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B Primary Research Literature Review 109

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110 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Overall Health Status/Mortality Baker et al. (2001) Lack of Health Insurance and Decline in Overall Health in Late Middle Age. N Engl J Med Brook et al. (1983) Does Free Care Improve Adults' Health? Results from a Randomized Controlled Trial. N Engl J Med Franks et al. (1993a) Health Insurance and Mortality. Evidence From a National Cohort. JAMS Franks et al. (1993b) Health Insurance and Subjective Health Status: Data from the 1987 National Medical Expenditure Survey. AmJ Pub Health Hahn and Flood. (1995) No Insurance, Public Insurance, and Private Insurance: Do These Options Contribute to Differences in General Health? J Health Care Poor Underserved Kasper et al. (2000) Gaining and Losing Health Insurance: Strengthening the Evidence for Effects on Access to Care and Health Outcomes. Med Care Res Rev 7,577 participants in Health & Retirement Survey. 51-61 yrs at baseline in 1992; 1994; 1996 3,958 participants ages 14-61 yrs at 6 sites. 1975-1982 4,694 adults 225, UI or privately insured at baseline NHANES I,Epi. Followup Study, 1971-1987 12,036 adults ages 25-64, 1987 NMES 36,259 adults 18-64. 1987 NMES 1,400 families with at least 1 member <65; 3,142 persons, Kaiser Survey of Family Heath Experience, 1995 - 1997 Major den between ~ M.D. visit mortality; overall he Mortality Multiple measures Self-repor stratified Measures self-repor1

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APPENDIX B Outcome Measures Findings 111 cent 1 994; ,ites. ed at tidy, <65; Heath Major decline in health between 1992 and 1996 M.D. visits; hospitalization mortality; clinical measures; overall heath status Mortality Multiple health status measures Self-reported health status stratified by age and income Measures of access; self-reported health status 21.6% of continuously UI, 16.1% of intermittently UI, 8.3% of continuously insured had a major health decline over 4-yr period. Continuously UI had an adjusted relative risk of 1.6 compared to continuously insured of a major health decline and an RR of 1.2 to develop a mobility limitation. For the intermittently insured, these respective RRs were 1.4 and 1.2 Over a 3-5 year period, participants were randomly assigned to HI plans with different cost sharing, from free care to major deductible. No difference was found, overall, on 8 of 10 measures of health status and health habits between cost- sharing and free-care groups. For low-income persons with high BP, diastolic BP was lower by 3 mm Hg in free-care group. Free care resulted in improved vision overall Over a 13-17 year follow-up period, the mortality hazard ratio was 1.25 for uninsured adults >25 years as compared with privately insured adults at baseline (CI: 100-1.55). Adjusted for health status and health behaviors as well as for demographics and SES. No interaction effects found Lacking insurance is associated with lower subjective health status, relative to privately insured, independent of other risk factors. This relationship was found in those at both higher and lower income levels (above and below 200% FPL). Uninsured had less heart disease, more strokes and rheumatism, worse physical and role function, worse MH status. 11 chronic conditions controlled for UI have lower health status than those with private coverage. Health status of adults with public insurance is lowest of all. Authors speculate that poorer health status leads to public coverage and/or public insurance differs from private Insurance Loss of insurance reduces access to care 2 years later. Those with Medicaid who lost coverage were more likely than those still covered by Medicaid to report no RSC (35% vs. 12%). Overall, no significant differences in health status after loss of health insurance, except for those losing Medicaid, who initially reported better health, but lost the gains over time

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112 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Lurie et al. (1984) 215 medically indigent adult patients at General h Termination from Medi-Cal: Does It UCLA Ambulatory Care Center and comparison control; p Affect Health? New EnglJ Med group of 109 patients whose benefits were getting ne not terminated Lurie et al. (1986) Termination of Medi- Cal B enefits: A Followup Study One Year Later New Engl J Med Ross and Mirowsky (2000) Does Medical Insurance Contribute to Socioeconomic Differentials in Health? Milbank Q Short and Lair (1994-1995) Health Insurance and Health Status: Implications for Financing Health Care Reform. Inquiry Sorlie et al. (1994) Mortality in the Uninsured Compared with That in Persons with Public and Private Health Insurance. Arch Intern Med Preventive Services 2,592 adults 18-95 yrs at baseline in 1995; 1,452 at follow-up in 1998. Survey of Aging, Status, and the Sense of Control 7,750 children ages 1-18; 17,341 adults 18-64; 1987 NMES 147,779 adults ages 25-64, Current Population Survey, 1982 - 1986 Health sta conditions Self-repor chronic cat Standardi Ayanian et al. (2000) 105,764 adults ages 18-64 (1997); Access to Unmet Health Needs of Uninsured 117,364 (1998); long-term UI (9.7%), to proven Adults in the United States. JAMS short-term UI (4.3%), insured (86.0%); BRFSS self-report

