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INTRODUCTION: Uninsured patients often have poor clinical outcomes associated with lower access to care. Hospital Presumptive Eligibility (HPE) provides up to 60-d emergency Medicaid coverage for uninsured, low-income patients. After obtaining 60-d HPE, patients must file for ongoing Medicaid to sustain coverage; however, navigating HPE approval is complex. We conducted a qualitative study to understand (1) stakeholder perspectives on the application process and workflow and (2) facilitators and barriers to HPE approval to understand process improvement opportunities. MATERIAL AND METHODS: We conducted semi-structured interviews between September-December 2021 with key stakeholders (social workers, financial counselors, case managers, and private third-party vendor representatives) involved in HPE coverage determination, screening, approval, and Medicaid sustainment at our institution. We performed a team-based thematic analysis to elicit factors influencing HPE screening and approval, and recommendations for process improvement. RESULTS: Study participants described the HPE application and Medicaid approval processes. Patient-level barriers included information disclosure and immigration status, inability to contact patients or next-of-kin, and knowledge gaps about insurance acquisition and sustainment. System-level barriers included technical challenges with the state HPE application portal, inadequate staffing for patient screening, and short emergency department stays that limited opportunities to initiate HPE. Stakeholders proposed improvements in education, patient outreach, and logistics. CONCLUSIONS: This qualitative study reveals the process of HPE approval and outlines barriers within HPE and Medicaid processing from the perspective of direct hospital stakeholders. We identified opportunities at the patient, hospital, and policy levels that could improve successful HPE application and approval rates.
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Seguro de Salud , Medicaid , Estados Unidos , Humanos , Patient Protection and Affordable Care Act , Pacientes no Asegurados , Cobertura del Seguro , Hospitales , Accesibilidad a los Servicios de SaludRESUMEN
INTRODUCTION: Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA. METHODS: The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay. RESULTS: Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001). CONCLUSIONS: NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.
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Apendicectomía , Apendicitis , Tiempo de Internación , Humanos , Apendicitis/cirugía , Apendicitis/economía , Apendicitis/terapia , Apendicitis/epidemiología , Adulto , Masculino , Femenino , Persona de Mediana Edad , Apendicectomía/economía , Apendicectomía/estadística & datos numéricos , Estados Unidos/epidemiología , Tiempo de Internación/estadística & datos numéricos , Tiempo de Internación/economía , Anciano , Adulto Joven , Adolescente , Laparoscopía/economía , Laparoscopía/estadística & datos numéricos , Estudios Retrospectivos , Tratamiento Conservador/economía , Tratamiento Conservador/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricosRESUMEN
INTRODUCTION: There has been a sharp climb in the Unites States' death rate among opioid and other substance abuse patients, as well as an increased prevalence in gun violence. We aimed to investigate the association between substance abuse and gun violence in a national sample of patients presenting to US emergency departments (EDs). METHODS: We queried the 2018-2019 Nationwide Emergency Department Sample for patients ≥18 years with substance abuse disorders (opioid and other) using International Classification of Diseases, 10th Revision, Clinical Modification codes. Within this sample, we analyzed characteristics and outcomes of patients with firearm-related injuries. The primary outcome was mortality; secondary outcomes were ED charges and length of stay. RESULTS: Among the 25.2 million substance use disorder (SUD) patients in our analysis, 35,306 (0.14%) had a firearm-related diagnosis. Compared to other SUD patients, firearm-SUD patients were younger (33.3 versus 44.7 years, P < 0.001), primarily male (88.6% versus 54.2%, P < 0.001), of lower-income status (0-25th percentile income: 56.4% versus 40.5%, P < 0.001), and more likely to be insured by Medicaid or self-pay (71.6% versus 53.2%, P < 0.001). Firearm-SUD patients had higher mortality (1.4% versus 0.4%, P < 0.001), longer lengths of stay (6.5 versus 4.9 days, P < 0.001), and higher ED charges ($9269 versus $5,164, P < 0.001). Firearm-SUD patients had a 60.3% rate of psychiatric diagnoses. Firearm-SUD patients had 5.5 times greater odds of mortality in adjusted analyses (adjusted odds ratio: 5.5, P < 0.001). CONCLUSIONS: Opioid-substance abuse patients with firearm injuries have higher mortality rates and costs among these groups, with limited discharge to postacute care resources. All these factors together point to the urgent need for improved screening and treatment for this vulnerable group of patients.
