Disparities in mortality after blunt injury: does insurance type matter?

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Insurance-Related Disparities in Withdrawal of Life Support and Mortality After Spinal Cord Injury

Importance

Identifying disparities in health outcomes related to modifiable patient factors can improve patient care.

Objective

To compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance.

Design, Setting, and Participants

This retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024.

Exposure

Uninsured or public insurance compared with private insurance.

Main Outcomes and Measures

Coprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients.

Results

The study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses.

Conclusions and Relevance

Health insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.

Association between Medicare eligibility at age 65 years and in-hospital treatment patterns and health outcomes for patients with trauma: regression discontinuity approach

OBJECTIVE

To determine whether health systems in the United States modify treatment or discharge decisions for otherwise similar patients based on health insurance coverage.

DESIGN

Regression discontinuity approach.

SETTING

American College of Surgeons' National Trauma Data Bank, 2007-17.

PARTICIPANTS

Adults aged between 50 and 79 years with a total of 1 586 577 trauma encounters at level I and level II trauma centers in the US.

INTERVENTIONS

Eligibility for Medicare at age 65 years.

MAIN OUTCOME MEASURES

The main outcome measure was change in health insurance coverage, complications, in-hospital mortality, processes of care in the trauma bay, treatment patterns during hospital admission, and discharge locations at age 65 years.

RESULTS

1 586 577 trauma encounters were included. At age 65, a discontinuous increase of 9.6 percentage points (95% confidence interval 9.1 to 10.1) was observed in the share of patients with health insurance coverage through Medicare at age 65 years. Entry to Medicare at age 65 was also associated with a decrease in length of hospital stay for each encounter, of 0.33 days (95% confidence interval -0.42 to -0.24 days), or nearly 5%), which coincided with an increase in discharges to nursing homes (1.56 percentage points, 95% confidence interval 0.94 to 2.16 percentage points) and transfers to other inpatient facilities (0.57 percentage points, 0.33 to 0.80 percentage points), and a large decrease in discharges to home (1.99 percentage points, -2.73 to -1.27 percentage points). Relatively small (or no) changes were observed in treatment patterns during the patients' hospital admission, including no changes in potentially life saving treatments (eg, blood transfusions) or mortality.

CONCLUSIONS

The findings suggest that differences in treatment for otherwise similar patients with trauma with different forms of insurance coverage arose during the discharge planning process, with little evidence that health systems modified treatment decisions based on patients' coverage.

Firearm trauma: Race and insurance influence mortality and discharge disposition

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.

Social determinants of trauma care: Associations of race, insurance status, and place on opioid prescriptions, postdischarge referrals, and mortality

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.

Race and Insurance Status are Associated With Different Management Strategies After Thoracic Trauma

INTRODUCTION

Health-care disparities based on race and socioeconomic status among trauma patients are well-documented. However, the influence of these factors on the management of rib fractures following thoracic trauma is unknown. The aim of this study is to describe the association of race and insurance status on management and outcomes in patients who sustain rib fractures.

METHODS

The Trauma Quality Improvement Program database was used to identify adult patients who presented with rib fractures between 2015 and 2016. Patient demographics, injury severity, procedures performed, and outcomes were evaluated. Multivariate logistic regression analysis was used to determine the effect of race and insurance status on mortality and the likelihood of rib fixation surgery and epidural analgesia for pain management.

RESULTS

A total of 95,227 patients were identified. Of these, 2923 (3.1%) underwent rib fixation. Compared to White patients, Asians (AOR: 0.57, P = 0.001), Blacks or African-Americans (AA) (AOR: 0.70, P < 0.001), and Hispanics/Latinos (HL) (AOR: 0.78, P < 0.001) were less likely to undergo rib fixation surgery. AA patients (AOR: 0.67, P = 0.004), other non-Whites (ONW) (AOR: 0.61, P = 0.001), and HL (AOR 0.65, P = 0.006) were less likely to receive epidural analgesia. Compared to privately insured patients, mortality was higher in uninsured patients (AOR: 1.72, P < 0.001), Medicare patients (AOR: 1.80, P < 0.001), and patients with other non-private insurance (AOR: 1.23, P < 0.001).

CONCLUSIONS

Non-White race is associated with a decreased likelihood of rib fixation and/or epidural placement, while underinsurance is associated with higher mortality in patients with thoracic trauma. Prospective efforts to examine the socioeconomic disparities within this population are warranted.

