title: The association between insurance status and in-hospital mortality on the public medical wards of a Kenyan referral hospital.
abstract: BACKGROUND
  Observational data in the United States suggests that those without health insurance have a higher mortality and worse health outcomes. A linkage between insurance coverage and outcomes in hospitalized patients has yet to be demonstrated in resource-poor settings.
  
  
  METHODS
  To determine whether uninsured patients admitted to the public medical wards at a Kenyan referral hospital have any difference in in-hospital mortality rates compared to patients with insurance, we performed a retrospective observational study of all inpatients discharged from the public medical wards at Moi Teaching and Referral Hospital in Eldoret, Kenya, over a 3-month study period from October through December 2012. The primary outcome of interest was in-hospital death, and the primary explanatory variable of interest was health insurance status.
  
  
  RESULTS
  During the study period, 201 (21.3%) of 956 patients discharged had insurance. The National Hospital Insurance Fund was the only insurance scheme noted. Overall, 211 patients (22.1%) died. The proportion who died was greater among the uninsured compared to the insured (24.7% vs. 11.4%, Chi-square = 15.6, p<0.001). This equates to an absolute risk reduction of 13.3% (95% CI 7.9-18.7%) and a relative risk reduction of 53.8% (95% CI 30.8-69.2%) of in-hospital mortality with insurance. After adjusting for comorbid illness, employment status, age, HIV status, and gender, the association between insurance status and mortality remained statistically significant (adjusted odds ratio (AOR) = 0.40, 95% CI 0.24-0.66) and similar in magnitude to the association between HIV status and mortality (AOR = 2.45, 95% CI 1.56-3.86).
  
  
  CONCLUSIONS
  Among adult patients hospitalized in a public referral hospital in Kenya, insurance coverage was associated with decreased in-hospital mortality. This association was comparable to the relationship between HIV and mortality. Extension of insurance coverage may yield substantial benefits for population health.
authors.affiliation: Department of Medicine, Center for Global Health, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Medicine, Moi University, Eldoret, Kenya; gstone@partners.org.
authors.forename: Geren S
authors.initials: GS
authors.lastname: Stone
authors.affiliation: Moi Teaching and Referral Hospital, Eldoret, Kenya.
authors.forename: Titus
authors.initials: T
authors.lastname: Tarus
authors.affiliation: Moi Teaching and Referral Hospital, Eldoret, Kenya.
authors.forename: Mainard
authors.initials: M
authors.lastname: Shikanga
authors.affiliation: Moi Teaching and Referral Hospital, Eldoret, Kenya.
authors.forename: Benson
authors.initials: B
authors.lastname: Biwott
authors.affiliation: Moi Teaching and Referral Hospital, Eldoret, Kenya.
authors.forename: Thomas
authors.initials: T
authors.lastname: Ngetich
authors.affiliation: Moi Teaching and Referral Hospital, Eldoret, Kenya.
authors.forename: Thomas
authors.initials: T
authors.lastname: Andale
authors.affiliation: Moi Teaching and Referral Hospital, Eldoret, Kenya.
authors.forename: Betsy
authors.initials: B
authors.lastname: Cheriro
authors.affiliation: Moi Teaching and Referral Hospital, Eldoret, Kenya.
authors.forename: Wilson
authors.initials: W
authors.lastname: Aruasa
mesh_terms: D000293:Adolescent; D000328:Adult; D000369:Aged, 80 and over; D017052:Hospital Mortality; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D007348:Insurance, Health / Q000706:statistics & numerical data*; D007630:Kenya / Q000453:epidemiology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D063728:Secondary Care Centers / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Africa; disparities; health insurance; hospital medicine