The Insurance Coverage Paradox - Characterizing Outcomes among Dual-Eligible Hemorrhagic Stroke Patients.

BACKGROUND: Socioeconomic factors, such as insurance status, have been shown to affect outcomes for patients following emergency injuries. Dual-eligible beneficiaries, receiving both Medicare and Medicaid, constitute an especially vulnerable population. There is limited data addressing whether dual-eligible beneficiaries with hemorrhagic stroke display unique characteristics and outcomes compared to patients with Medicare, Medicaid, or private insurance. STUDY DESIGN: We conducted a retrospective analysis of 10-years of National Inpatient Sample data. Using ICD-9-CM codes, we identified adult patients with known insurance status who were emergently hospitalized for intracranial hemorrhage; epidural, subdural, subarachnoid, and intracerebral hemorrhages were included. Patient characteristics including whether they underwent surgical intervention were collected. Multivariable logistic regression was used to adjust for confounders. Primary clinical outcomes of interest included mortality (in-hospital), complications (any), and favorable discharge (home/home with services). RESULTS: Among 410,621 patients, dual-eligible (6.8%) patients were on average older (mean age = 73yrs) compared to Medicaid (46yrs), private insurance (67yrs), or no-charge (47yrs) patients. Caucasian race was highest among Medicare patients (83%) while African-American race was highest among Medicaid (22%). Among all patients, 5.3% underwent operative intervention. Dual-eligibles had significantly higher odds of in-hospital mortality compared to no-charge (adjusted odds ratio (aOR) = 1.61, 95% CI = [1.04 - 2.49]), but no significant difference between Medicare and Medicaid although dual-eligibles. Dual-eligibles had significantly increased odds of complications compared to Medicaid (aOR = 1.23, 95% CI = [1.11 - 1.37]) and privately insured patients (aOR = 1.19, 95% CI = [1.11 - 1.28]), both p < 0.001, and lower odds of favorable discharge compared to all other groups, all p < 0.001. Dual-eligibles underwent a shorter length of stay, an 18% decrease, compared to Medicaid patients (ß-Coefficient = 0.82, 95% CI = [0.78 - 0.86], p < 0.001), and inflation adjusted admission costs that were 24% lower compared to Medicaid patients (ß-Coefficient = 0.76, 95% CI = [0.73 - 0.80], p < 0.001), amounting to a $3,684 decrease in cost. CONCLUSIONS: Dual-eligible beneficiaries experience unique health disparities from lower odds of favorable discharge to increased odds of complications and in-hospital mortality compared to other insured and uninsured groups. Adverse outcomes among dual-eligible beneficiaries highlight the need to uncover and address unknown sources of disparities to improve emergency treatment of hemorrhagic stroke in this population.

Mortality, morbidity and clinical care in a referral neonatal intensive care unit in Haiti.

BACKGROUND: Neonatal mortality rates in Haiti are among the highest in the Western hemisphere. Few mothers deliver with a skilled birth attendant present, and there is a significant lack of pediatricians. The neonatal intensive care unit (NICU) at St. Damien Pediatric Hospital, a national referral center, is one of only five neonatology departments in Haiti. In order to target limited resources toward improving outcomes, this study seeks to describe clinical care in the St. Damien NICU. METHODS: A retrospective medical record review was performed on available medical records on all admissions to the NICU between April 2016 and April 2017. RESULTS: 220 neonates were admitted to the NICU within the study epoch. The mortality rate was 14.5%. Death was associated with a maternal diagnosis of hypertension (p = 0.03) and neonatal diagnoses of lower gestational age (p<0.0001), lower birth weight (p<0.0001), prematurity (p = 0.002), RDS p = 0.01), sepsis (p<0.0001) and kernicterus (p = 0.04). The most common diagnoses were sepsis, chorioamnionitis, respiratory distress syndrome, jaundice, prematurity and perinatal asphyxia. CONCLUSIONS: This study demonstrates that preterm birth, sepsis, RDS and kernicterus are key contributors to neonatal mortality in a Haitian national pediatric referral center NICU and as such are promising interventional targets for reducing the neonatal mortality rate in Haiti.