title: Insurance status is associated with treatment allocation and outcomes after subarachnoid hemorrhage.
abstract: OBJECTIVE
  Subarachnoid hemorrhage (SAH) is a particularly devastating type of stroke which is responsible for one third of all stroke-related years of potential life lost before age 65. Surgical treatment has been shown to decrease both morbidity and mortality after subarachnoid hemorrhage. We hypothesized that payer status other than private insurance is associated with lower allocation to surgical treatment for patients with SAH and worse outcomes.
  
  
  METHODS
  We examined the association between insurance type and surgical treatment allocation and outcomes for patients with SAH while adjusting for a wide range of patient and hospital factors. We analyzed the Nationwide Inpatient Sample hospital discharge database using survey procedures to produce weighted estimates representative of the United States population.
  
  
  METHODS
  We studied 21047 discharges, representing a weighted estimate of 102595 patients age 18 and above with a discharge diagnosis of SAH between 2003 and 2008.
  
  
  METHODS
  Multivariable logistic and generalized linear regression analyses were used to assess for any associations between insurance status and surgery allocation and outcomes.
  
  
  RESULTS
  Despite the benefits of surgery 66% of SAH patients did not undergo surgical treatment to prevent rebleeding. Mortality was more than twice as likely for patients with no surgical treatment compared to those who received surgery. Medicare patients were significantly less likely to receive surgical treatment.
  
  
  CONCLUSIONS
  Nearly two thirds of patients with SAH don't receive operative care, and Medicare patients were significantly less likely to receive surgical treatment than other patients. Bias against the elderly and those with chronic illness and disability may play a part in these findings. A system of regionalized care for patients presenting with SAH may reduce disparities and improve appropriate allocation to surgical care and deserves prospective study.
authors.affiliation: Department of Surgery, Malcom Randall VA Medical Center, Gainesville, Florida, United States of America; Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, United States of America.
authors.forename: Charles
authors.initials: C
authors.lastname: Hobson
authors.affiliation: Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America.
authors.forename: John
authors.initials: J
authors.lastname: Dortch
authors.affiliation: Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America.
authors.forename: Tezcan
authors.initials: T
authors.lastname: Ozrazgat Baslanti
authors.affiliation: Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America.
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Layon
authors.affiliation: Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America.
authors.forename: Alina
authors.initials: A
authors.lastname: Roche
authors.affiliation: Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America.
authors.forename: Alison
authors.initials: A
authors.lastname: Rioux
authors.affiliation: Department of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida, United States of America.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Harman
authors.affiliation: Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America.
authors.forename: Brenda
authors.initials: B
authors.lastname: Fahy
authors.affiliation: Department of Anesthesiology, University of Florida, Gainesville, Florida, United States of America.
authors.forename: Azra
authors.initials: A
authors.lastname: Bihorac
mesh_terms: D000368:Aged; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000401:mortality* / Q000601:surgery*; D016896:Treatment Outcome; D014481:United States