THE EFFECTS OF INSURANCE STATUS ON PEDIATRIC TRAUMATIC BRAIN
INJURY OUTCOMES
by
Austin Murray
BA, Augustana College, 2012
Submitted to the Graduate Faculty of
Epidemiology
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2014 i
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Austin Murray
on
December 15, 2014
and approved by
Essay Advisor:
Anthony Fabio, PhD, MPH
Assistant Professor
Epidemiology
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Michael Bell, MD
Professor
Critical Care Medicine
University of Pittsburgh
______________________________________
______________________________________
ii
Copyright © by Austin Murray
2014
iii
Anthony Fabio, PhD, MPH
THE EFFECTS OF INSURANCE STATUS ON PEDIATRIC TRAUMATIC BRAIN
INJURY OUTCOMES
Austin Murray, MPH
University of Pittsburgh, 2014
ABSTRACT
Objective: To explore the current literature that describes the effects of insurance status on
traumatic brain injury (TBI) outcomes among pediatric patients in order to gain a better
understanding of its public health relevance. Method: This review was conducted using the
Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA). A search of
OVID Medline was conducted in December of 2013 for peer-reviewed articles that included
keywords related to “brain injuries” and “insurance status”. Results: After screening for
inclusion and exclusion criteria between the two researchers a total of 12 articles were included
and considered relevant for review. Discussion/Summary: The findings of this study indicate that
Insurance status has a significant effect on the health outcomes of pediatric patients who
experience TBI. It seems clear that insured patients have significantly lower odds of mortality
following traumatic brain injury. Additionally, those insured by the government, while still
faring better than uninsured patients still have higher odds of mortality than those who are
insured commercially. This study also found evidence that insurance status plays a role in long
term outcomes such as rehabilitation and disability.
iv
TABLE OF CONTENTS
1.0
INTRODUCTION ........................................................................................................ 1
1.1
TBI SIGNIFICANCE IN PUBLIC HEALTH .................................................. 2
1.1.1
ED Visits ........................................................................................................... 3
1.1.2
Hospitalizations................................................................................................ 4
1.1.3
Mortality ........................................................................................................... 5
1.1.4
Cost ................................................................................................................... 6
2.0
METHODS ................................................................................................................... 7
3.0
RESULTS ..................................................................................................................... 9
3.1
4.0
5.0
STUDY TYPES AND ARTICLE SUMMARIES ........................................... 10
DISCUSSION ............................................................................................................. 17
4.1.1
SES .................................................................................................................. 17
4.1.2
Racial factors.................................................................................................. 18
4.1.3
Quality of Care............................................................................................... 20
4.2
WEAKNESES AND LIMITATIONS .............................................................. 20
4.3
FUTURE DIRECTIONS................................................................................... 21
SUMMARY/CONCLUSIONS .................................................................................. 23
BIBLIOGRAPHY ....................................................................................................................... 24
v
LIST OF TABLES
Table 1. Articles Reviewed ........................................................................................................... 14
vi
LIST OF FIGURES
Figure 1. Inclusion/Exclusion Process .......................................................................................... 10
vii
1.0
INTRODUCTION
Trauma is a leading cause of death and disability among children living in the United States with
75-97% of all pediatric trauma deaths being attributed specifically to traumatic brain injury
(TBI). According to the CDC, patients between the ages of 0-19 are at the greatest risk of
experiencing a traumatic event leading to serious brain injury[1]. Research has identified a
number of racial, cultural, and economic characteristics that predict health outcomes among
pediatric TBI patients. Many studies report disparities among minorities and patients with low
socioeconomic status (SES), stating that they tend to have higher mortality rates and lower
recovery rates [2-5].
Studies have also shown that these same populations have a
disproportionally lower number of patients who undergo surgical intervention or get placed into
long-term rehabilitation programs. The existence of outcome disparities are clear, however the
underlying causes are still unapparent. It has been suggested that both insurance status, in
addition to race, is an independent predictor of TBI outcome [6]. Insurance status has also been
found to be an important factor in determining a child’s outcome after a traumatic injury [7].
