Impact of Insurance Expansion on Disposition for Pediatric Trauma Patients: A National Trauma Data Bank Cohort Study

Abstract

The insurance status of pediatric trauma patients is associated with access to post-discharge resources, including inpatient rehabilitation. Our goal was to understand the impact of changes in insurance coverage on access to post-acute care resources for pediatric trauma patients. We utilized the National Trauma Data Bank from 2012 to 2016 for all pediatric trauma patients with a highest body region abbreviated injury score >2. Our primary outcome was hospital discharge disposition location. We used multivariable regression to adjust for salient patient and trauma center characteristics. Additionally, we performed a sensitivity analysis including only high-volume hospitals to examine the relationship between the magnitude of facility level expansion in coverage and changes in patient disposition. We identified 195,649 pediatric trauma patients meeting inclusion criteria. From 2012 to 2016 the proportion of patients with Medicaid (35% versus 39%, P < 0.001) and private insurance (39% versus 45%, P < 0.001) increased. Increased discharges with home health (HH) (+0.6% adjusted risk difference 2012 to 2016, P < 0.001) and decreased discharges to inpatient rehabilitation and skilled nursing facilities (-0.6% adjusted risk difference 2012 to 2016, P=0.01) were associated with changes in insurance coverage. After stratifying high volume facilities by magnitude of increase in Medicaid and private insurance, we found that, for all groups, discharge to inpatient rehabilitation and skilled nursing facilities decreased (P < 0.01). Expanded insurance coverage for children was paradoxically associated with decreased discharge to inpatient rehabilitation and skilled nursing facilities after severe traumatic injury. These findings suggest that additional barriers may drive limitations in access to pediatric post-discharge services.