ImportanceIdentifying disparities in health outcomes related to modifiable patient factors can improve patient care.ObjectiveTo compare likelihood of withdrawal of life-supporting treatment (WLST) and mortality in patients with complete cervical spinal cord injury (SCI) with different types of insurance.Design, Setting, and ParticipantsThis retrospective cohort study collected data between 2013 and 2020 from 498 trauma centers participating in the Trauma Quality Improvement Program. Participants included adult patients (older than 16 years) with complete cervical SCI. Data were analyzed from November 1, 2023, through May 18, 2024.ExposureUninsured or public insurance compared with private insurance.Main Outcomes and MeasuresCoprimary outcomes were WLST and mortality. The adjusted odds ratio (aOR) of each outcome was estimated using hierarchical logistic regression. Propensity score matching was used as an alternative analysis to compare public and privately insured patients. Process of care outcomes, including the occurrence of a hospital complication and length of stay, were compared between matched patients.ResultsThe study included 8421 patients with complete cervical SCI treated across 498 trauma centers (mean [SD] age, 49.1 [20.2] years; 6742 male [80.1%]). Among the 3524 patients with private insurance, 503 had WLST (14.3%) and 756 died (21.5%). Among the 3957 patients with public insurance, 906 had WLST (22.2%) and 1209 died (30.6%). Among the 940 uninsured patients, 156 had WLST (16.6%) and 318 died (33.8%). A significant difference was found between uninsured and privately insured patients in the adjusted odds of WLST (aOR, 1.49; 95% CI, 1.11-2.01) and mortality (aOR, 1.98; 95% CI, 1.50-2.60). Similar results were found in subgroup analyses. Matched public compared with private insurance patients were found to have significantly greater odds of hospital complications (odds ratio, 1.27; 95% CI, 1.14-1.42) and longer hospital stay (mean difference 5.90 days; 95% CI, 4.64-7.20), which was redemonstrated on subgroup analyses.Conclusions and RelevanceHealth insurance type was associated with significant differences in the odds of WLST, mortality, hospital complications, and days in hospital among patients with complete cervical SCI in this study. Future work is needed to incorporate patient perspectives and identify strategies to close the quality gap for the large number of patients without private insurance.

中文翻译：

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脊髓损伤后生命支持撤退和死亡率的保险相关差异


重要性识别与可改变的患者因素相关的健康结果差异可以改善患者护理。目的比较不同类型保险的完全性颈脊髓损伤 （SCI） 患者退出生命支持治疗 （WLST） 的可能性和死亡率。设计、设置和参与者这项回顾性队列研究在 2013 年至 2020 年间从参与创伤质量改进计划的 498 个创伤中心收集了数据。参与者包括患有完全性宫颈 SCI 的成年患者（16 岁以上）。数据分析了 2023 年 11 月 1 日至 2024 年 5 月 18 日的数据。主要结局和指标共同主要结局是 WLST 和死亡率。使用分层 logistic 回归估计每个结局的调整比值比 （aOR）。倾向评分匹配用作比较公共和私人保险患者的替代分析。比较匹配患者之间的护理结局过程，包括医院并发症的发生和住院时间。结果该研究包括来自 498 个创伤中心的 8421 例完全性宫颈 SCI 患者 （平均 [SD] 年龄，49.1 [20.2] 岁;6742 名男性 [80.1%]）。在 3524 名拥有私人保险的患者中，503 名患有 WLST （14.3%），756 名死亡 （21.5%）。在 3957 名有公共保险的患者中，906 名患有 WLST （22.2%），1209 名死亡 （30.6%）。在 940 名未投保的患者中，156 名患有 WLST （16.6%），318 名死亡 （33.8%）。发现无保险患者和私人保险患者在 WLST （aOR， 1.49;95% CI， 1.11-2.01） 和死亡率 （aOR， 1.98;95% CI， 1.50-2.60） 的调整比值方面存在显著差异。在亚组分析中发现了类似的结果。 发现匹配的公共患者与私人保险患者相比，医院并发症的几率显著更高（比值比，1.27;95% CI，1.14-1.42）和更长的住院时间（平均差 5.90 天;95% CI，4.64-7.20），这在亚组分析中得到了再次证明。结论和相关性 在本研究中，健康保险类型与完全性宫颈 SCI 患者 WLST 的几率、死亡率、住院并发症和住院天数的显著差异相关。未来的工作需要纳入患者的观点，并确定缩小大量没有私人保险的患者的质量差距的策略。