Research clearly shows that insurance status affects treatment and health outcomes among about
patient, but literature on effects of insurance on pediatric TBI outcomes has yet to be widely
published. Additionally, changes in national health policies that were recently made, in large
part, to increase the number of individuals who carry insurance will likely have an effect on
health outcomes. It is important, then, to understand this relationship to provide a benchmark for
1
researchers, health workers, and policy makers. For these reasons, we conducted a systematic
literature review that aims to examine whether insurance status is related to mortality, placement
into rehabilitation treatment programs, and long term health outcomes among pediatric TBI
patients.
1.1
TBI SIGNIFICANCE IN PUBLIC HEALTH
Traumatic Brain injury (TBI) is characterized as an injury to the head that causes disruption to
normal brain function. It is the one of the leading causes of injury, death, and disability in the
United States and affects people of all demographics. TBI contributed to over 50,000 deaths in
2010 along with 280,000 hospitalizations and 2.2 million emergency department (ED) visits. TBI
related deaths account for about one third of all injury related deaths with an estimated 138
deaths associated with TBI every day. ED visits, hospitalizations, and death rates are higher
among men than women. Overall, TBI rates are highest among children between ages 0 and 4
years old, followed by young adults aged 15 to 24. The leading cause of TBI are falls followed
by Motor vehicle accidents and workplace/sports related injuries. Between 2001 and 2010, there
was an increase in total TBIs and TBI related ED visits from 420.6 ED visits/100,000 people to
715.7 ED visits/100,000people with a sharp increase starting in 2007 from a rate of 457.5 ED
visits/100,000 people. The number of TBI related hospitalizations, however remained relatively
constant at about 100 hospitalizations/100,000 people from 2001 to 2010. The TBI mortality rate
decreased after 2007, dropping from 18.2 deaths/100,000 people to 17.1 deaths/100,000 people
in 2012.
2
1.1.1 ED Visits
There were an estimated 715.7 ED visits due to TBI/100,000 people in 2010 which rose from
420.6 in 2001. Data from 2001 to 2010 show that men have consistently had higher rates of TBI
related ED visits. TBI ED visits among males and females have has an increasing trend from
2002 to 2010. Among males, the TBI related ED visits rose from 494.6 visits/100,000 men in
2001 to 800.4 visits/100,000 men in 2010, a 63% increase. There was a notable increase in ED
visits among men from 2007 to 2009 where the rates increased from 491.6 visits/100,000 men to
850.9 visits/100,000 men. Female rates have also increased. From 2001 to 2010, rates of female
TBI related ED visits went from 349.3 visits/100,000 women to 633.7 visits/100,000 women, an
81% increase, with a spike similar to men between 2007 and 2010 that went from 424.3
visits/100,000 women to 633.7 visits/100,000 women.
The youngest age groups consistently have the highest rates of TBI related ED visits with
the elderly following close behind. The 0-4 year age group has the highest rates of TBI related
ED visits with a rate of 2193.8 visits/100,000 people followed by the 15-24 year age group with
981.9 visits/100,000 people and 5-14 year age group with 888.7 visits/100,000 people. While
rates of TBI related ED visits gradually rose from 2001 to 2010, there was a marked increase in
TBI related ED visits among children age 0-4 from 2007 to 2010 that jumped from 1374.0/100k
to 2193.8/100,000, a 72% increase.
TBI related ED visits due to falls were the most common mechanism among the youngest
and oldest age groups with the proportion of TBIs due to falls decreasing sharply in the 5-14 and
15-24 year age groups and rising again in the 25-40 year and 45-64 year age groups. Among the
youngest and oldest age groups, 72.8% and 71.8%, respectively, of all TBI related ED visits
were due to falls in 2010. Despite having much lower rates than the 0 to 4 year age group, falls
3
were still quite common with 35.1% of all TBI related ED visits resulting from a fall. In this age
group, the proportion of falls was closely followed by Injuries caused by being struck by/against
something, generally sports setting, attributing for about 34.9% of TBI related ED visits In that
age group. TBI related ED visits due to assault were highest among the age groups of 15-24 and
24-44 composing of about 22% of all TBI related ED visits. These age groups also had relatively
similar proportions of TBI related ED visits due to falls and MVC’s.