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Servicio de Urgencia en Hospital , Trastornos Relacionados con Sustancias , Heridas por Arma de Fuego , Humanos , Masculino , Femenino , Adulto , Servicio de Urgencia en Hospital/estadística & datos numéricos , Estados Unidos/epidemiología , Heridas por Arma de Fuego/mortalidad , Heridas por Arma de Fuego/epidemiología , Heridas por Arma de Fuego/economía , Persona de Mediana Edad , Trastornos Relacionados con Sustancias/epidemiología , Adulto Joven , Tiempo de Internación/estadística & datos numéricos , Tiempo de Internación/economía , Violencia con Armas/estadística & datos numéricos , Epidemia de Opioides/estadística & datos numéricos , Adolescente , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/mortalidad , Trastornos Relacionados con Opioides/economía , Estudios RetrospectivosRESUMEN
INTRODUCTION: Emergency general surgery among cardiac surgery patients is increasingly common and consequential. We sought to characterize the true burden of emergency general surgery among hospitalized complex cardiac patients. METHODS: We performed a retrospective analysis of the 2016-2017 National Inpatient Sample. We included adult patients with a primary diagnosis of complex cardiac disease. We then compared patients who underwent emergency general surgery (GS-OR) with those who did not (non-GS-OR). The primary outcome was mortality; secondary outcomes included length of stay and hospitalization costs. RESULTS: We identified 10.2 million patients with a primary diagnosis of complex cardiac disease, of which 148,309 (1.4%) underwent GS-OR. Mortality rates were significantly higher in the GS-OR group (11.0% versus 5.0%, P < 0.001). Among all cardiac patients, GS-OR was associated with 2.2 times increased odds of death (aOR: 2.2, P < 0.001). GS-OR patients also had longer length of stays (14.1 versus 5.8 d, P < 0.001). Among all cardiac patients, GS-OR was associated with an 8.1-day longer length of stay (P < 0.001). GS-OR patients were less often routinely discharged home (31.7% versus 45.3%, P < 0.001) and incurred higher inpatient costs ($46,136 versus $16,303, P < 0.001). Among all cardiac patients, GS-OR patients incurred $30,102 higher hospitalization costs (P < 0.001). CONCLUSIONS: Emergency general surgery among cardiac surgery patients is associated with a greater than two-fold increase in mortality, longer length of stays, higher rates of nonroutine discharge, and higher hospitalization costs. Emergency general surgery complications account for 4.0% of total inpatient costs of cardiac surgery patients and merit further study.
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Cirugía General , Cardiopatías , Adulto , Humanos , Tiempo de Internación , Estudios Retrospectivos , Hospitalización , Alta del PacienteRESUMEN
INTRODUCTION: Trauma patients are twice as likely to be uninsured as the general population, which can lead to limited access to postinjury resources and higher mortality. The Hospital Presumptive Eligibility (HPE) program offers emergency Medicaid for eligible patients at presentation. The HPE program underwent several changes during the COVID-19 pandemic; we quantify the program's success during this time and seek to understand features associated with HPE approval. METHODS: A mixed methods study at a Level I trauma center using explanatory sequential design, including: 1) a retrospective cohort analysis (2015-2021) comparing HPE approval before and after COVID-19 policy changes; and 2) semistructured interviews with key stakeholders. RESULTS: 589 patients listed as self-pay or Medicaid presented after March 16, 2020, when COVID-19 policies were first implemented. Of these, 409 (69%) patients were already enrolled in Medicaid at hospitalization. Among those uninsured at arrival, 160 (89%) were screened and 98 (61%) were approved for HPE. This marks a significant improvement in the prepandemic HPE approval rate (48%). In adjusted logistic regression analyses, the COVID-19 period was associated with an increased likelihood of HPE approval (versus prepandemic: aOR, 1.64; P = 0.005). Qualitative interviews suggest that mechanisms include state-based expansion in HPE eligibility and improvements in remote approval such as telephone/video conferencing. CONCLUSIONS: The HPE program experienced an overall increased approval rate and adapted to policy changes during the pandemic, enabling more patients' access to health insurance. Ensuring that these beneficial changes remain a part of our health policy is an important aspect of improving access to health insurance for our patients.
