Race, insurance status, and traumatic brain injury outcomes before and after enactment of the Affordable Care Act

Influence of health insurance on withdrawal of life sustaining treatment for patients with isolated traumatic brain injury: a retrospective multi-center observational cohort study

BACKGROUND

Healthcare inequities for patients with traumatic brain injury (TBI) represent a major priority area for trauma quality improvement. We hypothesized a relationship between health insurance status and timing of withdrawal of life sustaining treatment (WLST) for adults with severe TBI.

METHODS

This multicenter retrospective observational cohort study utilized data collected between 2017 and 2020. We identified adult (age ≥ 16) patients with isolated severe TBI admitted participating Trauma Quality Improvement Program centers. We determined the relationship between insurance status (public, private, and uninsured) and the timing of WLST using a competing risk survival analysis framework adjusting for baseline, clinical, injury and trauma center characteristics. Multivariable cause-specific Cox regressions were used to compute adjusted hazard ratios (HR) reflecting timing of WLST, accounting for mortality events. We also quantified the between-center residual variability in WLST using the median odds ratio (MOR) and measured insurance status association with access to rehabilitation at discharge.

RESULTS

We identified 42,111 adults with isolated severe TBI treated across 509 trauma centers across North America. There were 10,771 (25.6%) WLST events in the cohort and a higher unadjusted incidence of WLST events was evident in public insurance patients compared to private or uninsured groups. After adjustment, WLST occurred earlier for publicly insured (HR 1.07, 95% CI 1.02-1.12) and uninsured patients (HR 1.29, 95% CI 1.18-1.41) compared to privately insured patients. Access to rehabilitation was lower for both publicly insured and uninsured patients compared to patients with private insurance. Accounting for case-mix, the MOR was 1.49 (95% CI 1.43-1.55), reflecting significant residual between-center variation in WLST decision-making.

CONCLUSIONS

Our findings highlight the presence of disparate WLST practices independently associated with health insurance status. Additionally, these results emphasize between-center variability in WLST, persisting despite adjustments for measurable patient and trauma center characteristics.

Demographic and Socioeconomic Trends in Cervical Fusion Utilization from 2004 Through 2021 and the COVID-19 Pandemic

BACKGROUND

Cervical fusion rates increased in the U.S. exponentially 1990-2014, but trends leading up to/during the COVID-19 pandemic have not been fully evaluated by patient socioeconomic status (SES). Here, we provide the most recent, comprehensive characterization of demographic and SES trends in cervical fusions, including during the pandemic.

METHODS

We collected the following variables on adults undergoing cervical fusions, 1/1/2004-3/31/2021, in Optum's Clinformatics Data Mart: age, Charlson Comorbidity Index, provider's practicing state, gender, race, education, and net worth. We performed multivariate linear and logistic regression to evaluate associations of cervical fusion rates with SES variables.

RESULTS

Cervical fusion rates increased 2004-2016, then decreased 2016-2020. Proportions of Asian, Black, and Hispanic patients undergoing cervical fusions increased (OR = 1.001,1.001,1.004, P < 0.01), with a corresponding decrease in White patients (OR = 0.996, P < 0.001) over time. There were increases in cervical fusions in higher education groups (OR = 1.006, 1.002, P < 0.001) and lowest net worth group (OR = 1.012, P < 0.001). During the pandemic, proportions of White (OR = 1.015, P < 0.01) and wealthier patients (OR ≥ 1.015, P < 0.01) undergoing cervical fusions increased.

CONCLUSIONS

We present the first documented decrease in annual cervical surgery rates in the U.S. Our data reveal a bimodal distribution for cervical fusion patients, with racial-minority, lower-net-worth, and highly-educated patients receiving increasing proportions of surgical interventions. White and wealthier patients were more likely to undergo cervical fusions during the COVID-19 pandemic, which has been reported in other areas of medicine but not yet in spine surgery. There is still considerable work needed to improve equitable access to spine care for the entire U.S.

POPULATION

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury

INTRODUCTION

Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients.

METHODS

We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups.

RESULTS

We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001).

CONCLUSIONS

PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

Association Between Health Insurance and Outcomes After Traumatic Brain Injury: A National ACS-TQP-PUF Database Study

INTRODUCTION

According to the US Census Bureau, roughly 8.6% of the population lacks health care coverage. Increasing evidence suggests that insurance status plays a role in outcomes after trauma. However, its role in the setting of traumatic brain injury (TBI) remains poorly understood.

