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Breeding T, Ngatuvai M, Rosander A, Maka P, Davis J, Knowlton LM, Hoops H, Elkbuli A. Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery. J Trauma Acute Care Surg 2023; 95:806-815. [PMID: 37405809 DOI: 10.1097/ta.0000000000004067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
ABSTRACT This is a 10-year review of The Journal of Trauma and Acute Care Surgery (JTACS) literature related to health care disparities, health care inequities, and patient outcomes. A retrospective review of articles published in JTACS between January 1, 2013, and July 15, 2022, was performed. Articles screened included both adult and pediatric trauma populations. Included articles focused on patient populations related to trauma, surgical critical care, and emergency general surgery. Of the 4,178 articles reviewed, 74 met the inclusion criteria. Health care disparities related to gender (n = 10), race/ethnicity (n = 12), age (n = 14), income status (n = 6), health literacy (n = 6), location and access to care (n = 23), and insurance status (n = 13) were described. Studies published on disparities peaked in 2016 and 2022 with 13 and 15 studies respectively but dropped to one study in 2017. Studies demonstrated a significant increase in mortality for patients in rural geographical regions and in patients without health insurance and a decrease in patients who were treated at a trauma center. Gender disparities resulted in variable mortality rates and studied factors, including traumatic brain injury mortality and severity, venous thromboembolism, ventilator-associated pneumonia, firearm homicide, and intimate partner violence. Under-represented race/ethnicity was associated with variable mortality rates, with one study demonstrating increased mortality risk and three finding no association between race/ethnicity and mortality. Disparities in health literacy resulted in decreased discharge compliance and worse long-term functional outcomes. Studies on disparities in JTACS over the last decade primarily focused on location and access to health care, age, insurance status, and race, with a specific emphasis on mortality. This review highlights the areas in need of further research and funding in the Journal of Trauma and Acute Care Surgery regarding health care disparities in trauma aimed at interventions to reduce disparities in patient care, ensure equitable care, and inform future approaches targeting health care disparities. LEVEL OF EVIDENCE Systematic Review; Level IV.
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Affiliation(s)
- Tessa Breeding
- From the Kiran Patel College of Allopathic Medicine (T.B., M.N.), NOVA Southeastern University, Fort Lauderdale, Florida; Arizona College of Osteopathic Medicine, Midwestern University (A.R.), Glendale, Arizona; John A. Burns School of Medicine (P.M.), Honolulu, Hawaii; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (J.D.), The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Trauma and Surgical Critical Care, Department of Surgery (L.M.K.), Stanford University Medical Center, Palo Alto, California; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (H.H.), Oregon Health & Sciences University, Portland, Oregon; Division of Trauma and Surgical Critical Care, Department of Surgery (A.E.), and Department of Surgical Education (A.E.), Orlando Regional Medical Center, Orlando, Florida
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Govier DJ, Than CT, Chawla N, Mulcahy AC, Hoggatt KJ, Yano EM, Hynes DM. Veterans Health Administration Healthcare Coverage and Medical Financial Hardship in Low-Income Veterans. Am J Prev Med 2023; 65:406-416. [PMID: 36906192 DOI: 10.1016/j.amepre.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/13/2023]
Abstract
INTRODUCTION The Veterans Health Administration (VA) provides low- to no-cost care to enrolled veterans with low incomes. This study assessed the associations between VA coverage and medical financial hardship among U.S. veterans with low incomes. METHODS Using 2015-2018 National Health Interview Survey data, veterans aged ≥18 years with incomes <200% of the Federal Poverty Level were identified (crude n=2,468, weighted n=3,872,252). Four types of medical financial hardship were assessed: objective, and subjective material, psychologic, and behavioral medical financial hardship. Survey-weighted proportions of veterans with medical financial hardship were calculated, and adjusted probabilities of medical financial hardship that accounted for Veteran characteristics, year-fixed effects, and survey sampling design were estimated. Analyses were conducted from August through December 2022. RESULTS Overall, 34.5% of veterans with low incomes had VA coverage. Among veterans without VA coverage, 38.7% had Medicare insurance, 18.2% had Medicaid insurance, 16.5% had private insurance, 13.5% had other public insurance, and 13.1% were uninsured. In adjusted analyses, veterans with VA coverage had lower probabilities of objective (-8.13 percentage point, p=0.008), subjective material (-6.55 percentage point, p=0.034), subjective psychologic (-10.33 percentage point, p=0.003), and subjective behavioral (-6.72 percentage point, p=0.031) medical financial hardship than veterans with Medicare and no VA coverage. CONCLUSIONS VA coverage was associated with protection against four types of medical financial hardship among veterans with low incomes, yet many are not enrolled. Research is needed to understand reasons these veterans lack VA coverage and to identify strategies to address medical financial hardship.