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COVID-19 , Medicaid , Estados Unidos/epidemiología , Humanos , Pandemias , Estudios Retrospectivos , COVID-19/epidemiología , Políticas , Cobertura del SeguroRESUMEN
BACKGROUND: Morning rounds by an acute care surgery (ACS) service at a level one trauma center are uniquely demanding, given the fast pace, high acuity, and increased patient volume. These demands notwithstanding, communication remains integral to the success of surgical teams. Yet there are limited published curricula that address trauma inpatient communication needs. Observations at our institution confirmed that the surgical team lacked a shared mental model for communication. We hypothesized that creating a relationship-centered rounding conceptual framework model would enhance the provider-patient experience. STUDY DESIGN: A mixed-methods approach was used for this study. A multi-pronged needs assessment was conducted. Provider communion items for Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to measure patients' expressed needs. Faculty with experience in relationship-centered communication observed morning rounds and documented demonstrated behaviors. A five-hour workshop was designed based on the identified needs. A pre-and post-course Assessment and course evaluation were conducted. Provider-related patient satisfaction items were measured six months before the course and six months after the workshop. RESULTS: Needs assessment revealed a lack of a shared communication framework and a lack of leadership skills for senior trauma residents. Barriers included: time constraints, patient load, and interruptions during rounds. The curriculum was very well received. The self-reflected behaviors that demonstrated the most dramatic change between the pre and post-workshop surveys were: I listened without interrupting; I spoke clearly and at a moderate pace; I repeated key points; and I checked that the patient understood. All these changed from being performed by 50% of respondents "about half of the time" to 100% of them "always". Press Ganey top box likelihood to recommend (LTR) and provider-related top box items showed a trend towards improvement after implementing the training with a percentage difference of up to 20%. CONCLUSION: The Inpatient Relationship Centered Communication Curriculum (I-RCCC) targeting senior residents and Nurse Practitioners (NP) was feasible, practical, and well-received by participants. There was a trend of an increase in LTRs and provider-specific patient satisfaction items. This curriculum will be refined based on the study results and potentially scalable to other surgical specialties.
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Curriculum , Pacientes Internos , Humanos , Comunicación , Cuidados Críticos , DocentesRESUMEN
BACKGROUND: The American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record. METHODS: Our institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine-a machine learning algorithm attuned for small sample sizes-was used to compare the associations between the two classification systems and decision to operate and incidence of complications. RESULTS: 67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%). CONCLUSIONS: This study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.