METHODS

The Trauma Quality Programs Participant Use Files were queried from 2017 to 2019. All patients with isolated TBI were identified. Isolated TBI was defined as: 1) Head Abbreviated Injury Scale (AIS) > 3 and 2) AIS <3 in all other anatomical regions. Patients dead on arrival, with Head AIS = 6, or missing key data were excluded. Demographic and clinical information was compared between those with and without insurance. Multivariate regressions were used to assess associations between insurance status and TBI outcomes (inhospital mortality, discharge to facility, total ventilator days, Intensive Care Unit length of stay (ICU LOS), and hospital LOS).

RESULTS

In total, 199,556 patients met inclusion criteria; 18,957 (9.5%) were uninsured. Compared to the insured, uninsured TBI patients were younger with a greater proportion of males. Uninsured patients were less severely injured and less comorbid. Uninsured patients had shorter unadjusted LOS in the ICU and hospital. Yet, uninsured patients experienced greater unadjusted inhospital mortality (12.7% versus 8.4%, P < 0.001). When controlling for covariates, lack of insurance was significantly associated with increased likelihood of mortality (OR 1.62; P < 0.001). This effect was most noticeable in patients with Head AIS = 4 (OR 1.55; P < 0.001) and Head AIS = 5 (OR 1.80; P < 0.001). Lack of insurance was also significantly associated with decreased likelihood of discharge to facility (OR 0.38), decreased ICU LOS (Coeff. -0.61), and decreased hospital LOS (Coeff. -0.82; all P < 0.001).

CONCLUSIONS

This study demonstrates that insurance status is independently associated with outcome disparities after isolated TBI. Despite the Affordable Care Act (ACA) reform, lack of insurance appears significantly associated with inhospital mortality, decreased likelihood of discharge to facility, and decreased time spent in the ICU and hospital.

Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

BACKGROUND

Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI.

METHODS

We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics.

RESULTS

We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001).

CONCLUSIONS

Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.

An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

BACKGROUND

Police transport (PT) of penetrating trauma patients in urban locations has become routine in certain metropolitan areas; however, whether it results in improved outcomes over prehospital Advanced life support (ALS) transport has not been determined in a multicenter study. We hypothesized that PT would not result in improved outcomes.

METHODS

This was a multicenter, prospective, observational study of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. Police transport and ALS patients were allocated via nearest neighbor, propensity matching. Transport mode also examined by Cox regression.

RESULTS

Of 1,618 total patients, 294 (18.2%) had PT and 1,324 (81.8%) were by ALS. After matching, 588 (294/cohort) remained. The patients were primarily Black (n = 497, 84.5%), males (n = 525, 89.3%, injured by gunshot wound (n = 494, 84.0%) with 34.5% (n = 203) having Injury Severity Score of 16 or higher. Overall mortality by propensity matching was not different between cohorts (15.6% ALS vs. 15.0% PT, p = 0.82). In severely injured patients (Injury Severity Score ≥16), mortality did not differ between PT and ALS transport (38.8% vs. 36.0%, respectively; p = 0.68). Cox regression analysis controlled for relevant factors revealed no association with a mortality benefit in patients transported by ALS.

CONCLUSION

Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Trends in Location of Death Among Older Adult Americans After Falls

Introduction: Fall-related mortality is increasing among older adults, yet trends and changes in the location of fall-attributed deaths are unknown; additionally, potential disparities are understudied. Methods: To assess trends/factors associated with place of death among older adult fall deaths in the US, a cross-sectional analysis of deaths using mortality data from 2003–2017 was performed. Results: Most deaths occurred in hospitals, however, the proportion decreased from 66.4% (n = 9,095) to 50.7% (n = 15,817). The proportion occurring in nursing facilities decreased from 15.9% (n = 2175) to 15.3% (n = 4,778), while deaths at home and in hospice facilities increased. Male, Black, Native American, and married decedents had increased odds of hospital death. Conclusion: As fall deaths increase among older adults, end-of-life needs of this population deserve increased attention. Research should explore needs and preferences of older adults who experience falls and their caregivers to reduce disparities in place of death and to ensure high quality of care is received.

