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      Association between insurance status and mortality in individuals with albuminuria: an observational cohort study

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          Abstract

          Background

          In the general population, the association between uninsurance and mortality is well established. We sought to evaluate the association of health insurance status with mortality among working-age participants with albuminuria in the Third National Health and Nutrition Examination Survey, 1988–1994 (NHANES III).

          Methods

          We used data from non-elderly adult participants (18–64) of NHANES III (1988–1994), a nationally representative study of the US civilian, noninstitutionalized population, who provided information on insurance and who had albuminuria, defined as a urine albumin-to-creatinine ratio [UACR] ≥ 30 mg/g and their subsequent mortality to December 31, 2006. Cox proportional hazards models were used to determine associations between insurance status and all-cause mortality and cardiovascular mortality in patients with CKD while adjusting in a stepwise fashion for sociodemographic factors, co-morbidities, and co-morbidity severity/control covariates.

          Results

          In our sample of individuals with albuminuria ( n = 903), mean estimated glomerular filtration rate (eGFR) was 101.6 ml/min/1.73 m 2 with 4.7 % with an eGFR <60. Approximately 15 % of the sample was uninsured, 18 % had public insurance and 67 % had private insurance. Compared to individuals with private insurance, those with public insurance or no insurance were significantly more likely to be a racial or ethnic minority, to have income <200 % below the federal poverty level, to have less than high school education; and they were less likely to be married and to report good or excellent health, all p < 0.05. Being uninsured or having public insurance was associated with increased all-cause mortality in the fully adjusted model (HR 2.97 and 3.65, respectively, p < 0.05). There was no significant relationship between insurance status and cardiovascular mortality.

          Conclusions

          In a nationally representative sample of individuals with albuminuria, uninsurance and public insurance were associated with increased mortality compared to the private insurance even after controlling for sociodemographic, health status, and health care variables. Improving access to care and the quality of care received may potentially reduce mortality in individuals with evidence of early CKD.

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          Most cited references12

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          Combining GFR and albuminuria to classify CKD improves prediction of ESRD.

          Despite the high prevalence of chronic kidney disease (CKD), relatively few individuals with CKD progress to ESRD. A better understanding of the risk factors for progression could improve the classification system of CKD and strategies for screening. We analyzed data from 65,589 adults who participated in the Nord-Trøndelag Health (HUNT 2) Study (1995 to 1997) and found 124 patients who progressed to ESRD after 10.3 yr of follow-up. In multivariable survival analysis, estimated GFR (eGFR) and albuminuria were independently and strongly associated with progression to ESRD: Hazard ratios for eGFR 45 to 59, 30 to 44, and 15 to 29 ml/min per 1.73 m(2) were 6.7, 18.8, and 65.7, respectively (P < 0.001 for all), and for micro- and macroalbuminuria were 13.0 and 47.2 (P < 0.001 for both). Hypertension, diabetes, male gender, smoking, depression, obesity, cardiovascular disease, dyslipidemia, physical activity and education did not add predictive information. Time-dependent receiver operating characteristic analyses showed that considering both the urinary albumin/creatinine ratio and eGFR substantially improved diagnostic accuracy. Referral based on current stages 3 to 4 CKD (eGFR 15 to 59 ml/min per 1.73 m(2)) would include 4.7% of the general population and identify 69.4% of all individuals progressing to ESRD. Referral based on our classification system would include 1.4% of the general population without losing predictive power (i.e., it would detect 65.6% of all individuals progressing to ESRD). In conclusion, all levels of reduced eGFR should be complemented by quantification of urinary albumin to predict optimally progression to ESRD.
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            Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income.

            Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.
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              Trends in statin use and low-density lipoprotein cholesterol levels among US adults: impact of the 2001 National Cholesterol Education Program guidelines.

              Few data are available on the use of statins after publication of the National Cholesterol Education Program Third Adult Treatment Panel (ATP-III) guidelines in 2001. To determine changes in statin use and its impact on low-density lipoprotein cholesterol (LDL-C) control among US adults from 1999 to 2004. High LDL-C levels and statin use among 1911 participants of the National Health and Nutrition Examination Survey (NHANES) 2003-2004 were determined and compared with 1770 and 2094 participants of NHANES 1999-2000 and NHANES 2001-2002, respectively. Statin use was obtained from review of participants' drug containers. High LDL-C levels and LDL-C control were defined, using risk-specific cut-points from the ATP-III guidelines. Statins were taken by 24 million Americans in 2003-2004, an increase from 12.5 million in 1999-2000. In 1999-2000, 2001-2002, and 2003-2004, statins were being used by 19.6%, 27.3%, and 35.9% of US adults with high LDL-C levels, respectively (p trend <0.001). Age-standardized mean LDL-C declined from 119.9 to 112.0 to 100.7 mg/dL among statin users between 1999-2000, 2001-2002, and 2003-2004. LDL-C control to ATP-III recommended targets was achieved by 49.7%, 67.4%, and 77.6% of statin users in 1999-2000, 2001-2002, and 2003-2004, respectively (p trend <0.001). Among US adults with high LDL-C, after multivariate adjustment, non-Hispanic blacks were 39% less likely (prevalence ratio = 0.61; 95 CI 0.39 to 0.97) than non-Hispanic whites to be taking statins. Statin use continues to increase among US adults and this has led to substantial improvements in LDL-C control. Nevertheless, suboptimal statin use, especially among racial/ethnic minorities, continues to prevent the maximal public health benefit from this effective drug class.
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                Author and article information

                Contributors
                msaunder@medicine.bsd.uchicago.edu
                aricar2@uic.edu
                jinsongc@uic.edu
                mchin@medicine.bsd.uchicago.edu
                jplash@uic.edu
                Journal
                BMC Nephrol
                BMC Nephrol
                BMC Nephrology
                BioMed Central (London )
                1471-2369
                9 March 2016
                9 March 2016
                2016
                : 17
                : 27
                Affiliations
                [ ]University of Chicago Medicine, 5841 S. Maryland, MC 5000, Chicago, IL 60637 USA
                [ ]University of Illinois at Chicago, 820 Wood St, MC 793, Chicago, IL 60612 USA
                [ ]University of Chicago Medicine, 5841 S. Maryland, MC 2007, Chicago, IL 60637 USA
                Article
                239
                10.1186/s12882-016-0239-1
                4784311
                26960447
                1b28b8b4-b56b-44ad-b4a5-01a4a70c90e0
                © Saunders et al. 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 22 June 2015
                : 1 March 2016
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000062, National Institute of Diabetes and Digestive and Kidney Diseases;
                Award ID: K24DK071933
                Award ID: K23DK103111
                Award Recipient :
                Funded by: National Institute of Diabetes and Digestive and Kidney Diseases
                Award ID: K23DK094829
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2016

                Nephrology
                albuminuria,insurance,nhanes,chronic kidney disease
                Nephrology
                albuminuria, insurance, nhanes, chronic kidney disease

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