Impact of Medicaid Expansion on Trauma Patients at Extreme Risk of Mortality: A Time-Series Analysis.

BACKGROUND: The 2014 expansion of Medicaid under the Affordable Care Act (ACA) reshaped healthcare delivery in the United States. This study assessed how Medicaid expansion affected in-hospital mortality in patients with extreme risk of mortality (EROM) from traumatic injuries. METHODS: Data from inpatients aged 18-64 years, registered in the National Inpatient Sample between 2007 and 2020, and identified with trauma-related All-Patient Refined Diagnosis Related Groups (APRDRG) codes, were analyzed. Within this group, a subset of patients was selected based on the APRDRG classification identifying them as at EROM for the principal unit of analysis. The cohort was divided into high-implementation (HIR) and low-implementation (LIR) regions based on Medicaid expansion coverage. In-hospital mortality was assessed using interrupted time-series analysis. Sensitivity analyses considered seasonality, autocorrelation, and exogenous events. RESULTS: Analysis encompassed 70 381 trauma inpatient stays, corresponding to 346 659 patients based on National Inpatient Sample weighting. There was a consistent monthly decline in in-hospital mortality of .08% (95% CI: -.103 to -.048; P < .001) prior to Medicaid expansion, a trend unaffected by expansion. This pattern persisted across both LIR and HIR Medicaid implementation regions. Although Medicaid enrollment increased in HIR, that in LIR remained unchanged. DISCUSSION: Over the study period, the in-hospital mortality among severely injured patients consistently decreased, and this trend was not influenced by Medicaid expansion. The statistical models and results from this study can offer valuable guidance to policymakers and healthcare leaders as they formulate more efficient and effective policies.

The role of race and insurance in trauma patients' mortality: A cross-sectional analysis based on a nationwide sample.

BACKGROUND: Persistent disparities in trauma in-hospital mortality owing to insurance status and race remain a prominent issue within healthcare. This study explores the relationships among insurance status, race, length of stay (LOS) in-hospital mortality outcomes in trauma patients at extreme risk of mortality (EROM) trauma patients. METHODS: Data was retrieved from the National Inpatient Sample, focusing on high-acuity trauma patients from 2007 to 2020, aged 18-64 years. Patients were identified using specific All Patient Refined Diagnosis Related Groups codes. Emphasis was placed on those with EROM owing to their resource-intensive nature and the potential influence of insurance on outcomes. Patients aged 65 years or older were excluded owing to distinct trauma patterns, as were those diagnosed with burns or non-trauma conditions. RESULTS: The study encompassed 70,381 trauma inpatients with EROM, representing a national estimate of 346,659. Being insured was associated with a 34% decrease in the odds of in-hospital mortality compared to being uninsured. The in-hospital mortality risk associated with insurance status varied over time, with insurance having no impact on in-hospital mortality during hospitalizations of less than 2 days (short LOS). In the overall group, Black patients showed an 8% lower risk of in-hospital mortality compared to White patients, while they experienced a 33% higher risk of in-hospital mortality during short LOS. CONCLUSION: Insured trauma inpatients demonstrated a significant reduction in the odds of in-hospital mortality compared to their uninsured counterparts, although this advantage was not present in the short LOS group. Black patients experienced lower in-hospital mortality rates compared to White patients, but this trend reversed in the short LOS group. These findings underscore the intricate relationships between insurance status, race, and duration of hospitalization, highlighting the need for interventions to improve patient outcomes.

Atmospheric dust characterisation in the mining district of Cartagena-La Unión, Spain: Air quality and health risks assessment.

