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Okpara CJ, Divers J, Winner M. Avoidance of care: how health-care affordability influenced COVID-19 disease severity and outcomes. Am J Epidemiol 2024; 193:987-995. [PMID: 38497546 DOI: 10.1093/aje/kwae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 02/21/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024] Open
Abstract
In this study we examined the association between payor type, a proxy for health-care affordability, and presenting COVID-19 disease severity among 2108 polymerase chain reaction-positive nonelderly patients admitted to an acute-care hospital between March 1 and June 30, 2020. The adjacent-category logit model was used to fit pairwise odds of individuals' having (1) an asymptomatic-to-mild modified sequential organ failure assessment (mSOFA) score (0-3) versus a moderate-to-severe mSOFA score (4-7) and (2) a moderate-to-severe mSOFA score (4-7) versus a critical mSOFA score (>7). Despite representing the smallest population, Medicare recipients experienced the highest in-hospital death rate (19%), a rate twice that of the privately insured. The uninsured had the highest rate of critical mSOFA score on admission and had twice the odds of presenting with a critical illness when compared with the privately insured (odds ratio = 2.08, P =.03). Because payor type was statistically related to the most severe presentations of COVID-19, we question whether policy changes affecting health-care affordability might have prevented deaths and rationing of scarce resources, such as intensive care unit beds and ventilators.
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Dualeh SHA, Schaefer SL, Kunnath N, Ibrahim AM, Scott JW. Health Insurance Status and Unplanned Surgery for Access-Sensitive Surgical Conditions. JAMA Surg 2024; 159:420-427. [PMID: 38324286 PMCID: PMC10851136 DOI: 10.1001/jamasurg.2023.7530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/14/2023] [Indexed: 02/08/2024]
Abstract
Importance Access-sensitive surgical conditions, such as abdominal aortic aneurysm, ventral hernia, and colon cancer, are ideally treated with elective surgery, but when left untreated have a natural history requiring an unplanned operation. Patients' health insurance status may be a barrier to receiving timely elective care, which may be associated with higher rates of unplanned surgery and worse outcomes. Objective To evaluate the association between patients' insurance status and rates of unplanned surgery for these 3 access-sensitive surgical conditions and postoperative outcomes. Design, Setting, and Participants This cross-sectional cohort study examined a geographically broad patient sample from the Healthcare Cost and Utilization Project State Inpatient Databases, including data from 8 states (Arizona, Colorado, Florida, Kentucky, Maryland, North Carolina, Washington, and Wisconsin). Participants were younger than 65 years who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2016 and 2020. Patients were stratified into groups by insurance status. Data were analyzed from June 1 to July 1, 2023. Exposure Health insurance status (private insurance, Medicaid, or no insurance). Main Outcomes and Measures The primary outcome was the rate of unplanned surgery for these 3 access-sensitive conditions. Secondary outcomes were rates of postoperative outcomes including inpatient mortality, any hospital complications, serious complications (a complication with a hospital length of stay longer than the 75th percentile for that procedure), and hospital length of stay. Results The study included 146 609 patients (mean [SD] age, 50.9 [10.3] years; 73 871 females [50.4%]). A total of 89 018 patients (60.7%) underwent elective surgery while 57 591 (39.3%) underwent unplanned surgery. Unplanned surgery rates varied significantly across insurance types (33.14% for patients with private insurance, 51.46% for those with Medicaid, and 72.60% for those without insurance; P < .001). Compared with patients with private insurance, patients without insurance had higher rates of inpatient mortality (1.29% [95% CI, 1.04%-1.54%] vs 0.61% [0.57%-0.66%]; P < .001), higher rates of any complications (19.19% [95% CI, 18.33%-20.05%] vs 12.27% [95% CI, 12.07%-12.47%]; P < .001), and longer hospital stays (7.27 [95% CI, 7.09-7.44] days vs 5.56 [95% CI, 5.53-5.60] days, P < .001). Conclusions and Relevance Findings of this cohort study suggest that uninsured patients more often undergo unplanned surgery for conditions that can be treated electively, with worse outcomes and longer hospital stays compared with their counterparts with private health insurance. As efforts are made to improve insurance coverage, tracking elective vs unplanned surgery rates for access-sensitive surgical conditions may be a useful measure to assess progress.
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Affiliation(s)
- Shukri H. A. Dualeh
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Sara L. Schaefer
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Nicholas Kunnath
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew M. Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Taubman College of Architecture and Urban Planning, University of Michigan, Ann Arbor
| | - John W. Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery, University of Washington, Seattle
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, University of Washington, Seattle
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Mendez I, Strassle PD, Rodriquez EJ, Ponce S, Le R, Green A, Martinez E, Pérez-Stable EJ, Nápoles AM. Racial and ethnic disparities in the association between financial hardship and self-reported weight change during the first year of the pandemic in the U.S. Int J Equity Health 2024; 23:12. [PMID: 38254081 PMCID: PMC10804602 DOI: 10.1186/s12939-023-02093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/30/2023] [Indexed: 01/24/2024] Open
Abstract
Studies have shown that financial hardship can impact weight change; however, it is unclear what the economic impact of the COVID-19 pandemic has had on weight change in U.S. adults, or whether racial-ethnic groups were impacted differentially. We estimated the association between financial hardship and self-reported weight change using data from the cross-sectional COVID-19's Unequal Racial Burden (CURB) survey, a nationally representative online survey of 5,500 American Indian/Alaska Native, Asian, Black/African American, Latino (English- and Spanish-speaking), Native Hawaiian/Pacific Islander, White, and multiracial adults conducted from 12/2020 to 2/2021. Financial hardship was measured over six domains (lost income, debt, unmet general expenses, unmet healthcare expenses, housing insecurity, and food insecurity). The association between each financial hardship domain and self-reported 3-level weight change variable were estimated using multinomial logistic regression, adjusting for sociodemographic and self-reported health. After adjustment, food insecurity was strongly associated with weight loss among American Indian/Alaska Native (aOR = 2.18, 95% CI = 1.05-4.77), Black/African American (aOR = 1.77, 95% CI = 1.02-3.11), and Spanish-speaking Latino adults (aOR = 2.32, 95% CI = 1.01-5.35). Unmet healthcare expenses were also strongly associated with weight loss among Black/African American, English-speaking Latino, Spanish-speaking Latino, and Native Hawaiian/Pacific Islander adults (aORs = 2.00-2.14). Other domains were associated with weight loss and/or weight gain, but associations were not as strong and less consistent across race-ethnicity. In conclusion, food insecurity and unmet healthcare expenses during the pandemic were strongly associated with weight loss among racial-ethnic minority groups. Using multi-dimensional measures of financial hardship provides a comprehensive assessment of the effects of specific financial hardship domains on weight change among diverse racial-ethnic groups.
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Affiliation(s)
- Izabelle Mendez
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland), USA.
| | - Paula D Strassle
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland), USA
| | - Erik J Rodriquez
- Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland), USA
- Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland), USA
| | - Stephanie Ponce
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland), USA
| | - Randy Le
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland), USA
| | - Alexis Green
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland), USA
| | - Emma Martinez
- Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland), USA
| | - Eliseo J Pérez-Stable
- Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland), USA
- Office of the Director, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland), USA
| | - Anna M Nápoles
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland), USA
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Gorenshtein L, Leraas H, Eze A, Lumpkin S, Chime C, Chang D, Wischmeyer P, Agarwal S, Fernandez J, Haines KL. The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury. J Surg Res 2024; 293:121-127. [PMID: 37738853 DOI: 10.1016/j.jss.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 07/08/2023] [Accepted: 07/24/2023] [Indexed: 09/24/2023]
Abstract
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.
