RELATIONSHIP BETWEEN PROCEDURES AND HEALTH-INSURANCE FOR CRITICALLY ILL PATIENTS WITH PNEUMOCYSTIS-CARINII PNEUMONIA

The objective of the present study was to assess the association betwe en type of health insurance coverage and use of diagnostic tests and t herapies among patients with AIDS-related Pneumocystis carinii pneumon ia (PCP). Fifty-six private, public, and community hospitals in Chicag o, Los Angeles, and Miami were selected for the study, and the charts of 890 patients with empirically treated or cytologically confirmed PC P, hospitalized during 1987 to 1990 were retrospectively reviewed. Pat ients were classified by insurance status: self-pay (n = 56), Medicaid (n = 254), or private insurance, including health maintenance organiz ations and Medicare (n = 580). Primary outcomes were the use and timin g of bronchoscopy, the type and timing of PCP therapy, and in-hospital mortality. The results indicate that Medicaid patients were less like ly than privately insured patients to undergo bronchoscopy (relative o dds = 0.61; 95% Cl = 0.40, 0.93; p = 0.02) or to have their diagnosis of PCP confirmed (relative odds = 0.51; 95% CI = 0.33, 0.77), after ad justing for patient, severity of illness, and hospital characteristics . Medicaid patients were approximately three-fourths more likely than privately insured patients (relative odds = 1.73; 95% CI = 1.01, 2.96; p = 0.04) to die in-hospital, after adjusting for patient, severity o f illness, and hospital characteristics. However, with further adjustm ent for confirmation of PCP, Medicaid patients no longer had a signifi cantly higher likelihood of dying in-hospital. We conclude that Medica id patients are less likely to receive diagnostic bronchoscopy than pr ivately insured or self-insured patients, more likely to be empiricall y treated for PCP, and more likely to die in-hospital. Higher mortalit y among Medicaid patients may result from failure to diagnose and trea t alternative pathogens, a consequence of worse access to invasive dia gnostic tests.