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Medicaid Insurance Is An Independent Predictor of Prolonged Hospital Length of Stay After Traumatic Brain Injury: A Stratified National Trauma Data Bank Cohort Analysis of 552,949 Patients

Friday, May 3, 2024

Presenting Author(s)

John K. Yue, MD

Resident Physician (PGY-6)
Department of Neurological Surgery, University of California, San Francisco
Daly City, CA, US

Co-Author(s)

LC

Lawrence Chyall, RN, MSN

Director of Quality
Department of Neurological Surgery, University of California, San Francisco, United States
Anthony M. DiGiorgio, DO, MHA

Assistant Professor
Department of Neurological Surgery, University of California, San Francisco
San Francisco, California, United States
CH

Cathra Halabi, MD

Assistant Professor
Department of Neurology, University of California, San Francisco, United States
MH

Michael C. Huang, MD

Professor
Department of Neurological Surgery, University of California, San Francisco, United States
Nishanth Krishnan, BS

Medical Student
Department of Neurological Surgery, University of California, San Francisco
San Francisco, CA, US
GM

Geoffrey T. Manley, MD, PhD

Professor, Vice Chair
Department of Neurological Surgery, University of California, San Francisco
San Francisco, CA, United States
Rithvik Ramesh, BA (he/him/his)

Medical Student
University of California, San Francisco
PT

Phiroz E. Tarapore, MD

Associate Professor
Department of Neurological Surgery, University of California, San Francisco
San Francisco, California, United States

Introduction: Hospital length of stay (HLOS) is a metric of injury severity, resource utilization, and healthcare access. Recent evidence have reported an association between Medicaid insurance and increased HLOS after traumatic brain injury (TBI). Our study aimed to validate the association between Medicaid and prolonged HLOS after TBI using the National Trauma Data Bank (NTDB).

Methods: NTDB Trauma Quality Programs Participant Use Files (Years 2003-2021) were queried for adult TBI patients using ICD-9/ICD-10 codes for traumatic intracranial injury. Patients with complete HLOS, age, sex, race, insurance payor, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and discharge disposition data were included (N=552,949). Analyses were stratified by TBI severity using GCS (severe=3-8, moderate=9-12, mild=13-15). HLOS was coded into Tiers by percentile within each TBI severity category (Tier 1=1-74th; 2=75-84th; 3=85-94th; 4=95-99th). Multivariable logistic regressions evaluated associations between insurance payor and prolonged (Tier 4) HLOS, controlling for sociodemographic, ISS, cranial surgery, and discharge disposition variables. Adjusted odds ratios (aOR) and [95% confidence intervals] were reported.

Results: HLOS Tiers consisted of 0-19, 20-27, 28-46, and ≥47-days (Tiers 1-4, respectively) in severe TBI (N=103,081), 0-15, 16-21, 22-37, and ≥38-days in moderate TBI (N=39,904), and 0-7, 8-10, 11-19, and ≥20-days in mild TBI (N=409,964). Proportions with Medicaid increased with HLOS Tier (Tier 1 vs. Tier 4 in severe TBI: 16.0%/36.1%; moderate TBI: 14.1%/31.6%; mild TBI: 10.2%/17.4%; all p< 0.001). Medicaid was an independent predictor of prolonged HLOS in all TBI severity strata (severe TBI: aOR=2.35 [2.19-2.52]; moderate TBI: aOR=2.30 [2.04-2.61]; mild TBI: aOR=1.75 [1.67-1.83]; reference category: private/commercial insurance).

Conclusion : Our study validates Medicaid insurance as an independent risk factor for prolonged HLOS in patients with traumatic intracranial injuries across TBI severity strata. Future research regarding potential disparities in healthcare delivery and reimbursement between Medicaid and other insurance payors are warranted. Our findings support the need for refinement of discharge coordination pathways for Medicaid patients with TBI, and have the potential to inform the development of prospective studies, policy interventions, and interventional trials for risk reduction.