title: Effect of insurance and racial disparities on outcomes in traumatic brain injury.
abstract: BACKGROUND
  We evaluated outcome and resource utilization disparities between commercially insured, Medicaid, and Medicare patients. We further analyzed racial disparities in a subset cohort.
  
  
  METHODS
  We reviewed the MarketScan database (2000-2009) for adult traumatic brain injury (TBI) patients. Analyses were performed to evaluate outcome differences by insurance type and race. Outpatient service utilization disparities by insurance and race were also evaluated.
  
  
  RESULTS
  Our study included 92,159 TBI patients, 44,108 (47.9%) of whom utilized commercial insurance, 19,743 (21.4%) utilized Medicaid, and 28,308 (30.7%) utilized Medicare. In-hospital mortality was lowest for commercially insured (5.0%) versus 7.6% and 8.5% for Medicaid and Medicare patients, respectively (p < 0.0001). Medicaid patients had a longer hospitalization than commercially insured (12 days versus 6 days; p < 0.0001). Medicaid patients were 1.29 and 1.78 times more likely to die and experience complications than the commercially insured. Females had a lower mortality risk (odds ratio [OR]: 0.80, p < 0.0001) and less complications (OR: 0.67; p < 0.0001) than males. Higher comorbidities increased mortality risk (OR: 2.71; p < 0.0001) and complications (OR: 2.96, p < 0.0001). Mild injury patients had lower mortality (OR: 0.01; p < 0.0001) and less complications (OR: 0.07; p < 0.0001). Medicare (OR: 1.33; p < 0.0001) and higher comorbidity (OR: 1.26; p < 0.0001) patients utilized outpatient rehabilitation services more frequently. Medicare patients had twice the emergency department visits as the commercially insured (p < 0.0001). Medicare (16.6%) patients utilized more rehabilitation than commercially insured (13.4%) and Medicaid (9.1%) patients. Racial disparities were analyzed in a subset of 12,847 white and 4,780 African American (AA) patients. Multivariate analysis showed that AAs were more likely to experience a complication than white patients (OR: 1.13; p = 0.0024) and less likely to utilize outpatient rehabilitation services (OR: 0.83; p = 0.0025) than whites.
  
  
  CONCLUSIONS
  Insurance and racial disparities continue to exist for TBI patients. Insurance status appears to have an impact on short- and long-term outcomes to a greater degree than patient race.
authors: Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States.
authors: Michael
authors: M
authors: Schiraldi
authors: Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States.
authors: Chirag G
authors: CG
authors: Patil
authors: Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States.
authors: Debraj
authors: D
authors: Mukherjee
authors: Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States.
authors: Beatrice
authors: B
authors: Ugiliweneza
authors: Department of Neurosurgery, Cedars-Sinai Medical Center, Maxine Dunitz Neurosurgical Institute, Los Angeles, California, United States.
authors: Miriam
authors: M
authors: Nuño
authors: Division of Neurosurgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States.
authors: Shivanand P
authors: SP
authors: Lad
authors: Department of Neurosurgery, University of Louisville, Louisville, Kentucky, United States.
authors: Maxwell
authors: M
authors: Boakye
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000208:ethnology / Q000401:mortality / Q000628:therapy; D005260:Female; D059033:For-Profit Insurance Plans / Q000706:statistics & numerical data*; D006296:Health Services / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data*; D006278:Medicare / Q000706:statistics & numerical data*; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D044469:Racial Groups / Q000706:statistics & numerical data*; D014481:United States / Q000208:ethnology