beneficiaries, receiving both Medicare and Medicaid, constitute a vulnerable population. There is a lack of data on the impact of dual-eligible status on hemorrhagic stroke outcomes. The aim of our study was to compare hemorrhagic stroke outcomes among dual-eligible patients compared to Medicare, Medicaid, privately insured, and no charge (free or charity) patients.Study Design: We conducted a 10-year span retrospective analysis of the National Inpatient Sample. Adult patients who were emergently hospitalized for intracranial hemorrhage were included. Multivariable logistic regression was used to adjust for confounders. Primary clinical outcomes of interest included mortality (in-hospital), complications (any), and favorable discharge (home/home with services).Results: A total of 410,621 patients met inclusion of which 6.8% were dual-eligible. Dual-eligibles had higher odds of in-hospital mortality compared to no-charge (adjusted odds ratio (aOR)=1.61, 95% CI= [1.04 – 2.49]) and increased odds of complications compared to Medicaid (aOR=1.23 [1.11 – 1.37]) and privately insured patients (aOR=1.19 [1.11 – 1.28]), both p<0.001. Dual-eligibles had lower odds of favorable discharge compared to all other groups (all p<0.001), and underwent shorter lengths of stay, an 18% decrease, compared to Medicaid patients (p<0.001). Inflation adjusted admission costs among dual-eligibles were 24% lower compared to Medicaid patients (p<0.001), amounting to a $3,684 decrease in cost.Conclusions: Dual-eligible beneficiaries experience unique health disparities from lower odds of favorable discharge to increased odds of complications and in-hospital mortality compared to other insured and uninsured groups. There is a need to uncover and address unknown sources of disparities to improve emergency treatment of hemorrhagic stroke among dual-eligibles.

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Sex Differences in Ischemic Stroke Outcomes in Patients With Pulmonary Hypertension

Journal of the American Heart Association ◽

10.1161/jaha.120.019341 ◽

2021 ◽

Author(s):

Tiberiu A. Pana ◽

Dana K. Dawson ◽

Mohamed O. Mohamed ◽

Fiona Murray ◽

David L. Fischman ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Sex Differences ◽

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Systemic Hypertension ◽

Stroke Outcomes ◽

Female Patients ◽

Prolonged Hospitalization ◽

The Impact

Background The association between systemic hypertension and cerebrovascular disease is well documented. However, the impact of pulmonary hypertension (PH) on acute ischemic stroke outcomes is unknown despite PH being recognized as a risk factor for acute ischemic stroke. We aimed to determine the association between PH and adverse in‐hospital outcomes after acute ischemic stroke, as well as whether there are sex differences in this association. Methods and Results Acute ischemic stroke admissions from the US National Inpatient Sample between October 2015 and December 2017 were included. The relationship between PH and outcomes (mortality, prolonged hospitalization >4 days, and routine home discharge) was analyzed using logistic regressions adjusting for demographics, comorbidities, and revascularization therapies. Interaction terms between PH and sex and age groups were also included. A total of 221 249 records representative of 1 106 045 admissions were included; 2.9% of patients had co‐morbid PH, and 35.34% of those were male. PH was not associated with in‐hospital mortality (odds ratio [OR], 0.96; 95% CI, 0.86–1.09) but was associated with increased odds of prolonged hospitalization (OR, 1.15; 95% CI, 1.09–1.22) and decreased odds of routine discharge (OR, 0.87; 95% CI, 0.81–0.94) for both sexes. Older patients with PH were significantly less likely to be discharged routinely ( P =0.028) than their younger counterparts. Compared with female patients with PH, men were 31% more likely to die in hospital ( P =0.024). Conclusions PH was not significantly associated with in‐hospital mortality but was associated with prolonged hospitalization and adverse discharge status. Male patients with PH were more likely to die in hospital than female patients.