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Toma de Decisiones Clínicas/métodos , Técnicas de Apoyo para la Decisión , Diverticulitis/diagnóstico , Complicaciones Posoperatorias/epidemiología , Índice de Severidad de la Enfermedad , Adulto , Anciano , Anciano de 80 o más Años , Diverticulitis/complicaciones , Diverticulitis/cirugía , Registros Electrónicos de Salud/estadística & datos numéricos , Estudios de Factibilidad , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Medición de Riesgo , Sociedades Médicas/normas , Máquina de Vectores de Soporte , Traumatología , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVES: Artificial intelligence (AI) has numerous applications in surgical quality assurance. We assessed AI accuracy in evaluating the critical view of safety (CVS) and intraoperative events during laparoscopic cholecystectomy. We hypothesized that AI accuracy and intraoperative events are associated with disease severity. METHODS: One thousand fifty-one laparoscopic cholecystectomy videos were annotated by AI for disease severity (Parkland Scale), CVS achievement (Strasberg Criteria), and intraoperative events. Surgeons performed focused video review on procedures with ≥1 intraoperative events (n = 335). AI versus surgeon annotation of CVS components and intraoperative events were compared. For all cases (n = 1051), intraoperative-event association with CVS achievement and severity was examined using ordinal logistic regression. RESULTS: Using AI annotation, surgeons reviewed 50âvideos/hr. CVS was achieved in ≤10% of cases. Hepatocystic triangle and cystic plate visualization was achieved more often in low-severity cases (P < 0.03). AI-surgeon agreement for all CVS components exceeded 75%, with higher agreement in high-severity cases (P < 0.03). Surgeons agreed with 99% of AI-annotated intraoperative events. AI-annotated intraoperative events were associated with both disease severity and number of CVS components not achieved. Intraoperative events occurred more frequently in high-severity versus low-severity cases (0.98 vs 0.40âevents/case, P < 0.001). CONCLUSIONS: AI annotation allows for efficient video review and is a promising quality assurance tool. Disease severity may limit its use and surgeon oversight is still required, especially in complex cases. Continued refinement may improve AI applicability and allow for automated assessment.
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Inteligencia Artificial , Colecistectomía Laparoscópica , Índice de Severidad de la Enfermedad , Humanos , Reproducibilidad de los Resultados , Estudios Retrospectivos , Grabación en VideoRESUMEN
BACKGROUND: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue. OBJECTIVE: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals. RESEARCH DESIGN: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges. RESULTS: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, â¼33,000 adults and children were enrolled in California's HPE program per month. CONCLUSION: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.
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Medicina Hospitalar/economía , Medicaid/economía , Patient Protection and Affordable Care Act/estadística & datos numéricos , California , Determinación de la Elegibilidad/métodos , Determinación de la Elegibilidad/estadística & datos numéricos , Humanos , Medicaid/estadística & datos numéricos , Estados UnidosRESUMEN
BACKGROUND: Domestic and intimate partner violence (DV) are under-reported causes of injury. We describe the health care utilization of DV patients, hypothesizing they are at increased risk of mortality. METHODS: We queried the 2014 Nationwide Emergency Department Sample for adult patients (18 y and older) with a primary diagnosis of trauma. DV was abstracted using International Statistical Classification of Diseases, ninth Revision codes for partner or spouse intimate violence, abuse, or neglect. The primary outcome was mortality; secondary outcomes included admission rates and charges. RESULTS: Among 14 million trauma patients, 654,356 (5.0%) had a diagnosis of DV. Compared with other trauma patients, DV patients were younger (34.6 versus 46.8 y, P < 0.001), more often male (69.5% versus 50.1%, P < 0.001), and more likely to be uninsured (31.5% versus 15.6%, P < 0.001). 9154 (1.4%) were injured because of intimate partner violence, of which 90.2% were female. Drug and alcohol abuse (22.2%), anxiety (1.8%), and depression (1.3%) were high among all DV trauma patients. DV emergency department charges were higher ($4462 versus $2,871, P < 0.001). In adjusted analyses, DV trauma patients had 2.1 higher odds of mortality (aOR: 2.31, P < 0.001). DV trauma patients were also associated with a $1516 increase in emergency department charges compared with non-DV trauma patients (95% CI: $1489-$1,542, P < 0.001). CONCLUSIONS: Injuries related to all types of DV are emerging as a public health crisis among both genders. To mitigate under-reporting, it is important to identify at-risk patients and provide them with appropriate resources.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Violencia de Pareja/estadística & datos numéricos , Violación/estadística & datos numéricos , Heridas y Lesiones/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Servicio de Urgencia en Hospital/economía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Estados Unidos/epidemiología , Heridas y Lesiones/economíaRESUMEN
