Introduction: Previous literature has described disparities in traumatic brain injury(TBI) outcomes by insurance status, but no study has focused on the disparities in presentation of TBI. We aimed to examine influence of insurance on severity of presentation in TBI.
Methods: In this retrospective cohort analysis the National Trauma Data Bank(NTDB), years 2010-2014, was queried for TBI diagnoses codes. Unadjusted and adjusted analyses were performed with respect to insurance type to evaluate for significant differences in head abbreviated injury score(AIS)>=4 and GCS 3-6.
Results: A total of 664,573 cases were included for analysis. Median age was 31 with 75% of patients >=19 years and 67% Caucasian. African-Americans, Native Americans, and Pacific Islanders had greater proportions of Medicaid patients than Caucasians(29%, 35%, and 22%, respectively vs. 16%, p<0.001). African-Americans and Pacific Islanders had greater proportions of self-pay patients compared to Caucasians(25% and 23% vs. 17%, p<0.001). Forty three percent of patients insured by Medicaid had a head AIS >=4, compared to 41% in self-payers, and 40% in the privately insured(p<0.001). A greater proportion of Medicaid and self-pay patients were noted to have lower GCS compared to private insurance(GCS 3-6: 13% and 15%, respectively, vs. 11%, p<0.001). On adjusted analysis Medicaid was independently associated with head AIS >=4(OR 1.13, 95% CI 1.12-1.15) and GCS 3-6(OR 1.29, 95% CI 1.26-1.32) compared to private insurance. Self-pay was also independently associated with GCS 3-6(OR 1.25, 95% CI 1.22-1.28).
Conclusions: We propose that the previously established effect of insurance status on outcomes may be a reflection of its association with more severe presentations rather than a direct effect on outcomes. In this analysis racial minorities suffering TBI compose a greater proportion of non-private insurance than Caucasians, and those insured by Medicaid or self-pay are more likely to present with serious TBIs.
Patient Care: Research in understanding and addressing health care disparities has been a focus of both governmental and major medical organizations over the last decade. Improving our understanding of the health care disparities that exist with respect to insurance status in traumatic brain injury will allow for insight into appropriate changes in policy and practice that can result in quality improvement for these patients, both in their care and in optimizing outcomes.
Learning Objectives: By the conclusion of this session, participants should be able to (1) Describe health care disparities for TBI in regards to race/ethnicity and insurance status, (2) Discuss how inferior socioeconomic status, or insurance associated with lower reimbursement, is a risk factor for more severe TBI
References: 1. Arango-Lasprilla JC, Rosenthal M, Deluca J, Komaroff E, Sherer M, Cifu D, Hanks R: Traumatic brain injury and functional outcomes: does minority status matter? Brain Inj 21(7):701–8, 2007.
2. Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell EE 3rd: Race and insurance status as risk factors for trauma mortality. Arch Surg 143(10):945–9, 2008.
3. US Department of Health and Human Services Agency for Healthcare Research and Quality: 2014 National Healthcare Quality and Disparities Report (QDR). 2015.