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Insurance type impacts the economic burden and survival of patients with newly diagnosed glioblastoma

Journal of Neurosurgery ◽

10.3171/2019.3.jns182629 ◽

2020 ◽

Vol 133 (1) ◽

pp. 89-99

Author(s):

Ankush Chandra ◽

Jacob S. Young ◽

Cecilia Dalle Ore ◽

Fara Dayani ◽

Darryl Lau ◽

...

Keyword(s):

Economic Burden ◽

Private Insurance ◽

Hospital Costs ◽

Primary Care Providers ◽

Tumor Diameter ◽

Inpatient Hospital ◽

Lengths Of Stay ◽

Insured Patients ◽

The Impact ◽

Privately Insured

OBJECTIVEGlioblastoma (GBM) carries a high economic burden for patients and caregivers, much of which is associated with initial surgery. The authors investigated the impact of insurance status on the inpatient hospital costs of surgery for patients with GBM.METHODSThe authors conducted a retrospective review of patients with GBM (2010–2015) undergoing their first resection at the University of California, San Francisco, and corresponding inpatient hospital costs.RESULTSOf 227 patients with GBM (median age 62 years, 37.9% females), 31 (13.7%) had Medicaid, 94 (41.4%) had Medicare, and 102 (44.9%) had private insurance. Medicaid patients had 30% higher overall hospital costs for surgery compared to non-Medicaid patients ($50,285 vs $38,779, p = 0.01). Medicaid patients had higher intensive care unit (ICU; p < 0.01), operating room (p < 0.03), imaging (p < 0.001), room and board (p < 0001), and pharmacy (p < 0.02) costs versus non-Medicaid patients. Medicaid patients had significantly longer overall and ICU lengths of stay (6.9 and 2.6 days) versus Medicare (4.0 and 1.5 days) and privately insured patients (3.9 and 1.8 days, p < 0.01). Medicaid patients had similar comorbidity rates to Medicare patients (67.8% vs 68.1%), and both groups had higher comorbidity rates than privately insured patients (37.3%, p < 0.0001). Only 67.7% of Medicaid patients had primary care providers (PCPs) versus 91.5% of Medicare and 86.3% of privately insured patients (p = 0.009) at the time of presentation. Tumor diameter at diagnosis was largest for Medicaid (4.7 cm) versus Medicare (4.1 cm) and privately insured patients (4.2 cm, p = 0.03). Preoperative (70 vs 90, p = 0.02) and postoperative (80 vs 90, p = 0.03) Karnofsky Performance Scale (KPS) scores were lowest for Medicaid versus non-Medicaid patients, while in subgroup analysis, postoperative KPS score was lowest for Medicaid patients (80, vs 90 for Medicare and 90 for private insurance; p = 0.03). Medicaid patients had significantly shorter median overall survival (10.7 months vs 12.8 months for Medicare and 15.8 months for private insurance; p = 0.02). Quality-adjusted life year (QALY) scores were 0.66 and 1.05 for Medicaid and non-Medicaid patients, respectively (p = 0.036). The incremental cost per QALY was $29,963 lower for the non-Medicaid cohort.CONCLUSIONSPatients with GBMs and Medicaid have higher surgical costs, longer lengths of stay, poorer survival, and lower QALY scores. This study indicates that these patients lack PCPs, have more comorbidities, and present later in the disease course with larger tumors; these factors may drive the poorer postoperative function and greater consumption of hospital resources that were identified. Given limited resources and rising healthcare costs, factors such as access to PCPs, equitable adjuvant therapy, and early screening/diagnosis of disease need to be improved in order to improve prognosis and reduce hospital costs for patients with GBM.

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Nutritional Supplementation of Naturally Occurring Vitamin D to Improve Hemorrhagic Stroke Outcomes

Frontiers in Neurology ◽

10.3389/fneur.2021.670245 ◽

2021 ◽

Vol 12 ◽

Author(s):

Rani Ashouri ◽

Madison Fangman ◽

Jordan Brielmaier ◽

Zoe A. Fields ◽

Natalie Campo ◽

...