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

OBJECTIVE

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

DESIGN

Retrospective cohort study.

SETTING

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

PATIENTS

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

EXPOSURE

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Health care disparity exists among those undergoing emergent hernia repairs in New York State

INTRODUCTION

Socioeconomic factors predispose certain populations to an increased exposure to emergent operative procedures. The aim of this study is to evaluate the role socioeconomic factors play in emergent repairs of inguinal, ventral and umbilical hernias.

METHODS

The SPARCS database was used to identify all patients undergoing emergent ventral hernia repair (EVR), emergent inguinal hernia repair (EIR), and emergent umbilical hernia repair (EUR) between 2008 and 2015. Chi-square test with exact p values from Monte Carlo simulation determined marginal associations between repairs (elective vs. emergent), and patient characteristics and comorbidities. Multivariable logistic regression models were further utilized to examine socioeconomic disparity.

RESULTS

107,887 ventral hernias, 66,947 inguinal hernias, and 63,515 umbilical hernias (total 238,349) were noted. African Americans were most likely to undergo an EVR compared to Caucasians (OR 1.55, 95% CI: 1.48-1.61), Asians (OR 1.31, 95% CI: 1.15-1.5), and Hispanics (OR 1.3, 95% CI: 1.23-1.37). African Americans were most likely to undergo EIR compared to Caucasians (OR 2.2, 95% CI: 2.06-2.36), Asians (OR 1.74, 95% CI: 1.49-2.02), and Hispanics (OR 1.22, 95% CI: 1.12-1.34). African Americans were most likely to undergo EUR compared to whites (OR 1.29, 95% CI: 1.22-1.36), Asians (26.62%, OR 1.21, 95% CI: 1.01-1.46) and Hispanic (28.03%, OR 1.08, 95% CI: 1.01-1.16). Medicaid patients were also more likely to undergo EVR (OR 1.31, OR 1.73), EIR (OR 2.92, OR 4.55) and EUR (OR 1.63, OR 2.31) compared to Medicare and commercial insurance.

CONCLUSION

Race is a contributing factor in who undergoes an emergent hernia repair in New York State. A significantly larger proportion of the African American population is undergoing hernia repair in the emergent setting. Socioeconomic status, as indicated by the significant number of Medicaid patients undergoing emergent hernia repairs, also plays a role.

Racial Disparities in Adult Blunt Trauma Patients With Acute Respiratory Distress Syndrome

OBJECTIVE

Study incidence and mortality for blunt trauma patients developing acute respiratory distress syndrome (ARDS) across race and insurance.

DESIGN

The National Trauma Data Bank (2007-2015) was queried for blunt trauma patients age >16. Covariates (age >65, injury severity score [ISS] >25, traumatic brain injury, lung injury, pneumonia, severe sepsis, hypotension on admission, and blood transfusion) were included in a multivariable logistic regression analysis.

SETTING

Despite progress in the treatment for ARDS, it remains a significant concern. Racial differences in response to trauma and ARDS have been inconsistently demonstrated. Since these prior studies, ARDS has been redefined by the Berlin Criteria, advances in care have been made, and health-care accessibility has changed.

PATIENTS

Adult blunt trauma patients with ISS > 15 and length of stay ≥ 3 days to examine patients at high risk of ARDS.

MEASUREMENTS AND MAIN RESULTS

There were 28 727 patients with ARDS. Most were white (76.2%), followed by blacks (11.5%), Hispanics (11.3%), and Asians (1.8%). Overall mortality was 20.5%. Compared to whites, blacks (odds ratio [OR]: 1.15, confidence interval [CI]: 1.10-1.20, P < .001) had higher risk of ARDS, being Hispanic was protective (OR: 0.80, CI: 0.76-0.83, P < .001). Asians with ARDS were at greater risk of death (OR: 1.31, CI: 1.07-1.61, P < .05) while being black was not associated with risk of death. Patients with private insurance had less diagnosed ARDS and those with ARDS had lower mortality than other insurances (OR: 0.86, CI: 0.79-0.92, P < .001).

CONCLUSIONS

Data from the National Trauma Data Bank (2007-2015) demonstrates racial and insurance disparities in the development of ARDS in blunt trauma patients. When compared to whites, blacks are at higher risk of developing ARDS while being Hispanic is protective. Likewise, Asians are at greatest risk of death and blacks have no difference in mortality when compared to whites. Patients with private insurance have lower risk of incidence and mortality.

