Healthcare inequities for patients with traumatic brain injury (TBI) represent a major priority area for trauma quality improvement. We hypothesized a relationship between health insurance status and timing of withdrawal of life sustaining treatment (WLST) for adults with severe TBI. This multicenter retrospective observational cohort study utilized data collected between 2017 and 2020. We identified adult (age ≥ 16) patients with isolated severe TBI admitted participating Trauma Quality Improvement Program centers. We determined the relationship between insurance status (public, private, and uninsured) and the timing of WLST using a competing risk survival analysis framework adjusting for baseline, clinical, injury and trauma center characteristics. Multivariable cause-specific Cox regressions were used to compute adjusted hazard ratios (HR) reflecting timing of WLST, accounting for mortality events. We also quantified the between-center residual variability in WLST using the median odds ratio (MOR) and measured insurance status association with access to rehabilitation at discharge. We identified 42,111 adults with isolated severe TBI treated across 509 trauma centers across North America. There were 10,771 (25.6%) WLST events in the cohort and a higher unadjusted incidence of WLST events was evident in public insurance patients compared to private or uninsured groups. After adjustment, WLST occurred earlier for publicly insured (HR 1.07, 95% CI 1.02–1.12) and uninsured patients (HR 1.29, 95% CI 1.18–1.41) compared to privately insured patients. Access to rehabilitation was lower for both publicly insured and uninsured patients compared to patients with private insurance. Accounting for case-mix, the MOR was 1.49 (95% CI 1.43–1.55), reflecting significant residual between-center variation in WLST decision-making. Our findings highlight the presence of disparate WLST practices independently associated with health insurance status. Additionally, these results emphasize between-center variability in WLST, persisting despite adjustments for measurable patient and trauma center characteristics.

中文翻译：

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健康保险对孤立性创伤性脑损伤患者退出维持生命治疗的影响：一项回顾性多中心观察性队列研究


创伤性脑损伤 （TBI） 患者的医疗保健不平等是创伤质量改善的主要优先领域。我们假设健康保险状况与严重 TBI 成人退出生命维持治疗 （WLST） 的时间之间存在关系。这项多中心回顾性观察队列研究利用了 2017 年至 2020 年间收集的数据。我们确定了参与创伤质量改进计划中心的孤立性严重 TBI 成年 （≥ 16 岁） 患者。我们使用针对基线、临床、伤害和创伤中心特征进行调整的竞争风险生存分析框架确定了保险状态（公共、私人和无保险）与 WLST 时间之间的关系。使用多变量原因特异性 Cox 回归来计算反映 WLST 时间的调整后风险比 （HR），并考虑死亡事件。我们还使用中位比值比 （MOR） 量化了 WLST 的中心间残余变异性，并测量了保险状况与出院时获得康复的相关性。我们在北美的 42,111 个创伤中心确定了 509 名患有孤立性严重 TBI 的成年人。队列中有 10,771 例 （25.6%） WLST 事件，与私人或无保险组相比，公共保险患者未调整的 WLST 事件发生率更高。调整后，与私人保险患者相比，公共保险患者 （HR 1.07,95% CI 1.02-1.12） 和无保险患者 （HR 1.29,95% CI 1.18-1.41） 的 WLST 发生得更早。与拥有私人保险的患者相比，公共保险和无保险患者获得康复的机会都较低。考虑到病例组合，MOR 为 1.49 （95% CI 1.43-1.55），反映了 WLST 决策中显着的残差中心间差异。我们的研究结果强调了与健康保险状况独立相关的不同 WLST 实践的存在。此外，这些结果强调了 WLST 的中心间变异性，尽管对可测量的患者和创伤中心特征进行了调整，但这种变异性仍然存在。