Insurance and racial differences in long-term acute care utilization after critical illness.
OBJECTIVE
To determine whether insurance coverage and race are associated with long-term acute care hospital utilization in critically ill patients requiring mechanical ventilation.


METHODS
Retrospective cohort study.


METHODS
Nonfederal Pennsylvania hospital discharges from 2004 to 2006.


METHODS
Eligible patients were aged 18 yrs or older, of white or black race, and underwent mechanical ventilation in an intensive care unit during their hospital stay.


METHODS
None.


RESULTS
We used multivariable logistic regression with hospital-level random effects to determine the independent association between discharge to long-term acute care hospital, insurance status, and race after appropriate controls, including a chart-based measure of severity of illness. The primary outcome measure was discharge to long-term acute care hospital. Of 66,233 eligible patients, 84.7% were white and 15.3% were black. More white patients than black patients had commercial insurance (23.4% vs. 14.9%) compared to Medicaid (10.6% vs. 29.7%) or no insurance (1.3% vs. 2.2%). Long-term acute care hospital transfer occurred in 5.0% of patients. On multivariable analysis in patients aged younger than 65 yrs, black patients were significantly less likely to undergo long-term acute care hospital transfer (odds ratio, 0.71; p = .003), as were patients with Medicaid vs. commercial insurance (odds ratio, 0.17; p < .001). Analyzing race and insurance together and accounting for hospital-level effects, patients with Medicaid were still less likely to undergo long-term acute care hospital transfer (odds ratio, 0.18; p < .001), but race effects were no longer present (odds ratio, 1.06; p = .615). No significant race effects were seen in the Medicare-eligible population aged 65 yrs or older (odds ratio for transfer to long-term acute care hospital, 0.93; p = .359).


CONCLUSIONS
Differences in long-term acute care hospital utilization after critical illness appear driven by insurance status and hospital-level effects. Racial variation in long-term acute care hospital use is not seen after controlling for insurance status and is not seen in a group with uniform insurance coverage. Differential access to postacute care may be minimized by expanding commercial or Medicare insurance availability and standardizing long-term acute care admission criteria across hospitals.
Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA. meghan.lane-fall@uphs.upenn.edu
Meghan B
MB
Lane-Fall
Theodore J
TJ
Iwashyna
Colin R
CR
Cooke
Nicole M
NM
Benson
Jeremy M
JM
Kahn
D000368:Aged; D044383:Black People / Q000706:statistics & numerical data; D016638:Critical Illness / Q000628:therapy*; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data; D007348:Insurance, Health / Q000706:statistics & numerical data*; D016015:Logistic Models; D008134:Long-Term Care / Q000706:statistics & numerical data*; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010360:Patient Transfer / Q000706:statistics & numerical data; D010414:Pennsylvania / Q000453:epidemiology; D044469:Racial Groups / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014481:United States; D044465:White People / Q000706:statistics & numerical data; D001741:Black or African American