Race and Ethnicity, Medical Insurance, and Within-Hospital Severe Maternal Morbidity Disparities

OBJECTIVE

To examine within-hospital racial and ethnic disparities in severe maternal morbidity rates and determine whether they are associated with differences in types of medical insurance.

METHODS

We conducted a population-based, cross-sectional study using linked 2010-2014 New York City discharge and birth certificate data sets (N=591,455 deliveries) to examine within-hospital black-white, Latina-white, and Medicaid-commercially insured differences in severe maternal morbidity. We used logistic regression to produce risk-adjusted rates of severe maternal morbidity for patients with commercial and Medicaid insurance and for black, Latina, and white patients within each hospital. We compared these within-hospital adjusted rates using paired t-tests and conditional logit models.

RESULTS

Severe maternal morbidity was higher among black and Latina women than white women (4.2% and 2.9% vs 1.5%, respectively, P<.001) and among women insured by Medicaid than those commercially insured (2.8% vs 2.0%, P<.001). Women insured by Medicaid compared with those with commercial insurance had similar risk for severe maternal morbidity within the same hospital (P=.54). In contrast, black women compared with white women had significantly higher risk for severe maternal morbidity within the same hospital (P<.001), as did Latina women (P<.001). Conditional logit analyses confirmed these findings, with black and Latina women compared with white women having higher risk for severe maternal morbidity (adjusted odds ratio [aOR] 1.52; 95% CI 1.46-1.62 and aOR 1.44; 95% CI 1.36-1.53, respectively) and women insured by Medicaid compared with those commercially insured having similar risk.

CONCLUSION

Within hospitals in New York City, black and Latina women are at higher risk of severe maternal morbidity than white women; this is not associated with differences in types of insurance.

Socioeconomic Status Affects Outcomes After Severity-Stratified Traumatic Brain Injury

BACKGROUND

Socioeconomic status (SES) and race have been shown to increase the incidence of being afflicted by a traumatic brain injury (TBI) resulting in worse posthospitalization outcomes. The goal of this study was to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed stratified by severity of TBI.

METHODS

This was a retrospective cohort study of patients with closed head injuries using the National Trauma Data Bank (2012-2015). Multivariate logistic/linear regression models were created to determine the impact of race and insurance status in groups graded by head Abbreviated Injury Scale (AIS).

RESULTS

We analyzed 131,461 TBI patients from NTDB. Uninsured patients experienced greater mortality at an AIS of 5 (odds ratio [OR] = 1.052, P = 0.001). Uninsured patients had a decreased likelihood of being discharged to inpatient rehabilitation with an increasing AIS beginning from an AIS of 2 (OR = 0.987, P = 0.008) to an AIS of 5 (OR = 0.879, P < 0.001). Black patients had an increased LOS as their AIS increased from an AIS of 2 (0.153 d, P < 0.001) to 5 (0.984 d, P < 0.001) with the largest discrepancy in LOS occurring at an AIS of 5.

CONCLUSIONS

Disparities in race and SES are associated with differences in mortality, LOS, and discharge to inpatient rehabilitation. Patients with more severe TBI have the greatest divergence in treatment and outcome when stratified by race and ethnicity as well as SES.

Payer Source Associated with Disparities in Procedural, but Not Surgical, Care in a Trauma Population

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.

The influence of payor status on outcomes associated with surgical repair of upper gastrointestinal perforations due to peptic ulcer disease in the United States

BACKGROUND

An association between lack of insurance and inferior outcomes has been well described for a number of surgical emergencies, yet little is known about the relationship of payor status and outcomes of patients undergoing emergent surgical repair for upper gastrointestinal (UGI) perforations. We evaluated the association of payor status and in-hospital mortality for patients undergoing emergency surgery for UGI perforations in the United States.

METHODS

Nationwide Inpatient Sample (NIS) was queried to identify patients between 18 and 64 years of age who underwent emergent (open or laparoscopic) repair for UGI perforations secondary to peptic ulcer disease (2010-2014). Primary outcome was in-hospital mortality. Secondary outcomes were major and minor postoperative complications. The main predictor outcome was insurance status (Private, Medicaid, Uninsured). Univariate and multivariable regression analyses were performed. Data were weighted to provide national estimates.

