Relationship of insurance type and treatment of severe status asthmaticus in working-age adults

Introduction

Prior studies suggest uninsured patients presenting to the emergency department with acute asthma receive poor quality of care. However, we do not know whether insurance status affects resource use and outcome after hospital admission for patients with status asthmaticus (SA).

Methods

We examined all nonfederal hospital discharges in 1999 from six US states. We selected patients hospitalized with SA and defined severe SA as SA with ICU admission. We excluded Medicare patients and focused on working-age adults (18–64 years), classifying insurance as commercial, Medicaid, and uninsured. We assigned comorbidity using the Charlson–Deyo index. We examined the association between insurance status and mechanical ventilation (MV), hospital costs, and hospital mortality.

Results

Of the 8.2 million hospital discharges, 62,968 (0.8%) had SA and 9742 had severe SA, of whom 4007 (41.1%) were working-age adults (population incidence of 10.7/100,000). Compared with commercially insured patients (n = 2299), Medicaid (n = 1057) and uninsured (n = 651) patients had higher MV rates (30.1% vs 39.1% and 40.1%, P < 0.001) Hospital length of stay (LOS), ICU LOS, mortality and mean costs were 6.2, 8.6 and 5.1 days, 3.5, 4.4 and 2.6 days, 1.9, 4.2 and 1.8% and $8800, $12,600, & $7400, respectively, for commercial, Medicaid and uninsured patients. Adjusting for age, comorbidity, gender, and race, Medicaid and uninsured patients were more likely to receive MV than commercially insured patients (odds ratio:1.51 and 1.41, P < 0.001 for each). Mortality was also higher, but this observation was not significant (odds ratio: 1.17, P = 0.9 and odds ratio: 2.1, P = 0.64). Uninsured patients also incurred lower adjusted hospital costs (P < 0.001) and hospital LOS (P < 0.001).

Conclusion

In comparison with patients managed under commercial insurance, patients admitted to hospital under no insurance or state-subsidized insurance appear sicker, as evidenced by higher MV rates and worse mortality. Possible reasons include a worse spectrum of disease in these populations, delayed presentation to hospital during an acute attack, or restricted admission policies.