title: Effect of insurance status on postacute care among working age stroke survivors.
abstract: OBJECTIVE
  Utilization of postacute care is associated with improved poststroke outcomes. However, more than 20% of American adults under age 65 are uninsured. We sought to determine whether insurance status is associated with utilization and intensity of institutional postacute care among working age stroke survivors.
  
  
  METHODS
  A retrospective cross-sectional study of ischemic stroke survivors under age 65 from the 2004-2006 Nationwide Inpatient Sample was conducted. Hierarchical logistic regression models controlling for patient and hospital-level factors were used. The primary outcome was utilization of any institutional postacute care (inpatient rehabilitation or skilled nursing facilities) following hospital admission for ischemic stroke. Intensity of rehabilitation was explored by comparing utilization of inpatient rehabilitation facilities and skilled nursing facilities.
  
  
  RESULTS
  Of the 33,917 working age stroke survivors, 19.3% were uninsured, 19.8% were Medicaid enrollees, and 22.8% were discharged to institutional postacute care. Compared to those privately insured, uninsured stroke survivors were less likely (adjusted odds ratio [AOR] 0.53, 95% confidence interval [CI] 0.47-0.59) while stroke survivors with Medicaid were more likely to utilize any institutional postacute care (AOR = 1.40, 95% CI 1.27-1.54). Among stroke survivors who utilized institutional postacute care, uninsured (AOR = 0.48, 95% CI 0.36-0.64) and Medicaid stroke survivors (AOR = 0.27, 95% CI 0.23-0.33) were less likely to utilize an inpatient rehabilitation facility than a skilled nursing facility compared to privately insured stroke survivors.
  
  
  CONCLUSIONS
  Insurance status among working age acute stroke survivors is independently associated with utilization and intensity of institutional postacute care. This may explain differences in poststroke outcomes among uninsured and Medicaid stroke survivors compared to the privately insured.
authors.affiliation: Stroke Program, University of Michigan Medical School, Ann Arbor, USA. lerusche@umich.edu
authors.forename: L E
authors.initials: LE
authors.lastname: Skolarus
authors.forename: W J
authors.initials: WJ
authors.lastname: Meurer
authors.forename: J F
authors.initials: JF
authors.lastname: Burke
authors.forename: J
authors.initials: J
authors.lastname: Prvu Bettger
authors.forename: L D
authors.initials: LD
authors.lastname: Lisabeth
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D003430:Cross-Sectional Studies; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health / Q000706:statistics & numerical data; D038801:International Classification of Diseases; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data; D020521:Stroke / Q000453:epidemiology; D000071939:Stroke Rehabilitation; D017741:Survivors; D055815:Young Adult