RESULTS

21,005 patients underwent surgical repair for UGI perforations. Patients with private insurance represented the largest payor group (47%). After adjustment of other factors, payor status was not a statistically significant predictor of in-hospital mortality (Medicaid vs. Private: [OR] 1.1; 95% [CI] 0.67-1.81; Uninsured vs. Private: OR 0.9, 95% CI 0.52-1.61). However, payor status remained a statistically significant predictor of major postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.8; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.5) and minor postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.9; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.6).

CONCLUSIONS

Emergency surgery for UGI perforations is associated with high mortality and morbidity across all payor classes; however, Medicaid is a predictor for both major and minor postoperative complications. Preventing perforation through preventative measures will be key to reducing the burden of peptic ulcer disease across all populations.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois

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.

Barriers to Hospice Care in Trauma Patients: The Disparities in End-of-Life Care

INTRODUCTION

End-of-life and palliative care are important aspects of trauma care and are not well defined. This analysis evaluates the racial and socioeconomic disparities in terms of utilization of hospice services for critically ill trauma patients.

METHODS

Trauma patients ≥15 years old from 2012 to 2015 were queried from the National Trauma Databank. Chi-square and multivariate logistic regression analyses for disposition to hospice were performed after controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was calculated for all patients discharged to hospice.

RESULTS

Chi-square analysis of 2 966 444 patient's transition to hospice found patients with cardiac disease, bleeding and psychiatric disorders, chemotherapy, cancer, diabetes, cirrhosis, respiratory disease, renal failure, cirrhosis, and cerebrovascular accident (CVA) affected transfer ( P < .0001). Logistic regression analysis after controlling for covariates showed uninsured patients were discharged to hospice significantly less than insured patients (odds ratio [OR]: 0.71; P < .0001). Asian, African American, and Hispanic patients all received less hospice care than Caucasian patients (OR: 0.65, 0.60, 0.73; P < .0001). Negative binomial regression analysis with margins for LOS showed Medicare patients were transferred to hospice 1.2 days sooner than insured patients while uninsured patients remained in the hospital 1.6 days longer ( P < .001). When compare to Caucasians, African Americans patients stayed 3.7 days longer in the hospital and Hispanics 2.4 days longer prior to transfer to hospice ( P < .0001). In all patients with polytrauma, African Americans stayed 4.9 days longer and Hispanics 2.3 days longer as compared to Caucasians ( P < .0001).

CONCLUSIONS

Race and ethnicity are independent predictors of a trauma patient's transition to hospice care and significantly affect LOS. Our data demonstrate prominent racial and socioeconomic disparities exist, with uninsured and minority patients being less likely to receive hospice services and having a delay in transition to hospice care when compared to their insured Caucasian counterparts.

Socioeconomic disparities in the thoracic trauma population

BACKGROUND

Health-care disparities based on socioeconomic status have been well documented in the trauma literature; however, there is a paucity of data on how these factors affect outcomes in patients experiencing severe thoracic trauma. This study aims to identify the effect of insurance status and race on patient mortality and disposition after thoracic trauma.

METHODS

The National Trauma Data Bank was queried from 2007 to 2012 for patients with sternal fractures, rib fractures, and flailed chest. Demographics data were examined for the cohort based on insurance status. Univariate and multivariate logistic regression models were used, controlling for patient comorbidities, age, injury severity score, and associated injuries, to determine the impact of race and insurance status on length of stay, mortality, and discharge disposition.

RESULTS

A total of 152,655 thoracic traumas were included in our analysis. As compared to privately insured patients, uninsured patients with thoracic trauma were 1.9 times more likely to die (odds ratio [OR]: 1.91, confidence interval [CI]: 1.76-2.09) and 4.6 times more likely to leave against medical advice (OR: 4.61, CI: 3.14-6.79). When compared to Caucasians, Hispanics had slightly higher in-hospital mortality (OR: 1.14, CI: 1.02-1.27), but there was no survival difference seen in black patients (OR: 0.95, CI: 0.86-1.05).

CONCLUSIONS

Insurance status appears to have a more significant effect on thoracic trauma patient outcomes than race, but substantial socioeconomic disparities were seen in this patient population. Further studies are needed to show reproducibility of our findings and to investigate the impact of universal health care and expansion of insurance availability on thoracic trauma outcomes.

LEVEL OF EVIDENCE

Level 3, economic/decision.