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Affiliation(s)
| | - Harold Leraas
- Department of Surgery, Duke University, Durham, North Carolina.
| | - Anthony Eze
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Chinecherem Chime
- School of Medicine, Howard University College of Medicine, Washington, District of Columbia
| | - Doreen Chang
- Department of Surgery, Duke University, Durham, North Carolina
| | - Paul Wischmeyer
- Department of Surgery, Duke University, Durham, North Carolina
| | - Suresh Agarwal
- Department of Surgery, Duke University, Durham, North Carolina
| | | | - Krista L Haines
- Department of Surgery, Duke University, Durham, North Carolina
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Wu YT, Biswas S, Matsushima K, Schellenberg M, Inaba K, Martin MJ. Predicting the Future in Trauma: Trauma and Injury Severity Score Loses Accuracy and Validity for Late Deaths After Injury. Am Surg 2023; 89:4077-4083. [PMID: 37184047 DOI: 10.1177/00031348231175501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND The Trauma and Injury Severity Score (TRISS) is widely used to predict mortality in trauma patients, but its performance metrics have not been analyzed for early vs later deaths. Therefore, we aimed to investigate the impact of time to death on the accuracy of TRISS. METHODS Patients from 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database were included. We compared predicted survival by TRISS using the areas under receiver operating characteristic curves (AUCs) and calibration curves between different cut-off times and subgroups. We further compared early (≤72 hr) and late (>72 hr) deaths based on mechanisms and severity. RESULTS Among the 1,180,745 patients, the total mortality rate was 6.4%, with 59% early deaths and 41% late deaths. The AUC of TRISS for all patients was .919 (95% CI: .918-.921) for ≤72 hr survival and .845 (95% CI: .843-.848) for >72 hr survival. Significant discrepancies in AUCs between the early and late death groups existed in all cohorts based on blunt/penetrating mechanisms and severity. TRISS predicted well in early survival of penetrating injury but was less reliable in late survival of penetrating injury and all blunt injury. TRISS tended to underestimate survival, particularly for patients with lower probability of survival, with increased discrepancies seen for predicting late deaths. CONCLUSIONS The predictive ability of TRISS varies significantly based on the timing of deaths and key injury factors. TRISS may be best utilized in predicting early survival in penetrating injury, but its reliability and accuracy diminish when predicting late deaths for all kinds of injury.
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Affiliation(s)
- Yu-Tung Wu
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Subarna Biswas
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Matthew J Martin
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
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Firearm trauma: Race and insurance influence mortality and discharge disposition. J Trauma Acute Care Surg 2022; 92:1005-1011. [PMID: 35609290 DOI: 10.1097/ta.0000000000003512] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Health insurance and race impact mortality and discharge outcomes in the general trauma population. It remains unclear if disparities exist by race and/or insurance in outcomes following firearm injuries. The purpose of this study was to assess differences in mortality and discharge based on race and insurance status following firearm injuries. METHODS The National Trauma Data Bank (2007-2016) was queried for firearm injuries by International Classification of Diseases, Ninth/Tenth Revision, Ecodes. Patients with known discharge disposition, age (18-64 years), race, and insurance were included in analysis (N = 120,005). To minimize bias due to missing data, we used multiple imputation for variables associated with outcomes following traumatic injury: Injury Severity Score, Glasgow Coma Scale score, respiratory rate, systolic blood pressure, and sex. Multivariable regression analysis was additionally adjusted for age, sex, Injury Severity Score, intent, Glasgow Coma Scale score, systolic blood pressure, heart rate, respiratory rate, year, and clustered by facility to assess differences in mortality and discharge disposition. RESULTS The average age was 31 years, 88.6% were male, and 50% non-Hispanic Blacks. Overall mortality was 11.5%. Self-pay insurance was associated with a significant increase in mortality rates in all racial groups compared with non-Hispanic Whites with commercial insurance. Hispanic commercial, Medicaid, and self-pay patients were significantly less likely to discharge with posthospital care compared with commercially insured non-Hispanic Whites. When examining racial differences in mortality and discharge by individual insurance types, commercially insured non-Hispanic Black and other race patients were significantly less likely to die compared with similarly insured non-Hispanic White patients. Regardless of race, no significant differences in mortality were observed in Medicaid or self-pay patients compared with non-Hispanic White patients. CONCLUSION Victims of firearm injuries with a self-pay insurance status have a significantly higher rate of mortality. Hispanic patients regardless of insurance status were significantly less likely to discharge with posthospital care compared with non-Hispanic Whites with commercial insurance. Continued efforts are needed to understand and address the relationship between insurance status, race, and outcomes following firearm violence. LEVEL OF EVIDENCE Prognostic and epidemiologic, Level IV.
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Grenn E, Kutcher M, Hillegass WB, Iwuchukwu C, Kyle A, Bruehl S, Goodin B, Myers H, Rao U, Nag S, Kinney K, Dickens H, Morris MC. Social determinants of trauma care: Associations of race, insurance status, and place on opioid prescriptions, postdischarge referrals, and mortality. J Trauma Acute Care Surg 2022; 92:897-905. [PMID: 34936591 PMCID: PMC9038661 DOI: 10.1097/ta.0000000000003506] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Racial disparities in trauma care have been reported for a range of outcomes, but the extent to which these remain after accounting for socioeconomic and environmental factors remains unclear. The objective of this study was to evaluate the unique contributions of race, health insurance, community distress, and rurality/urbanicity on trauma outcomes after carefully controlling for specific injury-related risk factors. METHODS All adult (age, ≥18 years) trauma patients admitted to a single Level I trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed. Primary outcomes were mortality, rehabilitation referral, and receipt of opioids in the emergency department. Demographic, socioeconomic, and injury characteristics as well as indicators of community distress and rurality based on home address were abstracted from a trauma registry database. RESULTS Analyses revealed that Black patients (n = 13,073) were younger, more likely to be male, more likely to suffer penetrating injuries, and more likely to suffer assault-based injuries compared with White patients (n = 10,946; all p < 0.001). In adjusted analysis, insured patients had a 28% lower risk of mortality (odds ratio, 0.72; p = 0.005) and were 92% more likely to be referred for postdischarge rehabilitation than uninsured patients (odds ratio, 1.92; p = 0.005). Neither race- nor place-based factors were associated with mortality. However, post hoc analyses revealed a significant race by age interaction, with Black patients exhibiting more pronounced increases in mortality risk with increasing age. CONCLUSION The present findings help disentangle the social determinants of trauma disparities by adjusting for place and person characteristics. Uninsured patients were more likely to die and those who survived were less likely to receive referrals for rehabilitation services. The expected racial disparity in mortality risk favoring White patients emerged in middle age and was more pronounced for older patients. LEVEL OF EVIDENCE Prognostic and epidemiological, Level III.