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Affiliation(s)
- Diana J Govier
- VA Health Services Research & Development (HSR&D) Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon; Department of Health Systems Management & Policy, Oregon Health & Science University - Portland State University School of Public Health, Portland, Oregon.
| | - Claire T Than
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Neetu Chawla
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Abby C Mulcahy
- VA Health Services Research & Development (HSR&D) Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon; Department of Health Systems Management & Policy, Oregon Health & Science University - Portland State University School of Public Health, Portland, Oregon
| | - Katherine J Hoggatt
- San Francisco VA Health Care System, San Francisco, California; Department of Medicine, University of California San Francisco, San Francisco, California
| | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, California; Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California
| | - Denise M Hynes
- VA Health Services Research & Development (HSR&D) Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon; School of Social and Behavioral Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon; Center for Quantitative Life Sciences, Oregon State University, Corvallis, Oregon; School of Nursing, Oregon Health & Science University, Portland, Oregon
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Knowlton LM, Tran LD, Arnow K, Trickey AW, Morris AM, Spain DA, Wagner TH. Emergency Medicaid programs may be an effective means of providing sustained insurance among trauma patients: A statewide longitudinal analysis. J Trauma Acute Care Surg 2023; 94:53-60. [PMID: 36138539 PMCID: PMC9805493 DOI: 10.1097/ta.0000000000003796] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to postdischarge resources, and provides patients with a path to sustain coverage through Medicaid. Because HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status 6 months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment. METHODS Using a customized longitudinal claims data set for HPE-approved patients from the California Department of Health Care Services, we analyzed adults with a primary trauma diagnosis (International Classification of Diseases version 10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at 6 months. Univariate and multivariate analyses were performed. RESULTS A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at 6 months. Compared with patients who did not sustain, those who sustained had higher Injury Severity Score (ISS > 15: 73.5% vs. 68.7%, p < 0.001), more frequent surgical intervention (74.8% vs. 64.5%, p < 0.001), and were more likely to be discharged to postacute services (23.9% vs. 10.4%, p < 0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%), and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS > 16) (vs. ISS < 15: adjusted odds ratio [aOR], 1.51; p = 0.02) and surgery (aOR, 1.85; p < 0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR, 0.05; p < 0.001) decreased the likelihood of Medicaid sustainment. CONCLUSION Hospital Presumptive Eligibility programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to health care services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Lisa Marie Knowlton
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Linda D. Tran
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Katherine Arnow
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Arden M. Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - David A. Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Todd H. Wagner
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
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Newsome K, Autrey C, Sen-Crowe B, Ang D, Elkbuli A. The Affordable Care Act and its Effects on Trauma Care Access, Short- and Long-term Outcomes and Financial Impact: A Review Article. ANNALS OF SURGERY OPEN 2022; 3:e145. [PMID: 37600113 PMCID: PMC10431310 DOI: 10.1097/as9.0000000000000145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 02/07/2022] [Indexed: 11/26/2022] Open
Abstract
Objective The purpose of this study is to evaluate the current evidence regarding the impact of the ACA on trauma outcomes and the financial impact on trauma patients and trauma systems. Background Traumatic injuries are the leading cause of death and disability between the ages of 1 to 47 years. Uninsured status has been associated with worse outcomes and higher financial strain. The Affordable Care Act (ACA) was signed into law with the aim of increasing health insurance coverage. Despite improvements in insured status, it is unclear how the ACA has affected trauma. Methods We conducted a literature search using PubMed and Google Scholar for peer-reviewed studies investigating the impact of the ACA on trauma published between January 2017 and April 2021. Results Our search identified 20 studies that evaluated the impact of ACA implementation on trauma. The evidence suggests ACA implementation has been associated with increased postacute care access but not significant changes in trauma mortality. ACA implementation has been associated with a decreased likelihood of catastrophic health expenditures for trauma patients. ACA was also associated with an increase in overall reimbursement and amount billed for trauma visits, but a decrease in Medicaid reimbursement. Conclusions Some improvements on the financial impact of ACA implementation on trauma patients and trauma systems have been shown, but studies are limited by methods of calculating costs and by inconsistent pre-/post-ACA timeframes. Further studies on cost-effectiveness and cost-benefit analysis will need to be conducted to definitively determine the impact of ACA on trauma.