Changes in racial and ethnic disparities in lumbar spinal surgery associated with the passage of the Affordable Care Act, 2006-2014

BACKGROUND CONTEXT

Since implementation of the Patient Protection and Affordable Care Act (ACA) in 2010, more Americans have health insurance, and many racial/ethnic disparities in healthcare have improved. We previously reported that Black and Hispanic patients undergo surgery for spinal stenosis at lower rates than do white patients.

PURPOSE

To assess changes in racial/ethnic disparities in rates of lumbar spinal surgery after passage of the ACA.

STUDY DESIGN

Retrospective analysis.

PATIENT SAMPLE

Approximately 3.2 million adults who underwent lumbar spinal surgery in the US from 2006 through 2014.

OUTCOME MEASURES

Racial disparities in discharge rates before versus after ACA passage.

METHODS

Using the Nationwide Inpatient Sample, the U.S. Census Bureau Current Population Survey Supplement, and International Classification of Diseases, Ninth Revision, Clinical Modification, criteria for definite lumbar spinal surgery, we calculated rates of lumbar spinal surgery as the number of hospital discharges divided by population estimates and stratified patients by race/ethnicity after controlling for sociodemographic characteristics. Calendar years were stratified as before ACA passage (2006-2010) or after ACA passage (2011-2014). Poisson regression was used to model hospital discharge rates as a function of race/ethnicity before and after ACA passage after adjustment for potential confounders.

RESULTS

All rates are expressed per 1,000 persons. The overall median discharge rate decreased from 1.9 before ACA passage to 1.6 after ACA passage (p < .001). After adjustment for sociodemographic factors, the Black:White disparity in discharge rates decreased from 0.40:1 before ACA to 0.44:1 after ACA (p < .001). A similar decrease in the Hispanic:White disparity occurred, from 0.35:1 before ACA to 0.38:1 after ACA (p < .001).

CONCLUSION

Small but significant decreases occurred in racial/ethnic disparities in hospital discharge rates for lumbar spinal surgery after ACA passage.

Surgical stabilization of rib fractures is associated with improved survival but increased acute respiratory distress syndrome

Background

How the surgical stabilization of rib fractures after trauma affects the development of acute respiratory distress syndrome and impacts survival has yet to be determined in a large database. We hypothesized that surgical stabilization of rib fractures would not decrease the incidence of acute respiratory distress syndrome.

Methods

The National Trauma Data Bank was queried for all traumatic rib fractures in 2016. Patients were divided into groups with single rib fractures, multiple rib fractures, and flail chest. Nonoperative therapy was compared with stabilization of rib fractures of 1 to 2 ribs or 3+ ribs.

Results

There were 114,972 total patients with rib fractures meeting inclusion criteria, with 5,106 (4.4%) having flail chest, 24,726 (21.5%) having single rib fractures, and 85,140 (74.1%) having multiple rib fractures. Those with flail chest (15.9%) were most likely to get rib plating in comparison to multiple rib fractures (0.9%) and single rib fractures (0.2%); P < .001. On logistic regression, surgical stabilization of rib fractures 1 to 2 ribs (odds ratio: 0.17, 95% confidence interval: 0.10–0.28) or 3+ ribs (odds ratio: 0.17, 95% confidence interval: 0.11–0.28), with nonoperative therapy as the reference was associated with survival. Variables associated with mortality included increasing age, male sex, increasing injury severity score, decreased Glasgow coma scale, requirement of transfusions, and hypotension on admission. Surgical stabilization of rib fractures 3+ ribs (odds ratio: 2.30, 95% confidence interval: 1.58–3.37) was associated with acute respiratory distress syndrome but not 1 to 2 ribs (odd ratio: 1.55, 95% confidence interval: 0.97–2.48). On logistic regression of only patients with flail chest, stabilization of rib fractures was associated with decreased mortality but not increased risk of acute respiratory distress syndrome.

Conclusion

The increased risk of acute respiratory distress syndrome should be considered in the preoperative assessment for stabilization of rib fractures.

Racial and Ethnic Differences in Health Care Utilization Following Severe Acute Brain Injury in the United States

OBJECTIVE

To examine racial and ethnic differences in the utilization of 3 interventions (tracheostomy placement, gastrostomy tube placement, and hospice utilization) among patients with severe acute brain injury (SABI).

DESIGN

Retrospective cohort study.

SETTING

Data from the National Inpatient Sample, from 2002 to 2012.