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Affiliation(s)
- Emily Grenn
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Matthew Kutcher
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - William B. Hillegass
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS
| | - Chinenye Iwuchukwu
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Amber Kyle
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Burel Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL
| | - Hector Myers
- Department of Psychology, Vanderbilt University, Nashville, TN
| | - Uma Rao
- Department of Psychiatry & Human Behavior and Center for Center for the Neurobiology of Learning and Memory, University of California – Irvine, California, USA
- Children’s Hospital of Orange County, Orange, CA, USA
| | - Subodh Nag
- Department of Biochemistry, Cancer Biology, Neuroscience & Pharmacology, Meharry Medical College, Nashville, TN
| | - Kerry Kinney
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS
| | - Harrison Dickens
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS
| | - Matthew C. Morris
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS
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The effect of COVID-19 on adult traumatic orthopedic injuries: a database study. Eur J Trauma Emerg Surg 2022; 48:2813-2822. [PMID: 35318484 PMCID: PMC8940592 DOI: 10.1007/s00068-022-01947-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/09/2022] [Indexed: 11/17/2022]
Abstract
Purpose This study compares orthopedic injuries, procedures, and hospital outcomes of patients presenting to trauma centers in Pennsylvania before and during the COVID-19 pandemic. Methods A retrospective review of adult patients presenting to hospitals with Pennsylvania Trauma Systems Foundation (PTSF) designations was performed. All patients 18 years of age and older who presented with orthopedic injuries were included. Demographic information, injury and hospital stay details, and mortality were reviewed. Data were compared between the cohorts of patients presenting during April 2020 (COVID cohort) and April 2017, April 2018, and April 2019 (pre-COVID cohort). Results Overall, 14,858 patients were reviewed, and 9427 patients were included in this study. There were fewer orthopedic injuries (4868 vs. 6603 yearly mean) in the COVID cohort which led to fewer procedures (1763 vs. 2329 yearly mean). The COVID cohort had a significantly shorter mean hospital length of stay compared to the pre-COVID cohort (4.7 days versus 5.2 days, p = 0.01). A higher mortality rate was seen in the COVID cohort (n = 115, 6.1%) compared to the pre-COVID cohort (n = 305, 4.0%; p < 0.01). Conclusion The characteristics of orthopedic injuries sustained by patients presenting to trauma centers during the COVID pandemic were not different from prior to the pandemic. However, there were decreases in the number of orthopedic injuries and procedures accompanied by a 50% increase in mortality seen in these patients during the pandemic. Resources should be appropriately marshalled to prevent rises in-hospital mortality for patients with orthopedic trauma treated during a pandemic. Level of evidence Level III.
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Chun M, Zhang Y, Nguyen A, Becnel C, Noguera V, Taghavi S, Guidry C, Hussein M, Toraih E, McGrew P. How Does Insurance Status Correlate With Trauma Mechanisms and Outcomes? A Retrospective Study at a Level 1 Trauma Center. Am Surg 2021; 88:859-865. [PMID: 34256642 DOI: 10.1177/00031348211032592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Studies showed that a lack of insurance is associated with worse trauma outcomes. We examine insurance status and trauma mortality in a diverse metropolitan city and hypothesize that the higher risk of mortality in uninsured patients is due to insurance status and other factors. METHODS A retrospective analysis of patients admitted to a Level 1 Trauma center for emergent surgery in a diverse metropolitan city from Jan 2016-May 2020 was conducted. Patients of different insurance statuses were analyzed for their injury mechanism and surgical intervention outcomes. Multivariate logistic regression was performed and the results were presented as odds ratio with 95% confidence intervals and P values. Statistical significance was set at P < .05. RESULTS 738 patients met study criteria. Medicaid patients made up the largest proportions of injury mechanisms: 65.1% of gunshot wound cases, sharp object (41.7%), and falls (32.5%). Private insurance (OR = .13, 95% CI: .05-.35, P = .000), Medicaid (OR = .19, 95% CI: .10-.35, P = .000), Medicare (OR = .65, 95% CI: 0.28-1.51, P = .31), and other insurance (OR = .44, 95% CI 0.22-.87, P = .01) were associated with survival. Uninsured patients had the highest mortality rate resulting from trauma at 32.6% (P < .001), and the lowest mortality rate belonged to the private insurance cohort (6.3%, P < .001). Uninsured patients accounted for 10.5% of gunshot wound cases, 8.5% of motor vehicle accident cases, 25% of sharp object cases, and 6.6% of falls. CONCLUSION Being uninsured was independently associated with mortality, while having insurance improved outcomes. Underlying mechanisms should be further elucidated to improve health equity and trauma outcomes in diverse patient populations.
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Affiliation(s)
- Magnus Chun
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - Yichi Zhang
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - An Nguyen
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - Chad Becnel
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - Valeria Noguera
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - Sharven Taghavi
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - Chrissy Guidry
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - Mohammed Hussein
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
| | - Eman Toraih
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA.,Department of Histology and Cell Biology, Genetics Unit, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Patrick McGrew
- Department of Surgery, 12255Tulane University School of Medicine, New Orleans, LA, USA
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Ahmed I, Merchant FM, Curtis JP, Parzynski CS, Lampert R. Impact of insurance status on ICD implantation practice patterns: Insights from the NCDR ICD registry. Am Heart J 2021; 235:44-53. [PMID: 33503408 DOI: 10.1016/j.ahj.2021.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Whether insurance status influences practice patterns in implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) defibrillators, when indicated, is not known. METHODS AND RESULTS We analyzed the NCDR ICD Registry to evaluate associations of insurance status with guidelines-based receipt of CRT, as well as device-type, complication rates, and use of optimal medical therapy defined by guidelines. Among 798,028 patients with de novo ICD implants, we included only patients < 65 years (those older have Medicare) and excluded those admitted before 2006 (n=1,835) or with insurance coverage other than Medicare, Medicaid or private insurance (n=25,695) leaving 286,556 for analysis. Inverse probability of treatment weighting was used to control for imbalances between groups. Mean age was 53 years, 29% were female. Patients with private insurance and Medicare were more likely to receive CRT-D when indicated (79.6%, OR 1.19 95% CI 1.09-1.28, P <.001 and 78.5%, OR 1.11 95% CI 1.01-1.21 P = .03, respectively) compared to the uninsured (76.7%). The uninsured were also more likely than other groups to receive a single-chamber device. Complication rates did not differ. Uninsured patients were, however, more likely to receive optimal medical therapy, particularly in the subgroup receiving the implant for primary prevention. CONCLUSIONS In propensity-weighted analysis, uninsured patients are less likely to receive CRT when indicated but more likely to be receiving optimal medical therapy at discharge. Reasons for differences in device implantation practices based on insurance status require further study.
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Association of insurance disparities and survival in adults with multiple myeloma: A non-concurrent cohort study. Leuk Res 2021; 104:106542. [PMID: 33721572 DOI: 10.1016/j.leukres.2021.106542] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 01/28/2021] [Accepted: 02/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Multiple myeloma (MM) accounts for 10 % of all hematological malignancies. As recent advances in MM treatment continue to improve survival rates, socioeconomic barriers need to be identified to ensure equal treatment. This study evaluates the association between insurance status and survival in patients with MM. METHODS This study analyzed patients with MM from the 2007-2016 Surveillance, Epidemiology, and End Results (SEER) Program database. Insurance status was categorized as uninsured, Medicaid, private insurance, and other insurance. Cancer-specific survival was measured at one- and five-years post diagnosis. RESULTS From 2007-2016, there were 41,846 patients with MM extracted from the SEER database. Those with private insurance had a higher proportion of participants that identified as married (65.5 %), resided in metropolitan cities (90.1 %), and identified as white (76 %) and non-Hispanic (90.8 %). The uninsured group had the highest proportion of Black participants compared to other insurance groups (37.4 %). After adjustment for age, sex, race, ethnicity, marital status, and residence, the likelihood of five-year survival was significantly lower in those respondents with Medicaid (adjusted (adj) Hazard Ratio (HR): 1.44; 95 % Confidence Interval (CI): 1.36-1.53), when compared with private insurance holders. Those who were uninsured had a 26 % increased mortality hazard than those with private insurance (95 % CI 1.04-1.53). CONCLUSION After adjustment, insurance status can influence the survival of adults with MM. As treatment modalities for MM continue to advance, the insurance status of a patient should not hinder their ability to receive the most effective and timely therapies.
