For patients with brain tumors, insurance status linked to differences in patient safety and quality of care

Not having private insurance is associated with higher rates of patient safety issues (PSIs) and hospital-acquired conditions (HACs) -- leading to longer hospital stays and worse patient outcomes, according to the study by Dr. Kristopher G. Hooten and colleagues of University of Florida, Gainesville. Especially with reporting of these quality metrics under health care reform, the authors call for efforts to address disparities in quality of care for vulnerable patient populations.

Insurance Status Linked to Patient Safety and Quality of Care

Using a nationwide hospital care database, the researchers analyzed nearly 550,000 patients with brain tumors receiving hospital care between 2002 and 2011. About 44 percent of patients were on Medicare and 41 percent had private insurance. The remaining 15 percent were classified as Medicaid or "self-pay" (uninsured) patients.

Overall rates of reportable PSIs and HACs were highest for Medicare patients: 22.8 and 4.0 percent, respectively. Further analysis of the effects of insurance status excluded the Medicare group -- because it was restricted to older adults, it wasn't comparable to the other groups.

The Medicaid/self-pay patients had more reportable quality problems than the privately insured patients. Patient safety issues were reported for 20.6 percent of Medicaid/self-pay patients, compared to 8.6 percent for those with private insurance. Hospital-acquired conditions were reported for 2.2 percent of the Medicaid/self-pay group versus 1.9 percent of the privately insured group.

There were several important differences in patient characteristics between groups -- including the fact that Medicaid/self-pay patients had more accompanying medical problems and were more likely to be hospitalized on an emergency basis, compared to those with private insurance.

After adjustment for patient factors, the differences by insurance status remained significant. The increased rates of PSIs and HACs in the Medicaid/self-pay group were associated with more time in the hospital and an increased risk of poor outcomes, including in-hospital death.

Differences Explained by Adjustment for Patient and Hospital Factors

Medicaid/self-pay patients were also more likely to be treated at government-funded and teaching hospitals, and the percentage of such patients was highest in Southern states. Controlling for hospital factors, in addition to patient factors, explained the effects of insurance status on PSIs and HACs.

That suggests that the higher rates of quality problems aren't explained by insurance status itself, but rather by a complex mix of related factors -- including differences in access to health care and prehospital treatment. Even though teaching hospitals treated more Medicaid/self-pay patients, their rates of PSIs and HACs were no higher than at non-teaching hospitals.

Under the Affordable Care Act, hospitals' reimbursement is tied to their performance on measures including PSIs and HACs. The new study shows that for patients with brain tumors, rates of reportable patient safety and care quality problems are higher for Medicaid and underinsured patients, and lead to worse patient outcomes. Similar disparities related to insurance status have been found in other groups of patients, such as those undergoing vascular or colorectal cancer surgery.

Further study is needed to evaluate possible measures to address HACs and PSIs in brain tumor patients -- focusing on common events such as falls, pressure ulcers, and postoperative respiratory failure. Dr. Hooten and colleagues conclude, "With the implementation of the Patient Safety and Affordable Care Act, the cause of these factors should be studied prospectively to begin the process of improving quality metrics in vulnerable patient populations."