PATIENTS

Adult patients with SABI defined as a primary diagnosis of stroke, traumatic brain injury, or post-cardiac arrest who received greater than 96 hours of mechanical ventilation.

EXPOSURE

Race/ethnicity, stratified into 5 categories (white, black, Hispanic, Asian, and other).

MEASUREMENTS AND MAIN RESULTS

Data from 86 246 patients were included in the cohort, with a mean (standard deviation) age of 60 (18) years. In multivariable analysis, compared to white patients, black patients had an 20% increased risk of tracheostomy utilization (relative risk [RR]: 1.20, 95% CI: 1.16-1.24, P < .001), Hispanic patients had a 10% increased risk (RR: 1.10, 95% CI: 1.06-1.14, P < .001), Asian patients had an 8% increased risk (RR: 1.08, 95% CI: 1.01-1.16, P = .02), and other race patients had an 10% increased risk (RR: 1.10, 95% CI: 1.04-1.16, P < .001). A similar relationship was observed for gastrostomy utilization. In multivariable analysis, compared to white patients, black patients had a 25% decreased risk of hospice discharge (RR: 0.75, 95% CI: 0.67-0.85, P < .001), Hispanic patients had a 20% decreased risk (RR: 0.80, 95% CI: 0.69-0.94, P < .01), and Asian patients had a 47% decreased risk (RR: 0.53, 95% CI: 0.39-0.73, P < .001). There was no observed relationship between race/ethnicity and in-hospital mortality.

CONCLUSIONS

Minority race was associated with increased utilization of tracheostomy and gastrostomy, as well as decreased hospice utilization among patients with SABI. Further research is needed to better understand the mechanisms underlying these race-based differences in critical care.

Examination of Racial Disparities in Adolescents Seen in the Emergency Department for Head, Neck, or Brain Injury

BACKGROUND

Given the frequency, severity, and attention of traumatic brain injury in children, benchmarking disparities and injury characteristics for adolescent patients is pivotal in understanding and enhancing both clinical care and outcomes.

OBJECTIVES

The purpose of this study was to investigate racial disparities on mechanism of injury, clinical outcomes, and social-health factors among adolescents treated in the emergency department (ED) for a head, neck, or brain injury.

METHODS

This study is the result of a retrospective chart review of head-, neck-, and brain-injured adolescent patients (n = 2857) treated at three community hospital EDs and one stand-alone ED. Outcome measures included patient demographics (gender, race/ethnicity, age), Glasgow Coma Scale score, hospital length of stay, intensive care unit length of stay, mechanism of injury, primary diagnosis, secondary diagnosis of a concussion, ventilation days, discharge disposition, and primary insurance.

RESULTS

There were racial differences in primary diagnosis, mechanism of injury, and insurance status. Results indicated that a higher proportion of white patients were diagnosed with a concussion compared with black patients (p < 0.001). Moreover, a higher proportion of white patients were seen in the ED for head, neck, or brain injury as a result of a sports or motor vehicle incident, whereas a leading mechanism among black patients was assault (p = 0.01). More white patients had private insurance, whereas more black patients had Medicaid (p < 0.001).

CONCLUSION

The disparities in mechanisms for which black and white adolescent patients are seeking care at the ED for head, neck, or brain injury help to identify social-health risks of sustaining a head, neck, or brain injury. These racial disparities between black and white adolescents seen at the ED for head, neck, or brain injury suggest the need for further research to better understand the national representation of these disparities.

Association of Insurance Status With Treatment and Outcomes in Pediatric Patients With Severe Traumatic Brain Injury

OBJECTIVE

To determine whether a health insurance disparity exists among pediatric patients with severe traumatic brain injury using the National Trauma Data Bank.

DESIGN

Retrospective cohort study.

SETTING

National Trauma Data Bank, a dataset containing more than 800 trauma centers in the United States.

