Variability of care among neurological intensive care unit patients: the role of insurance coverage

Background

The Brazilian constitution of 1988 established universal access to the health services through the creation of the Unified System of Health (SUS). To our best knowledge there is not yet an evaluation of the quality of the services offered, in spite of the progress brought by this democratic proposal.

Objective

To compare the mortality rate, predicted survival (Acute Physiology and Chronic Health Evaluation [APACHE] II), readmission rate, neurological intensive care unit (NICU) length of stay (LOS) and hospital LOS, and Glasgow Coma Scale (GCS) among SUS patients and those with private insurance.

Design, setting, and patients

A prospective observational study of 200 neurological and neurosurgical patients admitted between April and October 2002 at a NICU located in São Paulo city's central area hospital. Subsets of this population were also studied: tumoral excision, aneurysm surgery, laminectomy, stroke, neurological intravascular procedures, GCS ≤ 8, GCS > 8 and GCS > 14, and APACHE II mortality ≤ 10 and APACHE II mortality > 10. A bicaudal analysis was made, and P < 0.05 was considered significant.

Results

The LOS in NICU and in hospital was significantly higher for SUS patients. We found a significantly larger proportion of patients with a GCS ≤ 8 in the SUS group. This trend was maintained in the majority of subgroups of patients studied. The predicted mortality (APACHE II), mortality rate, readmission rate, age, APACHE II score, proportion of clinical patients and emergency surgery rate was similar among the two main groups and in the majority of subgroups studied.

Conclusion

Our data indicate a relationship between the insurance coverage and LOS (NICU and hospital). We also found a larger proportion of patients with reduced consciousness level, higher in the SUS group. These trends are maintained in the majority of subgroups studied, strongly suggesting a true variability in the process of care among the main groups studied. We believe that, at least in countries with similar health system structures, insurance coverage could play a substantial role in explaining care variability, and should be better studied.