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Farooq A, Paredes AZ, Merath K, Hyer JM, Mehta R, Sahara K, Tsilimigras DI, Moro A, Wu L, Cloyd J, Ejaz A, Pawlik TM. How Safe Are Safety-Net Hospitals? Opportunities to Improve Outcomes for Vulnerable Patients Undergoing Hepatopancreaticobiliary Surgery. J Gastrointest Surg 2020; 24:2570-2578. [PMID: 31792898 DOI: 10.1007/s11605-019-04428-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/30/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Safety-net hospitals are critical to the US health system as they provide care to vulnerable patients. The effect of hospital safety-net burden on patient outcomes in hepatopancreaticobiliary (HPB) surgery was examined. METHODS Discharge data between 2004 and 2014 from the National Inpatient Sample were utilized. Hospitals with a safety-net burden were divided into tertiles: low (LBH) (< 13.6%), medium (MBH) (13.6-33.3%), and high (HBH) (> 33.3%). The association of hospital safety-net burden with complications, in-hospital mortality, never events, and costs were defined. RESULTS Nearly 5% of the analytic cohort (n = 65,032) had surgery at a HBH. Patients treated at HBH were younger (median age, HBH 55 years vs LBH 62 years; p < 0.001), black or Hispanic (HBH 40.5% vs LBH 12.7%; p < 0.001), and of lowest income quartile (HBH 38.4% vs LBH 19.6%; p < 0.001). One-third of patients at HBH experienced a complication compared with only a quarter of patients at LBH (p < 0.001). HBH had higher rates of in-hospital mortality (HBH 6.5% vs. LBH 2.8%; p < 0.001), never events (HBH 5.4% vs. LBH 1.4%; p < 0.001), and a higher cost of surgery (HBH $30,716 vs. LBH $28,054; p < 0.001). CONCLUSION Perioperative outcomes were worse at HBH, highlighting that efforts are needed to improve their delivery of care.
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Affiliation(s)
- Ayesha Farooq
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Anghela Z Paredes
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Rittal Mehta
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Kota Sahara
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Amika Moro
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Lu Wu
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Columbus, OH, USA. .,Oncology, Health Services Management and Policy, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite, Columbus, OH, 670, USA.
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Galvani AP, Parpia AS, Foster EM, Singer BH, Fitzpatrick MC. Improving the prognosis of health care in the USA. Lancet 2020; 395:524-533. [PMID: 32061298 PMCID: PMC8572548 DOI: 10.1016/s0140-6736(19)33019-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 11/12/2019] [Accepted: 11/22/2019] [Indexed: 01/22/2023]
Abstract
Although health care expenditure per capita is higher in the USA than in any other country, more than 37 million Americans do not have health insurance, and 41 million more have inadequate access to care. Efforts are ongoing to repeal the Affordable Care Act which would exacerbate health-care inequities. By contrast, a universal system, such as that proposed in the Medicare for All Act, has the potential to transform the availability and efficiency of American health-care services. Taking into account both the costs of coverage expansion and the savings that would be achieved through the Medicare for All Act, we calculate that a single-payer, universal health-care system is likely to lead to a 13% savings in national health-care expenditure, equivalent to more than US$450 billion annually (based on the value of the US$ in 2017). The entire system could be funded with less financial outlay than is incurred by employers and households paying for health-care premiums combined with existing government allocations. This shift to single-payer health care would provide the greatest relief to lower-income households. Furthermore, we estimate that ensuring health-care access for all Americans would save more than 68 000 lives and 1·73 million life-years every year compared with the status quo.
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Affiliation(s)
- Alison P Galvani
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT 06510, USA.
| | - Alyssa S Parpia
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT 06510, USA
| | - Eric M Foster
- Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT 06510, USA
| | - Burton H Singer
- Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Meagan C Fitzpatrick
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
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Huguet N, Angier H, Hoopes MJ, Marino M, Heintzman J, Schmidt T, DeVoe JE. Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act. J Am Board Fam Med 2019; 32:883-889. [PMID: 31704757 PMCID: PMC7001872 DOI: 10.3122/jabfm.2019.06.190087] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/03/2019] [Accepted: 06/21/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To assess the prevalence of pre-existing conditions for community health center (CHC) patients who gained insurance coverage post-Affordable Care Act (ACA). METHODS We analyzed electronic health record data from 78,059 patients aged 19 to 64 uninsured at their last visit pre-ACA from 386 CHCs in 19 states. We compared the prevalence and types of pre-existing conditions pre-ACA (2012 to 2013) and post-ACA (2014 to 2015), by insurance status and race/ethnicity. RESULTS Pre-ACA, >50% of patients in the cohort had ≥1 Pre-existing condition. Post-ACA, >70% of those who gained insurance coverage had ≥1 condition. Post-ACA, all racial/ethnic subgroups showed an increase in the number of pre-existing conditions, with non-Hispanic Black and Hispanic patients experiencing the largest increases (adjusted prevalence difference, 18.9; 95% CI, 18.2 to 19.6 and 18.3; 95% CI, 17.8 to 18.7, respectively). The most common conditions post-ACA were mental health disorders with the highest prevalence among patients who gained Medicaid (45.6%) and lowest among those who gained private coverage (30.5%). CONCLUSIONS This study emphasizes the high prevalence of pre-existing conditions among CHC patients and the large increase in the proportion of patients with at least 1 of these diagnoses post-ACA. Given how common these conditions are, repealing pre-existing condition protections could be extremely harmful to millions of patients and would likely exacerbate health care and health disparities.
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Affiliation(s)
- Nathalie Huguet
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM).
| | - Heather Angier
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Megan J Hoopes
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Miguel Marino
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - John Heintzman
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Teresa Schmidt
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
| | - Jennifer E DeVoe
- From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (NH, HA, MM, JH, JED); OCHIN Inc., Portland, OR (MJH, TS); Biostatistics Group, Oregon Health and Science University-Portland State University School of Public Health, Portland, OR (MM)
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Jarman MP, Pollack Porter K, Curriero FC, Castillo RC. Factors mediating demographic determinants of injury mortality. Ann Epidemiol 2019; 34:58-64.e2. [PMID: 31053454 DOI: 10.1016/j.annepidem.2019.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/20/2019] [Accepted: 03/24/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Elevated injury mortality rates persist for men and people of color despite attempts to standardize trauma care in the United States. This study investigates the role of injury characteristics and access to trauma care as mediators of the relationships between race, ethnicity, sex, and injury mortality. METHODS Data on prehospital and trauma center care were examined for adult injured patients in Maryland who were transported by emergency medical services to designated trauma centers (n = 15,355) or who died while under emergency medical services care (n = 727). Potential mediators of the relationship between demographic characteristics and injury mortality were identified through exploratory analyses. Total, direct, and indirect effects of race, ethnicity, and sex were estimated using multivariable mediation models. RESULTS Prehospital time, hospital distance, injury mechanism, and insurance status mediated the effect of African American race, resulting in a 5.7% total increase (95% CI: 1.6%, 9.9%) and 5.6% direct decrease (95% CI: 1.1%, 9.9%) in odds of death. Mechanism, insurance, and distance mediated the effect of Hispanic ethnicity, resulting in an 11.4% total decrease (95% CI: 6.4%, 16.2%) and 13.4% direct decrease (95% CI: 8.1%, 18.3%) in odds of death. Injury severity, mechanism, insurance, and time mediated the effect of male sex, resulting in a 27.3% total increase (95% CI: 21.6%, 10.9%) and a 6.2% direct increase (95% CI: 1.8%, 10.9%) in odds of death. CONCLUSIONS Distance, injury characteristics, and insurance mediate the effects of demographic characteristics on injury mortality and appear to contribute to disparities in injury mortality.
