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

Abstract

BackgroundResearch 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.MethodsPatient 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.ResultsA 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).ConclusionsBoth 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.

Factors associated with imaging overuse in the emergency department: A systematic review

“…34 Patient race and insurance type influence the diagnostic workup received by patients in the ED, but it is unclear, again, whether this represents underuse or overuse of services. 35,36 Other studies have also demonstrated more intensive health service utilization, besides imaging, in the ED for patients who speak languages other than English, possibly in an effort to overcome diagnostic challenges posed by communication difficulties. 37,38…”

Effects of Physician Experience, Specialty Training, and Self-referral on Inappropriate Diagnostic Imaging

“…As noted, we observed relatively lower rates of inappropriate imaging among patients with an HMO plan, which is line with some literature suggesting these types of plans have in place more stringent pre-authorization requirements for expensive clinical services. 34,35 However, we did not have information regarding whether and how health plans reviewed specific claims included in the study. Based on discussions we have had with senior leaders of health insurance companies in Massachusetts, during the time frame covered by this study most orders for diagnostic imaging were required to undergo some form of pre-authorization review, but these review systems did not include the type of criteria that ACR guidelines entail and medical denial rates were very low.…”

“…HMO plans often feature pre-authorization requirements and related controls for expensive clinical services that some studies suggest influence utilization for imaging services. 34,35 For median household income, a proxy for a patient's financial resources for covering deductibles and co-pays connected with imaging procedures, we grouped patients by quartiles. For geographic location, we grouped patients based on whether their residence was located in the northeast, southeast, central, or western regions of the state as this may account for some differences in the availability of imaging technology.…”