The paralyzing effect of insurance status on throughput of acute spinal cord patients

The effect of social determinants of health on patient outcomes in acute trauma: A systematic review

INTRODUCTION

Social determinants of health (SDoH) may mediate disparities, but their effect on outcomes after trauma is not well known. The purpose of this review is to improve existing gaps of knowledge for a broad range of SDoH and trauma-related outcomes.

METHODS

This was a systematic search to identify studies that evaluated the effect of race, insurance status, socioeconomic status (SES), health literacy, and community deprivation on inpatient mortality, morbidity, and post-discharge health care utilization in diverse trauma populations ≥16 years. Data were extracted on study design, patient and injury characteristics, outcomes, and covariates. Qualitative analysis was performed and reported results were stratified by exposure. An overall assessment of the strength of evidence for key clinically relevant comparisons was conducted.

RESULTS

60 studies were included. Overall, race was not meaningfully predictive of mortality or morbidity, with evidence reporting inconsistent or small magnitude of effects. However, African American/Black race was consistently associated with decreased odds of discharge to rehabilitation. Compared to insured patients, uninsured patients may have greater mortality risk and be less likely to discharge to rehabilitation. Studies evaluating health literacy or community deprivation reported conflicting results.

CONCLUSIONS

Disparities related to race are most profound for post-discharge health care utilization, while insurance status may be a strong negative predictor of both mortality and discharge disposition. More research is needed on health literacy and community deprivation to better understand mechanisms of disparity after trauma. Interventions targeted at improving continuity of inpatient and outpatient care may be beneficial.

Exploring barriers to rehabilitation for individuals with spinal cord injury: a qualitative study in Iran

OBJECTIVES

Rehabilitation services are crucial for improving the quality of life and overall health of individuals with spinal cord injuries (SCIs). However, access to adequate rehabilitation remains limited in many regions, including Iran. This study aims to explore the barriers faced by individuals with SCIs in accessing appropriate rehabilitation services within Golestan province, northern of Iran.

METHODS

This study employed a qualitative approach to explore the barriers experienced by individuals with SCIs in accessing rehabilitation services. Fourteen participants were purposefully selected from the Golestan province (north of Iran) until data saturation was reached. Semi-structured interviews were conducted during the summer and fall of 2023, recorded, transcribed, and subjected to rigorous thematic analysis.

RESULTS

The study identified three primary categories of barriers: 1) Personal limiting factors, such as insufficient health literacy and inadequate home adaptations; 2) provider-related, including insufficient expertise, non-professional service delivery, inappropriate facility adaptations, limited service accessibility, and inadequate service provision; and 3) socio-supportive, encompassing companionship needs, financial constraints, insurance limitations, and bureaucratic hurdles.

CONCLUSION

The findings of this study highlight a complex interplay of patient, provider, and societal factors that impede access to rehabilitation services for individuals with spinal cord injuries in Golestan province. While provider-related challenges are prevalent, the significance of individual and socio-supportive factors cannot be overstated. To optimize rehabilitation outcomes, a holistic approach is essential, addressing not only physical impairments but also psychosocial and environmental barriers. The findings of this study underscore the complex interplay of patient, provider, and societal factors that influence access to rehabilitation services for individuals with spinal cord injuries. While provider-related challenges, such as insufficient expertise and limited service accessibility, are significant, the study emphasizes the crucial role of individual and socio-supportive factors in facilitating successful rehabilitation. Addressing these multifaceted barriers requires a holistic approach that considers not only physical impairments but also psychosocial and environmental needs.

Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department

Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.