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Disparities in Health Care Utilization of Adults With Traumatic Brain Injuries Are Related to Insurance, Race, and Ethnicity: A Systematic Review

Gao, Shiyao, MPH; Kumar, Raj, G., MPH; Wisniewski, Stephen, R., PhD; Fabio, Anthony, PhD, MPH

Journal of Head Trauma Rehabilitation: May/June 2018 - Volume 33 - Issue 3 - p E40–E50
doi: 10.1097/HTR.0000000000000338
Focus on Clinical Research and Practice

Objective: To characterize racial/ethnic and insurance disparities in the utilization of healthcare services among US adults with traumatic brain injury (TBI).

Methods: The PubMed database was used to search for articles that directly examined the association between race/ethnicity and insurance disparities and healthcare utilization among patients with TBI. Eleven articles that met the criteria and were published between June 2011 and June 2016 were finally included in the review.

Results: Lack of insurance was significantly associated with decreased use of inhospital and posthospital healthcare services among patients with TBI. However, mixed results were reported for the associations between insurance types and healthcare utilization. The majority of studies reported that racial/ethnic minorities were less likely to use inhospital and posthospital healthcare services, while some studies did not indicate any significant relation between race/ethnicity and healthcare utilization among patients with TBI.

Conclusions: This review provides evidence of a relation between insurance status and healthcare utilization among US adults with TBI. Insurance status may also account for some portion of the relation between race/ethnicity and healthcare utilization.

Epidemiology Data Center (Ms Gao and Drs Wisniewski and Fabio) and Departments of Epidemiology and Physical Medicine and Rehabilitation (Mr Kumar), University of Pittsburgh, Pittsburgh, Pennsylvania.

Corresponding Author: Anthony Fabio, PhD, MPH, Epidemiology Data Center, University of Pittsburgh, 4420 Bayard St, Ste 600, Pittsburgh, PA 15260 (afabio@pitt.edu).

The authors thank Barbara L. Folb for assistance with searching of relevant articles.

The authors declare no conflicts of interest.

ACCORDING to the Centers for Disease Control and Prevention, more than 1 million new cases of traumatic brain injury (TBI) were diagnosed among the general population with approximately 50 000 deaths every year.1 Each year, around 275 000 hospitalizations and 1.365 million visits to emergency departments were associated with TBI in the United States.2 Currently, an estimated 5.3 million individuals in the United States are living with disabilities due to TBI, including cognitive impairment and psychological issues.3 Moreover, TBI has imposed substantial financial and healthcare service burdens on society. Hu et al4 reported that the median hospital costs among adults with TBI were $13 000 for those 18 to 64 years of age and $9000 for those 65 years of age or older.

Racial/ethnic minorities appear to be at increased risk for TBI and poor health outcomes after TBI. According to the Centers for Disease Control and Prevention's report, between 2002 and 2006, the average annual rates of TBI-related emergency department visits were estimated to be 456.6 and 568.7 per 100 000 population among whites and African Americans, respectively. Compared with whites, African Americans also had higher annual TBI-related hospitalization rate (69.8 vs 78.7 per 100 000 population).2 On average, American Indian/Alaskan Natives had the highest annual TBI-related mortality rate among the general population and also for males and females, respectively.1 African Americans had the second highest annual average TBI-related mortality rates overall and for males.1 Minorities were also reported to have poorer functional outcomes on all measures at hospital discharge and 1 year postinjury than whites after TBI.5 It is important to note that racial/ethnic minorities are overrepresented among low-income populations and less likely to have medical insurance,6 which may contribute to their poor health status.

Insurance status is an important predictor of health outcomes among patients with TBI.7 , 8 Using the National Trauma Data Bank, Alban et al7 demonstrated that insured patients had lower mortality rates than uninsured patients after TBI. Gardizi and colleagues8 also reported that patients with government-funded insurance were more likely to experience higher levels of disability than those with commercial insurance after TBI. Although race/ethnicity and insurance status have been reported to be strongly related to health outcomes among patients with TBI,7–9 whether they are associated with healthcare service utilization among patients with brain injuries has been seldom discussed.