PATIENTS

Pediatric patients (< 18 yr old) with a severe isolated traumatic brain injury were identified in the National Trauma Database (years 2007-2016). Isolated traumatic brain injury was defined as patients with a head Abbreviated Injury Scale score of 3+ and excluded those with another regional Abbreviated Injury Scale of 3+.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Procedure codes were used to identify four primary treatment approaches combined into two classifications: craniotomy/craniectomy and external ventricular draining/intracranial pressure monitoring. Diagnostic criteria and procedure codes were used to identify condition at admission, including hypotension, Glasgow Coma Scale, mechanism and intent of injury, and Injury Severity Score. Children were propensity score matched using condition at admission and other characteristics to estimate multivariable logistic regression models to assess the associations among insurance status, treatment, and outcomes. Among the 12,449 identified patients, 91.0% (n = 11,326) had insurance and 9.0% (n = 1,123) were uninsured. Uninsured patients had worse condition at admission with higher rates of hypotension and higher Injury Severity Score, when compared with publicly and privately insured patients. After propensity score matching, having insurance was associated with a 32% (p = 0.001) and 54% (p < 0.001) increase in the odds of cranial procedures and monitor placement, respectively. Insurance coverage was associated with 25% lower odds of inpatient mortality (p < 0.001).

CONCLUSIONS

Compared with insured pediatric patients with a traumatic brain injury, uninsured patients were in worse condition at admission and received fewer interventional procedures with a greater odds of inpatient mortality. Equalizing outcomes for uninsured children following traumatic brain injury requires a greater understanding of the factors that lead to worse condition at admission and policies to address treatment disparities if causality can be identified.

Perceived health after adult traumatic brain injury: a Group-Based Trajectory Modeling (GBTM) analysis

OBJECTIVE

To provide nationally representative estimates of adults with traumatic brain injury (TBI) and identify clusters of individuals with TBI who follow similar perceived health trajectories using group-based trajectory modeling.

PARTICIPANTS

Adults (≥18 years old) from panels 9-19 (2004-2015) of the Medical Expenditure Panel Survey (MEPS) who experienced a TBI (n = 949).

DESIGN

Data from MEPS, a nationally representative database of noninstitutionalized individuals in the USA, were used to 1) produce a national annual estimate of adults with TBI and 2) identify subgroups of patients with TBI who followed different general and mental health trajectories.

MAIN MEASURES

Perceived general health (PGH), perceived mental health (PMH).

RESULTS

On average, 502 adults per 100,000 noninstitutionalized US adults experienced a TBI annually, and about one million adults are living with a TBI. Three distinct trajectory groups were identified in models of both perceived general health (PGH) and perceived mental health (PMH). TBI type, sex, and persistent disability predicted assignment to a group in the PGH model. TBI type, sex, age, insurance status, family poverty status, and persistent disability predicted assignment to a PMH trajectory.

CONCLUSION

Referrals and early-intervention resources should be distributed to individuals with increased risk of following low PGH and/or PMH trajectories.

"I'm Leaving": Factors That Impact Against Medical Advice Disposition Post-Trauma

BACKGROUND

Discharge against medical advice (AMA) is an important, yet understudied, aspect of health care-particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs.

OBJECTIVE

The goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment.

METHODS

We performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status.

RESULTS

Uninsured (odds ratio [OR] 2.72; 95% confidence interval [CI] 2.58-2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37-2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02-1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52-0.75), Asian (OR 0.59; 95% CI 0.49-0.69), and Hispanic (OR 0.80; 95% CI 0.75-0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury.

CONCLUSIONS

Insurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.

Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients

Importance

Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

Objective

To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.

Design, Setting, and Participants

Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states.

Interventions/Exposure

Policy implementation in January 2014.

Main Outcomes and Measures

Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation.

Results

A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation.

Conclusions and relevance

This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.

Did the Affordable Care Act Reach Penetrating Trauma Patients?

BACKGROUND

The benefits of the Affordable Care Act (ACA) for trauma patients have been well established. However, the ACA's impact on penetrating trauma patients (PTPs), a population that is historically young and uninsured, has not been defined. We hypothesized that PTPs in the post-ACA era would have better outcomes.

MATERIAL AND METHODS

The National Trauma Data Bank (NTDB) was queried for all PTPs from 2009 (pre-ACA) and 2011-2014 (post-ACA). Subset analysis was performed in patients aged 19-25 y, as this group was eligible for the ACA's dependent care provision (DCP).