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Affiliation(s)
- Molly P Jarman
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
| | - Keshia Pollack Porter
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
| | - Frank C Curriero
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
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16
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Pandit V, Jehan F, Zeeshan M, Koblinski JE, Martinez C, Khan M, Mogor OP, Nfonsam V. Failure to Rescue in Postoperative Patients With Colon Cancer: Time to Rethink Where You Get Surgery. J Surg Res 2019; 234:1-6. [DOI: 10.1016/j.jss.2018.08.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/06/2018] [Accepted: 08/24/2018] [Indexed: 12/21/2022]
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17
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Sossenheimer PH, Andersen MJ, Clermont MH, Hoppenot CV, Palma AA, Rogers SO. Structural Violence and Trauma Outcomes: An Ethical Framework for Practical Solutions. J Am Coll Surg 2018; 227:537-542. [PMID: 30149067 DOI: 10.1016/j.jamcollsurg.2018.08.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/31/2018] [Accepted: 08/10/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Philip H Sossenheimer
- The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, IL
| | - Michael J Andersen
- The University of Chicago Pritzker School of Medicine, The University of Chicago Medicine, Chicago, IL
| | - Max H Clermont
- Section for Trauma and Acute Care Surgery, The University of Chicago Medicine, Chicago, IL
| | - Claire V Hoppenot
- MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, Chicago, IL
| | - Alejandro A Palma
- Section of Emergency Medicine, The University of Chicago Medicine, Chicago, IL
| | - Selwyn O Rogers
- Section for Trauma and Acute Care Surgery, The University of Chicago Medicine, Chicago, IL.
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Akande M, Minneci PC, Deans KJ, Xiang H, Cooper JN. Association of Medicaid Expansion Under the Affordable Care Act With Outcomes and Access to Rehabilitation in Young Adult Trauma Patients. JAMA Surg 2018; 153:e181630. [PMID: 29874372 DOI: 10.1001/jamasurg.2018.1630] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Trauma is the leading cause of death and disability among young adults in the United States. Young adults are also the age group most likely to be uninsured. Implementation of Medicaid expansion through the Affordable Care Act (ACA) has increased insurance coverage, but its associations with trauma care and outcomes among young adults nationwide remain unknown. We examined whether Medicaid expansion, in its first year, was associated with changes in insurance coverage and improved outcomes in young adults hospitalized for traumatic injury. Objective To assess the associations of ACA Medicaid expansion with insurance coverage, in-hospital mortality, failure to rescue, access to rehabilitation, and unplanned readmissions among hospitalized young adult trauma patients across many US states. Design, Setting, and Participants We used the Healthcare Cost and Utilization Project State Inpatient Databases to examine changes in insurance coverage and risk adjusted outcomes among young adults (age 19 to 44 years) who were hospitalized for injuries before and after Medicaid expansion and open enrollment occurred (2012-2013 vs 2014) in 11 US states that expanded Medicaid through the ACA. We also performed difference-in-difference analyses to compare these changes between 3 expansion states and 3 non-expansion states within the same geographic region. Results Of the 141 187 trauma patients hospitalized across 11 Medicaid expansion states, 43 871 (31.1%) were women, and the mean (SD) age was 31.4 (7.6) years. Medicaid expansion was associated with an increase in Medicaid coverage from 16 229 individuals (16.7%) to 15 358 individuals (34.9%) (difference: 18.2% [95% CI, 16.5%-20.0%]; P < .001), a decrease in lack of insurance from 27 016 individuals (27.8%) to 5589 individuals (12.7%) (difference: -15.1% [95% CI, -16.8% to -13.5%]; P < .001), and an increase in discharge to rehabilitation from 9220 individuals (11.4%) to 4736 individuals (12.6%) (difference: 1.16% [95% CI, 0.55%-1.77%]; P < .001). We found no significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions. Similar results were found when 3 of these states were compared with 3 geographically and demographically similar states that had not enacted Medicaid expansion. Conclusions and Relevance The first year of implementation of Medicaid expansion and open enrollment across 11 selected US states was associated with significant increases in Medicaid coverage, reductions in uninsured rates, and increased access to postdischarge rehabilitation among young adults hospitalized for injury. However, this study found no significant reductions in in-hospital mortality, failure to rescue, or unplanned readmissions.
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Affiliation(s)
- Manzilat Akande
- Department of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Peter C Minneci
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Katherine J Deans
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research and Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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Berg GM, Searight M, Sorell R, Lee FA, Hervey AM, Harrison P. Payer Source Associated with Disparities in Procedural, but Not Surgical, Care in a Trauma Population. Am Surg 2018. [DOI: 10.1177/000313481808400856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trauma centers are legally bound by Emergency Medical Treatment and Active Labor Act to provide equal treatment to trauma patients, regardless of payer source. However, evidence has suggested that disparities in trauma care exist. This study investigated the relationships between payer source and procedures (total, diagnostic, and surgical) and the number of medical consults in an adult trauma population. This is a 10-year retrospective trauma registry study at a Level I trauma facility. Payer source of adult trauma patients was identified, demographics and variables associated with trauma outcomes were abstracted, and multivariate logistic regression tests were used to determine statistical differences in the number of procedures and medical consults. Of the 12,870 records analyzed, 69.1 per cent of patients were commercially insured, 21.2 per cent were uninsured, and 9.6 per cent had Medicaid. After controlling for patient- and injury-related variables, the commercially insured received more total procedures (4.30) than the uninsured (3.35) or those with Medicaid (3.34), and more diagnostic (2.59) procedures than the uninsured (2.03) or those with Medicaid (2.04). There was not a difference in the number of surgical procedures or medical consults among payer sources. This study noted that disparities (measured by the number of procedures received) compared by payer source existed in the care of trauma patients. However, for medical consults and definitive care (measured by surgical procedures), disparities were not observed. Future research should focus on secondary factors that influence levels of care such as patient-level factors (health literacy) and trauma program policies.
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Affiliation(s)
- Gina M. Berg
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
- Department of Trauma Services, Wesley Healthcare, Wichita, Kansas
| | - Maggie Searight
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Ryan Sorell
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Felecia A. Lee
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Ashley M. Hervey
- Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Paul Harrison
- Department of Trauma Services, Wesley Healthcare, Wichita, Kansas
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Ioannides KL, Baehr A, Karp DN, Wiebe DJ, Carr BG, Holena DN, Delgado MK. Measuring Emergency Care Survival: The Implications of Risk Adjusting for Race and Poverty. Acad Emerg Med 2018; 25:856-869. [PMID: 29851207 PMCID: PMC6274627 DOI: 10.1111/acem.13485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/30/2018] [Accepted: 05/25/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care-sensitive conditions mortality that could be used for hospital pay-for-performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients. METHODS We performed a cross-sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST-elevation myocardial infarction. We used multivariable logistic regression models to predict in-hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non-Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient-level covariates. We then ranked each hospital on observed-to-expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models. RESULTS The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19-1.36) and poor patients (aOR = 1.21, 95% CI = 1.12-1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C-statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest-performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest-performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001). CONCLUSIONS Sociodemographic risk adjustment of emergency care-sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay-for-performance programs.