Keyword(s):

Vitamin D ◽

Vitamin D Deficiency ◽

Hemorrhagic Stroke ◽

Delayed Cerebral Ischemia ◽

Vitamin D Supplementation ◽

Dietary Vitamin ◽

Stroke Incidence ◽

Stroke Outcomes ◽

Increased Risk ◽

The Impact

Vitamin D deficiency, if left untreated, is associated with bone disorders, cardiovascular damage, and an increased risk of ischemic stroke. While there are various nutritional options for the natural intake of vitamin D, we hope to elucidate the potential mechanisms dietary vitamin D may play in hemorrhagic stroke pathology. This scoping review outlines findings from studies relevant to the biochemical activity of vitamin D, the impact of vitamin D deficiency on hemorrhagic stroke outcomes, and the potential benefit of nutritional vitamin D on hemorrhagic stroke outcomes. Here, we analyze the relevant factors that can lead to vitamin D deficiency, and subsequently, a higher risk of hemorrhagic stroke incidence with worsened subsequent outcomes. The neuroprotective mechanisms through which vitamin D works to attenuate hemorrhagic stroke onset and post-stroke outcomes have not yet been thoroughly examined. However, researchers have proposed several potential protective mechanisms, including reduction of blood brain barrier disturbance by inhibiting the production of reactive oxygen species, mitigation of inflammation through a reduction of levels of proinflammatory cytokines, and prevention of cerebral vasospasm and delayed cerebral ischemia following subarachnoid hemorrhage and intracerebral hemorrhage. While more research is needed and there are limitations to vitamin D supplementation, vitamin D as a whole may play a significant role in the dynamics of hemorrhagic stroke. Further research should focus on expanding our understanding of the neuroprotective capacity and mechanisms of vitamin D, as well as how vitamin D supplementation could serve as an effective course of treatment of hemorrhagic strokes.

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Impact of Health Insurance Expansion on the Treatment of Colorectal Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2016.68.5701 ◽

2016 ◽

Vol 34 (34) ◽

pp. 4110-4115 ◽

Cited By ~ 15

Author(s):

Andrew P. Loehrer ◽

Zirui Song ◽

Alex B. Haynes ◽

David C. Chang ◽

Matthew M. Hutter ◽

...

Keyword(s):

Colorectal Cancer ◽

Health Care ◽

Health Care Reform ◽

Private Insurance ◽

Insurance Coverage ◽

The United States ◽

The Third ◽

Insured Patients ◽

The Impact ◽

Privately Insured

Purpose Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States. Lack of insurance coverage has been associated with more advanced disease at presentation, more emergent admissions at time of colectomy, and lower survival relative to privately insured patients. The 2006 Massachusetts health care reform serves as a unique natural experiment to assess the impact of insurance expansion on colorectal cancer care. Methods We used the Hospital Cost and Utilization Project State Inpatient Databases to identify patients with colorectal cancer with government-subsidized or self-pay (GSSP) or private insurance admitted to a hospital between 2001 and 2011 in Massachusetts (n = 17,499) and three control states (n = 144,253). Difference-in-differences models assessed the impact of the 2006 Massachusetts coverage expansion on resection of colorectal cancer, controlling for confounding factors and secular trends. Results Before the 2006 Massachusetts reform, government-subsidized or self-pay patients had significantly lower rates of resection for colorectal cancer compared with privately insured patients in both Massachusetts and the control states. The Massachusetts insurance expansion was associated with a 44% increased rate of resection (rate ratio = 1.44; 95% CI, 1.23 to 1.68; P < .001), a 6.21 percentage point decreased probability of emergent admission (95% CI, −11.88 to −0.54; P = .032), and an 8.13 percentage point increased probability of an elective admission (95% CI, 1.34 to 14.91; P = .019) compared with the control states. Conclusion The 2006 Massachusetts health care reform, a model for the Affordable Care Act, was associated with increased rates of resection and decreased probability of emergent resection for colorectal cancer. Our findings suggest that insurance expansion may help improve access to care for patients with colorectal cancer.

