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OCR for page 109
B
Primary Research Literature
Review
109
OCR for page 110
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
OCR for page 111
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
OCR for page 112
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
OCR for page 113
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
OCR for page 114
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:
OCR for page 115
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)
OCR for page 116
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
OCR for page 117
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
OCR for page 118
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'
OCR for page 119
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
OCR for page 144
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:
OCR for page 145
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)
OCR for page 146
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
OCR for page 147
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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Representative terms from entire chapter:
health insurance