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Affiliation(s)
- Kimon L.H. Ioannides
- Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Avi Baehr
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO
| | - David N. Karp
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Brendan G. Carr
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Daniel N. Holena
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M. Kit Delgado
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA
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Effects of Medicaid expansion on disparities in trauma care and outcomes in young adults. J Surg Res 2018; 228:42-53. [PMID: 29907229 DOI: 10.1016/j.jss.2018.02.058] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/08/2018] [Accepted: 02/27/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Racial/ethnic and socioeconomic disparities in trauma care and outcomes among young adults are well documented. As the Patient Protection and Affordable Care Act Medicaid expansion has increased insurance coverage among young adults, we aimed to investigate its impact on disparities in insurance coverage and outcomes among hospitalized young adult trauma patients. MATERIALS AND METHODS We used the healthcare cost and utilization project state inpatient databases to examine changes in insurance coverage and risk-adjusted outcomes from before (2012-2013) to after (2014) Medicaid expansion among young adults (age 19-44) hospitalized for injury across 11 Medicaid expansion states. Changes were compared across racial/ethnic and community-level income groups. We also compared changes in disparities between three expansion and three nonexpansion states in the US south. RESULTS In the first year of Medicaid expansion, non-Hispanic black trauma patients experienced a large decrease in uninsurance (34.3%-14.2%, P < 0.01), reducing the disparity in uninsurance between non-Hispanic black and non-Hispanic white patients (P < 0.05). There were no differences across racial/ethnic groups in changes in in-hospital mortality, failure to rescue, discharge to rehabilitation, or 30-d unplanned readmissions. Socioeconomic disparities in discharge to rehabilitation decreased (1.63% versus 0.06% increase among patients from the lowest and highest income communities, P < 0.05). In contrast, in the selected southern states, Medicaid expansion was associated with the introduction of a disparity in discharge to inpatient rehabilitation between Hispanics and non-Hispanic whites. CONCLUSIONS Medicaid expansion, in its first year, decreased racial and socioeconomic disparities in uninsurance and socioeconomic disparities in access to rehabilitation.
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Weygandt PL, Dresden SM, Powell ES, Feinglass J. Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois. West J Emerg Med 2018; 19:301-310. [PMID: 29560058 PMCID: PMC5851503 DOI: 10.5811/westjem.2017.10.34949] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/15/2017] [Accepted: 10/13/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois. Methods We performed a retrospective cohort study of 87,001 trauma inpatients from third quarter 2010 through second quarter 2015, which spans the implementation of the ACA in Illinois. We examined the effects of insurance expansion on trauma mortality using multivariable Poisson regression. Results There was no significant difference in mortality comparing the post-ACA period to the pre-ACA period incident rate ratio (IRR)=1.05 (95% confidence interval [CI] [0.93–1.17]). However, mortality was significantly higher among the uninsured in the post-ACA period when compared with the pre-ACA uninsured population IRR=1.46 (95% CI [1.14–1.88]). Conclusion While the ACA has reduced the number of uninsured trauma patients in Illinois, we found no significant decrease in inpatient trauma mortality. However, the group that remains uninsured after ACA implementation appears to be particularly vulnerable. This group should be studied in order to reduce disparate outcomes after trauma.
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Affiliation(s)
- Paul L Weygandt
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Scott M Dresden
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Emilie S Powell
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Joe Feinglass
- Northwestern University Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, Illinois
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Equal Access Is Quality: an Update on the State of Disparities Research in Trauma. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0114-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Holzmacher JL, Townsend K, Seavey C, Gannon S, Schroeder M, Gondek S, Collins L, Amdur RL, Sarani B. Association of Expanded Medicaid Coverage With Hospital Length of Stay After Injury. JAMA Surg 2017; 152:960-966. [PMID: 28658482 DOI: 10.1001/jamasurg.2017.1720] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance The expansion of Medicaid eligibility under the Affordable Care Act is a state-level decision that affects how patients with traumatic injury (trauma patients) interact with locoregional health care systems. Washington, DC; Maryland; and Virginia represent 3 unique payer systems with liberal, moderate, and no Medicaid expansion, respectively, under the Affordable Care Act. Characterizing the association of Medicaid expansion with hospitalization after injury is vital in the disposition planning for these patients. Objective To determine the association between expanded Medicaid eligibility under the Affordable Care Act and duration of hospitalization after injury. Design, Setting, and Participants This retrospective cohort study included patients admitted from Virginia, Maryland, and Washington, DC, to a single level I trauma center. Data were collected from January 1, 2013, through March 6, 2016, in Virginia and Washington, DC, and from May 1, 2013, through March 6, 2016, in Maryland. All patients with Medicare or Medicaid coverage and all uninsured patients were included. Patients with private insurance, patients with severe head or pelvic injuries, and those who died during hospitalization were excluded. Main Outcomes and Measures Hospital length of stay (LOS) and whether its association with patient insurance status varied by state of residence. Results A total of 2314 patients (1541 men [66.6%] and 773 women [33.4%]; mean [SD] age, 52.9 [22.8] years) were enrolled in the study. The uninsured rate in the Washington, DC, cohort (190 of 1699 [11.2%]) was significantly lower compared with rates in the Virginia (141 of 296 [47.6%]) or the Maryland (106 of 319 [33.2%]) cohort (P < .001). On multivariate regression controlling for injury severity and demographic variables, the difference in LOS for Medicaid vs non-Medicaid recipients varied significantly by state. For Medicaid recipients, mean LOS in Washington, DC, was significantly shorter (2.57 days; 95% CI, 2.36-2.79 days) than in Maryland (3.51 days; 95% CI, 2.81-4.38 days; P = .02) or Virginia (3.9 days; 95% CI, 2.79-5.45 days; P = .05). Conclusions and Relevance Expanded Medicaid eligibility is associated with shorter hospital LOS in mildly injured Medicaid recipients.
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Affiliation(s)
- Jeremy L Holzmacher
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Kerry Townsend
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Caleb Seavey
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Stephanie Gannon
- Department of Social Work, George Washington University Hospital, Washington, DC
| | - Mary Schroeder
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Stephen Gondek
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Lois Collins
- Department of Nursing, George Washington University Hospital, Washington, DC
| | - Richard L Amdur
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
| | - Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC
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Bukur M, Simon J, Catino J, Crawford M, Puente I, Habib F. The G60 Trauma Center: A Future Consideration? Am Surg 2017. [DOI: 10.1177/000313481708300617] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
With a considerably increasing elderly population, we sought to determine whether the volume of elderly trauma patients treated impacted outcomes at two different Level I trauma centers. This is a retrospective review of all elderly patients (>60 years) at two state-verified Level I trauma centers over the past five years. The elderly trauma center (ETC) saw a greater proportion (52%) of elderly patients than the reference trauma center (30%, TC). Demographic and clinical characteristics were abstracted and stratified into ETC and TC groups for comparison. Primary outcomes were overall postinjury complication and mortality rates, as well as death after major complication (failure to rescue). ETC patients were older (78.6 vs 70.5), more likely to be admitted with severe head injuries (head abbreviated injury score ≥ 3, 50.0% vs 32%), had a greater overall injury burden (injury severity score > 16 41.4% vs 21.1%), and required intensive care unit admission (81.3% vs 64%) than the TC group. Need for operative intervention, mechanism of injury, and comorbidities were similar between the two groups. Overall complications were higher in trauma patients admitted to the TC (21.9% vs 14.3%), as well as failure to rescue (4.0% vs 1.8%). Adjusting for confounding factors, ETC had significantly lower chance of developing a postinjury complication (adjusted odds ratios [AOR] = 0.4, 95% confidence interval [CI] = [0.3, 0.5]), failure to rescue (AOR = 0.3, 95% CI = [0.1, 0.5]), and overall mortality (AOR = 0.3, 95% CI = [0.2, 0.4]). Improved outcomes were demonstrated in the Level I center treating a higher proportion of elderly patients. Exact etiology of these benefits should be determined for quality improvement in care of the injured geriatric patient.
