Download PDF
J Neurol Surg A Cent Eur Neurosurg 2015; 76(03): 224-232
DOI: 10.1055/s-0034-1543958
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Effect of Insurance and Racial Disparities on Outcomes in Traumatic Brain Injury

Michael Schiraldi
1   Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States
*   Authors contributed equally to this manuscript.
,
Chirag G. Patil
1   Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States
*   Authors contributed equally to this manuscript.
,
Debraj Mukherjee
1   Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States
,
Beatrice Ugiliweneza
2   Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
,
Miriam Nuño
1   Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States
,
Shivanand P. Lad
3   Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States
,
Maxwell Boakye
2   Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
› Author Affiliations
Further Information

Publication History

08 April 2014

24 October 2014

Publication Date:
23 March 2015 (online)

    Permissions and Reprints

Abstract

Introduction We evaluated outcome and resource utilization disparities between commercially insured, Medicaid, and Medicare patients. We further analyzed racial disparities in a subset cohort.

Methods We reviewed the MarketScan database (2000–2009) for adult traumatic brain injury (TBI) patients. Analyses were performed to evaluate outcome differences by insurance type and race. Outpatient service utilization disparities by insurance and race were also evaluated.

Results Our study included 92,159 TBI patients, 44,108 (47.9%) of whom utilized commercial insurance, 19,743 (21.4%) utilized Medicaid, and 28,308 (30.7%) utilized Medicare. In-hospital mortality was lowest for commercially insured (5.0%) versus 7.6% and 8.5% for Medicaid and Medicare patients, respectively (p < 0.0001). Medicaid patients had a longer hospitalization than commercially insured (12 days versus 6 days; p < 0.0001). Medicaid patients were 1.29 and 1.78 times more likely to die and experience complications than the commercially insured. Females had a lower mortality risk (odds ratio [OR]: 0.80, p < 0.0001) and less complications (OR: 0.67; p < 0.0001) than males. Higher comorbidities increased mortality risk (OR: 2.71; p < 0.0001) and complications (OR: 2.96, p < 0.0001). Mild injury patients had lower mortality (OR: 0.01; p < 0.0001) and less complications (OR: 0.07; p < 0.0001). Medicare (OR: 1.33; p < 0.0001) and higher comorbidity (OR: 1.26; p < 0.0001) patients utilized outpatient rehabilitation services more frequently. Medicare patients had twice the emergency department visits as the commercially insured (p < 0.0001). Medicare (16.6%) patients utilized more rehabilitation than commercially insured (13.4%) and Medicaid (9.1%) patients. Racial disparities were analyzed in a subset of 12,847 white and 4,780 African American (AA) patients. Multivariate analysis showed that AAs were more likely to experience a complication than white patients (OR: 1.13; p = 0.0024) and less likely to utilize outpatient rehabilitation services (OR: 0.83; p = 0.0025) than whites.

Conclusions Insurance and racial disparities continue to exist for TBI patients. Insurance status appears to have an impact on short- and long-term outcomes to a greater degree than patient race.

Keywords

traumatic brain Injury (TBI) - disparities - length of stay (LOS) - discharge disposition - resource utilization
 