BACKGROUND: Hospitalized patients with hematologic malignancies (HMs) may require abdominal operations for complications of malignancy, treatment sequelae, or unrelated abdominal pathology. We determined predictors of mortality after emergency general surgery for patients with HM using national-level data. MATERIALS AND METHODS: We analyzed the 2010-2014 National Inpatient Sample for International Classification of Disease, Ninth Revision, Clinical Modification codes for HM and abdominal operations, comparing adult patient encounters with abdominal operations with HM to those without HM. Multivariate logistic regression was performed to identify predictors of mortality. RESULTS: Of the 7.9 million adult inpatient encounters where abdominal surgery was performed, 82,187 (1%) had concomitant diagnoses of HM. Mortality among patient encounters with HM was significantly higher than without HM (9.0% versus 2.0%; P < 0.0001). Patient encounters with HM and surgery and a diagnosis of acute abdominal pain had mortality rates as high as 41%. The median standardized risk ratio for death after the top 25 general surgery procedures was 2.9 (interquartile range: 2.2-3.8) among patients with HM. In adjusted analyses, odds of mortality among patients with HM undergoing surgery were increased by concomitant acute abdominal pain diagnosis (odds ratio [OR] = 2.6; P < 0.0001), coagulopathy (OR = 2.0; P < 0.0001), aplastic anemia (OR = 1.7; P < 0.0001), peripheral vascular disease (OR = 1.4; P = 0.001), and weight loss (OR = 1.3; P < 0.0001). CONCLUSIONS: Although uncommon, surgery on patients with HM is associated with mortality rates nearly five times higher than the general surgical population. Patients with HM requiring surgical intervention may be at particularly high odds of death and postoperative complications.
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Cavidad Abdominal/cirugía , Tratamiento de Urgencia/mortalidad , Neoplasias Hematológicas/cirugía , Mortalidad Hospitalaria , Procedimientos Quirúrgicos Operativos/mortalidad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Neoplasias Hematológicas/inmunología , Neoplasias Hematológicas/mortalidad , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Factores de Riesgo , Adulto JovenRESUMEN
OBJECTIVE: To assess the consistent availability of basic surgical resources at selected facilities in seven countries. METHODS: In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available. FINDINGS: Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh. CONCLUSION: Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.
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Cirugía General , Recursos en Salud/provisión & distribución , Accesibilidad a los Servicios de Salud , Bangladesh , Bolivia , Etiopía , Guatemala , Encuestas de Atención de la Salud , Humanos , Laos , Liberia , Rwanda , Factores de TiempoRESUMEN
ABSTRACT: The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the healthcare system - the patient, the healthcare organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints.
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Academic productivity is important for career advancement, yet not all trainees have access to structured research programs. Without formal teaching, acquiring practical skills for research can be challenging. A comprehensive research course that teaches practical skills to translate ideas into publications could accelerate trainees' productivity and liberate faculty mentors' time. We share our experience designing and teaching "A Practical Introduction to Academic Research", a course that teaches practical skills including building productive habits, recognizing common statistical pitfalls, writing cover letters, succinct manuscripts, responding to reviewers, and delivering effective presentations. We share open-source educational material used during the Winter 2022 iteration to facilitate curriculum adoption at peer institutions.
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We present the case of a previously healthy 29-year-old male who presented with a small bowel obstruction in the absence of previous abdominal surgery who was found to have evidence of an occult seatbeltabrasion and ultimately multifocal hollow viscus injury secondary to blunt abdominal trauma at the time of exploratory laparotomy. Hollow viscus injury is a rare, but potentially life-threatening, complication of blunt abdominal trauma. While cross-sectional imaging is an important diagnostic tool, results must be considered within a patient's clinical context as delays in surgical management can lead to significant morbidity and mortality.
