Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis

Yasmin A. Zerhouni, John W. Scott, Christina Ta, Paul Chiu Hsieh Hsu, Marie Crandall, Stephen C. Gale, Andrew J. Schoenfeld, Anthony J. Bottiggi, Edward E. Cornwell, Alexander Eastman, Jennifer Knight Davis, Bellal A Joseph, Bryce R.H. Robinson, Shahid Shafi, Cassandra Q. White, Brian H. Williams, Elliott R. Haut, Adil H. Haider

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS: This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS: From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION: Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE: Review, Economic/Decision, level III.

Original languageEnglish (US)
Pages (from-to)491-501
Number of pages11
JournalThe journal of trauma and acute care surgery
Volume87
Issue number2
DOIs
StatePublished - Aug 1 2019

Fingerprint

Patient Protection and Affordable Care Act
Meta-Analysis
Emergencies
Wounds and Injuries
Health Care Reform
Medicaid
Insurance Coverage
Subacute Care
Mortality
Inpatients
Odds Ratio
Confidence Intervals
Health Insurance
Insurance

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Impact of the Affordable Care Act on trauma and emergency general surgery : An Eastern Association for the Surgery of Trauma systematic review and meta-analysis. / Zerhouni, Yasmin A.; Scott, John W.; Ta, Christina; Hsu, Paul Chiu Hsieh; Crandall, Marie; Gale, Stephen C.; Schoenfeld, Andrew J.; Bottiggi, Anthony J.; Cornwell, Edward E.; Eastman, Alexander; Davis, Jennifer Knight; Joseph, Bellal A; Robinson, Bryce R.H.; Shafi, Shahid; White, Cassandra Q.; Williams, Brian H.; Haut, Elliott R.; Haider, Adil H.

In: The journal of trauma and acute care surgery, Vol. 87, No. 2, 01.08.2019, p. 491-501.

Research output: Contribution to journalArticle

Zerhouni, YA, Scott, JW, Ta, C, Hsu, PCH, Crandall, M, Gale, SC, Schoenfeld, AJ, Bottiggi, AJ, Cornwell, EE, Eastman, A, Davis, JK, Joseph, BA, Robinson, BRH, Shafi, S, White, CQ, Williams, BH, Haut, ER & Haider, AH 2019, 'Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis', The journal of trauma and acute care surgery, vol. 87, no. 2, pp. 491-501. https://doi.org/10.1097/TA.0000000000002368
Zerhouni, Yasmin A. ; Scott, John W. ; Ta, Christina ; Hsu, Paul Chiu Hsieh ; Crandall, Marie ; Gale, Stephen C. ; Schoenfeld, Andrew J. ; Bottiggi, Anthony J. ; Cornwell, Edward E. ; Eastman, Alexander ; Davis, Jennifer Knight ; Joseph, Bellal A ; Robinson, Bryce R.H. ; Shafi, Shahid ; White, Cassandra Q. ; Williams, Brian H. ; Haut, Elliott R. ; Haider, Adil H. / Impact of the Affordable Care Act on trauma and emergency general surgery : An Eastern Association for the Surgery of Trauma systematic review and meta-analysis. In: The journal of trauma and acute care surgery. 2019 ; Vol. 87, No. 2. pp. 491-501.
@article{a1a319d65b4842ed9893e76c1b0664b7,
title = "Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis",
abstract = "BACKGROUND: Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS: This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS: From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95{\%} confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95{\%} confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION: Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE: Review, Economic/Decision, level III.",
author = "Zerhouni, {Yasmin A.} and Scott, {John W.} and Christina Ta and Hsu, {Paul Chiu Hsieh} and Marie Crandall and Gale, {Stephen C.} and Schoenfeld, {Andrew J.} and Bottiggi, {Anthony J.} and Cornwell, {Edward E.} and Alexander Eastman and Davis, {Jennifer Knight} and Joseph, {Bellal A} and Robinson, {Bryce R.H.} and Shahid Shafi and White, {Cassandra Q.} and Williams, {Brian H.} and Haut, {Elliott R.} and Haider, {Adil H.}",
year = "2019",
month = "8",
day = "1",
doi = "10.1097/TA.0000000000002368",
language = "English (US)",
volume = "87",
pages = "491--501",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",
number = "2",

}

TY - JOUR

T1 - Impact of the Affordable Care Act on trauma and emergency general surgery

T2 - An Eastern Association for the Surgery of Trauma systematic review and meta-analysis

AU - Zerhouni, Yasmin A.

AU - Scott, John W.

AU - Ta, Christina

AU - Hsu, Paul Chiu Hsieh

AU - Crandall, Marie

AU - Gale, Stephen C.

AU - Schoenfeld, Andrew J.

AU - Bottiggi, Anthony J.

AU - Cornwell, Edward E.

AU - Eastman, Alexander

AU - Davis, Jennifer Knight

AU - Joseph, Bellal A

AU - Robinson, Bryce R.H.

AU - Shafi, Shahid

AU - White, Cassandra Q.

AU - Williams, Brian H.

AU - Haut, Elliott R.

AU - Haider, Adil H.

PY - 2019/8/1

Y1 - 2019/8/1

N2 - BACKGROUND: Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS: This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS: From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION: Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE: Review, Economic/Decision, level III.

AB - BACKGROUND: Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems. METHODS: This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data. RESULTS: From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous. CONCLUSION: Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed. LEVEL OF EVIDENCE: Review, Economic/Decision, level III.

UR - http://www.scopus.com/inward/record.url?scp=85070659319&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85070659319&partnerID=8YFLogxK

U2 - 10.1097/TA.0000000000002368

DO - 10.1097/TA.0000000000002368

M3 - Article

C2 - 31095067

AN - SCOPUS:85070659319

VL - 87

SP - 491

EP - 501

JO - Journal of Trauma and Acute Care Surgery

JF - Journal of Trauma and Acute Care Surgery

SN - 2163-0755

IS - 2

ER -