Advertisement

Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients

  • Lindsey Asti
    Affiliations
    Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205

    Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
    Search for articles by this author
  • Deena J. Chisolm
    Affiliations
    Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205

    Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210

    Division of Health Services Management & Policy, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, Ohio 43210
    Search for articles by this author
  • Henry Xiang
    Affiliations
    Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210

    Center for Pediatric Trauma Research and Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
    Search for articles by this author
  • Katherine J. Deans
    Affiliations
    Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205

    Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205

    Department of Surgery, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210

    Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
    Search for articles by this author
  • Jennifer N. Cooper
    Correspondence
    Corresponding author. Center for Surgical Outcomes Research and Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205. Tel.: +1 614 355 4526.
    Affiliations
    Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205

    Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205

    Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210

    Division of Epidemiology, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, Ohio 43210
    Search for articles by this author

      Abstract

      Background

      Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers.

      Methods

      Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles.

      Results

      Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage.

      Conclusions

      In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Sorensen M.J.
        • von Recklinghausen F.M.
        • Fulton G.
        • Burchard K.W.
        Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system.
        JAMA Surg. 2013; 148: 763-768
        • Ciesla D.J.
        • Sava J.A.
        • Street 3rd, J.H.
        • Jordan M.H.
        Secondary overtriage: a consequence of an immature trauma system.
        J Am Coll Surg. 2008; 206: 131-137
        • Adzemovic T.
        • Murray T.
        • Jenkins P.
        • et al.
        Should they stay or should they go? Who benefits from interfacility transfer to a higher-level trauma center following initial presentation at a lower-level trauma center.
        J Trauma Acute Care Surg. 2019; 86: 952-960
        • Goldstein S.D.
        • Van Arendonk K.
        • Aboagye J.K.
        • et al.
        Secondary overtriage in pediatric trauma: can unnecessary patient transfers be avoided?.
        J Pediatr Surg. 2015; 50: 1028-1031
        • Lindsey L.J.
        • Rasmussen L.S.
        • Hendrickson L.S.
        • et al.
        Trauma transfers discharged from the emergency department-Is there a role for telemedicine?.
        J Trauma Acute Care Surg. 2022; 92: 656-663
        • Xiang H.
        • Wheeler K.K.
        • Groner J.I.
        • Shi J.
        • Haley K.J.
        Undertriage of major trauma patients in the US emergency departments.
        Am J Emerg Med. 2014; 32: 997-1004
        • Bible J.E.
        • Kadakia R.J.
        • Kay H.F.
        • Zhang C.E.
        • Casimir G.E.
        • Devin C.J.
        How often are interfacility transfers of spine injury patients truly necessary?.
        Spine J. 2014; 14: 2877-2884
        • Nathens A.B.
        • Maier R.V.
        • Copass M.K.
        • Jurkovich G.J.
        Payer status: the unspoken triage criterion.
        J Trauma. 2001; 50: 776-783
        • Bekelis K.
        • Missios S.
        • Mackenzie T.A.
        The association of insurance status and race with transfers of patients with traumatic brain injury initially evaluated at level III and IV trauma centers.
        Ann Surg. 2015; 262: 9-15
        • Osen H.B.
        • Bass R.R.
        • Abdullah F.
        • Chang D.C.
        Rapid discharge after transfer: risk factors, incidence, and implications for trauma systems.
        J Trauma. 2010; 69: 602-606
        • Koval K.J.
        • Tingey C.W.
        • Spratt K.F.
        Are patients being transferred to level-I trauma centers for reasons other than medical necessity?.
        J Bone Joint Surg Am. 2006; 88: 2124-2132
        • Nacht J.
        • Macht M.
