Introduction: Effective management of hypertension is essential for the prevention of intracerebral hemorrhage (ICH), but disparities in access to healthcare create a barrier to achieving this aim.
Hypothesis: Among patients presenting for emergency care of hypertension, lack of insurance is associated with a higher risk of subsequent ICH.
Methods: We performed a retrospective cohort study using administrative data from all acute care hospitalizations and emergency department (ED) visits in California, Florida, and New York between the years of 2005 and 2011. Our cohort comprised patients discharged from the ED with a primary diagnosis of hypertension, defined as International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 401-405. Patients with a prior or concomitant diagnosis of cerebrovascular disease (ICD-9-CM codes 430-438) were excluded. Patients 65 years and older were excluded because these patients often have access to Medicare insurance. Our predictor variable was lack of insurance, as compared with Medicaid or commercial insurance. Patients were followed for the primary outcome of ICH, defined using previously validated ICD-9-CM codes. Survival statistics were used to calculate the cumulative rate of ICH and Cox proportional hazards analysis was used to assess the association between lack of insurance and development of ICH while adjusting for demographic characteristics and vascular risk factors.
Results: Among 361,019 patients with 3.4 (+/- 1.8) years of follow-up, the cumulative rate of ICH in patients without insurance was 1.03% (95% confidence interval [CI], 0.90-1.18%) as compared to 0.88% (95% CI, 0.80-0.96) in patients with insurance. After adjusting for demographic variables and vascular risk factors, lack of insurance was associated with the development of ICH (hazard ratio, 1.20; 95% CI, 1.07-1.34).
Conclusion: In a large, heterogeneous group of patients presenting for emergency care of hypertension, lack of insurance was associated with an increased risk of ICH after discharge. Further investigation is needed to address the impact of access to healthcare on rates of this disabling disease.