Abstract Body: Background: Safety-net hospitals (SNHs) are crucial in serving uninsured, underinsured, and socioeconomically disadvantaged populations, who often face financial limitations and resource shortages compared to their counterparts. We hypothesized that patients with ischemic stroke treated at SNHs would have inferior outcomes compared to non-SNHs, which may be related to the patient's socioeconomic status and care allocation.
Methods: The National Inpatient Sample Database was queried to identify adult patients (≥18 years) who were hospitalized for ischemic stroke from 2016 to 2019. Patients with safety-net features were those with Medicaid or no insurance. Hospitals were ranked based on the percentage of patients with safety-net features. Hospitals in the top quartile were defined as SNHs, and the remaining hospitals were defined as non-SNHs. The characteristics and outcomes of the patients with or without safety-net features treated at SNHs vs non-SNHs were compared after adjusting for patient and hospital characteristics. A composite overall outcome variable was also generated to include in-hospital mortality, acute renal failure, tracheostomy, and sepsis.
Results: We identified a weighted total of 1,823,985 patients, including 501,345 treated at SNHs and 1,550,100 at non-SNHs. The patients treated at SNHs were more likely to be non-white, had lower socioeconomic status but higher neurological severity, and more frequently required endovascular thrombectomy. They were associated with higher in-hospital mortality (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 1.09-1.19, p<0.001) and composite outcome (aOR 1.17, 95% CI 1.14-1.19), and longer hospital length of stay (5.6±7.7 vs 4.5±5.4 days, p<0.001) (Figure 1). Patients without safety-net features who were cared at SNHs had higher neurological acuity and worse outcomes compared to those treated at non-SNHs including in-hospital mortality (aOR 1.14, 95% CI 1.09-1.19), acute respiratory failure (aOR 1.24, 95% CI 1.20-1.29), tracheostomy (aOR 1.45, 95% CI 1.30-1.63), acute renal failure (aOR 1.16, 95% CI 1.13-1.19), and sepsis (OR 1.42, 95% CI 1.33-1.51) (Figure 2).
Conclusions: Patients treated for ischemic stroke at SNHs, regardless of their socioeconomic status and safety-net features, have higher in-hospital mortality and an increased risk for composite adverse outcomes. These findings support changes in resource allocation and efforts to improve the care of ischemic stroke in SNHs.