        • Ginde A.A.
        Interhospital transfers from U.S. emergency departments: implications for resource utilization, patient safety, and regionalization.
        Acad Emerg Med. 2013; 20: 888-893
        • Dengler B.A.
        • Plaza-Wuthrich S.
        • Chick R.C.
        • Muir M.T.
        • Bartanusz V.
        Secondary overtriage in patients with complicated mild traumatic brain injury: an observational study and socioeconomic analysis of 1447 hospitalizations.
        Neurosurgery. 2020; 86: 374-382
        • Parikh P.P.
        • Parikh P.
        • Mamer L.
        • McCarthy M.C.
        • Sakran J.V.
        Association of system-level factors with secondary overtriage in trauma patients.
        JAMA Surg. 2019; 154: 19-25
        • Garwe T.
        • Cowan L.D.
        • Neas B.
        • Cathey T.
        • Danford B.C.
        • Greenawalt P.
        Survival benefit of transfer to tertiary trauma centers for major trauma patients initially presenting to nontertiary trauma centers.
        Acad Emerg Med. 2010; 17: 1223-1232
        • Delgado M.K.
        • Yokell M.A.
        • Staudenmayer K.L.
        • Spain D.A.
        • Hernandez-Boussard T.
        • Wang N.E.
        Factors associated with the disposition of severely injured patients initially seen at non-trauma center emergency departments: disparities by insurance status.
        JAMA Surg. 2014; 149: 422-430
        • Missios S.
        • Bekelis K.
        Nonmedical factors and the transfer of spine trauma patients initially evaluated at level III and IV trauma centers.
        Spine J. 2015; 15: 2028-2035
        • Hamilton E.C.
        • Miller 3rd, C.C.
        • Cotton B.A.
        • Cox C.
        • Kao L.S.
        • Austin M.T.
        The association of insurance status on the probability of transfer for pediatric trauma patients.
        J Pediatr Surg. 2016; 51: 2048-2052
        • Kindermann D.R.
        • Mutter R.L.
        • Cartwright-Smith L.
        • Rosenbaum S.
        • Pines J.M.
        Admit or transfer? The role of insurance in high-transfer-rate medical conditions in the emergency department.
        Ann Emerg Med. 2014; 63: 561-571.e8
        • Medford-Davis L.N.
        • Holena D.N.
        • Karp D.
        • Kallan M.J.
        • Delgado M.K.
        Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury.
        Am J Emerg Med. 2018; 36: 797-803
        • Newgard C.D.
        • McConnell K.J.
        • Hedges J.R.
        Variability of trauma transfer practices among non-tertiary care hospital emergency departments.
        Acad Emerg Med. 2006; 13: 746-754
        • Zogg C.K.
        • Schuster K.M.
        • Maung A.A.
        • Davis K.A.
        Insurance status biases trauma-system utilization and appropriate interfacility transfer: national and longitudinal results of adult, pediatric, and older adult patients.
        Ann Surg. 2018; 268: 681-689
        • Hagedorn J.C.
        • Quistberg D.A.
        • Arbabi S.
        • Wessells H.
        • Vavilala M.S.
        Factors associated with secondary overtriage in renal trauma.
        Urology. 2019; 130: 175-180
        • Mohan D.
        • Rosengart M.R.
        • Farris C.
        • Cohen E.
        • Angus D.C.
        • Barnato A.E.
        Assessing the feasibility of the American College of Surgeons’ benchmarks for the triage of trauma patients.
        Arch Surg. 2011; 146: 786-792
        • Tang A.
        • Hashmi A.
        • Pandit V.
        • et al.
        A critical analysis of secondary overtriage to a level I trauma center.
        J Trauma Acute Care Surg. 2014; 77: 969-973
      1. About the affordable care act 2019.
        (Available at:)
        • National Center for Injury Prevention and Control. Centers for Disease Control and Prevention
        Ten leading causes of death and injury charts.
        (Available at:)
        • Smith J.C.
        • Medalla C.
        Health Insurance Coverage in the United States: 2014. Current Population Reports.
        U.S. Department of Commerce. Economics and Statistics Administration. U.S. Census Bureau, 2015
        • Metzger G.A.
        • Asti L.
        • Quinn J.P.
        • et al.
        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.
        J Am Coll Surg. 2021; 233: 776-793.e16
        • Zogg C.K.
        • Scott J.W.
        • Metcalfe D.
        • et al.
        Association of Medicaid Expansion with access to rehabilitative care in adult trauma patients.
        JAMA Surg. 2019; 154: 402-411
        • Akande M.
        • Minneci P.C.
        • Deans K.J.
        • Xiang H.
