Findings should prompt future investigations into care disparities at skilled-care facilities to mediate higher mortality rates observed among senior survivors of critical illness.
Yoland Philpotts, MD
A first-of-its-kind study found that mortality in the first year after critical illness is higher among older adults with Medicaid insurance compared to those with Medicare and additional commercial insurance, especially among those discharged to skilled-care facilities.
The study, presented at the 2018 American Thoracic Society International Conference in San Diego, should prompt future investigations into care disparities at skilled-care facilities that may mediate higher mortality rates observed among the poor older survivors of critical illness.
“Our most significant finding was that poor older adults with Medicaid insurance who receive treatment for a critical illness in the ICU are more likely to die after hospital discharge when compared to those with commercial insurance,” lead author, Yoland Philpotts, MD, Columbia University College of Physicians and Surgeons, said. “This was true even after taking into account differences in pre-existing health conditions and the severity of critical illness.”
Researchers used the New York Statewide Planning and Research Cooperative System (SPARCS) database and American Hospital Association Annual Survey to conduct a retrospective cohort of older (age ≥65 years) adults who were first hospitalized in intensive care and survived to discharge between January 1, 2010—December 31, 2014.
The primary outcome included mortality in the first year after hospital discharge.
Of the 339,261 survivors of critical illness, 20% died within 1 year of hospital discharge. Compared to patients with Medicare and commercial insurance, those with Medicare alone had no difference in 1-year mortality (adjusted hazard ratio [aHR], 1.01; 95% CI, 0.9—1.03), and those with Medicaid had 7% higher 1-year mortality rate (aHR, 1.07; 95% CI, 1.05–1.09).
This disparity was greatest found among survivors of critical illness with Medicaid discharged from the hospital to a nursing home. Philpotts noted that these patients have a 15% increased risk of death compared to patients with commercial insurance.
In addition to examining the differences in death rates for patients with co-existing health conditions, researchers sought to investigate if differences in age, race or household income affected patients’ post-hospital 1-year mortality. Teaching hospitals were separated from non-teaching hospitals, and urban from rural hospitals—none of the factors made a significant difference in patient mortality rates.
“The implications of our findings are important: to improve the long-term survival and quality-of-life of critical illness survivors, we may have to improve care not only within the hospital and ICU, but also after hospital discharge,” Philpotts added.
When comparing ethnicity, blacks had a similar 1-year mortality rate to whites, and Hispanics were associated with better 1-year survival (aHR 0.87; 95% CI, 0.84—0.89). When the analysis was stratified by race, the association between insurance status and mortality only varied among whites. White individuals with Medicaid had a 9% higher 1-year mortality rate versus those with Medicare and commercial insurance (aHR 1.09; 95% CI, 1.07–1.12).
Analyses stratified by location alone, however, showed that the 1-year adjusted mortality rate did not vary by insurance status, Medicare alone and Medicaid, for those discharged home (aHR 0.99; 95% CI, 0.96—1.02 and 0.99, 0.96–1.02), but was significantly greater for Medicaid recipients discharged to skilled-care facilities (aHR 1.18; 95% CI, 1.15–1.21).
Further studies are needed to identify the factors that mediate higher mortality among ICU survivors without commercial insurance, researchers noted.
“Our team will study insurance status and readmission to the hospital after critical illness for this vulnerable patient population,” Philpotts concluded. “A readmission to the hospital after critical illness is a potential marker of a barrier to high-quality care after discharge.”
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