  • References

  • 1 Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med 2002; 347 (20) 1585-1592
    Google Scholar
  • 2 Curry Jr WT, Barker II FG. Racial, ethnic and socioeconomic disparities in the treatment of brain tumors. J Neurooncol 2009; 93 (1) 25-39
    CrossrefPubMedGoogle Scholar
  • 3 Curry Jr WT, Carter BS, Barker II FG. Racial, ethnic, and socioeconomic disparities in patient outcomes after craniotomy for tumor in adult patients in the United States, 1988–2004. Neurosurgery 2010; 66 (3) 427-437 ; discussion 437–438
    CrossrefPubMedGoogle Scholar
  • 4 Eden SV, Heisler M, Green C, Morgenstern LB. Racial and ethnic disparities in the treatment of cerebrovascular diseases: importance to the practicing neurosurgeon. Neurocrit Care 2008; 9 (1) 55-73
    CrossrefPubMedGoogle Scholar
  • 5 Mukherjee D, Zaidi HA, Kosztowski TA , et al. Variations in referral patterns for hypophysectomies among pediatric patients with sellar and parasellar tumors. Childs Nerv Syst 2010; 26 (3) 305-311
    CrossrefPubMedGoogle Scholar
  • 6 Mukherjee D, Zaidi HA, Kosztowski T , et al. Disparities in access to neuro-oncologic care in the United States. Arch Surg 2010; 145 (3) 247-253
    CrossrefPubMedGoogle Scholar
  • 7 Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong II O. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep 2003; 118 (4) 293-302
    CrossrefPubMedGoogle Scholar
  • 8 Shafi S, de la Plata CM, Diaz-Arrastia R , et al. Ethnic disparities exist in trauma care. J Trauma 2007; 63 (5) 1138-1142
    CrossrefPubMedGoogle Scholar
  • 9 Kraus JF, Fife D, Ramstein K, Conroy C, Cox P. The relationship of family income to the incidence, external causes, and outcomes of serious brain injury, San Diego County, California. Am J Public Health 1986; 76 (11) 1345-1347
    CrossrefPubMedGoogle Scholar
  • 10 Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994. Acad Emerg Med 2000; 7 (2) 134-140
    CrossrefPubMedGoogle Scholar
  • 11 Arango-Lasprilla JC, Kreutzer JS. Racial and ethnic disparities in functional, psychosocial, and neurobehavioral outcomes after brain injury. J Head Trauma Rehabil 2010; 25 (2) 128-136
    CrossrefPubMedGoogle Scholar
  • 12 Gary KW, Arango-Lasprilla JC, Stevens LF. Do racial/ethnic differences exist in post-injury outcomes after TBI? A comprehensive review of the literature. Brain Inj 2009; 23 (10) 775-789
    CrossrefPubMedGoogle Scholar
  • 13 Hakmeh W, Barker J, Szpunar SM, Fox JM, Irvin CB. Effect of race and insurance on outcome of pediatric trauma. Acad Emerg Med 2010; 17 (8) 809-812
    CrossrefPubMedGoogle Scholar
  • 14 Maybury RS, Bolorunduro OB, Villegas C , et al. Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs. Surgery 2010; 148 (2) 202-208
    CrossrefPubMedGoogle Scholar
  • 15 Berry C, Ley EJ, Mirocha J, Salim A. Race affects mortality after moderate to severe traumatic brain injury. J Surg Res 2010; 163 (2) 303-308
    CrossrefPubMedGoogle Scholar
  • 16 Bowman SM, Martin DP, Sharar SR, Zimmerman FJ. Racial disparities in outcomes of persons with moderate to severe traumatic brain injury. Med Care 2007; 45 (7) 686-690
    CrossrefPubMedGoogle Scholar
  • 17 Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell III EE. Race and insurance status as risk factors for trauma mortality. Arch Surg 2008; 143 (10) 945-949
    CrossrefPubMedGoogle Scholar
  • 18 Bazarian JJ, Pope C, McClung J, Cheng YT, Flesher W. Ethnic and racial disparities in emergency department care for mild traumatic brain injury. Acad Emerg Med 2003; 10 (11) 1209-1217
    CrossrefPubMedGoogle Scholar
  • 19 Haider AH, Efron DT, Haut ER, DiRusso SM, Sullivan T, Cornwell III EE. Black children experience worse clinical and functional outcomes after traumatic brain injury: an analysis of the National Pediatric Trauma Registry. J Trauma 2007; 62 (5) 1259-1262 ; discussion 1262–1263
    CrossrefPubMedGoogle Scholar
  • 20 Downing SR, Oyetunji TA, Greene WR , et al. The impact of insurance status on actuarial survival in hospitalized trauma patients: when do they die?. J Trauma 2011; 70 (1) 130-134 ; discussion 134–135
    CrossrefPubMedGoogle Scholar
  • 21 Rosen H, Saleh F, Lipsitz S, Rogers Jr SO, Gawande AA. Downwardly mobile: the accidental cost of being uninsured. Arch Surg 2009; 144 (11) 1006-1011
    CrossrefPubMedGoogle Scholar
  • 22 Heffernan DS, Vera RM, Monaghan SF , et al. Impact of socioethnic factors on outcomes following traumatic brain injury. J Trauma 2011; 70 (3) 527-534
    CrossrefPubMedGoogle Scholar
  • 23 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40 (5) 373-383
    CrossrefPubMedGoogle Scholar
  • 24 Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45 (6) 613-619
    CrossrefPubMedGoogle Scholar
  • 25 Cryer C, Langley JD, Jarvis SN, Mackenzie SG, Stephenson SC, Heywood P. Injury outcome indicators: the development of a validation tool. Inj Prev 2005; 11 (1) 53-57
    CrossrefPubMedGoogle Scholar
  • 26 Langley J, Stephenson S, Cryer C. Measuring road traffic safety performance: monitoring trends in nonfatal injury. Traffic Inj Prev 2003; 4 (4) 291-296
    CrossrefPubMedGoogle Scholar
  • 27 Greene WR, Oyetunji TA, Bowers U , et al. Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma. Am J Surg 2010; 199 (4) 554-557
    CrossrefPubMedGoogle Scholar
  • 28 Rosen H, Saleh F, Lipsitz SR, Meara JG, Rogers Jr SO. Lack of insurance negatively affects trauma mortality in US children. J Pediatr Surg 2009; 44 (10) 1952-1957
    CrossrefPubMedGoogle Scholar
  • 29 Burstin HR, Lipsitz SR, Brennan TA. Socioeconomic status and risk for substandard medical care. JAMA 1992; 268 (17) 2383-2387
    Google Scholar
  • 30 Falcone Jr RA, Martin C, Brown RL, Garcia VF. Despite overall low pediatric head injury mortality, disparities exist between races. J Pediatr Surg 2008; 43 (10) 1858-1864
    Google Scholar
  • 31 Shafi S, Marquez de la Plata C, Diaz-Arrastia R , et al. Racial disparities in long-term functional outcome after traumatic brain injury. J Trauma 2007; 63 (6) 1263-1268 ; discussion 1268–1270
    CrossrefPubMedGoogle Scholar
  • 32 Staudenmayer KL, Diaz-Arrastia R, de Oliveira A, Gentilello LM, Shafi S. Ethnic disparities in long-term functional outcomes after traumatic brain injury. J Trauma 2007; 63 (6) 1364-1369
    CrossrefPubMedGoogle Scholar
  • 33 Nirula R, Nirula G, Gentilello LM. Inequity of rehabilitation services after traumatic injury. J Trauma 2009; 66 (1) 255-259
    CrossrefPubMedGoogle Scholar
  • 34 Osler TM, Cohen M, Rogers FB, Camp L, Rutledge R, Shackford SR. Trauma registry injury coding is superfluous: a comparison of outcome prediction based on trauma registry International Classification of Diseases-Ninth Revision (ICD-9) and hospital information system ICD-9 codes. J Trauma 1997; 43 (2) 253-256 ; discussion 256–257
    CrossrefPubMedGoogle Scholar