Impact of Type of Insurance on Infection Rates after Trauma
Jaswin Sawhney, Brown University; Andrew Stephen, Rhode Island Hospital; Stephanie Lueckel, Brown University; Michael Connolly, Brown Medical School/RI Hospital; Charles Adams, Jr., Brown Medical School/R.I. Hospital; David Tobin Harrington, Rhode Island Hospital; William Cioffi, Rhode Island Hospital; Daithi Heffernan, Brown University
We have previously shown that insurance, specifically government insurance, affects trauma related outcomes. Insurance status often affects diagnosis and management of medical conditions. Infection risk is often related to preinjury management of comorbidities. Despite the Affordable Care Act (ACA) of 2010, with increased government insurance, disparities in access to care and management of baseline health status continue to exist.Hypothesis:
Type of insurance will affect infection risk after trauma
A 10 year retrospective review of blunt trauma patients. Data reviewed included demographics, comorbidities, and injury severity score(ISS). Infections were either clinically evident (eg abscess, cellulitis) or culture based (eg UTI, catheter, pneumonia via alveolar lavage). We divided insurance types into Private/Commercial(PC), Medicare(MCare), Medicaid(MAid) and Self Pay(SP). Analyses were undertaken for younger (18-45yrs) and older (>/=65yrs) patients. To assess health care access and maintenance, pre-trauma HbA1c was reviewed in known diabetics.Results:
A total of 20,633 patients were included – 6,203 PC, 7,636 MCare, 2,798 MAid and 3,996 SP. Among patients aged 18-45 years, SP were youngest (SP=29.3; PC=29.8; MAid=30.3; MCare=33.9 years; p<0.05) and had highest ISS (11.4 vs 10.9 vs 9.9 vs 10.5;p<0.05). Rates of comorbidities were highest in MCare patients (28.1%) vs PC (16.7%), MAid (19.9%) and SP (12.9%);p<0.05. Specifically pre-trauma %HbA1c was highest in MAid patients(8.8%) vs PC(7.7%), MCare(7.2%) and SP(7.3%);p<0.05. Rates of infections were highest in MAid patients(7.7%) vs PC(5.6%), MCare(6.3%) and SP(4.3%);p<0.05. Across all insurance groups, the presence of comorbidities was associated with increased risk of infections (OR 4.1; 95%CI=3.2-4.9). Adjusting for age, gender, ISS and number of comorbidities, MAid was associated with a significantly increased risk of infection(OR 1.6; 95%CI=1.1-2.3). This held true across individual specific comparisons, MAid vs PC(OR 1.9; 95%CI=1.5-2.5), vs MCare(OR 2.01; 95%CI=1.2-3.2) and vs SP(OR2.2; 95%CI=1.7-2.9). Similar finding were noted in the older (>/=65 years) patients.Conclusions:
Not all insurance is created equally. Insurance type, specifically Medicaid, is associated with increased risk of trauma related infections.Despite the advent of the ACA with potentially more government insured patients, factors related to reasons for insurance, access and utilization of health care will continue to exist and affect trauma related infections.