The effect of socioeconomic status, insurance status, and insurance coverage benefits on mortality in critically ill patients admitted to the intensive care unit

Abstract

Socioeconomic status is well known to be related to mortality [1] and is an important health issue in the management of the intensive care unit (ICU) in the United States and Europe [2]. Previous research also shows that the absence of health insurance is associated with a higher mortality rate among patients admitted to the ICU but unadjusted for the severity of illness and data from a single center [3]. Many observational studies have similarly suggested that a lack of insurance is associated with a higher mortality rate, and a systematic review from the American Thoracic Society found that critically ill patients without health insurance receive fewer critical care procedures and show poorer outcomes [3]. Lyon et al. [4] performed a retrospective cohort study using Pennsylvania hospital discharge data, analyzing a total of 138,720 critically ill adults <64 years of age treated at 167 acute care hospitals. These authors found that the absence of health insurance is associated with a significant increase in 30day mortality and a decrease in the use of critical care procedures, such as tracheostomy, among critically ill patients using a detailed clinical risk-adjustment protocol. Their study also showed that use of a large multicenter dataset and detailed severity adjustment contributes to the analysis of health outcomes of uninsured critically ill patients [4].In Europe, two different health care systems exist, specifically the tax-based health care system (THS) and the social health insurance system (SHI). Wernly et al.[5] performed a retrospective post-hoc analysis of data from 16 European countries, analyzing critically ill patients >80 years of age admitted to the ICU. They evaluated 4,941 patients with THS and 2,876 with SHI from the previous Very elderly Intensive Patient (VIP)1 and VIP2 studies [5] and found that the associated 30-day mortality rate was similar between both systems; however, patients with SHI were older, sicker, and frailer at baseline. They interpreted their findings as being indicative that a liberal admission policy and an increase in treatment limitations resulted in a trend of ICU excess mortality among patients with SHI [5].In South Korea, Oh et al. [6] conducted a retrospective observational study of adults aged >20 years admitted to the ICU. They included 6,008 patients and found that socioeconomic status was not associated with 30-day mortality in the Korean National Health Insurance (NHI) coverage system. However, the occupation of the patient was associated with 1-year mortality [6]. Meanwhile, although the expansion of Medicaid services for low-income patients has improved mortality in the United States [7], the mortality rate is still higher among critically ill patients with public health insurance coverage only compared to those with ad-

Long-term recovery after critical illness in older adults

“…In 2019, a systemic review of 10 studies found patients with socioeconomic disadvantage had higher mortality across critical illness continuum; the authors advocated for inclusion of socioeconomic demographics in future critical care studies [51]. In a recent longitudinal study, Jain et al [52 ▪ ] evaluated the association of individual-level socioeconomic disadvantage, represented by dual-eligibility for Medicaid and Medicare, with the three outcomes of the post-ICU syndrome: physical function (operationalized as disability in ADLs), cognitive function, and mental health symptoms [53]. Socioeconomic disadvantage was associated with a 28% increase in disability and 9.8-fold greater odds of developing probable dementia in the year after critical illness.…”