Abstract 2719: The Impact of Insurance Status on Post-Acute Care among Working Age Stroke Survivors

Abstract

Listen

Translate article

Background and Purpose: Utilization of post-stroke rehabilitation is associated with improved functional outcomes. However, more than 20% of American adults under 65 are uninsured potentially leading to disparate utilization of post-acute care services. We sought to determine whether insurance status is associated with utilization and intensity of institutional post-acute care among working age stroke survivors. Methods: A retrospective cross-sectional study of ischemic stroke survivors under the age of 65 (n=33,917) from the 2004-2006 Nationwide Inpatient Sample (NIS) was conducted. Stroke survivors were categorized based on their insurance status as:1) private insurance; 2) Medicaid; 3) no insurance. Using hierarchical logistic regression models, we explored the association of insurance status and utilization of any institutional post-acute care (inpatient rehabilitation facility (IRF) or skilled nurse facility (SNF)) versus home. We then explored the association of insurance status and intensity of rehabilitation (IRF vs SNF) among those who utilized any institutional post-acute care. All models were controlled for patient factors including age, gender, comorbidities, length of stay, thrombolysis and hospital level factors including size, location, teaching status, region of the country, annual stroke discharges, annual stroke mortality and hospital uninsured. Results: Nineteen percent of the study population was uninsured while 20% were Medicaid enrollees. Median age of stroke survivors with private insurance was 56 (IQR 49-60) while that of the uninsured was 53 (IQR 47-59) and stroke survivors with Medicaid was 54 (IQR 47-60). Compared to those privately insured, uninsured stroke survivors were less likely to utilize any institutional post-acute care (adjusted OR=0.53, 95%CI 0.47-0.59). Conversely, stroke survivors with Medicaid were more likely to utilize any institutional post-acute care (adjusted OR=1.40, 95%CI 1.27-1.54) than privately insured stroke survivors. Among stroke survivors who utilized institutional post-acute care, uninsured (adjusted OR=0.48, 95%CI 0.36-0.64) and Medicaid stroke survivors (adjusted OR=0.27 95%CI 0.23-0.33) were less likely to utilize an IRF than a SNF compared to privately insured stroke survivors. Conclusion: The results suggest differences in utilization and intensity of institutional post-acute care for working age stroke survivors based on their insurance status. These findings are interesting in light of the Patient Protection and Affordable Care Act which will result in millions of uninsured individuals transitioning to Medicaid. On one hand our results suggest that this healthcare reform will result in increased utilization of institutional post-acute care among stroke survivors but on the other hand our results suggest that this rehabilitation may be less intense than if they were privately insured.