1.1.2 Hospitalizations
There were an estimated 91.7 hospitalizations due to TBI /100,000 people In the US in 2010
which increased from 82.7 hospitalizations/100,000 people in 2001. TBI related hospitalizations
were higher among men than women with rates of 106.3 hospitalizations/100,000 men and 77.6
hospitalizations/100,000 women in 2010. From 2001 to 2010, men have had some fluctuation in
TBI hospitalization rates but haven’t changed much in terms of trends with 104.0
hospitalizations/100,000 men in 2001 and 106.3 hospitalizations/100k men in 2010. Women,
though,
have
seen
an
increase
in
TBI
related
hospitalization
rates
with
62.1
hospitalizations/100,000 women in 2001 rising to 77.6 hospitalizations/100,000 women in 2010,
a 25% increase.
Elderly patients over the age of 65 had, by far, the highest rates of TBI related
hospitalizations at 294.0 hospitalizations/100,000 people. The next highest were the 15-24 year
and 45-64 year age groups, both at around 80 hospitalizations/100,000 people. Trends over time
differed by age group. The number of TBI related hospitalizations among those over 65 years
increased from 191.5 hospitalizations/100,000 people to 294.0 hospitalizations/100,000 people
over the span of 2001 and 2010, a 54% increase. The other age groups showed much less change
4
over time. TBI related hospitalizations gradually decreased from 2001 to 2010 among the
youngest age groups while there was a slow incline among adults aged 45-64, rising 32%
between 2001 and 2010.
Falls were the most common mechanism of injury among overall that resulted in TBI
related hospitalization. Among the age groups 0 to 4 years, 5 to 14, 45 to 64, and 65 and older,
falls were the most common mechanism of injury with 46.2%, 22.8%, 24.6%, and 37.7% of TBI
related hospitalizations being attributable to falls. Among those aged 15 to 24 years and 25 to 44
years, motor vehicle accidents were the most common mechanism resulting in hospitalization
with 32.6% and 24.6% of all TBI related admissions, respectively, being related to an MVC.
1.1.3 Mortality
Males have consistently had higher TBI mortality rates than females. In 2010 the TBI mortality
rate among males was 25.4/100,000 and 9.0/100,000 among females. From 2001 to 2010, male
TBI mortality decreased from 27.8/100,000 to 25.4/100,000, a 9% decrease. Female TBI
mortality also decreased from 9.6 in 2001 to 9.0 in 2010, a 6% decrease.
TBI mortality was highest among the 65 years and over group with 45 deaths/100,000 in
2010. The age groups 15-24 years, 25-44 years, and 45-64 years all had similar mortality rates in
2010, with 15.6 deaths/100,000, 14 deaths/100,000, and 17.6 deaths/100,000, respectively. The
youngest two age groups, 0-4 and 5-14, had the lowest mortality rates or 4.3 deaths/100,000 and
1.9 deaths/100,000, respectively. Mortality among those aged 65 and older increased from 41.2
deaths/100,000 in 2001 to 45.2 deaths/100,000 in 2010, a 10% increase. Conversely, mortality
among those aged 15-24 decreased from 23.4 deaths/100,000 to 15.6 deaths/100,000, a 33%
decrease.
5
1.1.4 Cost
TBI imposes a major economic burden to the survivors and their families. McGregor et al.
estimated that mild cases of TBI ranged from $33,284 to $35,954 and moderate cases ranged
from $25,174 to $81,153 per case. These estimates were based primarily on acute care costs and
do not take into account long term care and rehabilitation. The total annual direct medical costs,
rehabilitation costs, and indirect socioeconomic costs are estimated to be $60 billion. According
to a recent study, over 50% of TBI survivors were still moderately to severely disabled after 1
year. Another study found that most severe TBI survivors are neither employed nor enrolled in
school after 4 years. An estimated 3.2 to 5.3 million people in the US are living with long-term
disability as a result of head injury.