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Affiliation(s)
- Marko Bukur
- Division of Trauma and Surgical Critical Care, Delray Medical Center, Delray Beach, Florida
- Division of Trauma and Surgical Critical Care, Broward General Medical Center, Fort Lauderdale, Florida
- Herbert Wertheim College of Medicine, Florida International University, University Park, Florida
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Joshua Simon
- Department of Surgery, Larkin Community Hospital, South Miami, Florida
| | - Joseph Catino
- Division of Trauma and Surgical Critical Care, Delray Medical Center, Delray Beach, Florida
- Division of Trauma and Surgical Critical Care, Broward General Medical Center, Fort Lauderdale, Florida
| | - Margaret Crawford
- Division of Trauma and Surgical Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Ivan Puente
- Division of Trauma and Surgical Critical Care, Delray Medical Center, Delray Beach, Florida
- Division of Trauma and Surgical Critical Care, Broward General Medical Center, Fort Lauderdale, Florida
- Herbert Wertheim College of Medicine, Florida International University, University Park, Florida
- Charles E Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Fahim Habib
- Division of Trauma and Surgical Critical Care, Broward General Medical Center, Fort Lauderdale, Florida
- Herbert Wertheim College of Medicine, Florida International University, University Park, Florida
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Sawhney JS, Stephen AH, Nunez H, Lueckel SN, Kheirbek T, Adams CA, Cioffi WG, Heffernan DS. Impact of Type of Health Insurance on Infection Rates among Young Trauma Patients. Surg Infect (Larchmt) 2016; 17:541-6. [DOI: 10.1089/sur.2015.210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Jaswin S. Sawhney
- Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andrew H. Stephen
- Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Hector Nunez
- Rhode Island Hospital/Lifespan, Providence, Rhode Island
| | - Stephanie N. Lueckel
- Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tareq Kheirbek
- Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Charles A. Adams
- Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - William G. Cioffi
- Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Daithi S. Heffernan
- Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
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Kao MJ, Nunez H, Monaghan SF, Heffernan DS, Adams CA, Lueckel SN, Stephen AH. Trauma patients who present in a delayed fashion: a unique and challenging population. J Surg Res 2016; 208:204-210. [PMID: 27993211 DOI: 10.1016/j.jss.2016.09.037] [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: 04/08/2016] [Revised: 09/13/2016] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND A proportion of trauma patients present for evaluation in a delayed fashion after injury, likely due to a variety of medical and nonmedical reasons. There has been little investigation into the characteristics and outcomes of trauma patients who present delayed. We hypothesize that trauma patients who present in a delayed fashion are a unique population at risk of increased trauma-related complications. MATERIALS AND METHODS This was a retrospective review from 2010-2015 at a Level I trauma center. Patients were termed delayed if they presented >24 hours after injury. Patients admitted within 24 hours of their injury were the comparison group. Charts were reviewed for demographics, mechanism, comorbidities, complications and outcomes. A subgroup analysis was done on patients who suffered falls. RESULTS During the 5-y period, 11,705 patients were admitted. A total of 588 patients (5%) presented >24 h after their injury. Patients in the delayed group were older (65 versus 55 y, P < 0.001) and more likely to have psychiatric comorbidities (33% vs. 24%, P = 0.0001) than the control group. They were also more likely to suffer substance withdrawal (8.9% vs. 4.1%, P < 0.001) but had toxicology testing for drugs and alcohol done at significantly lower rates. Patients that presented delayed after falls were similar in age and injury severity score (ISS) but more likely to suffer substance withdrawal when compared to those with falls that presented within 24 hours. Patients with falls that presented delayed had toxicology testing at significantly lower rates than the comparison group. CONCLUSIONS Trauma patients that present to the hospital in a delayed fashion have unique characteristics and are more likely to suffer negative outcomes including substance withdrawal. Future goals will include exploring strategies for early intervention, such as automatic withdrawal monitoring and social work referral for all patients who present in a delayed fashion.
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Affiliation(s)
- Mary J Kao
- Division of Trauma and Surgical Critical Care, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Hector Nunez
- Division of Trauma and Surgical Critical Care, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Sean F Monaghan
- Division of Trauma and Surgical Critical Care, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Daithi S Heffernan
- Division of Trauma and Surgical Critical Care, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Charles A Adams
- Division of Trauma and Surgical Critical Care, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Stephanie N Lueckel
- Division of Trauma and Surgical Critical Care, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island
| | - Andrew H Stephen
- Division of Trauma and Surgical Critical Care, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island.
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Koleszar JC, Childs BR, Vallier HA. Frequency of Recidivism in Patients With Orthopedic Trauma. Orthopedics 2016; 39:300-6. [PMID: 27359281 DOI: 10.3928/01477447-20160623-05] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 04/20/2016] [Indexed: 02/03/2023]
Abstract
The goals of this study were to determine the frequency of trauma recidivism and to identify risk factors. The authors hypothesized that substance abuse and mental illness would be associated with recidivism. They performed a retrospective review of 879 patients who were treated surgically for high-energy fractures over a period of 4 years. Recidivism was defined as presentation to the trauma center for a new, unrelated injury. A recurrent recidivist was a repeat patient who returned for more than 1 additional injury. The study identified 164 (18.7%) patients who returned with a new injury. Mean age of recidivists was 37.1 years vs 40.7 years for nonrecidivists (P=.025). Of the recidivists, 80% were male, and this group was more likely to be unmarried (76.2% vs 67.2%, P=.044) and unemployed (40.4% vs 19.6%, P<.0001). Recidivists were also more likely to be uninsured (33.5% vs 17.8%, P<.0001) or to have Medicaid coverage (33.5% vs 23.2%, P<.0001). Recidivists were more likely to have used alcohol (47.2% vs 32.0%, P=.0007) or to be intoxicated (32.4% vs 21.2%, P=.005) and to use tobacco (66.2% vs 50.2%, P=.0003) or recreational drugs (59.1% vs 43.2%, P=.0004) at baseline. The rate of documented mental illness was also higher in repeat patients than in nonrepeat patients (28.1% vs 20.0%, P=.03). These findings showed that recidivism is common, occurring overall in 18.7% of the study sample within a mean of 2.9 years. Factors associated with recidivism included age younger than 40 years, unmarried status, substance use, unemployment, and lack of insurance coverage. The greatest independent risk factors for recidivism were Medicaid insurance or no insurance and a history of a gunshot wound or assault. [Orthopedics. 2016; 39(5):300-306.].
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Uninsured status may be more predictive of outcomes among the severely injured than minority race. Injury 2016; 47:197-202. [PMID: 26396045 PMCID: PMC4698055 DOI: 10.1016/j.injury.2015.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 08/04/2015] [Accepted: 09/06/2015] [Indexed: 02/02/2023]
Abstract
AIM Worse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers. METHODS We performed a retrospective analysis of the 2010-2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18-64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care. RESULTS There were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29-1.98, p<0.001) and black race (OR 1.24, 1.04-1.49, p=0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36-0.51, p<0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29-2.19, p<0.001) and decreased post-hospital care (OR 0.45, 0.32-0.63, p<0.001). CONCLUSION Uninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.
