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Lequerica AH, Sander AM, Pappadis MR, Ketchum JM, Jaross M, Kolakowsky-Hayner S, Rabinowitz A, Callender L, Smith M. The Association Between Payer Source and Traumatic Brain Injury Rehabilitation Outcomes: A TBI Model Systems Study. J Head Trauma Rehabil 2023; 38:E10-E17. [PMID: 35452026 PMCID: PMC10131079 DOI: 10.1097/htr.0000000000000781] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To examine the relationship between payer source for acute rehabilitation, residential median household income (MHI), and outcomes at rehabilitation discharge after traumatic brain injury (TBI). SETTING Acute inpatient rehabilitation facilities. PARTICIPANTS In total, 8558 individuals enrolled in the Traumatic Brain Injury Model Systems (TBIMS) National Database who were admitted to inpatient rehabilitation between 2006 and 2019 and were younger than 64 years. DESIGN Secondary data analysis from a multicenter longitudinal cohort study. MAIN MEASURES Payer source was divided into 4 categories: uninsured, public insurance, private insurance, and workers' compensation/auto. Relationships between payer source with residential MHI, rehabilitation length of stay (RLOS), and the FIM Instrument at discharge were examined. Covariates included age, injury severity, FIM at admission, and a number of sociodemographic characteristics including minority status, preinjury limitations, education level, and employment status. RESULTS Individuals with workers' compensation/auto or private insurance had longer RLOS than uninsured individuals or those with public insurance after controlling for demographics and injury characteristics. An adjusted model controlling for demographics and injury characteristics showed a significant main effect of payer source on FIM scores at discharge, with the highest scores noted among those with workers' compensation/auto insurance. The main effect of payer source on FIM at discharge became nonsignificant after RLOS was added to the model as a covariate, suggesting a mediating effect of RLOS. CONCLUSION Payer source was associated with preinjury residential MHI and predicted RLOS. While prior studies have demonstrated the effect of payer source on long-term outcomes due to lack of inpatient rehabilitation or quality follow-up care, this study demonstrated that individuals with TBI who are uninsured or have public insurance may be at risk for poorer functional status at the point of rehabilitation discharge than those with private insurance, particularly compared with those with workers' compensation/auto insurance. This effect may be largely driven by having a shorter length of stay in acute rehabilitation.
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Affiliation(s)
- Anthony H. Lequerica
- Center for Traumatic Brain Injury Research, Kessler Foundation, East Hanover, New Jersey
- Department of Physical Medicine and Rehabilitation, Rutgers – New Jersey Medical School, Newark, NJ
| | - Angelle M. Sander
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine and Harris Health, Houston, TX
- Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas
| | - Monique R. Pappadis
- Brain Injury Research Center, TIRR Memorial Hermann, Houston, Texas
- Department of Nutrition, Metabolism, and Rehabilitation Sciences, School of Health Professions, University of Texas Medical Branch at Galveston, Galveston, TX
| | | | | | | | | | - Librada Callender
- Research Department, Baylor Scott and White Institute for Rehabilitation, Dallas, TX
| | - Michelle Smith
- Department of Research, NYU Grossman School of Medicine, New York, NY
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de Angelis P, Kaufman EJ, Barie PS, Leahy NE, Winchell RJ, Narayan M. Disparities in Insurance Status are Associated With Outcomes But Not Timing of Trauma Care. J Surg Res 2022; 273:233-246. [PMID: 35144053 DOI: 10.1016/j.jss.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/19/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Patient factors influence outcomes after injury. Delays in care have a crucial impact. We investigated the associations between patient characteristics and timing of transfer from the emergency department to definitive care. METHODS This was a review of adult trauma patients treated between January 1, 2016, and December 31, 2018. Bivariate analyses were used to build Cox proportional hazards models. We built separate logistic and negative binomial regression models for secondary outcomes using mixed-step selection to minimize the Akaike information criterion c. RESULTS A total of 1219 patients were included; 68.5% were male, 56.8% White, 11.2% Black, and 7.8% Asian/Pacific Islander. The average age was 51 ± 21 y. Overall, 13.7% of patients were uninsured. The average length of stay was 5 d and mortality was 5.9%. Shorter transfer time out of the emergency department was associated with higher tier of activation (relative risk [RR] 1.39, 95% confidence interval [CI] 1.09-1.77; P = 0.0074), Injury Severity Score between 16 and 24 points (RR 1.57, 95% CI 1.04-2.32; P = 0.0307) or ≥25 (RR 3.85, 95% CI 2.45-5.94; P = 0.0001), and penetrating injury. Longer time to event was associated with Glasgow coma scale score ≥14 points (RR 0.47, 95% CI 0.27-0.85; P = 0.0141). Uninsured patients were less likely to be admitted (odds ratio 0.29, 95% CI 0.17-0.48; P = 0.0001) and more likely to experience shorter length of stay (incidence rate ratio 0.34, 95% CI 0.24-0.51; P = 0.0001). CONCLUSIONS Injury characteristics and insurance status were associated with patient outcomes in this retrospective, single-center study. We found no disparity in timing of intrafacility transfer, perhaps indicating that initial management protocols preserve equity.
