Association of Health Insurance Status with Outcomes of Sepsis in Adult Patients: A Retrospective Cohort Study
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Setting and Population
2.2. Data Collection and Outcome Measures
2.3. Statistical Analysis
3. Results
3.1. Characteristics of Study Patients
3.2. Comparison between NHI and MA Groups in the Full Cohort
3.3. Comparison between Survivors and Nonsurvivors and Multivariate Analysis for In-Hospital Mortality
3.4. Propensity Score-Matched Cohort
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Paoli, C.J.; Reynolds, M.A.; Sinha, M.; Gitlin, M.; Crouser, E. Epidemiology and costs of sepsis in the United States- An analysis based on timing of diagnosis and severity level. Crit. Care Med. 2018, 46, 1889–1897. [Google Scholar] [CrossRef] [PubMed]
- Rhodes, A.; Evans, L.E.; Alhazzani, W.; Levy, M.M.; Antonelli, M.; Ferrer, R.; Kumar, A.; Sevransky, J.E.; Sprung, C.L.; Nunnally, M.E.; et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med. 2017, 43, 304–377. [Google Scholar] [CrossRef] [PubMed]
- Poulsen, J.B.; Moller, K.; Kehlet, H.; Perner, A. Longterm physical outcome in patients with septic shock. Acta Anaesthesiol. Scand. 2009, 53, 724–730. [Google Scholar] [CrossRef] [PubMed]
- Granja, C.; Amaro, A.; Dias, C.; Costa-Pereira, A. Outcome of ICU survivors: A comprehensive review. The role of patient-reported outcome studies. Acta Anaesthesiol. Scand. 2012, 56, 1092–1103. [Google Scholar] [CrossRef]
- O’Brien, J.M., Jr.; Ali, N.A.; Levine, D.A.; Aberegg, S.K.; Lemeshow, S. Insurance type and sepsis-associated hospitalizations and sepsis-associated mortality among US adults: A retrospective cohort study. Crit. Care. 2011, 15, R130. [Google Scholar] [CrossRef] [Green Version]
- McBean, M.; Rajamani, S. Increasing rates of hospitalization due to septicemia in the US elderly population, 1986–1997. J. Infect. Dis. 2001, 183, 596–603. [Google Scholar] [CrossRef]
- Fronstin, P. Sources of health insurance and characteristics of the uninsured: Analysis of the March 2008 current population survey. EBRI Issue Brief 2008, 9, 1–33. [Google Scholar]
- Kumar, G.; Taneja, A.; Majumdar, T.; Jacobs, E.R.; Whittle, J.; Nanchal, R. The association of lacking insurance with outcomes of severe sepsis: Retrospective analysis of an administrative database. Crir. Care Med. 2014, 42, 583–591. [Google Scholar] [CrossRef] [Green Version]
- Koch, K.; Nørgaard, M.; Schønheyder, H.C.; Thomsen, R.W.; Søgaard, M. Effect of socioeconomic status on mortality after bacteremia in working-age patients. A Danish population-based cohort study. PLoS ONE 2013, 8, e70082. [Google Scholar] [CrossRef] [Green Version]
- Estenssoro, E.; Loudet, C.I.; Edul, V.S.K.; Osatnik, J.; Ríos, F.G.; Vásquez, D.N.; Pozo, M.O.; Lattanzio, B.; Pálizas, F.; Klein, F.; et al. Health inequities in the diagnosis and outcome of sepsis in Argentina: A prospective cohort study. Crit. Care. 2019, 23, 250. [Google Scholar] [CrossRef] [Green Version]
- Minejima, E.; Wong-Beringer, A. Impact of socioeconomic status and race on sepsis epidemiology and outcomes. J. Appl. Lab. Med. 2021, 6, 194–209. [Google Scholar] [CrossRef]