Variation in type and frequency of diagnostic imaging during trauma care across multiple time points by patient insurance type

BACKGROUND

Research has shown that uninsured patients receive fewer radiographic studies during trauma care, but less is known as to whether differences in care are present among other insurance groups or across different time points during hospitalization. Our objective was to examine the number of radiographic studies administered to a cohort of trauma patients over the entire hospital stay as well as during the first 24-hours of care.

METHODS

Patient data were obtained from an American College of Surgeons (ACS) verified Level I Trauma Center between January 1, 2011 and December 31, 2012. We used negative binomial regression to construct relative risk (RR) ratios for type and frequency of radiographic imaging received among persons with Medicare, Medicaid, no insurance, or government insurance plans in reference to those with commercial indemnity plans. The analysis was adjusted for patient age, sex, race/ethnicity, injury severity score, injury mechanism, comorbidities, complications, hospital length of stay, and Intensive Care Unit (ICU) admission.

RESULTS

A total of 3621 records from surviving patients age > =18 years were assessed. After adjustment for potential confounders, the expected number of radiographic studies decreased by 15 % among Medicare recipients (RR 0.85, 95 % CI 0.78-0.93), 11 % among Medicaid recipients (0.89, 0.81-0.99), 10 % among the uninsured (0.90, 0.85-0.96) and 19 % among government insurance groups (0.81, 0.72-0.90), compared with the reference group. This disparity was observed during the first 24-hours of care among patients with Medicare (0.78, 0.71-0.86) and government insurance plans (0.83, 0.74-0.94). Overall, there were no differences in the number of radiographic studies among the uninsured or among Medicaid patients during the first 24-hours of care compared with the reference group, but differences were observed among the uninsured in a sub-analysis of severely injured patients (ISS > 15).

CONCLUSIONS

Both uninsured and insured patients treated at a not-for-profit verified Level I Trauma Center receive fewer radiographic studies than patients with commercial indemnity plans, even after adjusting for clinical and demographic confounders. There is less disparity in care during the first 24-hours, which suggests that patient pathology is the determining factor for radiographic evaluation during the acute care phase. Results from this study offer initial evidence of disparity in diagnostic imaging across multiple insurance groups over different periods of trauma care.

Industrial Injury Hospitalizations Billed to Payers Other Than Workers' Compensation: Characteristics and Trends by State

OBJECTIVE

To describe characteristics of industrial injury hospitalizations, and to test the hypothesis that industrial injuries were increasingly billed to non-workers' compensation (WC) payers over time.

DATA SOURCES

Hospitalization data for 1998-2009 from State Inpatient Databases, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality.

STUDY DESIGN

Retrospective secondary analyses described the distribution of payer, age, gender, race/ethnicity, and injury severity for injuries identified using industrial place of occurrence codes. Logistic regression models estimated trends in expected payer.

PRINCIPAL FINDINGS

There was a significant increase over time in the odds of an industrial injury not being billed to WC in California and Colorado, but a significant decrease in New York. These states had markedly different WC policy histories. Industrial injuries among older workers were more often billed to a non-WC payer, primarily Medicare.

CONCLUSIONS

Findings suggest potentially dramatic cost shifting from WC to Medicare. This study adds to limited, but mounting evidence that, in at least some states, the burden on non-WC payers to cover health care for industrial injuries is growing, even while WC-related employer costs are decreasing-an area that warrants further research.

Disparity in reimbursement for tuberculosis care among different health insurance schemes: evidence from three counties in central China

Background

Health inequity is an important issue all around the world. The Chinese basic medical security system comprises three major insurance schemes, namely the Urban Employee Basic Medical Insurance (UEBMI), the Urban Resident Basic Medical Insurance (URBMI), and the New Cooperative Medical Scheme (NCMS). Little research has been conducted to look into the disparity in payments among the health insurance schemes in China. In this study, we aimed to evaluate the disparity in reimbursements for tuberculosis (TB) care among the abovementioned health insurance schemes.

Methods

This study uses a World Health Organization (WHO) framework to analyze the disparities and equity relating to the three dimensions of health insurance: population coverage, the range of services covered, and the extent to which costs are covered. Each of the health insurance scheme’s policies were categorized and analyzed. An analysis of the claims database of all hospitalizations reimbursed from 2010 to 2012 in three counties of Yichang city (YC), which included 1506 discharges, was conducted to identify the differences in reimbursement rates and out-of-pocket (OOP) expenses among the health insurance schemes.