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APPENDIX B Outcome Measures 113 Findings omparlson vere 995; Aging, Is 1 8-64; I BRFSS General health status; BP control; patient satisfaction; getting needed care Health status; chronic conditions; functional status Self-reported health status; chronic conditions Standardized mortality ratio Access to physician; access to preventive care; self-reported health status Two cohorts compared: one poor, chronically ill, and uninsured and one poor, chronically ill, and insured; 50% of the uninsured were able to identify an RSC compared to 96% (94% in 1986) of the insured. In 1984 study, 38% of the uninsured thought they could get care whenever they needed it compared to 93% of the insured. In 1986 study, 39% of the uninsured said they could get care whenever needed vs. 80% of the insured; 68% of the uninsured reported needing but not getting care vs. 17% of the insured. BP control significantly deteriorated for hypertensive uninsured individuals. Impossible to isolate the negative consequences of losing Medicaid from accompanying disruption in continuity of care at UCLA clinics. Satisfaction, access, health status worse after losing Medicaid Longitudinal study. No difference in chronic conditions between uninsured and privately insured. Those with Medicare and Medicaid report more chronic conditions than uninsured. No difference between UI, Medicaid, and those with private insurance in health status or physical functioning Examines how health affects HI status. Health of those with public insurance is worse than those with private insurance. Often significantly different from uninsured, who had fewer chronic conditions. Age and other covariates not controlled for With adjustment for age and income, UI in 3 of 4 race- gender strata had higher mortality over 5-year follow-up than those with employer-provided insurance, with RRs of 1.2 for white men, 1.5 for black men, 1.5 for white women, and 0.8 for black women. White uninsured workers had relative mortality risks 1.2 (men) and 1.3 (women) times higher than insured workers. Not adjusted for baseline health Long-term UI (21 year) adults were much more likely than short-term (<1 year) UI and insured adults not to have had routine check-up in the last two years (42.8%, 22.3%, and 17.8%, respectively). Deficits in cancer screening, cardiovascular risk reduction, and diabetes were more pronounced among long-term UI adults than among insured adults

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4 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Burstin et al. (1998) The Effect of Change of Health Insurance on Access to Care. Inquiry Cetjin et al. (1999) Adherence to Colposcopy Among Women with HIV Infection. J Acquire Immune Defic Syndr Faulkner and Schauffler (1997) The Effect of Health Insurance Coverage on the Appropriate Use of Recommended Clinical Preventive Services. AmJ Prep Med Powell-Griner et al. (1999) Health Coverage and Use of Preventive Services Among the Near Elderly in the United States. AmJ Pub Health Solis et al. (1990) Acculturation, Access to Care, and Use of Preventive Services by Hispanics: Findings from HHANES 1982-1984. Am J Pub Health Wagner and Guendelman (2000) Healthcare Utilization Among Hispanics: Findings From the 1994 Minority Health Survey. AmJ Manag Care 2,315 patients who presented to EDs at 5 urban teaching hospitals in Boston, 1993 462 women with or at risk for HIV infection, 1994-1995 53,981 adults ages 18-64; BRFSS, 1991 449,604 adults ages 55-64; BRFSS, 1993-1996 Hispanic adults 20 - 74 yrs; HHANES, 1982 - 1984 1,001 Hispanic respondents, 1994 Regular p . . . pnyslclan seeking cat Colposco~ of abnorrr Preventive preventive Health sta barrier to mammogr cholestero Use of pr' access to Use of he perceptlo:

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APPENDIX B 1 15 Outcome Measures Findings Regular physician; Those who lost their insurance had a greater likelihood physician follow-up; delays in compared with the privately insured of having no regular seeking care; preventive care physician (OR = 2.63), no physician follow-up (OR = 2.03), and delays in seeking care (OR = 2.21) than those who changed insurance plans (respectively, OR = 0.90, 0.94, and 1.67). Those who lost insurance were less likely to get vaccines (OR=0.24), check-ups in prior year (OR = 0.43), mammograms (OR = 0.61), and stool guaiac testing (OR = 0.68) than those who changed insurance (respectively, Ours = 1.06, 1.32, 0.97, and 1.08) Section, 93-1996 1982-1984 Colposcopy within 6 months HI predicted adherence in multiple logistic regression, but not of abnormal cytology finding in bivariate analysis. Sample reflects national population of HIV-positive women Preventive care; use of Higher level of insurance coverage is positively associated preventive services with receiving recommended clinical preventive services. Women are more likely than men to receive preventive care. For both men and women, those with no coverage for preventive services are less likely to receive them than those whose health plans cover some or most preventive care (OR= 0.5 Health status; RSC; cost as barrier to care; Pap test; mammogram; CBE; BP and cholesterol check Use of preventive services; access to care Use of health services; perception of health status Adjusted for sex, race, education, and marital status, UI adults 55-64 less likely than insured to have good or better health (OR = 0.8), RSC (OR = 0.25), more likely to report cost as barrier to care (OR = 7.6), less likely to have check-up (OR = 0.25), Pap test (OR = 0.38), mammogram (OR = 0.27), CBE (OR = 0.32), BP check (OR = 0.2), cholesterol check (OR = 0.35) Health insurance is independently associated with preventive services even with RSC taken into account. Women were more likely than men to have an RSC. Compared with Cuban Americans and Puerto Ricans, fewer Mexican Americans had any type of health insurance coverage (73.7%, 76.3%, and 66%, respectively) UI were less likely than those with HI to get any care and used less care (OR = 0.4). Immigrant Hispanics were less likely to use preventive services than U.S.-born Hispanics. Mexican Americans and Puerto Ricans were less likely than other Hispanics to use preventive services (OR = 0.5)

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116 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Waidmann and Rajan (2000) Race and Ethnic Disparities in Health Care Access and Utilization: An Examination. Med Care Res Rev Woolhandler and Himmelstein (1988) Reverse Targeting of Preventive Care Due to Lack of Health Insurance. JAMS Screening Breen et al. (2001) Progress in Cancer Screening Over a Decade. Results of Cancer Screening from the 1987, 1992, and 1998 NHIS. J Natl Cancer Inst Gordon et al. (1998) Type of Health Coverage and the Likelihood of Being Screened for Cancer. Med Care Hsia et al. (2000) The Importance of Health Insurance as a Determinant of Cancer Screening: Evidence from the Women's Health Initiative. Prev Med Moran et al. (2000) Factors Influencing Use of the Prostate-Specific Antigen Screening Test in Primary Care. Am J Manag Care Mosen et al. (1998) Is Access to Medical Care Associated with Receipt of HIV Testing and Counseling? AIDS Care Respondents to telephone survey, 1997 10,653 women ages 45 - 64; NHIS, 1982 Adult respondents; NHIS, 1982, 1987, and 1998 5,847 interviews; California BRFSS, 1989, 1990 55,278 women in the Women's Health Initiative Observational Study, 1994-1997 4,772 records of male patients 2 50; 109 PCPs surveyed, CO 1992-1994 217 patients hospitalized with a HIV-related illness at Los Angeles hospital, 1992-1993 Several m care and services Receipt 0 health ser Receipt 0 mammogr , slgmolclos Receipt 0 mammogr . . slgmolaos Breast, ce olorectal Prostate c PSA and ] Pre-hospi~ postdiagn' preventive

