98. Disparities in trauma care: the association of insurance status with diagnostic and therapeutic procedure administration in spine trauma

Abstract

<h3>BACKGROUND CONTEXT</h3> Research has suggested substantial disparities in the care of uninsured patients, manifesting as greater delays in care, fewer procedures conducted and greater postoperative complication rates when compared to insured patients. The manifestation of such disparities in the acute trauma setting pertaining to the spine is less understood and remains an issue of debate. <h3>PURPOSE</h3> To investigate the association of lack of insurance with the probability of diagnostic and therapeutic procedure administration to patients undergoing spine trauma in Level I-IV trauma centers. <h3>STUDY DESIGN/SETTING</h3> This was a retrospective cohort study. <h3>PATIENT SAMPLE</h3> A total of 222,602 patients who were registered in National Trauma Data Bank (NTDB) from 2011 to 2019 and initially evaluated in the emergency department of Level I-IV trauma centers in the United States for spine trauma were included. <h3>OUTCOME MEASURES</h3> The outcome measures were rates of select diagnostic and therapeutic procedures being administered to patients. <h3>METHODS</h3> We performed a retrospective cohort study involving spine trauma patients aged 18 to 64 years who were registered in the National Trauma Data Bank (NTDB) between 2011 and 2019. Patients who were missing insurance information, dead on arrival, or had an injury severity score (ISS) less than 9 were excluded. Baseline patient characteristics were compared using bivariate analysis, and multivariate logistic analysis was employed to investigate the association of insurance status with mortality and probability of select diagnostic and therapeutic procedures, adjusting for age, sex, race, ethnicity, ISS, presence of shock, mechanism of injury, intent of injury, Glasgow Coma Scale (GCS) motor score, significantly different comorbidities and year of admission. <h3>RESULTS</h3> Overall, 39,421 patients (17.71%) were uninsured and 183,181 patients (82.29%) were insured. Comorbidity analyses revealed significant differences in alcoholism, bleeding disorder, congestive heart failure, current smoker status, chronic renal failure, stroke, diabetes mellitus, functionally dependent health status, history of myocardial infarction, hypertension, respiratory disease, cirrhosis, and dementia. No differences existed in terms of ISS (17 vs 17; p=0.95), but the uninsured were more likely to present in shock (6.41% vs 5.62%; p <0.001). Mortality rate was greater in uninsured patients compared to their insured counterparts (7.19% vs. 4.70%; p < 0.001). Multivariable logistic regression analysis demonstrated an association of uninsured status with decreased likelihood of receiving magnetic resonance imaging of the spine (odds ratio [OR] = 0.98; p < 0.001) and operative spinal fixation (OR=0.98; p <0.001) and with increased likelihood of receiving computed tomography (CT) of the spine (OR=1.02, p 0.001) compared to insured patients. There were no differences in the likelihood of receiving plain radiography (OR=1.00; p=0.80) or packed red blood cell (PRBC) transfusion within 4 hours (OR=1.00; p=0.21). Subgroup analysis of Level I trauma centers demonstrated persistent insurance-based disparities in the likelihood of operative spinal fixation (OR=0.98; p <0.001) and withdrawal of care (OR=1.01; p <0.001) for the uninsured. <h3>CONCLUSIONS</h3> In summary, lack of insurance was associated with decreased probability of select diagnostic and therapeutic procedures and increased probability of withdrawal of care in spine trauma, with such disparities more pronounced for resource-intensive procedures such as MRI and operative fixation. Differences in care, especially pertaining to therapeutic procedures, continue to persist in Level I trauma centers. Disparities in diagnostic and therapeutic work-up in the acute post-trauma setting may contribute to insurance-based disparities in spine trauma outcomes. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.