6
2.0
METHODS
Our review was conducted using the Preferred Reporting Items of Systematic Reviews and
Meta-Analysis (PRISMA). We conducted a search of OVID Medline in December of 2013 for
peer-reviewed articles that included keywords related to “brain injuries” and “insurance status”.
We focused on studies that included pediatric patients and focused on health outcomes. We
defined traumatic brain injury as any injury that resulted in a diagnosis of traumatic brain injury,
as recorded in medical records.
We divided insurance status as commercial/private and
government. Outcomes were broken into two primary categories, in-hospital mortality and longterm outcomes. Long term outcomes were defined as any outcome that was measured after
hospital discharge and included placement into rehabilitation care and resulting disability.
Articles that were not available in English were not included in our analysis. We also
excluded articles focused on abuse as research indicates that child abuse cases are qualitatively
different from non-abuse cases. Articles that did not include pediatric aged cases were not
included in the analysis, as well as papers that did not specify head injury or insurance status.
Two independent researchers first screened the titles and abstracts of all potential articles
that were found during the search against the exclusion criteria. The articles were then read in
closer detail by the researchers who individually constructed a list of included and excluded
articles based on of the defined exclusion criteria. The two lists were compared and any
7
disagreement was reconciled before coming to a final list of articles that both researchers agreed
upon.
8
3.0
RESULTS
After using the listed OVID search terms, 47 potential articles were found. An additional 7
articles that appeared to meet criteria were found through a citation review, adding to a total of
54 potential articles. These articles were then read in detail in to determine whether they met the
proper inclusion and exclusion criteria. After screening and verification between the two
researchers, a total of 12 articles were included and considered relevant for review (Fig. 1).
9
Figure 1. Inclusion/Exclusion Process
3.1
STUDY TYPES AND ARTICLE SUMMARIES
We reviewed twelve articles that fit our criteria (Table 1).
Eleven of the articles were
retrospective analyses [6-16], eight of which collected medical records from the National
Trauma Data Bank[6-8, 10-13, 15], 1 from the PICU at a level 1 pediatric trauma hospital in
10
Milwaukee, Wisconsin[9], one from the Kids’ Inpatient Data Base[14], and one from the
Nationwide Independent Sample data base[16]. One study [10] sampled the National Trauma
Data bank in order to compare to their data which was collected from The Cincinnati Children’s
Hospital Medical Center. The remaining article was a prospective cohort study design which
collected data from The North Texas Traumatic Brain Injury Research Center which consists of
two urban level 1 trauma hospitals[17].
The literature reviewed in this study generally agrees that insurance status has a
protective effect on health outcome. Eleven studies compared outcomes between insured and
uninsured patients [6-9, 11-17]. Nine of these studies included in-hospital mortality as an
outcome and all nine found that a lack of insurance increased the odds of mortality [6-9, 11-14,
16]. Two studies included rehab placement as an outcome and both found that uninsured
patients were less likely to be placed into a rehabilitation facility [8, 15]. One study included
disability and functional measures as an outcome and found that uninsured patients had more
disability than their insured counterparts[17]. Nine studies divided insured patients into those
with private/commercial insurance and those with government insurance [7-10, 12, 13, 15-17].
One study further divided government insured patients into Medicare and Medicaid [8]. Of these
nine studies, six articles looked at in-hospital mortality [7-10, 12, 13, 16]. The literature seems
to suggest there is an increased risk of mortality among government insured patients compared to
commercially insured patients however there is quite a bit of uncertainty. Three of the seven
studies reported insignificant results [10, 12, 16] and the remaining studies, while statistically
significant, had confidence intervals very close to 1. Of the two studies that focused on
rehabilitation, both found that government insured patients had lower odds of being placed into a
11
rehabilitation program than privately insured [15, 17], however one yielded insignificant results
[17].