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APPENDIX B Outcome Measures Findings 117 Several measures of access to HI is associated with differences in use of services and, to a care and use of health lesser extent, with health status. HI accounts for 33% of the services difference between Latinos and non-Hispanic whites (37% of the difference between blacks and whites) in having an AS C, 19% (16%) of the difference in mammography, and 4% (3%)of the difference in health status. The contribution of HI to these racial-ethnic differences varies greatly by region and state 32 Receipt of preventive UI women 45-64 are less likely to receive BP checks, Pap health services smears, CBE, or glaucoma exams and 1998 Receipt of Pap smear, mammogram, FOBT, . . slgmolaoscopy RSC and health insurance are independently and strongly associated with receipt of services. Racial differences (black- white) are greater for UI than for insured. UI were less likely than privately insured to obtain a mammography (OR = 0.5), a Pap smear (OR = 0.37), or colorectal cancer screening (OR = 0.34 for men; 0.63 for women). Those with a RSC were more likely to receive a mammogram (OR = 3.9), a Pap smear (OR = 4.7), or colorectal cancer screening (OR = 5.2 for men; 3.5 for women) 989, 1990 Receipt of Pap smear, RSC is best predictor of receiving Pap smear, mammogram, mammogram, FOBT, FOBT, sigmoidoscopy, or colorectal screening (OR = 5.2 sigmoidoscopy for men; 3.5 for women). Trends in ORs for UI to private FFS plans suggest lower use by UI, but not statistically significant Breast, cervical, and olorectal cancer screening 997 Prostate cancer screening: PSA and DRE Among women < 65, UI less likely to receive cancer screening, independent of having a RSC. UI less likely than privately insured to have mammogram within 2 years (OR = 0.30); to have Pap smear within 3 years (OR = 0.34); to have sigmoidoscopy or FOBT within 5 years (OR = 0.50). Reference group is private prepaid plan enrollees Screening for prostate cancer increased significantly between 1992 and 1994. Trend toward greater screening for privately insured vs. UI, but no significant differences Pre-hospital HIV testing; Regular source of care has positive effect on receipt of vital, postdiagnosis receipt of HIV testing and counseling. Health insurance status is not preventive services related. Services through VA positively associated with getting preventive counseling. Limited generalizability because of small samples and low response rate

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118 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Perez and Tsou (1995) Prostate Cancer Screening Practices: Differences Between Clinic and Private Patients. Mt Sinai J Med Potosky et al. (1998) The Association Between Health Care Coverage and the Use of Cancer Screening Tests. Med Care Cervical and Breast Cancer Screening Burack et al. (1993) Patterns of Use of Mammography Among Inner-City Detroit Women: Contrasts Between a Health Department, HMO, and Private Hospital. Med Care Bush and Langer (1998) The Effects of Insurance Coverage and Ethnicity on Mammography Utilization in a Postmenopausal Population. West J Med Cummings et al. (2000) Predictors of Screenings Mammography: Implications for Office Practice. Arch Fam Med Eger and Peipert (1996) Risk Factors for Noncompliance in a Colposcopy Clinic. Journal of Reproductive Medicine Evans et al. (1998) Factors Associated with Repeat Mammography in a New York State Public Health Screening Program. J Public Health Manag Pract 142 male patients >40 yrs 9,455 adults; NHIS, 1992 2,880 inner-city minority women >40 yrs, 1988-1989 2,453 postmenopausal women 50 - 79 yrs; San Diego, 1993 843 women 250 yrs in rural communities 200 hospital patients, 1992 data 9,485 female participants in a breast cancer screening outreach program Prostate c PSA and ] Receipt 0 mammogr . . slgmolaos Mammog' use of ma Use of ma Mammog CBE; Pap Rate of cat colposcop Mammog'

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APPENDIX B Outcome Measures Findings 119 Prostate cancer screening: PSA and DRE Receipt of Pap smear, mammogram, FOBT, sigmoidoscopy, and DRE yrs, firs; ties Lancer Mammography referral; use of mammography Use of mammography Mammography screening; CBE; Pap smear Rate of compliance with colposcopy Mammography screening No difference found between private practice and clinic populations in the frequency of DRE. Private patients were much more likely to receive PSA, 68% compared to 10% UI less likely than Medicaid and private enrollees to receive preventive services. Mammograms (OR = 0.27), clinical breast exams (OR =0.33), Pap smears (OR = 0.43), fecal occult blood tests (OR = 0.29), or digital rectal exams (OR = 0.28). Medicaid FFS enrollees were more likely to receive a Pap smear than private enrollees (OR = 1.6). UI findings on receipt of sigmoidoscopy not statistically significant. OR comparison group is private managed care No differences found by health insurance status. HI status effects vary by site of care. Patient with more visits more likely to have mammography. Study population had access to . . ~ ... primary care with frequent uollzatlon Mammography use is higher among insured postmenopausal women than their uninsured counterparts with an RSC, but not among insured women without an RSC HI may be an important enabling factor in predicting screening mammography. In bivariate analysis of any HI vs. UI; RR for those with RSC = 1.6; for those without RSC, RR = 1.4. HI is not significant when separate variables for having a Pap smear and receiving a CBE are included in the model Noncompliant women were more likely to be UI or to have Medicaid (OR = 2.4; 95% CI: 0.85-6.7) HI not significantly associated with returning for regular mammogram screening in multivariate analysis. Could not account for mammography elsewhere