Disparities in the use of healthcare services among people from various racial, ethnic, and insurance groups may account for some of the observed differences in TBI outcomes. Understanding such disparities may lead to better treatment and long-term care across all populations with TBI. In this review, we aim to characterize racial/ethnic and insurance disparities in the utilization of inhospital and posthospital health services among US adults with TBI.

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METHODS

A recent systematic review of literature published before 2011 summarized findings of racial/ethnic and socioeconomic disparities in health services cost and utilization after TBI in the United States and worldwide,10 while our review focused more on the recent trends. Therefore, we acquired articles published only in the past 5 years. The process used to obtain citations is shown in Figure 1. We searched PubMed for related articles published between June 14, 2011, and June 11, 2016. The MeSH database was used to identify entry terms related with TBI in PubMed. Terms including “brain injury,” “brain injuries,” “brain trauma,” “brain traumas,” “traumatic brain injury,” “TBI,” “traumatic brain injuries,” “TBIs,” “acute brain injury,” and “acute brain injuries” were utilized to search for articles on TBI that had 1 or more of these terms in the title or abstract. To identify articles related to healthcare utilization, we applied 2 searches using general terms “(insur* OR race OR ethnic*) AND hospital AND utilization” and “(insur* OR race OR ethnic*) AND discharge.” Articles on disparities in healthcare utilization after TBI should be contained in both search results for TBI and healthcare utilization, so we used the “AND” operator to systematically identify those articles. Finally, a total of 56 articles were considered for review.

Figure 1

Figure 1

The inclusion criteria were (1) must include measures of healthcare utilization including inhospital or posthospital healthcare services associated with TBI, (2) must include adults, (3) must compare different racial or ethnic or insurance groups, and (4) must be published in English. Exclusion criteria were (1) focused on non-US populations, (2) focused on pediatric patients with TBI (<18 years of age), and (3) were reviews, editorial articles, or reports.

Titles and abstracts of all articles returned from the search engine were reviewed. Twelve articles in non-US settings were excluded. Ten articles that focused on pediatric TBI were also excluded as were 14 articles that did not include measures or results of healthcare utilization and 9 articles that did not include comparisons of different racial/ethnic or insurance groups in healthcare utilization after TBI. For the remaining 11 articles, full texts were reviewed. Citations for these articles were also considered, but none met the inclusion or exclusion criteria. Therefore, 11 articles were finally used in this review.

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RESULTS

Tables 1 and 2 indicate the characteristics of study populations and main findings of the 11 articles. Most articles reported that lack of insurance was strongly associated with decreased use of inhospital and posthospital health services. However, results were inconsistent about whether racial/ethnic minorities were less likely to utilize inhospital or posthospital healthcare services. All articles used retrospective cohort study design. Among them, 1 article matched on age, Injury Severity Score, Glasgow Coma Scale, and primary payer group.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

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Data sources

Five studies collected their data from nationwide databases including National Trauma Data Bank, Thomson Reuter's MarketScan database, and Nationwide Inpatient Sample.11–15 Two studies used statewide databases: Oregon Hospital Discharge Data Index and New York State Inpatient Databases Healthcare Cost and Utilization Project.16 , 17 One study of veterans with TBI used data from Veterans Health Administration Decision Support System and Vital Status files.18 Three other studies enrolled participants on the basis of the records from local hospitals or trauma centers (TCs) including Northwestern Memorial Hospital, Northwestern level I TC and Neurology/Neurosurgery Intensive Care Unit.19–21

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Study populations

A majority of studies included all adult patients with a diagnosis of TBI as their study populations, while others used extra inclusion criteria according to their hypotheses. Patients enrolled in the study by Crandall et al19 had mild TBIs that were determined by symptoms and Glasgow Coma Scale score of 13 to 15. Scheetz17 focused on older patients (≥65 years of age) with same-level falls admitted to hospitals. Rubin et al21 included patients with only severe TBI who had been mechanically ventilated. Pickham et al14 selected patients with TBI at high risks for both pulmonary embolism and bleeding complications from chemoprophylaxis.