Results

Tuberculosis patients had various inpatient expenses depending on which scheme they were covered by (TB patients covered by the NCMS have less inpatient expenses than those who were covered by the URBMI, who have less inpatient expenses than those covered by the UEBMI). We found a significant horizontal inequity of healthcare utilization among the lower socioeconomic groups. In terms of financial inequity, TB patients who earned less paid more. The NCMS provides modest financial protection, based on income. Overall, TB patients from lower socioeconomic groups were the most vulnerable.

Conclusion

There are large disparities in reimbursement for TB care among the three health insurance schemes and this, in turn, hampers TB control. Reducing the gap in health outcomes between the three health insurance schemes in China should be a focus of TB care and control. Achieving equity through integrated policies that avoid discrimination is likely to be effective.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0102-4) contains supplementary material, which is available to authorized users.

Uninsured status may be more predictive of outcomes among the severely injured than minority race

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.

Emergency Department Visits for Self-Inflicted Injuries in Adolescents

OBJECTIVES

To describe emergency department (ED) visits for self-inflicted injury (SII) among adolescents, examine trends in SII mechanisms, and identify factors associated with increased risk.

METHODS

Analyses included patients aged 10 to 18 years from the National Trauma Data Bank, years 2009 to 2012. We used Cochran-Armitage trend tests to examine change over time and generalized linear models to identify risk factors for SII.

RESULTS

We examined 286,678 adolescent trauma patients, 3664 (1.3%) of whom sustained an SII. ED visits for SII increased from 2009 to 2012 (1.1% to 1.6%, P for trend ≤ .001), whereas self-inflicted firearm visits decreased (27.3% to 21.9%, P for trend = .02). The most common mechanism in males was firearm (34.4%), and in females, cut/pierce (48.0%). Odds of SII were higher in females (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.13-1.77), older adolescents (OR 2.73, 95% CI 2.38-3.14), adolescents with comorbid conditions (OR 1.64; 95% CI 1.49-1.80), and Asian adolescents (OR 1.67, 95% CI 1.35-2.08) and lower in African American adolescents (OR 0.78, 95% CI 0.70-0.87). Adolescents in the public or self-pay insurance category had higher odds of SII (OR 1.44, 95% CI 1.27-1.64) than those in the private insurance category (OR 1.15, 95% CI 1.01-1.31). Adolescents with an SII had higher odds of death than those with other injuries (OR 12.9, 95% CI 6.78-24.6).

CONCLUSIONS

We found a significant increase in the number of SIIs by adolescents that resulted in ED visits from 2009 to 2012. Although SIIs increased, we found a significant decrease in the percentage of adolescents who self-injured with a firearm. SIIs reflect a small percentage of ED visits, but these patients have dramatically higher odds of death.

The severity of disparity: increasing injury intensity accentuates disparate outcomes following trauma

OBJECTIVE

Studies have shown disparities in mortality among racial groups and among those with differing insurance coverage. Our goal was to determine if injury severity affects these disparities.

METHODS

We classified patients from the 2003-2008 National Trauma Data Banks suffering moderate to severe injuries into six groups based on race/ethnicity and insurance, stratifying by injury severity. Logistic regression compared odds of death between races-ethnicities/insurance groups within these strata. We adjusted for age, gender, Injury Severity Score, Glasgow Coma Scale motor component, hypotension, and mechanism of injury.

RESULTS

Patients meeting inclusion criteria numbered 760,598. Disparities between races-ethnicities/insurance groups increased as injury severity worsened. Odds of death for uninsured Black patients compared with insured Whites increased from 1.82 among moderately injured patients to 3.14 among severely injured, hypotensive patients. A similar pattern was seen among uninsured Hispanic patients.

CONCLUSIONS

Disparities in trauma mortality suffered by minority and uninsured patients, when compared with non-minority and insured patients, worsen with increasing injury.

Association of insurance status with health outcomes following traumatic injury: statewide multicenter analysis

Introduction

Recognizing disparities in definitive care for traumatic injuries created by insurance status may help reduce the higher risk of trauma-related mortality in this population. Our objective was to understand the relationship between patients’ insurance status and trauma outcomes.