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44 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Emergency and Trauma Braveman et al. (1994) Insurance-Related Differences in the Risk of Ruptured Appendix. N Engl J Med Doyle (2001) Does Health Insurance Affect Treatment Decisions and Patient Outcomes? Using Automobile Accidents as Unexpected Health Shocks Ell et al. (1994) Acute Chest Pain in African Americans: Factors in the Delay in Seeking Emergency Care Am J Pub Health Haas and Goldman (1994) Acutely Injured Patients with Trauma in Massachusetts: Differences in Care and Mortality by Insurance Status. Am J Pub Health MacKenzie et al. (2000) Characterization of Patients With High-Energy Lower Extremity Trauma. J Orthop Trauma Nathens et al. (2001) Payer Status: The Unspoken Triage Criterion. J Trauma Thee et al. (1997) The Effect of Payer Status on Utilization of Hospital Resources in Trauma Care. Arch Surgery Rucker et al. (2001) Delay in Seeking Emergency Care. Acad Emery Med 91,339 adults discharged from hospital with Dx of acute appendicitis; California, 1984-1989 10,962 accident victims <65; 1992-1997 Wisconsin's Crash Outcome Data Evaluation System 254 patients at a public hospital; 194 patients at a private hospital; 1988 - 1990 Los Angeles 15,008 adult trauma patients <65; Massachusetts, 1990 601 patients 16 - 69, 8 Level I trauma centers 1994-1997 2008 adults <65 King County, Washington, central region trauma registry, 1995-1998 2,827 patient data from institutional trauma registry; Washington, 1990-1992 1,920 patients surveyed in 5 teaching hospital EDs Ruptured Mortality; LOS Access to pain; dela In-hospita receipt of Lower-ex amputatlo Patient try Mortality Self-repor seeking E:

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APPENDIX B Outcome Measures Findings 145 with 984-1 989 97 enters ;istry, auma Ruptured appendix Mortality; hospital charges; LOS Access to care; acute chest pain; delay in seeking care In-hospital mortality; ,~ receipt or services L. . . Ower-extremlty 1nJury; amputation Patient transfer Mortality rate; LOS Self-reported delays in seeking ED care UI more likely to have a ruptured appendix compared to privately insured (OR = 1.5). Same higher risk for Medicaid compared to privately insured. UI associated with delay in seeking care UI in severe auto accidents received 20% less treatment (lower charges, shorter LOS) and had a mortality rate of 5.2% compared with 3.8% for persons with private insurance (37% higher mortality). Limited adjustment for severity Health insurance of any kind was significantly related to decision time to seek care, but not to travel time. Those who did not go to hospital are not in study. UI associated with use of a public hospital UI receive less care and have a higher mortality rate than trauma patients with private insurance or Medicaid. They are as likely to receive care in an ICU as patients with private health insurance, but less likely to undergo an operative procedure (OR = 0.68) or receive physical therapy (OR = 0.61) and are more likely to die in the hospital (OR= 2.1 5) Uninsured no more likely to undergo amputation. Those with this injury more likely to be uninsured than general population Medicaid and UI analyzed together. Severe injuries and "noncommercial insurance" (Medicaid and UI) most likely to be transferred to Level 1 trauma center. Controlling for age, sex, and primary injury and severity, people without commercial insurance are more likely to be transferred (OR = 2.4). Effect most pronounced for least injured Medicaid and UI combined. Payer status did not affect mortality or use of hospital resources except for one subgroup: those who required transfer to LTC. For these patients, Medicaid and UI patients had greater LOS 32% of participants reported a delay in seeking ED care. Patients with no regular M.D. were more likely to delay care (OR = 2.0). UI tended to be more likely to delay care than those with any insurance, but finding was not statistically significant (OR = 1.26, CI: 0.88 - 1.81)