- Schnegelsberg, A.; Mackenhauer, J.; Nibro, H.L.; Dreyer, P.; Koch, K.; Kirkegaard, H. Impact of socioeconomic status on mortality and unplanned readmission in septic intensive care unit patients. Acta Anaesthesiol. Scand. 2016, 60, 465–475. [Google Scholar] [CrossRef] [PubMed]
- Sunden-Cullberg, J.; Nilsson, A.; Inghammar, M. Sex-based differences in ED management of critically ill patients with sepsis: A nationwide cohort study. Intensive Care Med. 2020, 46, 727–736. [Google Scholar] [CrossRef] [Green Version]
- Galiatsatos, P.; Brigham, E.P.; Pietri, J.; Littleton, K.; Hwang, S.; Grant, M.J.; Hansel, N.H.; Chen, E.S. The effect of community socioeconomic status on sepsis-attributal mortality. J. Crit. Care. 2018, 46, 129–133. [Google Scholar] [CrossRef]
- Goodwin, A.J.; Nadig, N.R.; McElligot, J.T.; Simpson, K.N.; Ford, D.W. The impact of place of residence on severe sepsis incidence and mortality. Chest 2016, 150, 829–836. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Singer, M.; Deutschman, C.S.; Seymour, C.W.; Shankar-Hari, M.; Annane, D.; Bauer, M.; Bellomo, R.; Berbnard, G.R.; Chiche, J.; Coopersmith, C.M.; et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 2016, 315, 801–810. [Google Scholar] [CrossRef] [PubMed]
- Dellinger, R.P.; Levy, M.M.; Rhodes, A.; Annane, D.; Gerlach, H.; Opal, S.M.; Sevransky, J.E.; Sprung, C.L.; Douglas, I.S.; Jaeschke, R.J.; et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Intensive Care Med. 2013, 39, 165–228. [Google Scholar] [PubMed]
- Lee, S.Y.; Chun, C.B.; Lee, Y.G.; Seo, N.K. The national health insurance system as one type of new typology: The case of South Korea and Taiwan. Health Policy 2008, 85, 105–113. [Google Scholar] [CrossRef] [PubMed]
- Korean Health Insurance Review and Assessment Service. National Health Insurance Statistical Yearbook; Health Insurance Review and Assessment Service: Wonju, Korea; National Health Insurance Service: Wonju, Korea, 2019.
- Kim, T.H.; Ro, Y.S.; Shin, S.D.; Song, K.J.; Hong, K.J.; Park, J.H.; Kong, S.Y. Association of health insurance with post-resuscitation care and neurological outcomes after return of spontaneous circulation in out-of-hospital cardiac arrest patients in Korea. Resuscitation 2019, 135, 176–182. [Google Scholar] [CrossRef]
- Danis, M.; Linde-Zwirble, W.T.; Astor, A.; Lidicker, J.R.; Angus, D.C. How does lack of insurance affect use of intensive care? A population-based study. Crit. Care Med. 2006, 34, 2043–2048. [Google Scholar] [CrossRef]
- Durairaj, L.; Will, J.G.; Torner, J.C.; Doebbeling, B.N. Prognostic factors for mortality following interhospital transfers to the medical intensive care unit of a tertiary referral center. Crit. Care Med. 2003, 31, 1981–1986. [Google Scholar] [CrossRef] [PubMed]
- Haas, J.S.; Goldman, L. Acutely injured patients with trauma in Massachusetts: Differences in care and mortality, by insurance status. Am. J. Public Health 1994, 84, 1605–1608. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Dellinger, R.P. The Surviving Sepsis Campaign: Where have we been and where are we going? Cleve. Clin. J. Med. 2015, 82, 237–244. [Google Scholar] [CrossRef] [PubMed]
