Introduction: The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services (CMS) hospital acquired conditions (HACs) are publicly reported quality metrics linked directly to reimbursement. The occurrence of PSIs/HACs is associated with increased mortality and hospital costs after stroke. The relationship between insurance status on PSI and HAC rates in hospitalized patients treated for acute ischemic stroke was determined using the Nationwide Inpatient Sample (NIS) database. The NIS contains data from approximately 20% of all non-federal hospital admissions in the United States over any given year.

Methods: The NIS was queried for all hospitalizations between 2002 and 2011 involving acute ischemic stroke. The rate of each PSI and HAC was determined by searching the hospital records for ICD-9 codes. SAS statistical software package was used to calculate rates and perform multivariate analyses to determine the effects of patient variables on the probability of developing each indicator. Outcome was stratified into "good" versus "poor" based on previously published dichotomization criteria of discharge disposition.

Results: The NIS query resulted in 1,507,336 separate patient admissions that had information on both primary payer and hospital teaching status. There were a total of 227,676 PSIs (15.1% of admissions) and 42,841 HACs reported (2.9%). PSIs and HACs occurred more frequently in Medicaid/self pay patients compared to those with private insurance (P < 0.0001). In multivariate analysis, patients with Medicaid, self pay or no charge had significantly longer lengths of stay, 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.

Patient Care: This data suggests that insurance status is an important predictor of both inpatient patient safety events as well as length of stay, mortality, and outcome after stroke. This project highlights important disparities within the United States healthcare system. Understanding the relationship between such disparities and outcomes is important in identifying avenues for improving the quality of care that is provided for stroke patients.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the relationship between insurance status and PSIs/HACs; 2) Discuss the relationship between insurance status and stroke outcome measures; 3) Identify potential reasons for worse outcomes in stroke patients lacking private insurance.

References: 1. Baker DW, Sudano JJ, Durazo-Arvizu R, Feinglass J, Witt WP, Thompson J. Health insurance coverage and the risk of decline in overall health and death among the near elderly, 1992-2002. Medical care. 2006;44:277-282 2. Baker DW, Sudano JJ, Albert JM, Borawski EA, Dor A. Lack of health insurance and decline in overall health in late middle age. The New England journal of medicine. 2001;345:1106-1112 3. Gezmu T, Gizzi MS, Kirmani JF, Schneider D, Moussavi M. Disparities in acute stroke severity, outcomes, and care relative to health insurance status. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2014;23:e93-98 4. Brinjikji W, Rabinstein AA, Cloft HJ. Socioeconomic disparities in the utilization of mechanical thrombectomy for acute ischemic stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013 5. Giacovelli JK, Egorova N, Nowygrod R, Gelijns A, Kent KC, Morrissey NJ. Insurance status predicts access to care and outcomes of vascular disease. Journal of vascular surgery. 2008;48:905-911 6. Shen JJ, Washington EL. Disparities in outcomes among patients with stroke associated with insurance status. Stroke; a journal of cerebral circulation. 2007;38:1010-1016 7. James ML, Grau-Sepulveda MV, Olson DM, Smith EE, Hernandez AF, Peterson ED, et al. Insurance status and outcome after intracerebral hemorrhage: Findings from get with the guidelines-stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2014;23:283-292 8. Schieb LJ, Mobley LR, George M, Casper M. Tracking stroke hospitalization clusters over time and associations with county-level socioeconomic and healthcare characteristics. Stroke; a journal of cerebral circulation. 2013;44:146-152 9. Rey V, Faouzi M, Huchmand-Zadeh M, Michel P. Stroke initial severity and outcome relative to insurance status in a universal health care system in switzerland. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2011;18:1094-1097 10. Sandel ME, Wang H, Terdiman J, Hoffman JM, Ciol MA, Sidney S, et al. Disparities in stroke rehabilitation: Results of a study in an integrated health system in northern california. PM & R : the journal of injury, function, and rehabilitation. 2009;1:29-40 11. Li C, Hedblad B, Rosvall M, Buchwald F, Khan FA, Engstrom G. Stroke incidence, recurrence, and case-fatality in relation to socioeconomic position: A population-based study of middle-aged swedish men and women. Stroke; a journal of cerebral circulation. 2008;39:2191-2196 12. Fowler-Brown A, Corbie-Smith G, Garrett J, Lurie N. Risk of cardiovascular events and death--does insurance matter? Journal of general internal medicine. 2007;22:502-507 13. Rahman M, Neal D, Fargen KM, Hoh BL. Establishing standard performance measures for adult stroke patients: A nationwide inpatient sample database study. World neurosurgery. 2013;80:699-708 e692 14. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8-27 15. Lawson MF, Neal DW, Mocco J, Hoh BL. Rationale for treating unruptured intracranial aneurysms: Actuarial analysis of natural history risk versus treatment risk for coiling or clipping based on 14,050 patients in the nationwide inpatient sample database. World neurosurgery. 2013;79:472-478 16. Hasan O, Orav EJ, Hicks LS. Insurance status and hospital care for myocardial infarction, stroke, and pneumonia. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2010;5:452-459 17. Tung YC, Chang GM. The effect of cuts in reimbursement on stroke outcome: A nationwide population-based study during the period 1998 to 2007. Stroke; a journal of cerebral circulation. 2010;41:504-509 18. Durant RW, Parmar G, Shuaib F, Le A, Brown TM, Roth DL, et al. Awareness and management of chronic disease, insurance status, and health professional shortage areas in the reasons for geographic and racial differences in stroke (regards): A cross-sectional study. BMC health services research. 2012;12:208 19. Schumacher HC, Bateman BT, Boden-Albala B, Berman MF, Mohr JP, Sacco RL, et al. Use of thrombolysis in acute ischemic stroke: Analysis of the nationwide inpatient sample 1999 to 2004. Annals of emergency medicine. 2007;50:99-107 20. Skolarus LE, Meurer WJ, Burke JF, Prvu Bettger J, Lisabeth LD. Effect of insurance status on postacute care among working age stroke survivors. Neurology. 2012;78:1590-1595 21. Ottenbacher KJ, Graham JE. The state-of-the-science: Access to postacute care rehabilitation services. A review. Archives of physical medicine and rehabilitation. 2007;88:1513-1521 22. Levine DA, Kiefe CI, Howard G, Howard VJ, Williams OD, Allison JJ. Reduced medication access: A marker for vulnerability in us stroke survivors. Stroke; a journal of cerebral circulation. 2007;38:1557-1564