Race, insurance status, and traumatic brain injury outcomes before and after enactment of the Affordable Care Act

Moffet, Eric W.; Zens, Tiffany; Haines, Krista; Beems, Megan; McQuistion, Kaitlyn; Leverson, Glen; Agarwal, Suresh

doi:10.1016/j.surg.2017.09.006

Cited by 20 publications

(15 citation statements)

References 35 publications

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“…Another question left unanswered is determining which metropolitan areas would stand to benefit the most from a strategy of police transport. Racial and ethnic disparities in access to trauma care have long been identified 25–27 . Black census tracts in New York, Los Angeles, and Chicago Cities were found to have decreased access to trauma care 28 .…”

Section: Discussionmentioning

confidence: 99%

An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

Taghavi

Maher

Goldberg

et al. 2022

J Trauma Acute Care Surg

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BACKGROUND:Police transport (PT) of penetrating trauma patients in urban locations has become routine in certain metropolitan areas; however, whether it results in improved outcomes over prehospital Advanced life support (ALS) transport has not been determined in a multicenter study. We hypothesized that PT would not result in improved outcomes. METHODS:This was a multicenter, prospective, observational study of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. Police transport and ALS patients were allocated via nearest neighbor, propensity matching. Transport mode also examined by Cox regression. RESULTS:Of 1,618 total patients, 294 (18.2%) had PT and 1,324 (81.8%) were by ALS. After matching, 588 (294/cohort) remained. The patients were primarily Black (n = 497, 84.5%), males (n = 525, 89.3%) ,injured by gunshot wound (n = 494, 84.0%) with 34.5% (n = 203) having Injury Severity Score of 16 or higher. Overall mortality by propensity matching was not different between cohorts (15.6% ALS vs. 15.0% PT, p = 0.82). In severely injured patients (Injury Severity Score ≥16), mortality did not differ between PT and ALS transport (38.8% vs. 36.0%, respectively; p = 0.68). Cox regression analysis controlled for relevant factors revealed no association with a mortality benefit in patients transported by ALS. CONCLUSION:Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population.

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Section: Discussionmentioning

confidence: 99%

An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

Taghavi

Maher

Goldberg

et al. 2022

J Trauma Acute Care Surg

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“…The study's findings are in keeping with what is known about anticipated changes in outcomes following ACA implementation among adult trauma patients. 12,13,[17][18][19][20] A prior riskadjusted assessment of before-and-after changes among young adult trauma patients aged 18 to 34 years reported a significant 5.4 percentage point increase in discharge to rehabilitation, 0.5 percentage point decrease in mortality, and 4.5 percentage point decrease in failure to rescue following ACA implementation in Maryland. 13 Overall results among adults within Medicaid expansion states were similar.…”

Section: Discussionmentioning

confidence: 99%

“…9,11 Emerging studies on the impact of health care reform suggest that changes to insurance coverage taking place as a result of the implementation of the 2010 Patient Protection and Affordable Care Act (ACA) are changing care trajectories for adult trauma patients. [12][13][14][15][16][17][18][19][20] Passage of the ACA was intended to improve access to care through improvements in insurance coverage. While the law and its various provisions, including expansion of parental private insurance coverage to children younger than 26 years, establishment of an individual insurance mandate, formation of state health insurance exchanges, expansion of tax support for employersponsored health insurance plans, and optional state expansion of Medicaid with temporary federal funding to all citizens with an income of less than 133% of the federal poverty level are known to have increased insurance coverage and selfreported access to care on a national scale, 21 the ACA's specific effect on trauma patients remains less clear.…”

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confidence: 99%

“…A growing number of single-center, projection, and noncontrolled beforeand-after studies point toward mixed effects. 12,13,[17][18][19][20][22][23][24][25] While they all acknowledge changes in the payer mix of patients, the magnitude and extent of the ACA's impact on insurance coverage among trauma patients is unknown, as is the law's success in improving trauma outcomes and promoting increased access to rehabilitation.…”

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confidence: 99%

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Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients

et al. 2019

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IMPORTANCE Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation. OBJECTIVE To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act. DESIGN, SETTING, AND PARTICIPANTS Quasi-experimental, difference-indifference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states. INTERVENTIONS/EXPOSURE Policy implementation in January 2014. MAIN OUTCOMES AND MEASURES Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation. RESULTS A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation. CONCLUSIONS AND RELEVANCE This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for...

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“…Although racial and ethnic disparities in health care utilization and health outcomes are well-documented in the United States, 11 most of the evidence is derived from studies based in ambulatory or general care settings. 3,12 –20 However, little data exist among patients who are at risk for high mortality and health care costs and receive care in an intensive care unit setting. A greater understanding of the relationships among race, ethnicity, and critical illness processes and outcomes may help to highlight opportunities for improving patient and family-centered care to patients with SABI.…”

Section: Introductionmentioning

confidence: 99%

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

Jones

Creutzfeldt

Cox

et al. 2020

J Intensive Care Med

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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.

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Race, insurance status, and traumatic brain injury outcomes before and after enactment of the Affordable Care Act

Cited by 20 publications

References 35 publications

An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients

Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients

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

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