Safety-Net Hospitals Have Higher Complication and Mortality Rates in the Neurosurgical Management of Traumatic Brain Injuries

Abstract

Clinical outcomes in the surgical management of severe traumatic brain injury (TBI) have been shown to vary across different hospital institutions. The effect of the safety-net burden on postoperative mortality, complication rates, and failure to rescue rates is unclear. We evaluated the relationship of the safety-net burden with outcomes in the treatment of patients with severe TBI undergoing neurosurgery. The hospitals were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time. Multivariate analyses were performed to examine significant associations with the degree of safety-net burden while controlling for potential confounders. Data from 20,989 encounters in 788 hospitals were included. Compared with low-burden hospitals (LBHs), high-burden hospitals (HBHs; odds ratio [OR], 1.48; 95% confidence interval [CI], 1.04-2.12; P= 0.03) had greater mortality rates. Major complications were more likely to occur at HBHs (OR, 1.44; 95% CI, 1.12-1.84; P < 0.01) compared with LBHs. The failure to rescue rates were similar among all safety-net burden hospital groups. Patients at HBHs also had an increased likelihood of an extended length of stay (OR, 1.92; 95% CI, 1.12-3.29; P= 0.02) and receiving a tracheostomy or gastrostomy (OR, 1.99; 95% CI, 1.36-2.89; P < 0.01) compared with patients at LBHs. The present study found that a greater hospital safety-net burden was independently associated with greater rates of mortality and major complications in the treatment of patients with severe TBI undergoing neurosurgery. Further research in evaluating the cause of disparities in mortality outcomes at high safety-burden hospitals is needed.