University of Florida researchers have found a correlation between Medicare and patient access to surgical treatment for subarachnoid hemorrhage, a type of stroke that affects as many as 30,000 Americans each year — often causing death or long-term impairment and disability.
For patients who have suffered this type of stroke, surgical intervention can spell the difference between recovery or long-term disability and death, yet patients on Medicare are less likely than those with private insurance to be referred for surgical treatment, according to findings published last month in the journal PLOS ONE. This may represent a conscious or unconscious bias against Medicare patients, who are typically older and have preexisting disabilities or chronic illnesses, the researchers say.
The study was conducted by Dr. Azra Bihorac, a professor of anesthesiology, medicine and surgery at the UF College of Medicine, and Dr. Charles Hobson, a surgical critical care specialist at the Malcom Randall Veterans Affairs Medical Center and a doctoral candidate in health services research at the UF College of Public Health and Health Professions.
“Not every hospital has skilled neurosurgeons who specialize in subarachnoid hemorrhage,” Dr. Bihorac said. “If these hospitals don’t have the necessary expertise, then they may actually overestimate the risk of a bad prognosis. They may assume that the patient won’t do well anyway, so they won’t proceed with surgery.”
For the study, the researchers analyzed data from the National Inpatient Sample hospital discharge database. The data includes information on more than 21,000 adult patients discharged from 2003 to 2008 with a diagnosis of subarachnoid hemorrhage. Approximately 62 percent of the sample was female and the mean age was 59 years — younger than is typical with other types of stroke.
Compared with privately insured patients, Medicare patients were almost 45 percent less likely to undergo surgical treatment and were more than twice as likely to die in the hospital. This may be because Medicare patients tend to be older or have additional health issues, Dr. Hobson said.
“It’s not that you don’t get surgery because you have Medicare — your doctor isn’t checking your insurance,” he said. “But having Medicare as primary health insurance may be a proxy for bias against the elderly and those with chronic illnesses.”
Subarachnoid hemorrhage accounts for 5 percent of all strokes, according to the American Heart Association. It occurs when there is bleeding in the area between the brain and the thin tissues that cover the brain, most often caused by an aneurysm. The condition causes sudden, severe head pain and must be treated immediately to prevent brain injury, disability and death. Risk factors include a family history of aneurysms, high blood pressure and smoking.
Approximately 10 to 15 percent of these patients die before reaching the hospital. For those who survive, the next 48 hours are critical, Dr. Bihorac said. During this time, the main goal of the treatment team is to stop the patient from re-bleeding, a repeated rupture in the same location of the aneurysm and the leading cause of death in people who survive the initial hemorrhage.