12
Table 1. Articles Reviewed
20
Table 1 Continued
20
Table 1 Continued
20
4.0
DISCUSSION
On the whole, the literature suggests that there is a protective relationship of having insurance on
pediatric TBI outcomes. In all eight studies that looked at mortality among that patients who
lacked insurance had significantly increased odds of mortality. This trend in insurance status has
been seen in other issues as well [2-5]. Studies have found that insurance status is an independent
predictor of outcome in issues such as breast cancer [18], leukemia [19], and diabetes [20].
Further dividing insurance status into commercial and government categories gives little insight
about whether insurance type affects outcome as results were conflicting and most results were
only borderline significant.
The findings in the reviewed articles provide strong evidence that insurance has a
protective association with pediatric TBI outcomes. The mechanism by which insurance effects
outcomes is still unclear, however, it is complex with insurance effecting outcomes in a number
of ways. The articles reviewed provide some insight into what they may be.
4.1.1 SES
Socioeconomic status has been linked to poor health outcomes for many different health issues
for a number of different reasons. It’s been suggested that insurance status and SES are closely
associated to each other. That is, people of low SES are generally less likely to have insurance
20
and are therefore more prone to have poor outcomes. Several of the studies reviewed provided
additional insight into other ways in which SES may affect insurance status and outcomes among
pediatric TBI patients. Hospitals located in areas with lower economic success have historically
seen lower quality in care and worse outcomes in a variety of diseases and surgical
interventions.[21-23] Piatt et al. found that patients who live in Zip codes with higher median
income tended to have significantly decreased mortality rates, increased charges, and more major
and minor neurological surgeries.[14] Interestingly enough, another study we reviewed, done by
Tilford et al. [16] found no increase in mortality among patients from low-income households.
These conflicting results suggest that there is likely some difference between households with
low incomes and larger areas with low median income. Hospitals who perform poorly have been
noted to serve higher populations of minority, uninsured, and low income patients. [21-23] This
means that hospitals whose patients are more likely to be a minority, have low-income, and are
underinsured are burdened with providing care with constrained budgets. This generally
manifests in staffing shortages, outdated equipment and technology, and the inability to invest in
quality of care improvements. [22-24] It is likely that a disproportionate number of uninsured
individuals are treated in these challenged hospitals which could explain in part the disparities
seen in uninsured children and TBI outcomes. While interesting, there wasn’t enough evidence
available in this review to draw any conclusions on the relationship between SES, insurance
status, and health outcomes.
4.1.2 Racial factors
Racial disparities in pediatric TBI outcomes have been well established. We found that in almost
every study, race was a significant factor in mortality and rehabilitation placement. There is,
20
however some question as to how much insurance status plays into this. Shafi et al. [15, 17],
Cassidy et al. [9], Haider et al. [12], and Bowman et al [8] all showed higher percentages of
uninsured patients in minorities compared to whites. This suggests that insurance and race are
associated in some why and could account for at least some of the apparent racial disparities. The
extent of the role this plays is less apparent. One study [15] found that after controlling for
insurance status, associated injuries, overall injury severity, age, and gender there was no
significant difference between African American patients placed into rehab and white patients.
It’s worth noting, however, there was still a significant difference in Hispanics. Piatt et al. found
that while whites were more likely to receive a minor neurosurgical procedure, there was no
significant difference in the number of major neurosurgical procedures and total charges after
adjusting for confounders[14]. The findings of Boeman et al. [8] conflict with this finding. Even
after adjusting for sex, severity, and insurance blacks and Hispanics were significantly less likely
to be admitted to a rehabilitation program. When looking at mortality, this same study found no
significant difference by race. This finding was contradicted by Haider et al. [6] who found that
odds of mortality does increase even after stratifying by insurance status. The contradicting
evidence makes interpretation difficult. Shafi et al. [17] attempted to address this and found that
observed racial disparities in moderate to severe disability decreased in odds from 2.17 to 1.17
after including insurance status into the model. Given that there are known racial disparities in
many health issues it is not likely that insurance status is able to account for the observed racial
disparities in TBI. The two factors, however, are clearly not independent of one another and
more research is needed to better understand this relationship.
