McCutcheon Brandon A, Chang David C, Marcus Logan, Gonda David D, Noorbakhsh Abraham, Chen Clark C, Talamini Mark A, Carter Bob S
Department of Surgery, and.
Division of Neurosurgery, University of California, San Diego, California.
J Neurosurg. 2015 Aug;123(2):406-14. doi: 10.3171/2015.3.JNS131356. Epub 2015 May 8.
This study was designed to assess the relationship between insurance status and likelihood of receiving a neurosurgical procedure following admission for either extraaxial intracranial hemorrhage or spinal vertebral fracture.
A retrospective analysis of the Nationwide Inpatient Sample (NIS; 1998-2009) was performed. Cases of traumatic extraaxial intracranial hematoma and spinal vertebral fracture were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Within this cohort, those patients receiving a craniotomy or spinal fusion and/or decompression in the context of an admission for traumatic brain or spine injury, respectively, were identified using the appropriate ICD-9 procedure codes.
A total of 190,412 patients with extraaxial intracranial hematoma were identified between 1998 and 2009. Within this cohort, 37,434 patients (19.7%) received a craniotomy. A total of 477,110 patients with spinal vertebral fracture were identified. Of these, 37,302 (7.8%) received a spinal decompression and/or fusion. On multivariate analysis controlling for patient demographics, severity of injuries, comorbidities, hospital volume, and hospital characteristics, uninsured patients had a reduced likelihood of receiving a craniotomy (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.71-0.82) and spinal fusion (OR 0.67, 95% CI 0.64-0.71) relative to insured patients. This statistically significant trend persisted when uninsured and insured patients were matched on the basis of mortality propensity score. Uninsured patients demonstrated an elevated risk-adjusted mortality rate relative to insured patients in cases of extraaxial intracranial hematoma. Among patients with spinal injury, mortality rates were similar between patients with and without insurance.
In this study, uninsured patients were consistently less likely to receive a craniotomy or spinal fusion for traumatic intracranial extraaxial hemorrhage and spinal vertebral fracture, respectively. This difference persisted after accounting for overall injury severity and patient access to high- or low-volume treatment centers, and potentially reflects a resource allocation bias against uninsured patients within the hospital setting. This information adds to the growing literature detailing the benefits of health reform initiatives seeking to expand access for the uninsured.
本研究旨在评估保险状况与因颅外颅内出血或脊椎骨折入院后接受神经外科手术可能性之间的关系。
对全国住院患者样本（NIS；1998 - 2009年）进行回顾性分析。使用国际疾病分类第九版（ICD - 9）诊断编码确定创伤性颅外颅内血肿和脊椎骨折病例。在该队列中，分别使用适当的ICD - 9手术编码确定那些在因创伤性脑损伤或脊柱损伤入院时接受开颅手术或脊柱融合和/或减压的患者。
1998年至2009年间共确定了190,412例颅外颅内血肿患者。在该队列中，37,434例患者（19.7%）接受了开颅手术。共确定了477,110例脊椎骨折患者。其中，37,302例（7.8%）接受了脊柱减压和/或融合手术。在对患者人口统计学、损伤严重程度、合并症、医院规模和医院特征进行多变量分析时，与参保患者相比，未参保患者接受开颅手术（比值比[OR] 0.76，95%置信区间[CI] 0.71 - 0.82）和脊柱融合手术（OR 0.67，95% CI 0.64 - 0.71）的可能性降低。当根据死亡倾向评分对未参保和参保患者进行匹配时，这一具有统计学意义的趋势仍然存在。在颅外颅内血肿病例中，未参保患者相对于参保患者表现出风险调整后死亡率升高。在脊柱损伤患者中，参保和未参保患者的死亡率相似。
在本研究中，未参保患者分别接受创伤性颅内颅外出血开颅手术或脊柱骨折脊柱融合手术的可能性始终较低。在考虑总体损伤严重程度和患者进入高容量或低容量治疗中心的机会后，这种差异仍然存在，并且可能反映了医院环境中对未参保患者的资源分配偏见。这些信息为日益增多的详细阐述旨在扩大未参保者就医机会的医疗改革举措益处的文献增添了内容。