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The Impact of Pregnancy on Hemorrhagic Stroke in Young Women

Cerebrovascular Diseases ◽

10.1159/000490803 ◽

2018 ◽

Vol 46 (1-2) ◽

pp. 10-15 ◽

Cited By ~ 6

Author(s):

Eliza C. Miller ◽

Kathryn M. Sundheim ◽

Joshua Z. Willey ◽

Amelia K. Boehme ◽

Dritan Agalliu ◽

...

Keyword(s):

Risk Factors ◽

Young Women ◽

Hemorrhagic Stroke ◽

Patient Characteristics ◽

Vascular Lesion ◽

Vascular Lesions ◽

Lower Odds ◽

Cerebral Vasoconstriction ◽

The Impact ◽

Prior Stroke

Background: Pregnancy is a sex-specific risk factor for causing hemorrhagic stroke (HS) in young adults. Unique physiological characteristics during pregnancy may alter the relative risk for HS in pregnant/postpartum (PP) women compared to HS in other young women. We compared patient characteristics and HS subtypes between young non-pregnant and PP women. Methods: We reviewed the medical records of all women 18–45 years old admitted to our center with HS from October 15, 2008 through March 31, 2015, and compared patient characteristics and stroke mechanisms using logistic regression. Results: Of the 130 young women with HS during the study period, 111 were non-PP women, and 19 PP women. PP women had lower proportions of vascular risk factors such as hypertension, prior stroke, and smoking, and a higher proportion of migraine (36.8 vs. 14.4%, p = 0.01). After adjusting for hypertension, smoking, migraine, prior stroke and prior myocardial infarction, PP women had lower odds of having an underlying vascular lesion (OR 0.14, 95% CI 0.04–0.44, p = 0.0009) and a higher proportion of the reversible cerebral vasoconstriction syndrome (RCVS) as cause of their HS. Conclusions: Women with pregnancy-associated HS had fewer cerebrovascular risk factors, lower odds of having underlying vascular lesions, and higher proportion of migraine and RCVS compared with similar-aged non-pregnant women. Pregnancy-associated HS appears to represent a unique pathophysiological process, requiring targeted study.

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The impact of craniotomy for brain tumor case volume on patient safety indicators and in-hospital mortality

Clinical Neurology and Neurosurgery ◽

10.1016/j.clineuro.2020.106043 ◽

2020 ◽

Vol 196 ◽

pp. 106043

Author(s):

Paul R. Clark ◽

Robert J. Dambrino ◽

Sean M. Himel ◽

Zachary S. Smalley ◽

Wondwosen K. Yimer ◽

...

Keyword(s):

Patient Safety ◽

Brain Tumor ◽

Hospital Mortality ◽

Case Volume ◽

Patient Safety Indicators ◽

The Impact

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Ethnic comparison in takotsubo syndrome: novel insights from the International Takotsubo Registry

Clinical Research in Cardiology ◽

10.1007/s00392-021-01857-4 ◽

2021 ◽

Author(s):

Yoichi Imori ◽

Ken Kato ◽

Victoria L. Cammann ◽

Konrad A. Szawan ◽

Manfred Wischnewsky ◽

...