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Affiliation(s)
- Kevin Newsome
- From the Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Cody Autrey
- From the Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Brendon Sen-Crowe
- Dr. Kiran C. Patel College of Allopathic Medicine, NSU NOVA Southeastern University, Fort Lauderdale, FL
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, Ocala, FL
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL
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Fu SJ, Arnow K, Trickey A, Spain DA, Morris A, Knowlton L. Financial Burden of Traumatic Injury Amongst the Privately Insured. Ann Surg 2022; 275:424-432. [PMID: 34596072 DOI: 10.1097/sla.0000000000005225] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to evaluate the overall financial burden associated with traumatic injury amongst patients with private insurance and assess the effect of high deductible plans on out-of-pocket costs (OOPCs). SUMMARY OF BACKGROUND DATA Traumatic injury can be a source of unexpected financial burden for households. However, the effect of increasing participation in higher cost-sharing private health insurance plans remains unknown. METHODS We conducted a retrospective cohort observational study, using the Clinformatics Data Mart Database, a nationwide single-payer administrative claims database to identify US adults who required emergency department services or hospital admission for single traumatic injury from 2008 to 2018. A 2-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month OOPCs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure (CHE) after injury. RESULTS Of 426,945 included patients, 53% were male, 71% were white, and median age was 42 years. Patients faced monthly OOPC of $660 at the time of their injury. High deductible plan enrollment was associated with an increase of $1703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to high deductible health plan enrollment, worsening injury severity and longer hospital stays were also associated with increased 12-month OOPC after trauma. Non-white minorities paid less 12-month OOPC after trauma compared to non-Hispanic white patients, but also used fewer services. Overall, the incidence of CHE was 5%; however high-deductible health plan enrollees faced a 13% chance of CHE. CONCLUSIONS Privately insured trauma patients face substantial OOPCs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.