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Affiliation(s)
- Paolo de Angelis
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York.
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Department of Surgery, Penn Medicine, Philadelphia, Pennsylvania
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Nicole E Leahy
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Robert J Winchell
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York; Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mayur Narayan
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
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Dubey P, Saxena A, Jordan JE, Xian Z, Javed Z, Jindal G, Vahidy F, Sostman DH, Nasir K. Contemporary national trends and disparities for head CT use in emergency department settings: Insights from National Hospital Ambulatory Medical Care Survey (NHAMCS) 2007-2017. J Natl Med Assoc 2022; 114:69-77. [PMID: 34986985 DOI: 10.1016/j.jnma.2021.12.001] [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: 04/27/2021] [Revised: 09/07/2021] [Accepted: 12/07/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The exponential growth in CT utilization in emergency department (ED) until 2008 raised concerns regarding cost and radiation exposure. Head CT was one of the commonest studies. This led to mitigating efforts such as appropriate use guidelines, policy and payment reforms. The impact of these efforts is not fully understood. In addition, disparities in outcomes of acute conditions presenting to the ED is well known however recent trends in imaging utilization patterns and disparities are not well understood. In this study, we describe nationwide trends and disparities associated with head CT in ED settings between 2007 and 2014. METHODS We analyzed 2007-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) with the primary goal to assess the rate and patterns of head CT imaging in ED. RESULTS There were an estimated 117 million in 2007 and 139 million ED visits in 2017. There was a 4% increase in the any CT use in 2017 compared to 2007. No significant change in head CT utilization rate was seen. The 2007 head CT rate was 6.7% (95% CI: 6.1-7.3) compared to 7.7% (95% CI: 6.8-8.6) in 2017. Trauma, Headache and Dizziness are the top three indications for head CT use in the ED respectively. On adjusted analyses, significantly higher head CT utilization was seen in elderly, (age>65 yrs) and significantly lower utilization rate was seen in Non-Hispanic Black and Medicaid patients, and patients in rural locations. CONCLUSIONS Previously reported exponential growth of CT use in ED is no longer seen. In particular, there was no significant change in ED head CT use between 2007 and 2017. Headache and Dizziness remain commonly used indications despite limited utility in most clinical scenarios, indicating continued need for appropriate use of imaging. There is significantly lower CT utilization in Non-Hispanic Black, Medicaid patients and those in rural locations, suggesting disparities in diagnostic work-up in marginalized and rural populations. This underscores the need for standardizing care regardless of race, insurance status and location.
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Affiliation(s)
- Prachi Dubey
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA.
| | | | - John E Jordan
- Providence Little Company of Mary Medical Center, Torrance, California, USA; Stanford University School of Medicine, Stanford, CA, USA
| | - Zhaoying Xian
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
| | - Zulqarnain Javed
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
| | - Gaurav Jindal
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Farhaan Vahidy
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
| | - Dirk H Sostman
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
| | - Khurram Nasir
- Houston Methodist Hospital. Houston Methodist Research Institute, Houston, TX, USA
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Inampudi C, Ciccotosto GD, Cappai R, Crack PJ. Genetic Modulators of Traumatic Brain Injury in Animal Models and the Impact of Sex-Dependent Effects. J Neurotrauma 2021; 37:706-723. [PMID: 32027210 DOI: 10.1089/neu.2019.6955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Traumatic brain injury (TBI) is a major health problem causing disability and death worldwide. There is no effective treatment, due in part to the complexity of the injury pathology and factors affecting its outcome. The extent of brain injury depends on the type of insult, age, sex, lifestyle, genetic risk factors, socioeconomic status, other co-injuries, and underlying health problems. This review discusses the genes that have been directly tested in TBI models, and whether their effects are known to be sex-dependent. Sex differences can affect the incidence, symptom onset, pathology, and clinical outcomes following injury. Adult males are more susceptible at the acute phase and females show greater injury in the chronic phase. TBI is not restricted to a single sex; despite variations in the degree of symptom onset and severity, it is important to consider both female and male animals in TBI pre-clinical research studies.