        • Chisolm D.J.
        • Cooper J.N.
        Effects of Medicaid expansion on disparities in trauma care and outcomes in young adults.
        J Surg Res. 2018; 228: 42-53
        • Akande M.
        • Minneci P.C.
        • Deans K.J.
        • Xiang H.
        • Cooper J.N.
        Association of Medicaid expansion under the Affordable Care Act with outcomes and access to rehabilitation in young adult trauma patients.
        JAMA Surg. 2018; 153: e181630
        • Ross M.R.
        • Hurst P.M.
        • Asti L.
        • Cooper J.N.
        Impact of Medicaid expansion on young adult firearm and motor vehicle crash trauma patients.
        Surg Open Sci. 2022; 8: 9-19
        • Zogg C.K.
        • Payró Chew F.
        • Scott J.W.
        • et al.
        Implications of the patient protection and Affordable Care Act on insurance coverage and rehabilitation use among young adult trauma patients.
        JAMA Surg. 2016; 151: e163609
        • HCUP User Support
        Agency for Healthcare research and quality.
        (Available at:)
        https://www.hcup-us.ahrq.gov/
        Date: 2021
        Date accessed: March 26, 2021
        • The American College of Surgeons
        National Trauma Data Standard: Data Dictionary.
        2015 (Available at:)
        • Con J.
        • Long D.
        • Sasala E.
        • et al.
        Secondary overtriage in a statewide rural trauma system.
        J Surg Res. 2015; 198: 462-467
        • Clark D.E.
        • Osler T.M.
        • Hahn D.R.
        ICDPIC: Stata module to provide methods for translating International Classification of Diseases (Ninth Revision) diagnosis codes into standard injury categories and/or scores.
        (Available at:)
        • Agency for Healthcare Research and Quality, Healthcare cost and utilization Project
        HCUP tools and software.
        (Available at:)
        https://www.hcup-us.ahrq.gov/tools_software.jsp
        Date: 2021
        Date accessed: November 18, 2021
        • Centers for Disease Control and Prevention
        Table 1. Recommended framework of E-code groupings for presenting injury mortality and morbidity data.
        (Available at:)
        https://www.cdc.gov/injury/wisqars/ecode_matrix.html
        Date: August 10, 2011
        Date accessed: June 19, 2020
        • National Center for Health Statistics
        NCHS urban-rural classification scheme for counties.
        (Available at:)
        • Sebastião Y.V.
        • Metzger G.A.
        • Chisolm D.J.
        • et al.
        Impact of ICD-9-CM to ICD-10-CM coding transition on trauma hospitalization trends among young adults in 12 states.
        Inj Epidemiol. 2021; 8: 4
        • Wasicek P.J.
        • Kantar R.S.
        • Gebran S.
        • et al.
        Less operating and more overtriage: national trends in interfacility transfer of facial fracture patients.
        Plast Reconstr Surg. 2022;
        • Cutler D.M.
        • Scott Morton F.
        Hospitals, market share, and consolidation.
        JAMA. 2013; 310: 1964-1970
        • Crowley B.M.
        • Griffin R.L.
        • Smedley W.A.
        • et al.
        Secondary overtriage of trauma patients: analysis of clinical and geographic patterns.
        J Surg Res. 2020; 254: 286-293
        • Zogg C.K.
        • Schuster K.M.
        • Maung A.A.
        • Davis K.A.
        The extent to which geography explains one of trauma's troubling trends: insurance-based differences in appropriate inter-facility transfer.
        J Trauma Acute Care Surg. 2022;
        • American College of Surgeons
        Committee on trauma resources for optimal care of the injured patient.
        American College of Surgeons, Chicago, IL2014
        • Peng J.
        • Wheeler K.
        • Groner J.I.
        • Haley K.J.
        • Xiang H.
        Undertriage of pediatric major trauma patients in the United States.
        Clin Pediatr (Phila). 2017; 56: 845-853
        • Wick J.
        • Le H.
        • Wick K.
        • et al.
        Patient characteristics, injury Types, and costs associated with secondary over-triage of isolated cervical spine fractures.
        Spine (Phila Pa 1976). 2022; 47: 414-422
        • Kanter J.H.
        • Pomponio M.K.
        • Khan I.
        • Hong J.
        Understanding secondary overtriage for neurosurgical patients in a rural tertiary care setting.
        Clin Neurol Neurosurg. 2022; 213: 107101
        • Pontell M.E.
        • Colazo J.M.
        • Drolet B.C.
        Unnecessary interfacility transfers for craniomaxillofacial trauma.
        Plast Reconstr Surg. 2020; 145: 975e-983e