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Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example. Med Care 2015; 53:18-24. [PMID: 25373403 DOI: 10.1097/mlr.0000000000000251] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. OBJECTIVES The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. RESEARCH DESIGN This was a retrospective cohort study of a quality improvement intervention. SUBJECTS The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. MEASURES In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. RESULTS Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. CONCLUSIONS Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.
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Does unit designation matter? A dedicated trauma intensive care unit is associated with lower postinjury complication rates and death after major complication. J Trauma Acute Care Surg 2015; 78:920-7; discussion 927-9. [PMID: 25909410 DOI: 10.1097/ta.0000000000000613] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent data suggest that specialty intensive care units (ICUs) have outcomes better than those of mixed ICUs. The cause for this apparent discrepancy has not been well established. We hypothesized that trauma patients admitted to a dedicated trauma ICU (TICU) would have a lower complication rate as well as death after complication (failure to rescue [FTR]). METHODS This was a retrospective review of the ICUs of two Level I trauma centers covered by one group of surgical intensivists. One center has a dedicated TICU, while the other has a mixed ICU. Demographic and clinical characteristics were stratified into TICU and ICU groups. The primary outcomes were postinjury complications and FTR. Multivariate regression was used to derive factors associated with complications and FTR. RESULTS During the 5-year study period, 3,833 patients were analyzed. TICU patients were older (57.8 vs. 47.0 years, p < 0.0001), had higher Charlson score (2 vs. 1, p = 0.001), had more severe head injuries (Head Abbreviated Injury Scale [AIS] score ≥ 3, 50.0% vs. 37.5%, p < 0.0001), and had greater injury burden (Injury Severity Score [ISS] > 16, 49.6% vs. 38.6%, p < 0.0001) than those admitted to the mixed ICU. Need for immediate operative intervention was similar (18.0% vs. 17.6%, p = 0.788). Overall complications were significantly higher in trauma patients admitted to the mixed ICU (27.5% vs. 17.0%, p < 0.0001), as well as FTR (3.7% vs. 1.8%, p < 0.0001). Trauma patients admitted to a dedicated TICU had significantly lower chance of developing a postinjury complication (adjusted odds ratio [AOR], 0.5; p < 0.0001), FTR (AOR, 0.3; p < 0.0001), and overall mortality (AOR, 0.4; p < 0.0001). CONCLUSION Admission of critically ill trauma patients to a TICU staffed by a surgical intensivist is associated with a lower complication rate and FTR. Factors such as trauma nursing experience, education, and unit management structure should be further explored to elucidate the observed improved outcomes. LEVEL OF EVIDENCE Prognostic study, level III.
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Bell TM, Boustany KC, Jenkins PC, Zarzaur BL. The relationship between trauma center volume and in-hospital outcomes. J Surg Res 2015; 196:350-7. [DOI: 10.1016/j.jss.2015.02.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/06/2015] [Accepted: 02/06/2015] [Indexed: 02/06/2023]
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Joseph B, Zangbar B, Khalil M, Kulvatunyou N, Haider AA, O'Keeffe T, Tang A, Vercruysse G, Friese RS, Rhee P. Factors associated with failure-to-rescue in patients undergoing trauma laparotomy. Surgery 2015; 158:393-8. [PMID: 26013985 DOI: 10.1016/j.surg.2015.03.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 03/02/2015] [Accepted: 03/04/2015] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Quality improvement initiatives have focused primarily on preventing in-hospital complications. Patients developing complications are at a greater risk of mortality; however, factors associated with failure-to-rescue (death after major complication) in trauma patients remain undefined. The aim of this study was to identify risk factors associated with failure-to-rescue in patients undergoing trauma laparotomy. METHODS An -8-year, retrospective analysis of patients undergoing trauma laparotomy was performed. Patients who developed major in-hospital complications were included. Major complications were defined as respiratory, infectious, cardiac, renal, or development of compartment syndrome. Regression analysis was performed to identify independent factors associated with failure-to-rescue after we adjusted for demographics, mechanism of injury, abdominal abbreviated injury scale, initial vital signs, damage control laparotomy, and volume of crystalloids and blood products administered. RESULTS A total of 1,029 patients were reviewed, of which 21% (n = 217) patients who developed major complications were included. The mean age was 39 ± 18 years, 82% were male, 61% had blunt trauma, and median abdominal abbreviated injury scale was 25 [16-34, interquartile range]. Respiratory complications (n = 77) followed by infectious complications (n = 75) were the most common complications. The failure-to-rescue rate was 15.7% (n = 34/217). Age, blunt trauma, severe head injury, uninsured status, and blood products administered on the second day were independent predictor for failure-to-rescue. CONCLUSION When major complications develop, age, uninsured status, severity of head injury, and prolonged resuscitation are associated independently with failure-to-rescue, whereas initial resuscitation, coagulopathy, and acidosis did not predict failure to rescue. Quality-of-care programs focus in patient level should be on improving the patient's insurance status, preventing secondary brain injury, and further development of resuscitation guidelines.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ.
| | - Bardiya Zangbar
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Mazhar Khalil
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Narong Kulvatunyou
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Ansab A Haider
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Terence O'Keeffe
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Andrew Tang
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Gary Vercruysse
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Randall S Friese
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
| | - Peter Rhee
- Division of Trauma, Department of Surgery, University of Arizona, Tucson, AZ
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The impact of preexisting comorbidities on failure to rescue outcomes in nonelderly trauma patients. J Trauma Acute Care Surg 2015; 78:312-7. [PMID: 25757116 DOI: 10.1097/ta.0000000000000467] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Death after complication or "failure to rescue" (FTR) contributes to differences in risk-adjusted mortality rates among trauma centers and is considered an indicator of quality of care. Successful management of trauma patients requires not only appropriately responding to complications but also timely recognition of adverse events. Identifying associations between patient characteristics, such as the presence of comorbidities, and FTR outcomes can potentially improve early detection of complications and can reduce the risk of in-hospital mortality. METHODS We performed a retrospective cohort study that analyzed patient records included in the National Trauma Data Bank from years 2008 to 2010. Cox regression modeling was used to determine the contribution of individual comorbidities to FTR outcomes while controlling for confounding variables. RESULTS Diabetes, congestive heart failure, history of myocardial infarction, and dialysis were associated with greater hazard ratios (HRs) (95% confidence interval [CI]) for FTR (1.19 [1.05-1.35], 1.63 [1.30-2.05], 1.40 [1.08-1.81], 2.34 [1.72-3.19], respectively). Smoking, alcoholism, and respiratory disease were associated with a lower risk of FTR (HR [95% CI], 0.68 [0.60-0.77]; 0.88 [0.80-0.98]; and 0.77 [0.66-0.91], respectively). Obesity and hypertension were not associated with increased risk of FTR. CONCLUSION Preexisting comorbidities contributed significantly to risk of death after complication in the trauma population. Identifying processes of care that lead to better management of complications in patients with comorbidities would improve trauma centers' overall mortality outcomes. LEVEL OF EVIDENCE Prognostic study, level IV.
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Zielinski MD. Regarding "worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?". Surgery 2015; 157:830. [PMID: 25617241 DOI: 10.1016/j.surg.2014.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 11/20/2014] [Indexed: 10/24/2022]
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Insurance status is a predictor of failure to rescue in trauma patients at both safety net and non–safety net hospitals. J Trauma Acute Care Surg 2013; 75:728-33. [DOI: 10.1097/ta.0b013e3182a53aaa] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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