Department of Surgery, Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
JAMA Netw Open. 2024 Jul 1;7(7):e2421711. doi: 10.1001/jamanetworkopen.2024.21711.
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.
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.
Insurance type (private insurance, Medicaid, uninsured).
An adjusted time-to-event analysis for association between insurance status and time to WLST was performed, with analyses accounting for clustering by hospital.
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.
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.
对于重症创伤患者的生命维持治疗（WLST）决策非常复杂且涉及多个因素，患者的保险状况可能会影响决策。
确定美国创伤中心接受治疗的重症受伤成年人的患者保险类型（私人保险、医疗补助和无保险）是否与 WLST 时间相关。
设计、地点和参与者：本回顾性基于登记的队列研究包括来自美国一级和二级创伤中心的报告数据，这些中心参与了美国外科医师学院创伤质量改进计划（TQIP）登记处。参与者包括在 2017 年 1 月 1 日至 2020 年 12 月 31 日期间受伤且需要入住重症监护病房的成年创伤患者。如果患者在到达或急诊室死亡或有预先存在的不复苏指令，则将其排除在外。分析于 2023 年 12 月 12 日进行。
保险类型（私人保险、医疗补助、无保险）。
进行了保险状况与 WLST 时间之间关联的调整后的时间事件分析，分析考虑了医院聚类的影响。
这项研究纳入了 307731 名患者，其中 160809 名（52.3%）有私人保险，88233 名（28.6%）有医疗补助，58689 名（19.1%）没有保险。平均（SD）年龄为 40.2（14.1）岁，232994 名（75.7%）为男性，59551 名（19.4%）为非裔美国或黑人患者，201012 名（65.3%）为白人患者。共有 12962 名患者（4.2%）在住院期间接受了 WLST。与私人保险（HR，1.54；95%CI，1.46-1.62）和医疗补助（HR，1.47；95%CI，1.39-1.55）相比，无保险患者进行 WLST 的时间明显更早。这一发现经排除入院后 48 小时内死亡和将非撤回死亡作为竞争风险后进行敏感性分析仍然稳健。
在这项对美国重症创伤成年患者的队列研究中，与私人保险或医疗补助保险相比，无保险患者的 WLST 时间更早。根据我们的研究结果，患者的支付能力可能与 WLST 决策的转变有关，这表明社会经济因素对患者结局的影响。
