Race, Ethnicity, Health Insurance, and Mortality in Older Survivors of Critical Illness

Abstract

Objective To determine whether minority race or ethnicity are associated with mortality and mediated by health insurance coverage among older (age ≥65 years) survivors of critical illness. Design A retrospective cohort study. Setting Two New York City academic medical centers. Patients A total of 1,947 consecutive white (1,107), black (361), and Hispanic (479) older adults who had their first medical-ICU admission from 2006 through 2009 and survived to hospital discharge. Interventions None. Measurements and Main Results We obtained demographic, insurance, and clinical data from electronic health records, determined each patient’s neighborhood-level socioeconomic data from 2010 US Census tract data, and determined death dates using the Social Security Death Index. Subjects had a mean (SD) age of 79 (8.6) years and median (IQR) follow-up time of 1.6 (0.4–3.0) years. Blacks and Hispanics had similar mortality rates compared to whites (adjusted-hazard ratio [HR] 0.92, 95% CI 0.76–1.11 and adjusted-HR 0.92, 95% CI 0.76–1.12, respectively). Compared to those with commercial insurance and Medicare, higher mortality rates were observed for those with Medicare only (adjusted-HR 1.43, 95% CI 1.03–1.98) and Medicaid (adjusted-HR 1.30, 95% CI 1.10–1.52). Medicaid recipients who were the oldest ICU survivors (age >82 years), survivors of mechanical ventilation, and discharged to skilled-care facilities had the highest mortality rates (p-for-interaction 0.08, 0.03, and 0.17, respectively). Conclusions Mortality after critical illness among older adults varies by insurance coverage, but not by race or ethnicity. Those with federal or state insurance coverage only had higher mortality rates than those with additional commercial insurance.

Health Insurance and Disparities in Mortality among Older Survivors of Critical Illness: A Population Study

“…We were unable to control for direct or surrogate measures of pre‐hospitalization disability (eg, admission from nursing home) or for preferences for life‐sustaining therapy at hospital discharge, both of which are important predictors of post‐hospitalization mortality in older ICU survivors . However, in our prior study of older ICU survivors from two New York City medical centers, after controlling for these variables, the HR of the association between Medicaid insurance and the post‐hospitalization mortality rate was greater than what we observed in this study …”

“…[9][10][11]38 However, in our prior study of older ICU survivors from two New York City medical centers, after controlling for these variables, the HR of the association between Medicaid insurance and the post-hospitalization mortality rate was greater than what we observed in this study. 14 The Medicare Shared Savings Program for Accountable Care Organizations was implemented during the study period, and we were unable to adjust for how this new program may affect survivors of critical illness with different types of insurance. We also sought to examine the possibility of residual confounding with a quantitative bias analysis.…”

“…In our previous work, we found that mortality among older medical ICU survivors from two New York City tertiary care medical centers differs by insurance status but not race or ethnicity. 14 Those with commercial insurance had a lower post-hospitalization mortality rate than those with Medicare only or Medicaid insurance, independent of several demographic, clinical, and hospital characteristics. These results, however, may not be generalizable to older adults who receive surgical or coronary intensive care, and who are treated in community hospitals or less urban environments.…”

Impacts of Financial Coverage on Long-Term Outcome of Intensive Care Unit Survivors in South Korea

“…This burden also impacts their caregivers, and is a serious problem that can cause psychological stress. A recent observational study conducted in two academic hospitals in New York City reported that race or ethnicity was not associated with long-term mortality among ICU survivors, while insurance status was closely associated 11. In other words, the lack of insurance coverage was associated with increased mortality among ICU survivors, and thus this study has emphasized the need for the provision of appropriate financial coverage for ICU survivors.…”

Medical resource utilization patterns and mortality rates according to age among critically ill patients admitted to a medical intensive care unit

“…As ICU care requires substantial resources, and because some interventions can be unnecessary, harmful, or futile—particularly when caring for critically ill elderly patients—specific ICU treatment decisions are influenced by multiple factors, such as regional health care capacity, health insurance systems, and cultural and religious considerations. [1,29,30] However, our knowledge about critical care in different regional and cultural contexts is currently limited. [1] Further researches are required to address the effects of different cultural and regional backgrounds on critical care.…”