Introduction:  Adult severe traumatic brain injury (TBI) remains a leading cause of morbidity and mortality with up to 60% of patients not surviving or requiring 24-hour assistance. Sociodemographic factors, such as insurance status, have been demonstrated to impact outcomes in various trauma populations including TBI.  In this study, we determine the impact of insurance status on management and outcome of adult severe TBI patients in a national cohort from the United States.

Methods:  The National Trauma Data Bank (NTDB) was analyzed from January 1, 2007, to December 31, 2014, and 48,786 patients with severe TBI and no other significant traumatic injury were identified.  For isolated TBI, we used patients with a head Abbreviated Injury Scale (AIS) score of 3+ and excluded those with another regional AIS of 3+. ICD-9 procedure codes were used to identify four primary treatment approaches: craniotomy/craniectomy and external ventricular draining (EVD)/intracranial pressure monitoring (ICP). Multivariate logistic regression was used to determine the impact of insurance status on procedures and patient outcomes. Patient and injury characteristics were included in the analysis.

Results:  Median age of the cohort was 40 years and 36,656 (75.1%) were insured.  The most common mechanism of injury was motor vehicle collision.  66% of insured patients and 68% of uninsured patients had a presentation Glasgow coma score (GCS) of 3. Insured patients had significantly more ICP monitors placed (12.5% vs.9.1%; p<0.0001), craniotomies performed (17.5% vs. 13.3%; p<0.0001), intensive care unit admissions (88.7% vs 82.5%; p<0.0001), and discharges to rehabilitation centers (53.9% vs. 32.6%; p<0.0001) in comparison to uninsured patients.  Uninsured patients were more likely to expire (32% vs. 25.9%; p<0.0001) or be discharged home (61.4% vs. 38.8%; p<0.0001).  In a regression model, insured patients had a 37% and 29% increase odds ratio of receiving an intracranial pressure monitor and cranial surgery, respectively. Insured patients with a GCS of 3 at presentation had a 40% higher odds ratio of receiving neurosurgical intervention in comparison to uninsured patients with a GCS 3.  Among this sub-cohort, insured status was associated with a 33% decrease in odds of dying.

Conclusions:  Uninsured adult severe TBI patients received less interventional procedures and had an increased odds of dying in comparison to the insured population.  Further studies are needed to determine the reasons behind these treatment and outcomes disparities in order to decrease morbidity and mortality in this patient population following severe TBI.

Effect of Insurance Status on Treatment and Outcomes in Adult Patients with Severe Traumatic Brain Injury