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Affiliation(s)
- Sue J Fu
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
- Health Research and Development, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Katherine Arnow
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Amber Trickey
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - David A Spain
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Arden Morris
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Lisa Knowlton
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
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Liu C, Scannell CA, Kenison T, Wren SM, Saliba D. Improvements and Gaps in Financial Risk Protection Among Veterans Following the Affordable Care Act. J Gen Intern Med 2022; 37:573-581. [PMID: 33959882 PMCID: PMC8101607 DOI: 10.1007/s11606-021-06807-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite public perception, most of the nearly 20 million US veterans have health coverage outside the Veterans Health Administration (VHA), and VHA eligibility and utilization vary across veterans. Out-of-pocket healthcare spending thus remains a potential source of financial hardship for veterans. The Affordable Care Act (ACA) aimed to expand health insurance access, but its effect on veterans' financial risk protection has not been explored. OBJECTIVE To evaluate whether ACA implementation was associated with changes in veterans' risk of catastrophic health expenditures, and to characterize drivers of catastrophic health spending among veterans post-ACA. DESIGN Using multivariable linear probability regression, we examined changes in likelihood of catastrophic health spending after ACA implementation, stratifying by age (18-64 vs 65+), household income tercile, and payer (VHA vs non-VHA). Among veterans with catastrophic spending post-ACA, we evaluated sources of out-of-pocket spending. PARTICIPANTS Nationally representative sample of 13,030 veterans aged 18+ from the 2010 to 2017 Medical Expenditure Panel Survey. INTERVENTION ACA implementation, January 1, 2014. MAIN MEASURES Likelihood of catastrophic health expenditures, defined as household out-of-pocket spending exceeding 10% of household income. KEY RESULTS Among veterans aged 18-64, ACA implementation was associated with a 26% decrease in likelihood of catastrophic health expenditures (absolute change, -1.4 percentage points [pp]; 95% CI, -2.6 to -0.2; p=0.03), which fell from 5.4% pre-ACA to 3.9% post-ACA. This was driven by a 38% decrease in catastrophic spending among veterans with non-VHA coverage (absolute change, -1.8pp; 95% CI, -3.0 to -0.6; p=0.003). In contrast, catastrophic expenditure rates among veterans aged 65+ remained high, at 13.0% pre- and 12.5% post-ACA. Major drivers of veterans' spending post-ACA include dental care, prescription drugs, and home care. CONCLUSIONS ACA implementation was associated with reduced household catastrophic health expenditures for younger but not older veterans. These findings highlight gaps in veterans' financial protection and areas amenable to policy intervention.
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Affiliation(s)
- Charles Liu
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA.
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
| | - Christopher A Scannell
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Tiffany Kenison
- National Clinician Scholars Program, University of California Los Angeles, Los Angeles, CA, USA
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA
| | - Sherry M Wren
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Health Administration, Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Debra Saliba
- Veterans Health Administration, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Borun Center for Gerontological Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Metzger GA, Asti L, Quinn JP, Chisolm DJ, Xiang H, Deans KJ, Cooper JN. Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level. J Am Coll Surg 2021; 233:776-793.e16. [PMID: 34656739 PMCID: PMC8627499 DOI: 10.1016/j.jamcollsurg.2021.08.694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/21/2021] [Accepted: 08/25/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income. STUDY DESIGN Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years. RESULTS Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD -16.5 percentage points; 95% CI, -17.1 to -15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD -0.4 percentage points; 95% CI, -0.8 to -0.1 percentage points). CONCLUSIONS The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.
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Affiliation(s)
- Gregory A Metzger
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - John P Quinn
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Medical Student Research Program, College of Medicine, The Ohio State University, Columbus, OH
| | - Deena J Chisolm
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Health Services Management & Policy, College of Public Health, The Ohio State University, Columbus, OH
| | - Henry Xiang
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH.
