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Gebran A, El Moheb M, Herrera-Escobar JP, Proaño-Zamudio JA, Maurer LR, Lamarre TE, Bou Zein Eddine S, Sanchez SE, Nehra D, Salim A, Velmahos GC, Kaafarani HMA. Insurance Not Socioeconomic Status is Associated With Access to Postacute Care After Injury: A Multicenter Cohort Study. J Surg Res 2024; 293:307-315. [PMID: 37806216 DOI: 10.1016/j.jss.2023.08.036] [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: 12/13/2022] [Revised: 07/19/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Access to postacute care services in rehabilitation or skilled nursing facilities is essential to return trauma patients to their preinjury functional level but is often hindered by systemic barriers. We sought to study the association between the type of insurance, socioeconomic status (SES) measures, and postacute care utilization after injury. METHODS Adult trauma patients with an Injury Severity Score (ISS) ≥9 admitted to one of three Level I trauma centers were contacted 6-12 mo after injury to gather long-term functional and patient-centered outcome measures. In addition to SES inquiry specifically focused on education and income levels, patients were asked to subjectively categorize their perceived SES (p-SES) as high, mid-high, mid-low, or low. Insurance and income data were retrieved from trauma registries. Multivariable regression models were built to determine the association between type of insurance, SES, and discharge disposition after adjusting for patient and injury characteristics and hospitalization events. RESULTS A total of 1373 patients were included, of which 44% were discharged to postacute care facilities. The median age (IQR) was 65 (46, 76) years, 56% of patients were male, 11% were on Medicaid, 68% had attained education higher than high school, 27% had low income, and 29% reported a low/mid-low p-SES. Medicaid patients were less likely to be discharged to postacute care compared to privately insured (OR [95% CI]: 0.41 [0.29-0.58]) and Medicare patients (OR [95% CI]: 0.29 [0.16-0.50]). The latter relationship was true across p-SES categories. P-SES, income and educational level were not associated with discharge destination. CONCLUSIONS Insurance status, specifically having Medicaid, can pose a barrier to access to postacute care services in the trauma patient population across patients of all SES. Initiatives and policies that aim at reducing these access disparities are warranted.
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Affiliation(s)
- Anthony Gebran
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Juan P Herrera-Escobar
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Taylor E Lamarre
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Savo Bou Zein Eddine
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Sabrina E Sanchez
- Division of Trauma, Acute Care Surgery & Surgical Critical Care, Boston University School of Medicine, Boston, Massachusetts
| | - Deepika Nehra
- Division of Trauma, Burn & Critical Care Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Ali Salim
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts.
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Herrera-Escobar JP, Reidy E, Phuong J, Brasel KJ, Cuschieri J, Fallat M, Potter BK, Price MA, Bulger EM, Haider AH, Bonne S, Brasel KJ, Cuschieri J, de Roon-Cassini T, Dicker RA, Fallat M, Ficke JR, Gabbe B, Gibran NS, Heinemann AW, Ho V, Kao LS, Kellam JF, Kurowski BG, Levy-Carrick NC, Livingston D, Mandell SP, Manley GT, Michetti CP, Miller AN, Newcomb A, Okonkwo D, Potter BK, Seamon M, Stein D, Wagner AK, Whyte J, Yonclas P, Zatzick D, Zielinski MD. Developing a National Trauma Research Action Plan: Results from the long-term outcomes research gap Delphi survey. J Trauma Acute Care Surg 2022; 93:854-862. [PMID: 35972140 DOI: 10.1097/ta.0000000000003747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the National Academies of Sciences, Engineering, and Medicine 2016 report on trauma care, the establishment of a National Trauma Research Action Plan to strengthen and guide future trauma research was recommended. To address this recommendation, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care. We describe the gap analysis and high-priority research questions generated from the National Trauma Research Action Plan panel on long-term outcomes. METHODS Experts in long-term outcomes were recruited to identify current gaps in long-term trauma outcomes research, generate research questions, and establish the priority for these questions using a consensus-driven, Delphi survey approach from February 2021 to August 2021. Panelists were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability including both military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population, Intervention, Compare/Control, and Outcome model. On subsequent surveys, panelists were asked to prioritize each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category. RESULTS Thirty-two subject matter experts generated 482 questions in 17 long-term outcome topic areas. By Round 3 of the Delphi, 359 questions (75%) reached consensus, of which 107 (30%) were determined to be high priority, 252 (70%) medium priority, and 0 (0%) low priority. Substance abuse and pain was the topic area with the highest number of questions. Health services (not including mental health or rehabilitation) (64%), mental health (46%), and geriatric population (43%) were the topic areas with the highest proportion of high-priority questions. CONCLUSION This Delphi gap analysis of long-term trauma outcomes research identified 107 high-priority research questions that will help guide investigators in future long-term outcomes research. LEVEL OF EVIDENCE Diagnostic Tests or Criteria; Level IV.
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Affiliation(s)
- Juan P Herrera-Escobar
- From the Center for Surgery and Public Health (J.P.H.-E., E.R., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Department of Biomedical Informatics and Medical Education (J.P.), University of Washington, Seattle, Washington; Division of Trauma, Critical Care and Acute Care Surgery (K.J.B.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (J.C.), University of San Francisco California, San Francisco, California; Department of Surgery (M.F.), University of Louisville, Louisville, Kentucky; Walter Reed Department of Surgery (B.K.P.), Uniformed Services University, Bethesda, Maryland; Coalition for National Trauma Research (M.A.P.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; Office of the Dean, Aga Khan University Medical College (A.H.H.), Karachi, Pakistan
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