Adult patients without health insurance admitted to intensive care units (ICUs) in Pennsylvania hospitals are at a 21 percent increased risk of death compared to similar patients with private insurance, according to researchers at the University of Pennsylvania. The difference in mortality risk was not explained by patient characteristics or differences in care at the hospital level, suggesting that uninsured patients might receive poorer care.

Compared to similar patients with private insurance or Medicaid, uninsured ICU patients were also less likely to receive certain common critical care procedures, including placement of central venous catheters, tracheostomies, and acute hemodialysis.

“Previous studies suggested that uninsured critically ill patients may have a higher mortality, and may be less likely to receive certain critical care procedures,” says Sarah M. Lyon, MD, pulmonary and critical care fellow at the University of Pennsylvania. “But we found that these differences are primarily caused by differences in quality within hospitals rather than across hospitals.

“The higher mortality for uninsured patients does not appear to be caused by uninsured patients tending to go to hospitals with poor overall quality. Instead, we found that even when admitted to the same hospitals, and controlling for other differences between patients, critically ill individuals without insurance are less likely to survive than those with private insurance or Medicaid.”

Using state hospital discharge data, the researchers analyzed 30-day mortality and the use of several key ICU procedures in all adult patients under 65 admitted to Pennsylvania ICUs from 2005 to 2006. They categorized the 166,995 patients as having private health insurance (67.7 percent), Medicaid (28.5 percent), or being uninsured (3.8 percent). When the researchers analyzed mortality at 30 days, they found that uninsured patients were 21 percent more likely to die than were patients with private insurance; those with Medicaid had a 3 percent greater risk of death.

“We still do not understand all the reasons for differences in survival between the insured and uninsured,” Lyon says. “Critically ill patients without insurance may arrive at the hospital in more advanced stages of illness, perhaps in ways we could not control for in our study.”

A greater concern is that physicians and hospitals might treat patients without insurance differently than those who have coverage. “More work is needed before we can say with certainty that treatment biases caused these results,” she says.

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