RESULTS

There were 9,714,471 patients in the study, with 2,053,501 (21.1%) pre-ACA and 7,660,970 (78.9%) post-ACA. When compared to pre-ACA, patients in the post-ACA cohort were more likely to have commercial/private insurance, less likely to have Medicaid, and more likely to be uninsured. On logistic regression, the pre-ACA era was associated with mortality (HR: 1.02, 95% CI: 1.01-1.04, P = 0.004). Being uninsured was associated with mortality (HR: 1.89, 95% CI: 1.87-1.92, P < 0.001). On subset analysis of the DCP age group, post-ACA patients were more likely to be uninsured (24.1% versus 17.6%; P < 0.001). In addition, for the DCP age group, pre-ACA era was not associated with mortality (HR: 1.03, 95% CI: 0.99-1.06, P = 0.20).

CONCLUSIONS

Although the ACA provided a survival benefit to PTPs overall, it did not increase insurance coverage for this population. In addition, the DCP of the ACA did not improve insurance access for PTP in the eligible age group. Further efforts are needed to extend insurance access to this population.

The Impact of Race and Socioeconomic Status on Treatment and Outcomes of Blunt Splenic Injury

BACKGROUND

Racial, ethnic, and socioeconomic disparities have been shown to exist in trauma patients. Management of blunt splenic injuries (BSIs) can include splenectomy, embolization, or nonoperative management. This study assesses the effect of race and insurance status on outcomes in patients after blunt splenic trauma.

METHODS

The National Trauma Data Bank was used to study patients aged 15-89 y with BSIs from 2013 to 2015. Patients with abbreviated injury scores greater than two in nonabdominal areas, excluding extremities, were eliminated, as were patients with other concomitant abdominal injuries requiring repair. Variables of interest were compared across groups using chi-square tests, and those with significant associations were used in multivariate regression models for each outcome.

RESULTS

We analyzed 13,537 BSI patients. Uninsured patients had increased odds of mortality, more splenic operations, and were less likely to have nonoperative management (P < 0.001). Uninsured patients were also twice as likely to be discharged home and three times as likely to leave against medical advice (P < 0.001). African Americans and Hispanics had higher mortality (odds ratio [OR] 2.03, CI 1.34-3.08; OR 1.58, CI 1.03-2.44, respectively). African Americans had more splenic operations (OR 1.33, CI 1.08-1.64) and were 60% less likely to receive angioembolization (CI 0.41-0.84). Hispanics had fewer splenic operations (OR 0.79, CI 0.63-0.98).

CONCLUSIONS

Noteworthy differences exist in the management of splenic trauma patients based on race/ethnicity and socioeconomic status, despite controlling for demographics and injury characteristics. Insurance status and race likely affect surgical treatment plans and mortality, particularly for uninsured, black, and Hispanic patients, but further research is needed to identify the root cause of these disparities.

Socioeconomics affecting quality outcomes in Asian trauma patients within the United States

INTRODUCTION

Asian-Americans and Pacific Islanders are often considered as a uniform group when examining race in health outcomes. However, the generally favorable economic outcomes in this group belie significant socioeconomic variance between its heterogeneous subgroups. This study evaluates the impact of socioeconomic status on the health outcomes of Asian trauma patients.

METHODS

From 2012 to 2015, 52,704 Asians who presented to trauma centers were registered with the National Trauma Data Bank with known disposition. Chi² and multivariate logistic regression analysis for mortality were performed controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was performed. Subgroup analysis was done for polytrauma (Injury Severity Score >15, n = 14,787).

RESULTS

Asians represent 1.8% of the trauma population. Uninsured Asians were 1.9 times more likely to die than privately insured Asians (P < 0.001). Medicare patients were 1.8 times more likely to die (P < 0.001). Eighty-one Asians identified themselves as Hispanic, and there was no significant difference in their mortality or LOS for this group (P = 0.06, P = 0.18). Bleeding disorders, diabetes, cirrhosis, hypertension, respiratory disease, cancer, esophageal varices, angina, cerebrovascular accident, and dependent health care before trauma all individually affected mortality and were controlled for in this model (P < 0.05). LOS was 1.7 d longer in Medicaid patients (2.2 d with polytrauma) and 1.1 d longer in workman's compensation patients (2.1 d with polytrauma). Uninsured had a shorter LOS (P < 0.005). Asian males with polytrauma stayed 1.6 d longer than females (P < 0.001), and age did not affect LOS for this group.

CONCLUSIONS

Noteworthy socioeconomic disparities influence Asian trauma patients independent of their race. Mortality is affected by insurance status, despite controlling for injury severity and comorbidities.