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Affiliation(s)
- Chaitanya Inampudi
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria, Australia
| | - Giuseppe D Ciccotosto
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria, Australia
| | - Roberto Cappai
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Crack
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria, Australia
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Dismuke-Greer CE, Fakhry SM, Horner MD, Pogoda TK, Pugh MJ, Gebregziabher M, Hall CL, Taber D, Spain DA. Ethnicity/race and service-connected disability disparities in civilian traumatic brain injury mechanism of injury and VHA health services costs in military veterans: Evidence from a Level 1 Trauma Center and VA Medical Center. TRAUMA-ENGLAND 2021. [DOI: 10.1177/1460408620914436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The objective of this study was to examine the association of military veteran socio-demographics and service-connected disability with civilian mechanism of traumatic brain injury and long-term Veterans Health Administration (VHA) costs. Methods We conducted a 17-year retrospective longitudinal cohort study of veterans with a civilian-related traumatic brain injury from a Level 1 Trauma Center between 1999 and 2013, with VHA follow-up through 2016. We merged trauma center VHA data, and used logit to model mechanism of injury, and generalized linear model to model VHA costs. Results African American race or Hispanic ethnicity veterans had a higher unadjusted rate of civilian assault/gun as mechanism of injury (15.38%) relative to non-Hispanic White (7.19%). African American race or Hispanic veterans who were discharged from the trauma center with traumatic brain injury and followed in VHA had more than twice the odds of assault/gun (OR 2.47; 95% CI 1.16:5.26), after adjusting for sex, age, and military service-connected disability. Veterans with service-connected disability ≥50% had more than twice the odds of assault/gun (OR 2.48; 95% CI 0.97:6.31). Assault/gun was associated with significantly higher annual VHA costs post-discharge ($16,807; 95% CI 672:32,941) among non-Hispanic White veterans. Military service-connected disability ≥50% was associated with higher VHA costs among both non-Hispanic White ($44,987; 95% CI $17,159:$72,816) and African American race or Hispanic ($37,901; 95% CI $4,543:$71,258) veterans. Conclusions We found that African American race or Hispanic veterans had higher adjusted likelihood of assault/gun mechanism of traumatic brain injury, and non-Hispanic White veterans had higher adjusted annual VHA resource costs associated with assault/gun, post trauma center discharge. Veterans with higher than 50% service-connected disability had higher likelihood of assault/gun and higher adjusted annual VHA resource costs. Assault/gun prevention efforts may be indicated within the VHA, especially in minority and service-connected disability veterans. More data from Level 1 Trauma Centers are needed to assess the generalizability of these findings.
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Affiliation(s)
- CE Dismuke-Greer
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Health Care System, Palo Alto, USA
| | - SM Fakhry
- Center for Trauma and Acute Care Surgery Research, CSG, HCA Healthcare, Nashville, USA
| | - MD Horner
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston, USA
| | - TK Pogoda
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, USA
- Boston University School of Public Health, Boston, USA
| | - MJ Pugh
- Salt Lake City VA Health Care System and University of Utah Health Sciences, Salt Lake City, USA
| | - M Gebregziabher
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston, USA
| | - CL Hall
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VAMC, Charleston, USA
| | - D Taber
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VAMC, Charleston, USA
| | - DA Spain
- Department of Surgery, Stanford University, Stanford Healthcare, Stanford, USA
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Trofimova AV, Duszak R, Kadom N, Sadigh G. Increasing and disparate use of neuroimaging for adults and children with non-traumatic headaches in the US emergency departments: Opportunities for improvement. Headache 2020; 61:179-189. [PMID: 33316103 DOI: 10.1111/head.14020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/01/2020] [Accepted: 09/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Optimization of neuroimaging practices for headache is considered a national priority; however, nationwide patterns and predictors of neuroimaging use for headache in the US emergency departments (EDs) are unknown. OBJECTIVE To analyze temporal neuroimaging utilization trends for adults and children with non-traumatic headache in the US EDs and identify factors predictive of neuroimaging use in this patient population. METHODS Retrospective cross-sectional study using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database for administrative encounter-level data analysis of a nationwide group of adult and pediatric patients with primary diagnosis of headache (ICD-9CM codes 784.0x, 339.xx, 346.xx) visited the US EDs between January 1, 2006 and December 31, 2014. Temporal trends and independent predictors of neuroimaging use (e.g., patient and hospital characteristics, primary payment sources) were determined. RESULTS In 2006-2014, a weighted group of 18,146,302 patients with a primary diagnosis of non-traumatic headache visited US EDs. Advanced neuroimaging utilization increased from 18.6% (n = 350,777) to 34.8% (n = 756,895) in the total group, from 18.8% (n = 314,646) to 36.5% (n = 698,080) in the adult subgroup (+94.1%), and from 16.9% (n = 36,131) to 22.0% (n = 58,815) (+30.2%) in the pediatric subgroup (+87.0%) between 2006 and 2014. The strongest predictors of higher neuroimaging utilization were hospital location in the Northeast (OR 3.17, 95% CI 2.67-3.76) or South (OR 2.42, 95% CI 2.03-2.88) regions. Lower utilization of imaging was associated with weekend ED visits (OR 0.92, 95% CI 0.92-0.93), female gender (OR 0.82, 95% CI 0.81-0.83), and Medicare, Medicaid, or self-pay (vs. private insurance) encounters. CONCLUSION Neuroimaging utilization in patients with headache in US EDs nearly doubled in 2006-2014, and was used in 34.8% of all ED encounters in 2014. Utilization was higher and increased at faster rates for adults than children. In US EDs, imaging for headache is preferentially performed on commercially insured and male patients, at urban hospitals, in certain geographic regions, and on weekdays, raising concerns regarding disparate imaging use.
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Affiliation(s)
- Anna V Trofimova
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Gelareh Sadigh
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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