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Measures of healthcare utilization

Of the 11 articles, 6 evaluated both racial/ethnic disparities and insurance disparities in healthcare utilization, 4 looked only at racial/ethnic disparities, and 1 reported only insurance disparities. For healthcare utilizations, different studies focused on different healthcare services ranging from inhospital procedures to rehabilitation admissions. Scheetz's17 study aimed to identify potential predictors for TC admissions and hospital length of stay (LOS) among older patients with TBI. Hospital LOS was also measured in the study by Schiraldi et al.15 The placement of inferior vena cava filter was the primary outcome in the study by Pickham et al.14 Rubin et al21 used withdrawals of mechanical ventilation (WMV) and the time to WMV as their primary outcomes. Missios and Bekelis13 focused on the procedural volumes that patients received during hospitalization for TBI in their study. In addition, 7 of the 11 studies examined discharge destinations, rehabilitation use, or outpatient follow-up visits to healthcare settings as outcomes.11 , 12 , 15 , 16 , 18–20

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Racial/ethnic disparities in healthcare utilization

Most studies included non-Hispanic whites, African Americans, and Hispanics, while some also included individuals from other racial groups.11–13 , 16–19 Two studies compared only healthcare utilizations between 2 racial groups—whites and African Americans, or whites and Hispanics.15 , 20 In the study by Rubin et al,21 race was categorized only as white and nonwhite. For inhospital procedures, nonwhite patients with severe TBI were less likely to have mechanical ventilation withdrawn even after adjusting for socioeconomic or marital status, severity of illness, and previous decisions about surgery or invasive procedures.21 However, this difference did not contribute to lower mortality among nonwhite patients.21 No significant association was found between race and inhospital procedural volume for TBI after controlling for insurance status.13 One study of veterans, however, noted that Hispanic veterans were less likely than non-Hispanic whites to utilize all examined services except imaging.18

Mixed results have been reported regarding the association between race and hospital LOS among patients with TBI. In the study by Scheetz,17 black race was a strong risk factor for longer hospital LOS, while African Americans and whites had similar LOS in the study by Schiraldi et al.15 Scheetz17 also showed that Hispanic ethnicity and “other” race except for white and black were strong predictors of admission to TCs among older patients with fall-induced TBI. For posthospital healthcare utilizations, 5 studies indicated that racial/ethnic minorities were less likely to be discharged to inpatient/outpatient/intensive rehabilitation and posthospitalization care (PHC) or to visit TBI clinics and neurology and mental healthcare services.11 , 12 , 15 , 16 , 18 One study reported that African Americans were less likely than whites to use outpatient rehabilitation services but more likely to use emergency services.15 However, 2 studies did not find such racial/ethnic disparities in posthospital care utilization after TBI.19 , 20 The study by Crandall et al19 showed that race did not predict patients' follow-up with TC or rehabilitation institute. In the study by Janus et al,20 ethnicity was not significantly associated with discharge destination among patients with TBI.

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Insurance-related disparities in healthcare utilization

Insurance disparities in healthcare utilization were widely reported in the reviewed studies. In the study by Pickham et al,14 patients without health insurance had a prophylactic inferior vena cava filter placed less often than patients with any form of insurance, even after adjusting for patient and hospital characteristics. Lack of insurance was also strongly associated with low inhospital procedural volume among patients with TBI.13 Scheetz17 found that among older patients with TBI, insurance status was an important predictor for TC admissions. Patients with commercial insurance or other types of insurance such as worker's compensation or government programs for veterans were more likely to be admitted to TC than those having Medicare as the primary payer.17 In addition, patients with commercial insurance had much better inhospital outcomes including lower inpatient mortality and shorter index hospitalizations than patients with Medicaid.15 Lack of insurance was also a strong risk factor for lower posthospital healthcare utilization among patients with TBI. Overall, patients without insurance were less likely to be discharged to rehabilitation or PHC than insured patients with TBI.11 , 16 , 19 Among insured patients with TBI, insurance type was tested for associations with use of posthospital healthcare services. One study demonstrated that Medicaid patients used outpatient rehabilitation less often and emergency services more often than patients with commercial insurance.15 However, Kane et al16 found that patients with public insurance or Worker's compensation were more likely to be discharged to PHC than patients with commercial insurance.

