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

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.