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146 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Svenson and Spurlock (2001) Insurance Status and Admission to Hospital for Head Injuries: Are We Part of a Two-Tiered Medical System. Am J Emerg Med Cardiovascular Disease Blustein et al. (1995) Sequential Events Contributing to Variations in Cardiac Revascularization Rates. Med Care Brooks et al. (2000) The Marginal Benefits of Invasive Treatments for Acute Myocardial Infarction: Does Insurance Coverage Matter? Inquiry Canto et al. (1999) The Association Between the On-site Availability of Cardiac Procedures and the Utilization of Those Services for Acute Myocardial Infarction by Payer Group. Olin Cardiol Canto et al. (2000) Payer Status and the Utilization of Hospital Resources in Acute Myocardial Infarction. Arch Intern Med Carlisle et al. (1997) Racial and Ethnic Disparities in the Use of Cardiovascular Procedures: Associations with Type of Health Insurance. Am J Pub Health Carlisle and Leake (1998) Differences in the Effect of Patients' Socioeconomic Status on the Use of Invasive Cardiovascular Procedures Across Health Insurance Categories. Am J Pub Health 8,591 ED patients with head injury in Kentucky 5,857 AMI hospital admissions <65: 1991, California 30,606 patients, HCUP data Washington, 1988-1993 275,046 patients National Registry of MI-II, 1994 - 1996 332,221 patients National Registry of Myocardial Infarction-II, 1994 - 1996 104,952 hospital discharges in Los Angeles county, California, 1986 - 1988 206,233 discharged patients with heart disease; California, 1991-1993 Admissior LOS In-hospita revascular admission Adj usted 1, 7, 30, year Coronary In-hospita AMI, CA Angiograt angioplast

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APPENDIX B Outcome Measures Findings 147 Kentucky on, Admission to hospital; cost; LOS In-hospital mortality; revascularization; hospital admission Adjusted mortality at days 1, 7, 30, and 90 and at one year Coronary arteriography In-hospital mortality Medicaid and UI less likely than privately insured with head injury to be admitted. Cost: public < uninsured < private. LOS: similar across groups. For those with less severe head injuries, insurance status is significantly associated with discretionary medical decision making in ED care. Method to adjust for severity of injury questionable UI less likely than privately insured patients to receive revascularization at hospitals offering it (OR = 0.43 to FFS, 0.53 to HMO). Less likely to receive revascularization at every step of the care process. In-hospital death rate is higher for UI: OR = 1.13 (compared to Medicaid), 1.77 (compared to FFS), 2.07 (compared to HMO). Compared to privately insured, UI less likely to be admitted to hospital offering revascularization (OR = 0.71), less likely to be transferred to receive revascularization (OR = 0.42), and less likely to be readmitted for revascularization (OR = 0.63). Clinical adjustments; no assessment of appropriateness of procedures Cardiac catheterization within 90 days for marginal patients in each insurance category had greater survival benefits up to 90 days for UI than for FFS, HMO, or Medicaid patients. Suggests that UI who receive the procedure are at a higher level of severity than insured patients UI equally likely to receive acute reperfusion therapy and less likely to undergo catheterization (OR = 0.68), PTCA (OR = 0.8), or CABG (OR = 0.78) than privately insured. Admission to hospital that offers arteriography increases likelihood of receiving it (OR for UI =1.7). Extensive adjustments for clinical factors and prior history In-hospital mortality for uninsured vs. FFS (OR = 1.29) is the same as Medicaid to FFS. No significant differences among in- hospital mortality rates for HMO, FFS, and Medicare reles AMI, CAD, and angina Uninsured African-American patients significantly less likely to have arteriography, CABG, or angioplasty than white UI patients (OR = 0.33-0.5). No disparities related to ethnicity in privately insured group Angiography; CABG; Examined differences within insurance classes by angioplasty neighborhood SES. Residents of high-SES areas were more likely and those of low-SES areas less likely to undergo each of 3 invasive procedures (angiography, CABG, angioplasty) than those of middle-SES areas. SES effects were found for Medicare and HMO patients, but were less pronounced (not significantly different) in FFS and UI patients

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48 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Daumit et al. (1999) Use of Cardiovascular Procedures Among Black Persons and White Persons: A 7-Year Nationwide Study in Patients with Renal Disease. Ann Intern Med Daumit et al. (2000) Relation of Gender and Health Insurance to Cardiovascular Procedure Use in Persons with Progression of Chronic Renal Disease. Med Care Kreindel et al. (1997) Health Insurance Coverage and Outcome Following Acute Myocardial Infarction: A Community-wide Perspective. Arch Intern Med Kuykendall et al. (1995) Expected Source of Payment and Use of Hospital Services for Coronary Atherosclerosis. Med Care Leape et al. (1999) Underuse of Cardiac Procedures: Do Women, Ethnic Minorities and the Uninsured Fail to Receive Needed Revascularization? Ann Intern Med Mancini et al. (2001) Coronary Artery Bypass Surgery: Are Outcomes Influenced by Demographics or Ability to Pay? Ann Surg 4,987 adults with ESRD 1986-1987 USRDS data (Same data sample as above) 3,735 AMI patients in Worcester, Massachusetts, 1986 - 1993 24,424 hospital discharge abstracts, California, 1989 631 patients in 13 New York City hospitals, 1992 1,556 CABG patients in single public hospital in Los Angeles, 1990-2000 Cardiac c. angioplast Cardiac c. angioplast In-hospita mortality LOS; rev CABG, P. Survival 0

