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Impact of the Affordable Care Act on trauma and emergency general surgery

An Eastern Association for the Surgery of Trauma systematic review and meta-analysis

Zerhouni, Yasmin A. MD; Scott, John W. MD, MPH; Ta, Christina BA; Hsu, Paul Chiu-Hsieh PhD; Crandall, Marie MD, MPH; Gale, Stephen C. MD, MBA; Schoenfeld, Andrew J. MD, MSc; Bottiggi, Anthony J. MD; Cornwell, Edward E. III MD; Eastman, Alexander MD, MPH; Davis, Jennifer Knight MD; Joseph, Bellal MD; Robinson, Bryce R. H. MD, MS; Shafi, Shahid MD, MPH, MBA; White, Cassandra Q. MD; Williams, Brian H. MD; Haut, Elliott R. MD, PhD; Haider, Adil H. MD, MPH

Journal of Trauma and Acute Care Surgery: August 2019 - Volume 87 - Issue 2 - p 491–501
doi: 10.1097/TA.0000000000002368

BACKGROUND Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems.

METHODS This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data.

RESULTS From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37–0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88–1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous.

CONCLUSION Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed.

LEVEL OF EVIDENCE Review, Economic/Decision, level III

From the Center for Surgery and Public Health (Y.A.Z., C.T., A.J.S., A.H.H.), Harvard Medical School, Harvard T. Chan School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts; UCSF-East Bay Department of Surgery (Y.A.Z., C.T., A.J.S., A.H.H.), Oakland, California; Harborview Medical Center (J.W.S., B.R.H.R.), University of Washington, Seattle, Washington; Department of Epidemiology and Biostatistics (P.C-H.H.), University of Arizona, Tuscon, Arizona; University of Florida College of Medicine Jacksonville (M.C., S.C.G.), Jacksonville, Florida; UT Health-East Texas (SDG), Tyler, Texas; Department of Orthopaedic Surgery (A.J.S.), Brigham and Women's Hospital, Boston, Massachusetts, University of Kentucky (A.J.B.), Louisville, Kentucky; Howard University (E.E.C.), Washington, D.C.; University of Texas Southwestern, Parkland Memorial Hospital (A.E.), Dallas, Texas; Department of Surgery, West Virginia University (J.K.D.), Morgantown, West Virginia; University of Arizona (B.J.), Tuscon, Arizona; Baylor Scott & White Health (S.S.), Dallas, Texas; Augusta University (C.Q.W.), Augusta, Georgia; Parkland Health & Hospital System (B.H.W.), Dallas, Texas; The Johns Hopkins University School of Medicine and The Johns Hopkins Bloomberg School of Public Health (E.R.H.), Baltimore, Maryland; and Department of Surgery (A.H.H.), Brigham and Women's Hospital, Boston, Massachusetts.

Submitted: September 21, 2018, Revised: March 28, 2019, Accepted: April 7, 2019, Published online: Month May 13, 2019.

Address for reprints: Marie Crandall, MD, 655 W. 8th Street, Jacksonville, FL 32209; email:

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (

Online date: July 12, 2019

© 2019 Lippincott Williams & Wilkins, Inc.