- Castellanos-Ortega, A.; Suberviola, B.; Garcia-Astudillo, L.A.; Holanda, M.S.; Ortiz, F.; Llorca, J.; Delgado-Rodriguez, M. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: Results of a three-year follow-up quasi-experimental study. Crit. Care Med. 2010, 38, 1036–1043. [Google Scholar] [CrossRef]
- Schnitzler, M.A.; Lambert, D.L.; Mundy, L.M.; Woodward, R.S. Variations in healthcare measures by insurance status for patients receiving ventilator support. Clin. Perform. Qual. Health Care 1998, 6, 17–22. [Google Scholar]
- Haider, A.H.; Chang, D.C.; Efron, D.T.; Haut, E.R.; Crandall, M.; Cornwell, E.E. Race and insurance status as risk factors for trauma mortality. Arch. Surg. 2008, 143, 945–949. [Google Scholar] [CrossRef]
Characteristics | Full Study Cohort | Propensity-Matched Cohort a | |||||||
---|---|---|---|---|---|---|---|---|---|
Total (n = 2526) | National Health Insurance (n = 2329) | Medical Aid (n = 197) | p-Value | Total (n = 576) | National Health Insurance (n = 384) | Medical Aid (n = 192) | p-Value | SMD | |
Age (years) | 72.0 (63.0–79.0) | 73.0 (63.0–79.0) | 71.0 (60.0–81.0) | 0.293 | 72.0 (61.3–80.0) | 73.0 (63.0–80.0) | 71.0 (60.0–81.0) | 0.335 | 0.0625 |
Sex (male) | 1489 (58.9) | 1390 (59.7) | 99 (50.3) | 0.009 | 288 (50.0) | 192 (50.0) | 96 (50.0) | 1.000 | 0.0000 |
Comorbidities | |||||||||
Diabetes | 843 (33.4) | 765 (32.9) | 78 (39.6) | 0.061 | 247 (42.9) | 169 (44.0) | 78 (40.6) | 0.494 | 0.0688 |
Hypertension | 1127 (44.7) | 1039 (44.7) | 88 (44.7) | 1.000 | 268 (46.5) | 181 (47.1) | 87 (45.3) | 0.745 | 0.0365 |
Chronic kidney disease | 204 (8.1) | 180 (7.7) | 24 (12.2) | 0.027 | 68 (11.8) | 44 (11.5) | 24 (12.5) | 0.819 | 0.0314 |
Initial vital signs | |||||||||
Mean BP (mmHg) | 72.0 (60.0–90.0) | 72.0 (60.0–90.0) | 74.0 (58.0–96.0) | 0.731 | 74.0 (60.0–93.8) | 74.0 (61.0–93.0) | 74.5 (58.5–96.0) | 0.801 | 0.0081 |
Source of visit to ED | 0.1358 | ||||||||
Community | 1300 (51.5) | 1193 (51.2) | 107 (54.3) | 0.416 | 344 (59.7) | 238 (62.0) | 106 (55.2) | 0.141 | |
Nosocomial | 1121 (44.4) | 1042 (44.7) | 79 (40.1) | 0.231 | 205 (35.6) | 129 (33.6) | 76 (39.6) | 0.186 | |
Nursing home | 99 (3.9) | 89 (3.8) | 10 (5.1) | 0.442 | 25 (4.3) | 16 (4.2) | 9 (4.7) | 0.942 | |
Source of infection | |||||||||
Respiratory | 1067 (42.2) | 982 (42.2) | 85 (43.1) | 0.791 | 257 (44.6) | 172 (44.8) | 86 (44.3) | 0.976 | 0.0369 |
Genitourinary | 748 (29.6) | 664 (28.5) | 64 (32.5) | 0.851 | 189 (32.8) | 125 (32.6) | 64 (33.3) | 0.925 | 0.0114 |
Hepatobiliary | 235 (9.3) | 228 (9.8) | 17 (8.6) | 0.554 | 57 (9.9) | 40 (10.4) | 17 (8.9) | 0.657 | 0.0282 |
Gastrointestinal | 206 (8.2) | 186 (8.0) | 20 (10.2) | 0.294 | 60 (10.4) | 40 (10.4) | 20 (10.4) | 1.000 | 0.0089 |
Others | 216 (8.6) | 204 (8.8) | 12 (6.1) | 0.201 | 41 (7.1) | 29 (7.6) | 12 (6.3) | 0.688 | 0.0860 |
Multiple sources | 53 (2.1) | 43 (1.8) | 10 (5.1) | 0.010 | 35 (6.1) | 25 (6.5) | 10 (5.2) | 0.666 | 0.0584 |
Septic shock | 630 (24.9) | 576 (24.7) | 54 (27.4) | 0.440 | 171 (29.7) | 117 (30.5) | 54 (28.1) | 0.629 | 0.0520 |
SOFA score | 6.0 (4.0–9.0) | 6.0 (4.0–9.0) | 7.0 (4.0–9.0) | 0.181 | 7.0 (4.0–9.0) | 7.0 (4.0–9.0) | 7.0 (4.0–9.0) | 0.837 | 0.0038 |
Cardiovascular | 1.0 (0.0–4.0) | 1.0 (0.0–4.0) | 1.0 (0.0–4.0) | 0.332 | 1.0 (0.0–4.0) | 1.0 (0.0–4.0) | 1.0 (0.0–4.0) | 0.163 | |
