Health disparities and stroke: the influence of insurance status on the prevalence of patient safety indicators and hospital-acquired conditions

Abstract

Object: The Agency for Healthcare Research and Quality patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are publicly reported quality metrics linked directly to reimbursement. The occurrence of PSIs and HACs is associated with increased mortality and hospital costs after stroke. The relationship between insurance status and PSI and HAC rates in hospitalized patients treated for acute ischemic stroke was determined using the Nationwide Inpatient Sample (NIS) database.

Methods: The NIS was queried for all hospitalizations involving acute ischemic stroke between 2002 and 2011. The rate of each PSI and HAC was determined by searching the hospital records for ICD-9 codes. The SAS statistical software package was used to calculate rates and perform multivariable analyses to determine the effects of patient variables on the probability of developing each indicator.

Results: The NIS query revealed 1,507,336 separate patient admissions that had information on both primary payer and hospital teaching status. There were 227,676 PSIs (15.1% of admissions) and 42,841 HACs reported (2.8%). Patient safety indicators occurred more frequently in Medicaid/self-pay/no-charge patients (19.1%) and Medicare patients (15.0%) than in those with private insurance (13.6%; p < 0.0001). In a multivariable analysis, Medicaid, self-pay, or nocharge patients had significantly longer hospital stays, higher mortality, and worse outcomes than those with private insurance (p < 0.0001).

Conclusions: Insurance status is an independent predictor of patient safety events after stroke. Private insurance is associated with lower mortality, shorter lengths of stay, and improved clinical outcomes.

Keywords: AHRQ = Agency for Healthcare Research and Quality; CMS = Centers for Medicare and Medicaid Services; ENR = estimated national rate; HAC = hospital-acquired condition; NIS = Nationwide Inpatient Sample; PSI = patient safety indicator; hospital-acquired condition; insurance; patient safety indicators; pay for performance; stroke; vascular disorders.