The relationship between insurance class and severity of presentation of inflammatory bowel disease in children
Objective: To determine whether there is an association between insurance class and the severity of presentation of inflammatory bowel disease in children. Methods: Twenty underinsured (either no insurance or Medicaid) children were computer-matched with 20 children with private insurance with regard to diagnosis and age but without regard to severity of disease from a pool of 63 patients (20 underinsured patients and 43 insured patients). We compared four patient-reported parameters and eight laboratory values. Results: There were 22 patients with Crohn's disease (11 underinsured and 11 insured) and 18 patients with ulcerative colitis (nine underinsured and nine insured), with a mean age at diagnosis of 13.7 ± 4.2 yr in the underinsured and 13.4 ± 3.8 yr in the privately insured patients. Patients in the underinsured category had more than 2.5 times the weight loss of the privately insured patients (20.0 ± 13.9 vs. 7.8 ± 8.6, p < 0.005) and longer delay in months (10.3 ± 10.9 vs. 2.7 ± 2.6, p < 0.005) before the diagnosis was made. Laboratory data in the underinsured children indicated that they were more ill at time of presentation than the insured patients. The underinsured patients had significantly lower hemoglobins (10.5 ± 2.4 vs. 12.5 ± 2.1, p < 0.01), a higher erythrocyte sedimentation rate (59 ± 35 vs. 21 ± 24, p < 0.005), and higher platelet counts (536 ± 205 x 103 vs. 418 ± 140 x 103, p < 0.05) compared to the insured group. Alkaline phosphatase levels, normally elevated in children during osseous growth, were significantly depressed in the underinsured group when compared with the insured group (117 ± 42 vs. 155 ± 71, p = 0.05). Conclusion: Underinsured children have clinical and laboratory parameters that indicate that their disease is more severe at presentation than privately insured patients. We postulate that this is partly related to the fact that underinsured patients have inferior access to quality healthcare when compared to privately insured patients.