title: Association of Insurance Status with Stroke-Related Mortality and Long-term Survival after Stroke.
abstract: BACKGROUND
  Lack of insurance is a barrier to optimal stroke risk factor control but data on its long-term impact on stroke outcomes are sparse. We assessed the association between health insurance and long-term mortality after stroke.
  
  
  METHODS
  Using data from the National Health and Nutrition Examination Surveys 1999-2004 with follow-up mortality assessment through 2006, we examined the independent effect of health insurance on (1) stroke mortality among all adult participants (n = 15,049) and (2) vascular and all-cause mortality rates among participants with self-reported stroke (n = 563).
  
  
  RESULTS
  Among individuals without a previous stroke, uninsured individuals aged less than 65 years were more likely to die of stroke than those with insurance (adjusted hazard ratio [HR], 3.13; 95% confidence interval [CI], .96-10.23); however, among those aged 65 years or older, those with private insurance, private plus Medicare, or Medicare plus Medicaid had similar risk of stroke mortality when compared to those with Medicare alone. Stroke survivors aged 65 years or older with private insurance were less likely to die from vascular causes (adjusted HR, .38; 95% CI, .23-.63) compared to those with Medicare alone. For stroke survivors aged less than 65 years, uninsured individuals had similar all-cause mortality rates compared to their counterparts with insurance.
  
  
  CONCLUSIONS
  Insurance status influences risk of dying from a stroke in the general population, as well as long-term mortality rates among stroke survivors in the United States, but these relationships vary by age.
authors.affiliation: Department of Neurology, University of Southern California, Los Angeles, CA; Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA. Electronic address: mikemnop@gmail.com.
authors.forename: Michael
authors.initials: M
authors.lastname: McManus
authors.affiliation: Department of Neurosciences, Medical University of South Carolina, Charleston, SC.
authors.forename: Bruce
authors.initials: B
authors.lastname: Ovbiagele
authors.affiliation: Department of Biomathematics, University of California, Los Angeles, Los Angeles, CA.
authors.forename: Daniela
authors.initials: D
authors.lastname: Markovic
authors.affiliation: Department of Neurology, University of Southern California, Los Angeles, CA; Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA.
authors.forename: Amytis
authors.initials: A
authors.lastname: Towfighi
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D005260:Female; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D009310:National Health Insurance, United States / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology* / Q000401:mortality*; D016019:Survival Analysis; D017741:Survivors / Q000706:statistics & numerical data*; D014481:United States
keywords: Stroke; insurance status; mortality; outcomes; prevention