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DISCUSSION

Insurance-related disparities in healthcare utilization among patients with TBI were widely reported in the articles included in our systematic review. However, results were inconsistent about the racial/ethnic disparities in healthcare utilization in this population. Lack of insurance was significantly associated with decreased use of inhospital procedures such as a prophylactic inferior vena cava filter and posthospitalization or rehabilitative care. In addition, insurance type was also related to health service utilization among patients with TBI, although results were inconsistent about the association between insurance type and risk for low posthospital health service utilization. In some studies, nonwhite patients including African Americans and Hispanics were less likely to use higher-level rehabilitation services than whites. However, other studies did not report any significant relation between race/ethnicity and inhospital or posthospital health service utilization among patients with TBI.

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Racial/ethnic disparities in healthcare utilization

The majority of the articles in this review demonstrated that, compared with non-Hispanic whites, racial/ethnic minorities were less likely to use healthcare services, especially posthospital rehabilitation after TBI. A similar conclusion was drawn by Dismuke et al10 in a systematic review that summarized findings from literature published between 2000 and 2011. The observed racial/ethnic disparities in rehabilitation use among patients with TBI have been reported by reviewed studies using different populations including veterans, younger adults, and older adults.10–12 , 16 These studies, based on databases ranging from nationwide data to records from single hospitals, all supported race/ethnicity as an important predictor of posthospital healthcare utilization among people with TBI. Although 2 studies did not show any significant relation between race/ethnicity and posthospital healthcare use,19 , 20 limitations in these studies may preclude such findings. Both studies were performed at single sites, results of which may not be generalizable to all patients with TBI in the United States. The study by Crandall et al19 enrolled patients with only mild TBI and measured their follow-up with TC or Rehabilitation Institute of Chicago. The observed statistically nonsignificant relation between race and healthcare utilization in their study may not be true for the general population. In the study by Janus et al,20 hospital discharge destinations were simply categorized into home and care facility. Potential misclassification of posthospital healthcare use within this study may account for the observed statistically nonsignificant association between ethnicity and discharge destination among patients with TBI.

The basis for the relation between race/ethnicity and inhospital healthcare utilization among patients with TBI is not clear due to the very limited studies. Although 2 studies focusing on the relation between race and hospital LOS reported conflicting results,13 , 21 this might be caused by inherent differences between the populations. One study enrolled all adults with TBI, while the other only recruited older adults with TBI from a fall.15 , 17 In addition, one study showed that WMV were less likely in nonwhite patients than whites with severe TBI, while the other one did not indicate any significant association between race and inhospital procedural volume.13 , 21 However, both studies have several limitations. In the study by Missios and Bekelis,13 only 5 trauma interventions that were strongly related to severe TBI were considered to calculate the procedural volume; other supportive or medical procedures were not taken into account. In the study by Rubin et al,21 several potential confounders including medical interventions and comorbidity of patients were not adjusted, which may obscure the true relation between race and WMV. Thus, we cannot definitely draw a conclusion about the relation between race/ethnicity and inhospital healthcare utilization such as LOS, procedural volume, or a specific procedure among patients with TBI because of the limitations of the few qualifying studies.

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Insurance-related disparities in healthcare utilization

Seven articles included in this review reported the relation between insurance status and healthcare utilization among patients with TBI. Results from these studies provided sufficient evidence that those uninsured were less likely to use inhospital or posthospital healthcare than those insured. Populations ranging from younger adults to older adults, from people with mild TBI to people with severe TBI were included in those studies, suggesting that insurance disparities in healthcare utilization is a public health issue among the general population. Furthermore, different data resources including local hospital data, statewide data, and nationwide data have been utilized to compare the use of healthcare services between uninsured and insured populations in current literature. Different measures of healthcare utilization including inhospital procedural volume, hospital LOS, TC admission, posthospital rehabilitation service use, and posthospital emergency service use were utilized by those studies. The consistent results presented by these studies strongly support the hypothesis that lack of insurance significantly decreases the probability of receiving appropriate inhospital treatments and posthospital rehabilitation care. The findings suggest that insurance status may be an important moderating factor influencing the association between demographic factors (eg, race, ethnicity, socioeconomic status) and TBI outcomes.