Nowadays, air pollution has a major impact on the environment and human health. Owen gauges allow the sampling of atmospheric depositions in polluted sites for further characterisation. This paper shows the study of the air particles of an old mining zone in Cartagena-La Unión (South-east of Spain) in order to quantify their potential risk on human health. There were 4 strategic sites monitored: the main mining tailing (Avenque), the urban area (La Unión), an agricultural zone (formerly mining) and a site in the Mediterranean coast. Physico-chemical and mineralogical characterisation was applied to atmospheric fallouts. The granulometry revealed a dust particle size around 15 µm, with the coarsest particles in the urban area and the thinnest at the tailing site. XRD analyses showed the presence of quartz, carbonates, sulphides and sulphates. Observations with SEM-EDX confirmed chemical spectra and allowed us to classify the particles into well-crystallised minerals and heterogeneous dusts. Total metal content determination was carried out by ICP-MS analyses and results showed Zn, Pb, As and Cd fluxes (respectively 2549, 1275, 68 and 7 µg·m-2·d-1) exceeding the limit values set by European legislations in the mining area. The fluxes of Zn, Pb and As also exceed these standards in the urban area whereas the coastal zone only exceeds the thresholds in the case of As. Inhalation health risk (defined by US EPA, 2009) was quantified in the sites using total and bioaccessible metal contents of the dusts. Risk calculations using total metal content considering a residential scenario showed acceptable risk for all sites except for the mining tailing which presented non-acceptable cancer and hazard risk mainly due to the total As and Pb contents. When considering the bioaccessible fraction of As and Pb, the risk diminished to acceptable values, demonstrating the overestimation produced when using total metal contents.

Environmental impact assessment of industrial activities on heavy metals distribution in street dust and soil.

Street dust and soil are important materials for evaluating the contaminants level in industrial areas. Detailed size-resolved distribution of metal(loid)s in street dusts and soils influenced by industrial activities has rarely been investigated. This study was carried out to understand how industrialization might affect the size distribution of metal(loid)s concentration and contamination level in the street dust and soil from Murcia, southern Spain. An industrial and a natural areas were selected and surface soil and street dust samples were taken. They were fractionated into eleven size classes and total concentrations of Pb, Zn, Cu, Cd, Cr, Ni, As and Fe were determined in both the bulk samples and their fractions. Enrichment factor, geoaccumulation index, and mass loading of different heavy metal(loids) were calculated. The results indicated that the street dust from natural and industrial areas had almost the same particle size distribution, both containing higher percentage of coarse-sized particles than the soil. Industrialization seems to have only slightly affected the concentration of most elements studied in the soil. In contrast, the concentrations of the heavy elements in bulk industrial dust samples and all their size fractions were extremely higher than those from the natural area. This means that the industrial activities only affected the size dependency of the concentration (contamination level) of certain elements (Pb, Zn, Cu, Cd, and Cr) in the street dust, but not in the soil.

Heavy metal concentrations in particle size fractions from street dust of Murcia (Spain) as the basis for risk assessment.

Street dust has been sampled from six different types of land use of the city of Murcia (Spain). The samples were fractionated into eleven particle size fractions (<2, 2-10, 10-20, 20-50, 50-75, 75-106, 106-150, 150-180, 180-425, 425-850 µm and 850-2000 µm) and analyzed for Pb, Cu, Zn and Cd. The concentrations of these four potentially toxic metals were assessed, as well as the effect of particle size on their distribution. A severe enrichment of all metals was observed for all land-uses (industrial, suburban, urban and highways), with the concentration of all metals affected by the type of land-use. Coarse and fine particles in all cases showed concentrations of metals higher than those found in undisturbed areas. However, the results indicated a preferential partitioning of metals in fine particle size fractions in all cases, following a logarithmic distribution. The accumulation in the fine fractions was higher when the metals had an anthropogenic origin. The strong overrepresentation of metals in particles <10 µm indicates that if the finest fractions are removed by a vacuum-assisted dry sweeper or a regenerative-air sweeper the risk of metal dispersion and its consequent risk for humans will be highly reduced. Therefore, we recommend that risk assessment programs include monitoring of metal concentrations in dust where each land-use is separately evaluated. The finest particle fractions should be examined explicitly in order to apply the most efficient measures for reducing the risk of inhalation and ingestion of dust for humans and risk for the environment.