Keyword(s):

Hospital Mortality ◽

Clinical Characteristics ◽

Ethnic Disparities ◽

Japanese Patients ◽

Learning Approach ◽

Takotsubo Syndrome ◽

Unique Identifier ◽

Hospital Outcomes ◽

Machine Learning Approach ◽

The Impact

Abstract Background Ethnic disparities have been reported in cardiovascular disease. However, ethnic disparities in takotsubo syndrome (TTS) remain elusive. This study assessed differences in clinical characteristics between Japanese and European TTS patients and determined the impact of ethnicity on in-hospital outcomes. Methods TTS patients in Japan were enrolled from 10 hospitals and TTS patients in Europe were enrolled from 32 hospitals participating in the International Takotsubo Registry. Clinical characteristics and in-hospital outcomes were compared between Japanese and European patients. Results A total of 503 Japanese and 1670 European patients were included. Japanese patients were older (72.6 ± 11.4 years vs. 68.0 ± 12.0 years; p < 0.001) and more likely to be male (18.5 vs. 8.4%; p < 0.001) than European TTS patients. Physical triggering factors were more common (45.5 vs. 32.0%; p < 0.001), and emotional triggers less common (17.5 vs. 31.5%; p < 0.001), in Japanese patients than in European patients. Japanese patients were more likely to experience cardiogenic shock during the acute phase (15.5 vs. 9.0%; p < 0.001) and had a higher in-hospital mortality (8.2 vs. 3.2%; p < 0.001). However, ethnicity itself did not appear to have an impact on in-hospital mortality. Machine learning approach revealed that the presence of physical stressors was the most important prognostic factor in both Japanese and European TTS patients. Conclusion Differences in clinical characteristics and in-hospital outcomes between Japanese and European TTS patients exist. Ethnicity does not impact the outcome in TTS patients. The worse in-hospital outcome in Japanese patients, is mainly driven by the higher prevalence of physical triggers. Trial Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01947621.

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The presence of liver cirrhosis is a strong negative predictor of survival for patients admitted to the intensive care unit – Cirrhosis in intensive care patients

Zeitschrift für Gastroenterologie ◽

10.1055/a-1401-2387 ◽

2021 ◽

Author(s):

Jörg Bojunga ◽

Mireen Friedrich-Rust ◽

Alica Kubesch ◽

Kai Henrik Peiffer ◽

Hannes Abramowski ◽

...

Keyword(s):

Intensive Care Unit ◽

Liver Cirrhosis ◽

Intensive Care ◽

Hospital Mortality ◽

Intensive Care Treatment ◽

Matched Cohort ◽

Care Treatment ◽

Cirrhotic Patients ◽

The Impact ◽

Cirrhotic Group

Abstract Background and Aims Liver cirrhosis is a systemic disease that substantially impacts the body’s physiology, especially in advanced stages. Accordingly, the outcome of patients with cirrhosis requiring intensive care treatment is poor. We aimed to analyze the impact of cirrhosis on mortality of intensive care unit (ICU) patients compared to other frequent chronic diseases and conditions. Methods In this retrospective study, patients admitted over three years to the ICU of the Department of Medicine of the University Hospital Frankfurt were included. Patients were matched for age, gender, pre-existing conditions, simplified acute physiology score (SAPS II), and therapeutic intervention scoring system (TISS). Results A total of 567 patients admitted to the ICU were included in the study; 99 (17.5 %) patients had liver cirrhosis. A total of 129 patients were included in the matched cohort for the sensitivity analysis. In-hospital mortality was higher in cirrhotic patients than non-cirrhotic patients (p < 0.0001) in the entire and matched cohort. Liver cirrhosis remained one of the strongest independent predictors of in-hospital mortality (entire cohort p = 0.001; matched cohort p = 0.03) along with dialysis and need for transfusion in the multivariate logistic regression analysis. Furthermore, in the cirrhotic group, the need for kidney replacement therapy (p < 0.001) and blood transfusion (p < 0.001) was significantly higher than in the non-cirrhotic group. Conclusions In the presented study, liver cirrhosis was one of the strongest predictors of in-hospital mortality in patients needing intensive care treatment along with dialysis and the need for ventilation. Therefore, concerted efforts are needed to improve cirrhotic patients’ outcomes, prevent disease progression, and avoid complications with the need for ICU treatment in the early stages of the disease.