Methods

We collected data on all patients involved in traumatic injury from eight Level I and 15 Level IV trauma centers, and four non-designated hospitals through Arizona State Trauma Registry between January 1, 2008 and December 31, 2011. Of 109,497 records queried, we excluded 29,062 (26.5%) due to missing data on primary payer, sex, race, zip code of residence, injury severity score (ISS), and alcohol or drug use. Of the 80,435 cases analyzed, 13.3% were self-pay, 38.8% were Medicaid, 13% were Medicare, and 35% were private insurance. We evaluated the association between survival and insurance status (private insurance, Medicare, Medicaid, and self-pay) using multiple logistic regression analyses after adjusting for race/ethnicity (White, Black/African American, Hispanic, and American Indian/Alaska Native), age, gender, income, ISS and injury type (penetrating or blunt).

Results

The self-pay group was more likely to suffer from penetrating trauma (18.2%) than the privately insured group (6.0%), p<0.0001. There were more non-White (53%) self-pay patients compared to the private insurance group (28.3%), p<0.0001. Additionally, the self-pay group had significantly higher mortality (4.3%) as compared to private insurance (1.9%), p<0.0001.

A simple logistic regression revealed higher mortality for self-pay patients (crude OR= 2.32, 95% CI [2.07–2.67]) as well as Medicare patients (crude OR= 2.35, 95% CI [2.54–3.24]) as compared to private insurance. After adjusting for confounding, a multiple logistic regression revealed that mortality was highest for self-pay patients as compared to private insurance (adjusted OR= 2.76, 95% CI [2.30–3.32]).

Conclusion

These results demonstrate that after controlling for confounding variables, self-pay patients had a significantly higher risk of mortality following a traumatic injury as compared to any other insurance-type groups. Further research is warranted to understand this finding and possibly decrease the mortality rate in this population.

Dependent coverage provision led to uneven insurance gains and unchanged mortality rates in young adult trauma patients

Insurance coverage has increased among young adults as a result of the Affordable Care Act (ACA) provision that allows young adults to remain covered under their parents' plans until age twenty-six. However, little is known about the provision's effects on the clinical outcomes and insurance coverage of patients with trauma--the most frequent cause of death and physical disability among young adults. Using 2007-12 data from the National Trauma Data Bank, we conducted a difference-in-differences analysis of coverage rates among trauma patients ages 19-25 (compared to patients ages 26-34, who served as the control group), and we examined trauma-relevant outcomes by patient, injury, and hospital characteristics. We found a 3.4-percentage-point decrease in uninsurance status among younger trauma patients following the policy change. The decrease was concentrated among men, non-Hispanic whites, those with relatively less severe injuries, and those who presented to nonteaching hospitals. We did not detect significant changes in the use of intensive care or in overall mortality. The heterogeneous coverage impact of the ACA dependent coverage provision on high- versus low-risk trauma patients has implications for future efforts to expand coverage.

Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?

BACKGROUND

We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation.

METHODS

A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005-2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled.

RESULTS

The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage.

CONCLUSION

Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.

Who pays for work-related traumatic injuries? Payer distribution in washington state by ethnicity, injury severity, and year (1998-2008)

BACKGROUND

Acute work-related trauma is a leading cause of death and disability for U.S. workers but it is difficult to obtain information about injured workers not covered by workers' compensation (WC). This study aimed to: (1) describe trends in expected payer and linkage to WC claims, (2) compare characteristics of injured workers who did and did not have a linked WC claim, and (3) describe variation in expected payer and linkage to WC claims by ethnicity and injury severity.

METHODS

Data for injuries occurring from 1998 through 2008 were obtained from the Washington State Trauma Registry and linked to WC claims.

RESULTS

We found that 27% of work-related traumatic injuries did not have WC listed as a payer, while 37% did not link to a WC claim. Among those with WC listed as a payer, the odds of having a linked WC claim were 57% lower for workers with other non-WC insurance compared with the otherwise uninsured. Latinos were more likely to have a linked WC claim compared with non-Latinos, but there was no significant difference after partially controlling for WC-covered employment and other insurance.

CONCLUSIONS

This study demonstrated the importance of considering differential access to other insurance coverage and adaptation by health care settings to financial pressures when assessing trends in occupational injury incidence and reporting, especially when using WC as a proxy for work-relatedness. The addition of occupation, industry, and work status to trauma registries and hospital discharge databases would improve surveillance, research, policy and prevention efforts.