Critical care outcomes tied to insurance status, systematic review finds

"Patients in the United States who do not have health insurance and become critically ill receive fewer critical care services and may experience worse clinical outcomes," said J. Randall Curtis, M.D., M.P.H., president of the ATS, and an investigator for the review. "Improving preexisting health care coverage may be one mechanism to reduce such disparities."

The researchers reviewed more than 5,500 citations on critical care and insurance status, ultimately identifying 29 observational studies that described the admissions and outcomes for critically ill patients with and without insurance.

The results are published as an official systematic review in the May 1 issue of the American Journal of Respiratory and Critical Care Medicine.

Currently, one-third of the population under the age of 65 is uninsured for a portion of any given year, and the costs of critical care is approaching one percent of the U.S. gross domestic product.

In addition to reduced services and greater discharge delays among uninsured, the review found that while uninsured patients were slightly more likely to be admitted overall, the difference was not statistically significant, those with traumatic injuries were 63 percent as likely to be admitted as those with insurance.

"The finding that the uninsured were more likely to be admitted to the ICU after arriving at the hospital could occur if the uninsured delayed going to a hospital until experiencing a more advanced stage of illness," wrote Robert Fowler, M.D., associate professor of medicine at Sunnybrook Hospital, the University of Toronto, and lead author of the systematic review. "That the uninsured were perhaps less likely to use an ambulance to get to the hospital provides some support for this concept."

Finally, uninsured patients were more likely to face discharge delays.

"Although U.S. hospitals are legally obligated to care for patients who are emergently ill, they are not obligated to be the continuing provider for medically stabilized uninsured patients," Dr. Fowler noted. The increase in discharge delay may be due to the "difficulty in finding healthcare providers or facilities to accept these patients."

Overall, lack of insurance is independently associated with reduced access to care and poorer outcomes. "We found evidence that patients who are critically ill with lesser degrees of insurance coverage receive fewer critical care services compared with those who have more insurance. Developing more comprehensive programs and legislation to improve health coverage for patients who are acutely ill would therefore seem a logical avenue for investigation," the authors conclude.

While increasing access to insurance inevitable raises concerns about costs, the costs of underinsurance are already borne by society at large, as uninsured patients rely more heavily on emergent care, and the ultimate responsibility for unpaid bills falls to the states and ultimately the tax payers. Furthermore, concerns about possible over-usage are not substantiated by research. Recent evidence shows that individuals who move from no insurance to more comprehensive coverage do not use more resources than the consistently and long-term insured.

"[O]ur review indicates that there may be inequalities in the provision of care to a vulnerable segment, that is, those who are very sick and in need of care but who cannot afford care," concluded the authors. "Even with increased access to health insurance, other factors such as poverty, limited health literacy, limited social support, and homelessness will continue to conspire against equitable care. As a society, we should urgently explore options to reduce such disparities across the population and particularly for those most vulnerable and those most in need."