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Does Infection Site Matter? A Systematic Review of Infection Site Mortality in Sepsis

Journal of Intensive Care Medicine ◽

10.1177/0885066615627778 ◽

2016 ◽

Vol 32 (8) ◽

pp. 473-479 ◽

Cited By ~ 5

Author(s):

Christine A. Motzkus ◽

Roger Luckmann

Keyword(s):

Hospital Mortality ◽

Respiratory Infections ◽

Source Control ◽

Soft Tissue Infections ◽

Infection Site ◽

Treatment Protocols ◽

Disease States ◽

Pubmed Database ◽

The Impact ◽

Lower Mortality Risk

Purpose: Sepsis treatment protocols emphasize source control with empiric antibiotics and fluid resuscitation. Previous reviews have examined the impact of infection site and specific pathogens on mortality from sepsis; however, no recent review has addressed the infection site. This review focuses on the impact of infection site on hospital mortality among patients with sepsis. Methods: The PubMed database was searched for articles from 2001 to 2014. Studies were eligible if they included (1) one or more statistical models with hospital mortality as the outcome and considered infection site for inclusion in the model and (2) adult patients with sepsis, severe sepsis, or septic shock. Data abstracted included stage of sepsis, infection site, and raw and adjusted effect estimates. Nineteen studies were included. Infection sites most studied included respiratory (n = 19), abdominal (n = 19), genitourinary (n = 18), and skin and soft tissue infections (n = 11). Several studies found a statistically significant lower mortality risk for genitourinary infections on hospital mortality when compared to respiratory infections. Conclusion: Based on studies included in this review, the impact of infection site in patients with sepsis on hospital mortality could not be reliably estimated. Misclassification among infections and disease states remains a serious possibility in studies on this topic.

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Development of the Madrid Stroke Programme: Milestones and Changes in Stroke Trends and Mortality from 1997 to 2017

Neuroepidemiology ◽

10.1159/000514077 ◽

2021 ◽

pp. 1-6

Author(s):

Silvia Pastor ◽

Elena de Celis ◽

Itsaso Losantos García ◽

María Alonso de Leciñana ◽

Blanca Fuentes ◽

...

Keyword(s):

Hospital Mortality ◽

Hospital Admissions ◽

Temporal Trends ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Care Organization ◽

Stroke Units ◽

Health Region ◽

Number Of Patients ◽

The Impact

Introduction: Stroke is a serious health problem, given it is the second leading cause of death and a major cause of disability in the European Union. Our study aimed to assess the impact of stroke care organization measures (such as the development of stroke units, implementation of a regional stroke code, and treatment with intravenous thrombolysis and mechanical thrombectomy) implemented from 1997 to 2017 on hospital admissions due to stroke and mortality attributed to stroke in the Madrid health region. Methods: Epidemiological data were obtained from the National Statistics Institute public website. We collected data on the number of patients discharged with a diagnosis of stroke, in-hospital mortality due to stroke and the number of inhabitants in the Madrid health region each year. We calculated rates of discharges and mortality due to stroke and the number of inhabitants per SU bed, and we analysed temporal trends in in-hospital mortality due to stroke using the Daniels test in 2 separate time periods (before and after 2011). Figures representing annual changes in these data from 1997 to 2017 were elaborated, marking stroke care organizational measures in the year they were implemented to visualize their temporal relation with changes in stroke statistics. Results: Hospital discharges with a diagnosis of stroke have increased from 170.3/100,000 inhabitants in 1997 to 230.23/100,000 inhabitants in 2017. However, the in-hospital mortality rate due to stroke has decreased (from 33.3 to 15.2%). A statistically significant temporal trend towards a decrease in the mortality percentage and rate was found from 1997 to 2011. Conclusions: Our study illustrates how measures such as the development of stroke units, implementation of a regional stroke code and treatment with intravenous thrombolysis coincide in time with a reduction in in-hospital mortality due to stroke.

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