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Dalton MK, Riviello R, Kubasiak JC, Sokas CM, Osman SY, Jin G, Nitzschke SL, Ortega G. The impact of the Affordable Care Act's medicaid expansion on patients admitted for burns: An analysis of national data. Burns 2021; 48:1340-1346. [PMID: 34903411 DOI: 10.1016/j.burns.2021.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 10/24/2021] [Accepted: 10/29/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The first states began implementing the Medicaid expansion provisions of the Patient Protection and Affordable Care Act (ACA) in 2014. Studies have yet to address its impact on burn patients. METHODS Burn patients in geographic regions that expanded Medicaid coverage were compared to patients in regions that did not expand Medicaid before and after implementation of the ACA using bivariate statistics and a difference-in-differences model. A multivariable logistic regression was used to identify factors associated with having Medicaid insurance. The primary outcome of this study was the rate of Medicaid insurance. RESULTS Of 25,331 discharges, we found greater increases in Medicaid coverage after the ACA in the Medicaid expander regions (23.4-40.2%) compared to the non-expander regions (18.5-20.1%). The difference-in-differences estimate between the expander and non-expander regions was 0.15 (95% CI: 0.11-0.18, p < 0.001). Patients admitted in expander regions were more likely to be insured by Medicaid (OR 1.57 [95%CI 1.21-2.05]), as were patients of Black race (OR 1.25 [95%CI 1.19-1.32), Hispanic ethnicity (OR 1.29 [95%CI 1.14-1.46]), and female sex (OR 1.59 [95%CI 1.11-2.27]). We also found a significant interaction between time period (pre-ACA/post-ACA) and expander region location (OR 2.10 [95%CI 1.67-2.62]). CONCLUSIONS The Medicaid expansion provision of the ACA led to increased Medicaid coverage among burn patients which was significantly higher in areas with widespread implementation of the expansion.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Robert Riviello
- Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - John C Kubasiak
- Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Claire M Sokas
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Samia Y Osman
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ginger Jin
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Gezzer Ortega
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Olafson SN, Cohen RB, Parsikia A, Moran B, Kaplan MJ, Leung P. Insurance Status Impacts Hospital Discharge for Penetrating Trauma Survivors. Am Surg 2021; 88:1996-2002. [PMID: 34053228 DOI: 10.1177/00031348211023396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite equalized acute care in trauma, disparities exist in the long-term outcomes of trauma survivors. Prior studies have revealed insurance status plays a role in the discharge destination of blunt trauma survivors. This is yet to be described in patients with penetrating traumatic injury. METHODS A retrospective chart review from 2009 to 2019 from an urban Level 1 trauma center identified adult patients who survived penetrating trauma to discharge. Patients were categorized by insurance status. Patient demographics, discharge destination, and hospital length of stay (LOS) were analyzed using the t-test and ANOVA. RESULTS 1806 patients were identified with 1410 survivors to hospital discharge. Among the survivors, 26.8% were uninsured, 13.1% were privately insured, and 60.0% had Medicare/Medicaid. The uninsured patients were significantly less likely to be discharged to a rehabilitation facility or skilled nursing facility (OR = .49, 95% CI .35-.71) compared to the insured patients. Uninsured survivors had shorter LOS compared to the other groups (5.8 vs. 7.3, P < .01.) Severity of injury did not significantly influence the discharge destination or LOS between the groups. CONCLUSION Despite recent health care reform, many trauma patients remain uninsured. Our study shows that uninsured penetrating trauma survivors are less likely to be discharged to rehabilitation and skilled nursing facilities. This may contribute to uninsured trauma survivors not receiving appropriate post-traumatic care and could lead to the accrual of undue disability, long-term complications, and increased societal burdens.
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Affiliation(s)
- Samantha N Olafson
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Ryan B Cohen
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Afshin Parsikia
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Benjamin Moran
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Mark J Kaplan
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
| | - Pak Leung
- Department of Surgery, 6566Einstein Medical Center, Philadelphia, PA, USA
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Association of medicaid expansion of the Affordable Care Act with the stage at diagnosis and treatment of papillary thyroid cancer: A difference-in-differences analysis. Am J Surg 2021; 222:562-569. [PMID: 33541689 DOI: 10.1016/j.amjsurg.2021.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Affordable Care Act's (ACA) Medicaid expansion has increased insurance coverage and improved various cancer outcomes. Its impact in papillary thyroid cancer (PTC) remains unclear. METHODS Non-elderly patients (40-64 years-old) with PTC living in low-income areas either in a 2014 expansion, or a non-expansion state were identified from the National Cancer Database between 2010 and 2016. Insurance coverage, stage at diagnosis, and RAI administration were analyzed using a difference-in-differences analysis. RESULTS 10,644 patients were included. Compared with non-expansion states, the percentage of uninsured patients (adjusted-DD -2.6% [95%-CI -4.3to-0.8%],p = 0.004) and patients with private insurance decreased, and those with Medicaid coverage increased (adjusted-DD 9.7% [95%-CI 6.9-12.5%],p < 0.001) in expansion states after ACA implementation. The percentage of patients with pT1 did not differ between expansion and non-expansion states; neither did the use of RAI. CONCLUSIONS Medicaid expansion has resulted in a smaller uninsured population in PTC patients, but without earlier disease presentation nor change in RAI treatment.
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