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

Racial and Ethnic Disparities in Hip Fracture Surgery Care in the United States From 2006 to 2015: A Nationwide Trends Study

“…17,25,30 The improvements found in this study may be partly due to numerous national efforts within the last two decades, aimed at specifically advancing care for minority patients within the United States. 15,31-33 Legislative enactments including the Affordable Care Act and the expansion of Medicaid have also increased access to emergency care for many minority groups 14,34,35 while also possibly increasing quality of care for these patients through pay-for-performance and public quality reporting programs. 4 In parallel, orthopaedic-specific initiatives by the American Academy of Orthopaedic Surgeons 9 and others 8-10,13 have sought to eliminate disparities in orthopaedic care through research initiatives, such as the “Musculoskeletal Healthcare Disparities Symposium” and priority action plans aimed at raising awareness, while also attempting to increase diversity within the orthopaedics workforce.…”

Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level

“…[24][25][26] To date, studies examining the effects of the ACA Medicaid expansion on access to care Abbreviations and Acronyms ACA ¼ Affordable Care Act CMS ¼ Centers for Medicare and Medicaid Services DD ¼ difference-in-difference ED ¼ emergency department ISS ¼ Injury Severity Score LOS ¼ length of stay SID ¼ State Inpatient Database and outcomes among trauma patients have been limited by their examination of just the first 1 to 2 years of Medicaid expansion, their single state or single-center design, or their examination of in-hospital outcomes only. 27 The aim of this study was to evaluate the effects of the ACA Medicaid expansion, in its first 4 years, on insurance coverage, trauma outcomes, and access to rehabilitation among young adult trauma patients across multiple states, overall and by race, ethnicity, and community income level. We hypothesized that the ACA Medicaid expansion has been associated with reductions in uninsurance, inhospital mortality, and unplanned ED visits and readmissions at 30 and 90 days, and that it has increased access to rehabilitation.…”

“… 24 – 26 To date, studies examining the effects of the ACA Medicaid expansion on access to care and outcomes among trauma patients have been limited by their examination of just the first 1 to 2 years of Medicaid expansion, their single state or single-center design, or their examination of in-hospital outcomes only. 27 …”

Physical and Psychological Health Behavior Changes During the COVID-19 Pandemic that May Inform Surgical Prehabilitation: a Narrative Review

“…Under usual circumstances, access to surgical care within a certain country or region may be affected by numerous factors such as patients' class, race, ethnicity, or gender [96,97,98]. Similarly, social determinants of health (SDOH) such as health insurance, or lack thereof, may affect people's health and access to surgical care and post-surgical care such as rehabilitation [99,100,101,102]. During the pandemic, health disparities have been widely documented in the USA and numerous other countries [97,98].…”