title: The association of insurance status and race with the procedural volume of traumatic brain injury patients.
abstract: BACKGROUND
  The influence of non-medical factors on the volume of procedures undergone by TBI patients remains an issue of debate. We investigated the association of lack of insurance and African-American race with the procedural volume of TBI patients.
  
  
  METHODS
  We performed a retrospective cohort study involving TBI patients, who were registered in the National Trauma Data Bank (NTDB) between 2009 and 2011. Multivariable logistic regression with mixed effects to control for clustering at the hospital level was used to investigate the association of insurance status and race with high volume of procedures for TBI patients.
  
  
  RESULTS
  Of the 392,292 TBI patients, who were registered in NTDB and met the inclusion criteria, 9850 (3.8%) underwent high procedural volume, defined as 2 or more procedures during hospitalization (2 standard deviations over the mean). Multivariable logistic regression analysis demonstrated an association of uninsured patients with decreased possibility of high procedural volume (OR, 0.68; 95% CI, 0.63-0.73). This persisted after using a mixed effects model to control for clustering at the hospital level (OR, 0.66; 95% CI, 0.61-0.71). In stratified samples, uninsured patients demonstrated similar associations even for GCS below 8 (OR, 0.69; 95% CI, 0.64-0.75), or ISS above 15 (OR, 0.74; 95% CI, 0.69-0.79). Multivariable logistic regression analysis did not demonstrate an association of African Americans with procedural volume (OR, 0.93; 95% CI, 0.86-1.02).
  
  
  CONCLUSIONS
  During the hospitalization of TBI patients, lack of insurance was associated with lower procedural volume. When controlling for insurance status, we did not observe any race associated disparities in procedural volume.
authors.affiliation: Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, United States.
authors.forename: Symeon
authors.initials: S
authors.lastname: Missios
authors.affiliation: Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States. Electronic address: kbekelis@gmail.com.
authors.forename: Kimon
authors.initials: K
authors.lastname: Bekelis
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000070642:Brain Injuries, Traumatic / Q000191:economics / Q000453:epidemiology*; D016208:Databases, Factual; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
keywords: Insurance coverage; NTDB; Procedural volume; Race; Resource utilization; Traumatic brain injury