J Neurol Surg A Cent Eur Neurosurg 2015; 76(03): 224-232
DOI: 10.1055/s-0034-1543958
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Effect of Insurance and Racial Disparities on Outcomes in Traumatic Brain Injury

Michael Schiraldi
1   Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States
*   Authors contributed equally to this manuscript.
Chirag G. Patil
1   Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States
*   Authors contributed equally to this manuscript.
Debraj Mukherjee
1   Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States
Beatrice Ugiliweneza
2   Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
Miriam Nuño
1   Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States
Shivanand P. Lad
3   Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States
Maxwell Boakye
2   Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States
› Author Affiliations
Further Information

Publication History

08 April 2014

24 October 2014

Publication Date:
23 March 2015 (online)


Introduction We evaluated outcome and resource utilization disparities between commercially insured, Medicaid, and Medicare patients. We further analyzed racial disparities in a subset cohort.

Methods We reviewed the MarketScan database (2000–2009) for adult traumatic brain injury (TBI) patients. Analyses were performed to evaluate outcome differences by insurance type and race. Outpatient service utilization disparities by insurance and race were also evaluated.

Results Our study included 92,159 TBI patients, 44,108 (47.9%) of whom utilized commercial insurance, 19,743 (21.4%) utilized Medicaid, and 28,308 (30.7%) utilized Medicare. In-hospital mortality was lowest for commercially insured (5.0%) versus 7.6% and 8.5% for Medicaid and Medicare patients, respectively (p < 0.0001). Medicaid patients had a longer hospitalization than commercially insured (12 days versus 6 days; p < 0.0001). Medicaid patients were 1.29 and 1.78 times more likely to die and experience complications than the commercially insured. Females had a lower mortality risk (odds ratio [OR]: 0.80, p < 0.0001) and less complications (OR: 0.67; p < 0.0001) than males. Higher comorbidities increased mortality risk (OR: 2.71; p < 0.0001) and complications (OR: 2.96, p < 0.0001). Mild injury patients had lower mortality (OR: 0.01; p < 0.0001) and less complications (OR: 0.07; p < 0.0001). Medicare (OR: 1.33; p < 0.0001) and higher comorbidity (OR: 1.26; p < 0.0001) patients utilized outpatient rehabilitation services more frequently. Medicare patients had twice the emergency department visits as the commercially insured (p < 0.0001). Medicare (16.6%) patients utilized more rehabilitation than commercially insured (13.4%) and Medicaid (9.1%) patients. Racial disparities were analyzed in a subset of 12,847 white and 4,780 African American (AA) patients. Multivariate analysis showed that AAs were more likely to experience a complication than white patients (OR: 1.13; p = 0.0024) and less likely to utilize outpatient rehabilitation services (OR: 0.83; p = 0.0025) than whites.

Conclusions Insurance and racial disparities continue to exist for TBI patients. Insurance status appears to have an impact on short- and long-term outcomes to a greater degree than patient race.

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