Respiratory | 2.0 (0.0–2.0) | 2.0 (0.0–2.0) | 2.0 (0.0–2.0) | 0.341 | 2.0 (0.0–2.0) | 2.0 (0.3–2.0) | 2.0 (0.0–2.0) | 0.811 | |
Renal | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | 0.064 | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | 0.128 | |
Hepatobiliary | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.018 | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.426 | |
Neurologic | 1.0 (0.0–2.0) | 0.0 (0.0–2.0) | 1.0 (0.0–3.0) | <0.001 | 1.0 (0.0–2.0) | 1.0 (0.0–2.0) | 1.0 (0.0–3.0) | 0.169 | |
Coagulation | 0.0 (0.0–2.0) | 0.0 (0.0–2.0) | 0.0 (0.0–1.0) | <0.001 | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.473 | |
Initial lactate > 2 mmol/L | 1145 (45.3) | 1027 (44.1) | 118 (59.9) | <0.001 | 356 (61.8) | 240 (62.5) | 116 (60.4) | 0.693 | 0.0425 |
DNR | 359 (14.2) | 339 (14.6) | 20 (10.2) | 0.112 | 59 (10.2) | 39 (10.2) | 20 (10.4) | 1.000 | 0.0085 |
AMA | 22 (0.9) | 18 (0.8) | 4 (2.0) | 0.091 | 11 (1.9) | 7 (1.8) | 4 (2.1) | 1.000 | 0.0182 |
Full Study Cohort | Propensity-Matched Cohort | |||||||
---|---|---|---|---|---|---|---|---|
Total (n = 2526) | National Health Insurance (n = 2329) | Medical Aid (n = 197) | p-Value | Total (n = 576) | National Health Insurance (n = 384) | Medical Aid (n = 192) | p-Value | |
Primary end point | ||||||||
In-hospital mortality | 636 (25.2) | 594 (25.5) | 42 (21.3) | 0.201 | 124 (21.5) | 82 (21.4) | 42 (21.9) | 0.971 |
Secondary end points | ||||||||
28-day mortality | 637 (25.2) | 591 (25.4) | 46 (23.4) | 0.551 | 135 (23.4) | 91 (23.7) | 44 (22.9) | 0.917 |
90-day mortality | 849 (33.6) | 773 (33.2) | 76 (38.6) | 0.142 | 198 (34.4) | 125 (32.6) | 73 (38.0) | 0.226 |
Additional end points | ||||||||
Organ support therapy | ||||||||
Vasopressor | 990 (39.2) | 918 (39.4) | 72 (36.5) | 0.448 | 224 (39.0) | 152 (39.7) | 72 (37.5) | 0.677 |
Mechanical ventilation | 518 (20.5) | 481 (20.7) | 37 (18.8) | 0.583 | 118 (20.5) | 81 (21.1) | 37 (19.3) | 0.688 |
Conventional hemodialysis | 87 (3.4) | 76 (3.3) | 11 (5.6) | 0.100 | 34 (5.9) | 23 (6.0) | 11 (5.7) | 1.000 |
Continuous renal replacement therapy | 200 (7.9) | 186 (8.0) | 14 (7.1) | 1.000 | 56 (9.7) | 42 (10.9) | 14 (7.3) | 0.214 |
ICU length of stay | 0.0 (0.0–4.0) | 0.0 (0.0–4.0) | 0.0 (0.0–4.0) | 0.632 | 0.0 (0.0–4.0) | 0.0 (0.0–4.0) | 0.0 (0.0–4.0) | 0.810 |
Hospital length of stay | 10.0 (5.0–18.0) | 10.0 (5.0–18.0) | 11.0 (5.5–21.5) | 0.101 | 11.0 (5.0–18.0) | 11.0 (5.0–18.0) | 11.0 (5.3–21.8) | 0.291 |
Characteristics | Total (n = 2526) | Survivors (n = 1890) | Nonsurvivors (n = 636) | p-Value |
---|---|---|---|---|
Age (years) | 72.0 (63.0–79.0) | 72.0 (62.0–79.0) | 73.0 (65.0–81.0) | 0.012 |
Sex (male) | 1489 (58.9) | 1076 (56.9) | 413 (64.9) | <0.001 |
Comorbidities | ||||
Diabetes | 843 (33.4) | 634 (33.6) | 209 (33.0) | 0.801 |
Hypertension | 1127 (44.7) | 858 (45.4) | 269 (42.5) | 0.200 |
Chronic kidney disease | 204 (8.1) | 145 (7.7) | 59 (9.3) | 0.199 |
Initial vital signs | ||||
Mean BP (mmHg) | 72.0 (60.0–90.0) | 73.0 (60.0–91.0) | 69.0 (58.0–88.0) | 0.004 |
Source of visit to ED | ||||
Community | 1300 (51.5) | 1027 (54.3) | 273 (42.9) | <0.001 |
