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Design and Participants: This retrospective registry-based cohort study determined if patient insurance type (private, Medicaid, and uninsured) is associated with time to WLST in critically injured adults cared for at US trauma centers (2017-2020). Data from Level I and Level II trauma centers that participated in the American College of Surgeons Trauma Quality Improvement Program registry were included. Participants were injured between 2017 and 2020, required an intensive care unit stay, and were excluded if they died on arrival or in the emergency department or had a preexisting do-not-resuscitate directive. An adjusted time-to-event analysis for association between insurance status and time to WLST was performed, with analyses accounting for clustering by hospital.
Results: Patients (N=307,731) were aged mean 40 years old (SD=14); 76% male; and 19% Black and 65% White. Fifty-two percent had private insurance, 29% were on Medicaid, and 19% were uninsured. In total, 4.2% underwent WLST, with a higher proportion in the population of patients without insurance (5.0%) vs Medicaid (4.2%) and private insurance (3.9%; standardized mean difference [SMD]=0.04). Time to WLST was mean 7.8 days (SD=10), with 6.5 days (9.8) in the uninsured group, 7.8 days (9.7) in private insurance, and 8.9 days (12) in Medicaid; SMD=0.16. After adjusting for relevant covariates, patients who were uninsured underwent earlier WLST vs private insurance (adjusted hazard ratio=1.6; 95% CI=1.5-1.7) and Medicaid (1.5; 1.5-1.6). There was no difference in time to WLST between Medicaid and privately insured (1.0; 0.98-1.1).
Commentary: This large national study, which demonstrated earlier WLST in uninsured critically ill trauma patients, differs from previous studies because it includes a younger population with overrepresentation from marginalized populations. The authors hypothesize that the uninsured may lack surrogate decision makers (SDMs) due to poor social support, resulting in institutional processes for WLST decision making that may be subject to financial conflict of interest or may merely be more efficient than engaging with SDMs. However, without more detail on the decision-making process, is unclear whether insurance status biases communication with surrogates or whether it directly affects decisions made by surrogates, institutions, or both. Unmeasured confounders such as immigration status or language may also play a role. Regardless of the decision to withdraw life-sustaining therapy, increased mortality was observed in the uninsured population.
Bottom Line: This study suggests that lack of insurance leads to differential WLST decisions in trauma patients. This adds to a growing body of literature3 highlighting the importance of social determinants of health in end-of-life outcomes.
Reviewer: Rebecca Goett, MD FACEP FAAHPM, Hackensack Meridian Jersey Shore University Medical Center, Neptune, NJ
References:
1. Braganza MA, Glossop AJ, Vora VA. Treatment withdrawal and end-of-life care in the intensive care unit. BJA Educ. 2017;17(12):396-400. doi:10.1093/bjaed/mkx031.
2. Yarnell CJ, Fu L, Bonares MJ, Nayfeh A, Fowler RA. Association between Chinese or South Asian ethnicity and end-of-life care in Ontario, Canada. CMAJ. 2020;192(11):e266-e274. doi:10.1503/cmaj.190655.
3. Volandes AE, Paasche-Orlow M, Gilick MR, et al. Health literacy not race predicts end-of-life care preferences. J Palliat Med. 2008;11:(5):754-762.
Source: Hoit G, Wijeysundera DN, Hamad DM, et al. Insurance type and withdrawal of life-sustaining therapy in critically injured trauma patients. JAMA Netw Open. 2024;7(7):e2421711. doi:10.1001/jamanetworkopen.2024.21711.
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