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APPENDIX B Outcome Measures Findings 149 Cardiac catheterization; angioplasty; CABG Cardiac catheterization; angioplasty; CABG In-hospital, post-AMI mortality LOS; revascularization CABG, PTCA Survival over study period Differences between blacks and whites in use of cardiovascular procedures narrowed markedly once ESRD developed and insurance (Medicare) was universal. At baseline, UI blacks with evidence of coronary disease were much less likely to receive cardiovascular procedures than UI whites (OR = 0.07); at follow-up, previously UI black patients were slightly more likely to undergo a cardiac procedure than UI white patients. UI blacks and whites had the greatest disparity in the use of procedures at baseline and the largest change at follow-up, post-Medicare Compared to men with private insurance, both women and men without insurance were less likely to receive cardiovascular procedures prior to ESRD (ORs = 0.19 and 0.47, respectively). At follow-up when everyone had Medicare (ESRD), gender differences in procedure use were eliminated for UI No significant difference in in-hospital mortality for UI to privately insured (OR = 1.21; CI: 0.60 - 2.44). No SES or provider adjustment UI patients were much less likely than FFS or HMO patients to undergo revascularization (either CAB G or PTCA) (ORs = 0.46 and 0.59, respectively). UI more likely to have a longer LOS without revascularization than HMO or FFS patients (OR = 1.95). Weak adjustment for clinical factors, no adjustment for SES or provider factors. No assessment of appropriateness Sample consisted of patients meeting panel criteria for necessary revascularization. No difference in rates of revascularization according to HI status found in hospitals that provide CABG and coronary angioplasty. Underuse was significantly greater in hospitals without these services, particularly for UI. In these hospitals, 52% of UI received indicated procedure vs. 82% of privately insured. No significant difference in adjusted in-hospital mortality between UI and privately insured UI patients had significantly better survival at 10 years than insured patients (87% vs. 76%). No adjustment for marked differences in insured and uninsured groups, including younger age distribution of UI patients. 66% of sample was UI

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150 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Sada et al. (1998) Influence of Payor on Use of Invasive Cardiac Procedures and Patient Outcome After Myocardial Infarction in the United States. J Am Coll Cardiol Young and Cohen (1991) Inequities in Hospital Care, the Massachusetts Experience. Inquiry Palliative Care Holcombe and Griffin (1993) Effect of Insurance Status on Pain Medication Prescriptions in a Hematology/Oncology Practice. S MedJ Kollef (1996) Private Attending Physician Status and the Withdrawal of Life-Sustaining Interventions in a Medical Intensive Care Unit Population. Crit Care Med Kollef and Ward (1999) The Influence of Access to a Private Attending Physician on the Withdrawal of Life-Sustaining Therapies in the Intensive Care Unit. Critical Care Medicine Ambulatory Care Sensitive Conditions Bindman et al. (1995) Preventable Hospitalizations and Access to Care. JAMS 17,600 AMI patients <65 in National Registry of Myocardial Infarction, 1994 - 1995 4,972 patients admitted with AMI, 1987 710 patient charts, Louisiana State University Medical Center, 1990 Patients in the medical ICU of one hospital, 1993-1994 Patients within the medical ICU of one hospital, 1996 Telephone surveys of 6,674 adults 18-64; mail survey of physicians in 41 areas; 1990 U. S. Census In-hospita nondiscre~ LOS Mortality 30 days pi Receipt 0 procedure Receipt 0 class of pa Withdraw duration ventilation medical c; charges Access to attending Preventab