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BACKGROUND: Traumatic injury leads to significant disability, with injured patients often requiring substantial health care resources to return to work and baseline health. Temporary disability or inability to work can result in changes or loss of employer-based private insurance coverage, which may significantly impact health care access and outcomes. Among privately insured patients, we hypothesized increased instability in insurance coverage for patients with higher severity of injury. METHODS: Adults 18 years and older presenting to a hospital with traumatic injury were evaluated for insurance churn using Clinformatics Data Mart private-payer claims. Insurance churn was defined as cessation of enrollment in the patient's private health insurance plan. Using Injury Severity Score (ISS), we compared insurance churn over the year following injury between patients with mild (ISS, <9), moderate (ISS, 9-15), severe (ISS, 16-24), and very severe (ISS, >24) injuries. Kaplan-Meier analysis was used to compare time with insurance churn by ISS category. Flexible parametric regression was used to estimate hazard ratios for insurance churn. RESULTS: Among 750,862 privately insured patients suffering from a traumatic injury, 50% experienced insurance churn within 1 year after injury. Compared with patients who remained on their insurance plan, patients who experienced insurance churn were younger and more likely male and non-White. The median time to insurance churn was 7.7 months for those with mild traumatic injury, 7.5 months for moderately or severely injured, and 7.1 months for the very severely injured. In multivariable analysis, increasing injury severity was associated with higher rates of insurance churn compared with mild injury, up to 14% increased risk for the very severely injured. CONCLUSION: Increasing severity of traumatic injury is associated with higher levels of health coverage churn among the privately insured. Lack of continuous access to health services may prolong recovery and further aggravate the medical and social impact of significant traumatic injury. LEVEL OF EVIDENCE: Economic and Value Based Evaluations; Level III.
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Accesibilidad a los Servicios de Salud , Cobertura del Seguro , Seguro de Salud , Adulto , Humanos , Masculino , Bases de Datos Factuales , Puntaje de Gravedad del Traumatismo , Estados UnidosRESUMEN
BACKGROUND: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to postdischarge resources, and provides patients with a path to sustain coverage through Medicaid. Because HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status 6 months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment. METHODS: Using a customized longitudinal claims data set for HPE-approved patients from the California Department of Health Care Services, we analyzed adults with a primary trauma diagnosis (International Classification of Diseases version 10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at 6 months. Univariate and multivariate analyses were performed. RESULTS: A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at 6 months. Compared with patients who did not sustain, those who sustained had higher Injury Severity Score (ISS > 15: 73.5% vs. 68.7%, p < 0.001), more frequent surgical intervention (74.8% vs. 64.5%, p < 0.001), and were more likely to be discharged to postacute services (23.9% vs. 10.4%, p < 0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%), and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS > 16) (vs. ISS < 15: adjusted odds ratio [aOR], 1.51; p = 0.02) and surgery (aOR, 1.85; p < 0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR, 0.05; p < 0.001) decreased the likelihood of Medicaid sustainment. CONCLUSION: Hospital Presumptive Eligibility programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to health care services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.
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Cuidados Posteriores , Medicaid , Adulto , Estados Unidos , Humanos , Alta del Paciente , Etnicidad , Cobertura del Seguro , Seguro de SaludRESUMEN
Health equity is defined as the sixth domain of healthcare quality. Understanding health disparities in acute care surgery (defined as trauma surgery, emergency general surgery and surgical critical care) is key to identifying targets that will improve outcomes and ensure delivery of high-quality care within healthcare organizations. Implementing a health equity framework within institutions such that local acute care surgeons can ensure equity is a component of quality is imperative. Recognizing this need, the AAST (American Association for the Surgery of Trauma) Diversity, Equity and Inclusion Committee convened an expert panel entitled 'Quality Care is Equitable Care' at the 81st annual meeting in September 2022 (Chicago, Illinois). Recommendations for introducing health equity metrics within health systems include: (1) capturing patient outcome data including patient experience data by race, ethnicity, language, sexual orientation, and gender identity; (2) ensuring cultural competency (eg, availability of language services; identifying sources of bias or inequities); (3) prioritizing health literacy; and (4) measuring disease-specific disparities such that targeted interventions are developed and implemented. A stepwise approach is outlined to include health equity as an organizational quality indicator.