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- Title
Insurance Type and Withdrawal of Life-Sustaining Therapy in Critically Injured Trauma Patients.
- Authors
Hoit, Graeme; Wijeysundera, Duminda N.; Hamad, Doulia M.; Nauth, Aaron; Atrey, Amit; Halai, Mansur; Walser, Eric; Nikouline, Anton; Nathens, Avery B.; Khoshbin, Amir
- Abstract
This cohort study examines patients' insurance type and the decision to withdraw life-sustaining treatment in trauma patients who are critically injured using data from level I and level II trauma centers in the US. Key Points: Question: Is insurance type associated with time to withdrawal of life-sustaining therapy in adult trauma patients in the US? Findings: In this cohort study of 307 731 patients, patients who were uninsured were significantly more likely to undergo earlier withdrawal of life-sustaining therapy compared with those with private insurance and Medicaid. Meaning: These findings suggest that being uninsured is associated with a shift in decision-making toward earlier withdrawal of life-sustaining therapy, which could indicate that socioeconomic status informs end-of-life care for patients with critical injuries. Importance: Withdrawal of life-sustaining therapy (WLST) decisions for critically injured trauma patients are complicated and multifactorial, with potential for patients' insurance status to affect decision-making. Objectives: To determine if patient insurance type (private insurance, Medicaid, and uninsured) is associated with time to WLST in critically injured adults cared for at US trauma centers. Design, Setting, and Participants: This retrospective registry-based cohort study included reported data from level I and level II trauma centers in the US that participated in the American College of Surgeons Trauma Quality Improvement Program (TQIP) registry. Participants included adult trauma patients who were injured between January 1, 2017, and December 31, 2020, and required an intensive care unit stay. Patients were excluded if they died on arrival or in the emergency department or had a preexisting do not resuscitate directive. Analyses were performed on December 12, 2023. Exposures: Insurance type (private insurance, Medicaid, uninsured). Main Outcomes and Measures: An adjusted time-to-event analysis for association between insurance status and time to WLST was performed, with analyses accounting for clustering by hospital. Results: This study included 307 731 patients, of whom 160 809 (52.3%) had private insurance, 88 233 (28.6%) had Medicaid, and 58 689 (19.1%) were uninsured. The mean (SD) age was 40.2 (14.1) years, 232 994 (75.7%) were male, 59 551 (19.4%) were African American or Black patients, and 201 012 (65.3%) were White patients. In total, 12 962 patients (4.2%) underwent WLST during their admission. Patients who are uninsured were significantly more likely to undergo earlier WLST compared with those with private insurance (HR, 1.54; 95% CI, 1.46-1.62) and Medicaid (HR, 1.47; 95% CI, 1.39-1.55). This finding was robust to sensitivity analysis excluding patients who died within 48 hours of presentation and after accounting for nonwithdrawal death as a competing risk. Conclusions and Relevance: In this cohort study of US adult trauma patients who were critically injured, patients who were uninsured underwent earlier WLST compared with those with private or Medicaid insurance. Based on our findings, patient's ability to pay was may be associated with a shift in decision-making for WLST, suggesting the influence of socioeconomics on patient outcomes.
- Subjects
UNITED States; WOUND care; PATIENTS; DO-not-resuscitate orders; HEALTH insurance; TERMINATION of treatment; PROBABILITY theory; EMERGENCY medical services; CATASTROPHIC illness; DECISION making; RETROSPECTIVE studies; HOSPITAL emergency services; DESCRIPTIVE statistics; EVALUATION of medical care; TRAUMA centers; LONGITUDINAL method; LIFE support systems in critical care; INTENSIVE care units; COMPARATIVE studies; DATA analysis software; CONFIDENCE intervals; SENSITIVITY &; specificity (Statistics); SOCIAL classes
- Publication
JAMA Network Open, 2024, Vol 7, Issue 7, pe2421711
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.21711