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APPENDIX B Outcome Measures Findings 151 14-1995 37 In-hospital mortality; UI less likely than FFS patients to receive nondiscretionary nondiscretionary angiography; angiography (OR = 0.48). Payer status not associated with LOS length of stay. Medicaid patients had higher mortality than FFS Mortality in hospital and at 30 days post-discharge. Receipt of invasive cardiac procedures Receipt of pain medication; class of pain medication Withdrawal of life support; duration of mechanical ventilation; ICU LOS; medical care costs; patient charges UI had higher 30-day postdischarge mortality relative to FFS (OR = 1.6) and HMO (OR = 1.5). Compared with FFS, UI were less likely to receive 2 of 3 cardiac procedures (CABG and angioplasty) (OR = 0.6). Compared to HMO patients, UI were about equally likely to receive arteriography and CABG, but less likely to receive angioplasty (OR = 0.6). No assessment of procedure appropriateness; no validation of AMI diagnosis or clinical covariates Medicaid outpatients are more likely to receive any pain medications than UI or Medicare patients. Also more likely to receive longer-lasting, more efficacious, and more expensive pain medications Having private HI and private attending M.D. are correlated. Patients without private HI (Medicaid and UI) are more likely to have life-sustaining treatment withdrawn (OR = 4.4) than are privately insured Access to a private Having a private M.D. is strongly associated with no attending M.D. withdrawal of care. Private insurance is strongly associated with having a private M.D. (OR = 3.5) 64; Preventable hospitalizations Access to care and area-wide rates of uninsured were inversely related to hospitalization rate for five chronic conditions: asthma, hypertension, CHF, COPD, and diabetes. Authors hypothesize that even acutely ill UI are less likely to seek care. Ecological findings

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52 CARE WITHOUT COVERAGE: TOO LITTLE, TOO LATE Sample Size/Data Source Outcome Gaskin and Hoffman (2000) Racial and Ethnic Differences in Preventable Hospitalizations Across 10 States. Med Care Res Rev Weissman et al. (1992) Rates of Avoidable Hospitalization by Insurance Status in Massachusetts and Maryland. JAMS 1996 hospital discharge data from 10 states representing 42% of U. S. population Massachusetts and Maryland hospital discharges for patients <65, 1987 Preventab Preventab NOTES: ACSUS = AIDS Cost and Services Utilization Study; AMI = acute myocardial infarction; AOR = adjusted odds ratio; BP = blood pressure; BRFSS = Behavioral Risk Factor Surveillance System; CAB G = coronary artery bypass graft; CAD = coronary artery disease; CBE = clinical breast exam; CHF = congestive heart failure; CI = confidence interval; COPD = chronic obstructive pulmonary disease; DRE = digital rectal examination; Dx = diagnosis; ED = emergency department; EPO = erythropoietin; ESRD = end-stage renal disease; FFS = fee for service; FOBT = fecal occult blood test; FPL = federal poverty level; HAART = highly active antiretroviral therapy; HCSUS = HIV Cost and Services Utilization Study; HCUP = Healthcare Cost and Utilization Project; HI = health insurance; HIE = Health Insurance Experiment (RAND); HMO = health maintenance organization; HRQOL = health-related quality of life; ICU = intensive care unit; LOS = length of stay; LTC = long-term care; MH = mental health; MIDUS = Midlife Development in the

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APPENDIX B Outcome Measures Findings 153 tates ischarges Preventable hospitalizations Preventable hospitalizations Analysis was stratified by health insurance status, thus no direct comparison by HI status made. Within classes of HI status, blacks and Hispanics more likely to have preventable hospitalizations In Massachusetts, hospitalization rates for uninsured and privately insured were significantly different for 10 of 12 conditions. In Maryland, for 9 of 12 conditions. UI and Medicaid patients more likely than privately insured to be hospitalized (ORs = 1.3-1.7 for UI compared to private, and 1.3-1.7 for Medicaid compared to private) United States; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NMES = National Medical Expenditures Survey; NNRTI = nonnucleoside reverse transcriptase inhibitor; NSD = no significant difference; OR = odds ratio; PCP = Pneumocystis carinii pneumonia; PHP = prepaid health plan; PI = protease inhibitor; PSA = prostate-specific antigen; PTCA = percutaneous transluminal coronary angioplasty; QOL = quality of life; RPCS = regular primary care source; RR = relative risk; RSC = regular source of care; Rx = prescription medication; SES = socioeconomic status; SLE = systemic lupus erythematosus; SMR = standardized mortality ratio; Tx = treatment or therapy; UCLA = University of California at Los Angeles; UI = uninsured; USC = usual source of care; USRDS = U.S. Renal Data System; VA = Department of Veterans Affairs.

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