title: Mandatory health care insurance is associated with shorter hospital length of stay among critically injured trauma patients.
abstract: BACKGROUND
  The implementation of the Affordable Care Act stimulated interest in outcomes of patients in Massachusetts, a state mandating health insurance as of 2006. We sought to determine the impact of an insurance mandate on hospital use and outcomes among trauma intensive care unit (ICU) patients.
  
  
  METHODS
  This is a retrospective cohort study of trauma patients admitted to the ICU conducted at an academic, trauma center. Patients before (2004-2006) and after (2008-2012) the implementation of mandatory health insurance were compared using propensity matching to control for confounders. Outcomes were hospital length of stay (LOS), ICU LOS, in-hospital mortality, and discharge disposition.
  
  
  RESULTS
  Overall, 1,668 trauma patients were included, with 530 matched on the propensity score in each group. Hospital LOS decreased by a median of 2.0 days, from 9.0 days (interquartile range, 4-15 days; p < 0.01) before to 7.0 days (interquartile range, 4-14) after implementation of the legislation. There were no differences in ICU LOS (3.0 days to 3.0 days, p = 0.44) and mortality (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.83-1.63). Compared with discharges to home, the patients were more likely to be discharged home with home health services after the legislation (OR, 1.70; 95% CI, 1.08-2.68), but there was no significant change in the likelihoods of the patients being discharged to skilled nursing and rehabilitation facilities (OR, 0.97; 95% CI, 0.72-1.31).
  
  
  CONCLUSIONS
  Implementation of health care reform was associated with a decrease in hospital LOS, with an increase in use of home health services and no change in ICU LOS and mortality among trauma ICU patients at our institution.
  
  
  METHODS
  Prognostic/epidemiologic study, level III.
authors: From the Division of Trauma Emergency Surgery and Surgical Critical Care (J.L., M.S., H.K., E.K., D.D.Y., M.D, G.V.), and Department of Anesthesia, Critical Care and Pain Medicine (M.E.), Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts; Inserm Research Center for Epidemiology and Biostatistics (U897) (T.K.); University of Bordeaux (T.K.), Bordeaux, France; Icahn School of Medicine of Mount Sinai (K.S.), New York, New York; and Department of Emergency Medicine (A.S.R.), Brigham and Women's Hospital & Harvard Medical School, Boston, Massachusetts.
authors: Jarone
authors: J
authors: Lee
authors: Monisha
authors: M
authors: Sudarshan
authors: Tobias
authors: T
authors: Kurth
authors: Haytham
authors: H
authors: Kaafarani
authors: Eric
authors: E
authors: Klein
authors: D Dante
authors: DD
authors: Yeh
authors: Marc A
authors: MA
authors: deMoya
authors: Matthias
authors: M
authors: Eikermann
authors: Kaushal
authors: K
authors: Shah
authors: George
authors: G
authors: Velmahos
authors: Ali S
authors: AS
authors: Raja
mesh_terms: D005260:Female; D018166:Health Care Reform / Q000458:organization & administration / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015601:Injury Severity Score; D007348:Insurance, Health / Q000458:organization & administration* / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D037141:Mandatory Programs / Q000706:statistics & numerical data*; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D057216:Propensity Score; D012189:Retrospective Studies; D014947:Wounds and Injuries / Q000628:therapy*