Nosocomial | 1121 (44.4) | 794 (42.0) | 327 (51.4) | <0.001 |
Nursing home | 99 (3.9) | 67 (3.5) | 32 (5.0) | 0.095 |
Source of infection | ||||
Respiratory | 1067 (42.2) | 733 (38.8) | 334 (52.5) | <0.001 |
Genitourinary | 748 (29.6) | 576 (30.5) | 172 (27.0) | 0.423 |
Hepatobiliary | 235 (9.3) | 181 (9.6) | 54 (8.5) | 0.372 |
Gastrointestinal | 206 (8.2) | 139 (7.4) | 67 (10.5) | 0.011 |
Others | 216 (8.6) | 167 (8.8) | 49 (7.7) | 0.377 |
Multiple sources | 53 (2.1) | 38 (2.0) | 15 (2.4) | 0.596 |
Septic shock | 630 (24.9) | 356 (18.8) | 274 (43.1) | <0.001 |
SOFA score | 6.0 (4.0–9.0) | 6.0 (4.0–8.0) | 8.0 (5.0–11.0) | <0.001 |
Cardiovascular | 1.0 (0.0–4.0) | 1.0 (0.0–4.0) | 3.0 (0.0–4.0) | <0.001 |
Respiratory | 2.0 (0.0–2.0) | 1.0 (0.0–2.0) | 2.0 (1.0–2.0) | <0.001 |
Renal | 1.0 (0.0–2.0) | 0.0 (0.0–1.0) | 1.0 (0.0–2.0) | <0.001 |
Hepatobiliary | 0.0 (0.0–1.0) | 0.0 (0.0–1.0) | 0.0 (0.0–2.0) | <0.001 |
Neurologic | 1.0 (0.0–2.0) | 0.0 (0.0–2.0) | 1.0 (0.0–3.0) | <0.001 |
Coagulation | 0,0 (0.0–2.0) | 0.0 (0.0–1.0) | 1.0 (0.0–2.0) | <0.001 |
Initial lactate >2 mmol/L | 1145 (45.3) | 748 (39.6) | 397 (62.4) | <0.001 |
DNR | 359 (14.2) | 94 (5.0) | 265 (41.7) | <0.001 |
AMA | 22 (0.9) | 17 (0.9) | 5 (0.8) | 0.790 |
Variables | OR | 95% CI | p-Value |
---|---|---|---|
Age (increase by year) | 1.003 | 0.994–1.012 | 0.569 |
Sex (female) | 0.764 | 0.603–0.968 | 0.026 |
Hypertension | 0.840 | 0.667–1.058 | 0.138 |
Mean BP (mmHg) | 1.003 | 0.998–1.009 | 0.202 |
Source of visit to ED | |||
Community | reference | ||
Nosocomial | 1.348 | 1.082–1.679 | <0.001 |
Source of infection | |||
Respiratory | reference | ||
Genitourinary | 0.358 | 0.247–0.518 | <0.001 |
Hepatobiliary | 0.744 | 0.550–1.008 | 0.056 |
Gastrointestinal | 1.328 | 0.904–1.951 | 0.148 |
Others | 0.994 | 0.664–1.488 | 0.976 |
Multiple sources | 0.772 | 0.364–1.635 | 0.499 |
Septic shock | 1.965 | 1.506–2.563 | <0.001 |
SOFA score | 1.128 | 1.090–1.166 | <0.001 |
Initial lactate > 2 mmol/L | 1.286 | 0.962–1.719 | 0.089 |
DNR | 12.001 | 9.010–15.984 | <0.001 |
Health insurance status | 0.873 | 0.572–1.333 | 0.530 |
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Wang, G.-S.; You, K.-M.; Jo, Y.-H.; Lee, H.-J.; Shin, J.-H.; Jung, Y.-S.; Hwang, J.-E. Association of Health Insurance Status with Outcomes of Sepsis in Adult Patients: A Retrospective Cohort Study. Int. J. Environ. Res. Public Health 2021, 18, 5777. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18115777
Wang G-S, You K-M, Jo Y-H, Lee H-J, Shin J-H, Jung Y-S, Hwang J-E. Association of Health Insurance Status with Outcomes of Sepsis in Adult Patients: A Retrospective Cohort Study. International Journal of Environmental Research and Public Health. 2021; 18(11):5777. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18115777
Chicago/Turabian StyleWang, Gaon-Sorae, Kyoung-Min You, You-Hwan Jo, Hui-Jai Lee, Jong-Hwan Shin, Yoon-Sun Jung, and Ji-Eun Hwang. 2021. "Association of Health Insurance Status with Outcomes of Sepsis in Adult Patients: A Retrospective Cohort Study" International Journal of Environmental Research and Public Health 18, no. 11: 5777. https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph18115777