20
4.1.3 Quality of Care
It has been hypothesized that patients without insurance are likely to receive lower quality of
care. TBI is expensive because it often requires emergency surgical intervention and long term
treatment and rehabilitation services. Uninsured individuals are likely not able to pay for the
services offered by hospitals and other practices which makes medical decision making more
complicated as hospitals and clinicians may be reluctant to order expensive tests and procedures
that they know will likely not be paid for. Piatt et al. [14] found that self-pay status was highly
associated with fewer major procedures and Bowman et al. [8] found that self-pay patients were
significantly less likely to be admitted to a rehabilitation program. Furthermore, Tilford et al.
[16] found that uninsured children were significantly less likely to receive intracranial pressure
monitoring, a measure of treatment aggression that he showed had a protective effect on
mortality, and that aggressiveness of treatment can account for up to one third of the disparity
between insured and uninsured patients. It was unclear exactly why uninsured patients were
receiving this demonstrably lower standard of care however there may be many reasons. A
number of possibilities have been suggested however at this point there has only been
speculation and very little is known.
4.2
WEAKNESES AND LIMITATIONS
There are a number of weaknesses to the studies reviewed. Only eleven articles were found that
met the inclusion criteria. The underwhelming amount of literature that looked at children
specifically made it impossible to draw any strong conclusions. While they seemed to align with
20
other health issues, more studies that focus specifically on pediatric TBI cases need to be
conducted in order to develop a real understanding of the situation.
Of the eleven articles that were reviewed, only one was a prospective study.
The
remaining ten analyzed retrospective data. Furthermore, the ten retrospective studies all used
data collected from the National Trauma Data bank. While the national data bank provides data
representative of the US, the fact that almost all of the studies reviewed made conclusions based
on samples drawn from the same pool of data introduces potential bias into the review.
A large amount of the literature reviewed in this study had a primary focus on racial and
ethnic issues with insurance being a secondary category included in the model. This is a concern
because there may be confounding the relationship between insurance and outcomes specifically
that these studies did not take into account because they were primarily focused on race and
ethnicity.
4.3
FUTURE DIRECTIONS
This review helped to explore the effect of insurance on pediatric TBI outcomes but it also
highlighted the need for more research in this field. The majority of the articles reviewed were
retrospective and drew data from the National Trauma Data Bank. Prospective studies are needed
in order to gain a better understanding of the relationship between insurance and TBI. In addition
to adding diversity and volume to the limited literature currently available, these studies will
have the added benefit of allowing for long term follow up data that could include rehabilitation
placement, disability, comorbidity, and long term mortality measures.
20
The mechanism by which insurance status effects health outcome is still relatively
unclear. In order to better understand this, studies that track the use and allocation of resources
should be done. With this information it will be possible to determine whether insurance affects
factors such as aggressiveness of treatment and type and quality of treatment. It will also provide
data that could highlight where resources are needed in order to improve health outcomes.
20
5.0
SUMMARY/CONCLUSIONS
The findings of this study indicate that Insurance status has a significant effect on the health
outcomes of pediatric patients who experience TBI. It seems clear that insured patients have
significantly lower odds of mortality following traumatic brain injury.
Additionally, those
insured by the government, while still faring better than uninsured patients still have higher odds
of mortality than those who are insured commercially. This study also found evidence that
insurance status plays a role in long term outcomes such as rehabilitation and disability. These
trends are seen in other health issues such as cancer and heart disease which seems to indicate
that disparities by insurance status is a complex problem that can affect many people in a number
of ways. While the conclusions seemed to align with other health issues, more studies that focus
only on pediatric TBI cases need to be conducted in order to develop a real understanding of the
situation. This is especially the case now, given the recent change in US healthcare policy. With
the intention of increasing the number of insured individuals and improving healthcare
outcomes, it is important to establish healthcare states as they stand so future researchers and
policymakers will have something to use as a benchmark to compare to.
20
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