title: Impact of Insurance Status on Outcomes and Use of Rehabilitation Services in Acute Ischemic Stroke: Findings From Get With The Guidelines-Stroke.
abstract: Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government-sponsored insurance had worse quality of care or in-hospital outcomes in acute ischemic stroke.
  
  
  
  Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in-hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines-Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (<65 years, OR 1.33 [95% CI 1.22-1.45]; ≥65 years OR 1.54 [95% CI 1.34-1.75]), and among survivors, were less likely to go to inpatient rehab (<65 OR 0.63 [95% CI 0.6-0.67]; ≥65 OR 0.56 [95% CI 0.5-0.63]). In contrast, patients with Medicare and Medicaid were more likely to be discharged to a Skilled Nursing Facility (<65 years OR 2.08 [CI 1.96-2.2]; OR 2.01 [95% CI 1.91-2.13]; ≥65 years OR 1.1 [95% CI 1.07-1.13]; OR 1.41 [95% CI 1.35-1.46]).
  
  
  
  Preventative care prior to ischemic stroke, time to presentation for acute treatment, access to rehabilitation, and in-hospital mortality differ by patient insurance status.
authors.affiliation: Section of Emergency Medicine, Baylor College of Medicine, Houston, TX medford.davis@gmail.com.
authors.forename: Laura N
authors.initials: LN
authors.lastname: Medford-Davis
authors.affiliation: Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA.
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
authors.forename: Haolin
authors.initials: H
authors.lastname: Xu
authors.affiliation: Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
authors.affiliation: Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX.
authors.forename: Robert
authors.initials: R
authors.lastname: Suter
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.|Department of Cardiology, Duke University Medical Center, Durham, NC.
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.|Department of Neurology, Duke University Medical Center, Durham, NC.
authors.forename: Ying
authors.initials: Y
authors.lastname: Xian
authors.affiliation: Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.|Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC.
authors.forename: Roland A
authors.initials: RA
authors.lastname: Matsouaka
authors.affiliation: Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Lee H
authors.initials: LH
authors.lastname: Schwamm
mesh_terms: D000368:Aged; D000552:Ambulances / Q000706:statistics & numerical data; D000924:Anticholesteremic Agents / Q000627:therapeutic use; D000959:Antihypertensive Agents / Q000627:therapeutic use; D002545:Brain Ischemia / Q000534:rehabilitation*; D003920:Diabetes Mellitus / Q000188:drug therapy / Q000453:epidemiology; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D006937:Hypercholesterolemia / Q000188:drug therapy / Q000453:epidemiology; D006973:Hypertension / Q000188:drug therapy / Q000453:epidemiology; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D007348:Insurance, Health / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D006278:Medicare; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D012866:Skilled Nursing Facilities / Q000706:statistics & numerical data; D020521:Stroke; D000071939:Stroke Rehabilitation / Q000706:statistics & numerical data*; D013997:Time Factors; D014481:United States
chemical_list: D000924:Anticholesteremic Agents; D000959:Antihypertensive Agents; D007004:Hypoglycemic Agents
keywords: health outcomes; health policy; health services research; insurance; stroke, ischemic