Research Reports - Effect of insurance and racial disparities on outcomes in traumatic brain injury

J Neurol Surg A Cent Eur Neurosurg. 2015 Mar 23

Schiraldi M(1), Patil CG(1), Mukherjee D(1), Ugiliweneza B(2), Nuño M(1), Lad
SP(3), Boakye M(2)

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.

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