Because of the limited studies, the relation between insurance type and healthcare utilization among patients with TBI is not clear. Kane et al16 concluded that patients with public insurance or workers' compensation were more likely to use posthospital healthcare services than patients with private insurance. However, Schiraldi and his colleagues15 found that Medicaid patients used outpatient rehabilitation services less often than commercially insured patients after TBI. Differences in study designs may have led to inconsistent results in these 2 articles. Unlike other studies involving uninsured patients with TBI, Schiraldi and his colleagues recruited only subjects with at least 1 type of insurance—commercial insurance, Medicaid, or Medicare. The distribution of insurance types was quite different in the 2 studies. In the study by Kane et al,16 only 27.0% of the participants carried commercial insurance, while 47.9% of the participants in the study by Schiraldi et al15 used commercial insurance. Shift in payer of health insurance between admission and discharge can also occur among the uninsured and Medicaid patients with motor vehicle injuries in both studies. Since no-fault care insurance takes precedence over Medicaid, it might affect findings on insurance disparities in healthcare utilization. Furthermore, different definitions of posthospital healthcare utilization in these 2 articles may yield different results. Residence in long-term care facilities, which was 1 type of PHC use in the study by Kane et al,16 is common among severely injured Medicaid, Medicare, and uninsured patients. Because of those variations in the study design and procedures of the 2 articles, inconsistent results were reported concerning which insurance type predicts most frequent use of posthospital healthcare services. To answer this question, more studies on patients with TBI with different types of health insurance coverage are needed.

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Complex relations among race/ethnicity, insurance, and TBI outcomes

According to all articles included in this review, insurance status appears to have greater impact on inhospital and post-hospital healthcare utilization than does race/ethnicity alone among populations with TBI. Although insurance disparities in the use of inhospital and posthospital healthcare services have been widely reported, racial/ethnic disparities in the same outcomes were found only in some of the studies. Crude racial/ethnic disparities in healthcare utilization disappeared after adjusting for insurance status in some reports.

Studies published before 2011 (which were not included in this review) assessed insurance status and race/ethnicity as potential predictors of mortality and other short-term and long-term outcomes. Minorities including African Americans and Hispanics had poorer functional outcomes at hospital discharge and 1 year postinjury than non-Hispanic whites after TBI.5 , 9 , 22 In the study by Heffernan et al,23 patients with commercial insurance were less likely to die than either patients with Medicaid/Medicare or uninsured patients after TBI. Similar results were demonstrated in the study by Schiraldi et al15; Medicaid patients were 1.29 and 1.78 times more likely to die and experience complications than patients with commercial insurance.

Racial/ethnic and insurance disparities in health outcomes after TBI can be explained by corresponding disparities in healthcare utilization. Haas and Goldman24 found that excess mortality in uninsured patients with acute trauma may be caused by the lower rates of medical resource use compared with those of insured patients. The uninsured might also be at increased risk of suffering medical injuries due to substandard medical care.25 Furthermore, inpatient and outpatient therapies are essential to the rehabilitation of patients with TBI.26 Intensive rehabilitation during the early months after injury has a great impact on functional recovery of patients with TBI including returning to work and integration into community.27 , 28 The associations between race, ethnicity, or insurance and healthcare utilization identified in our review may, in part, explain those racial/ethnic and insurance disparities in health outcomes after TBI.

Minorities are less likely to have health insurance than non-Hispanic whites,6 reducing the likelihood of utilizing health services. For example, in the study by Missios and Bekelis et al,13 African Americans were found to be less likely to receive high medical procedural volumes than whites after TBI. This relation, however, became insignificant after controlling for insurance status.13 Therefore, inferior insurance status among minorities may account for their inadequate use of healthcare services after injury. Future studies examining the influence of demographic factors on outcomes after TBI should adjust for insurance status as a potential confounder.

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CONCLUSION

There is a strong relation between insurance status and healthcare utilization among adults with TBI. Race/ethnicity is also an important predictor of healthcare utilization. Associations are reported in our review, but we cannot infer causal relations among race/ethnicity, insurance status, and healthcare utilization among patients with TBI. Prospective studies and data collection will be needed to better evaluate any causal relations among race/ethnicity, socioeconomic factors, and outcomes after TBI. Efforts to diminish race/ethnic or insurance disparities in healthcare utilization may address disparities in other health outcomes among populations with TBI.

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Keywords:

ethnicity; healthcare disparities; healthcare utilization; insurance; race; traumatic brain injuries

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