对于严重受伤的创伤患者,撤销维持生命治疗(WLST)的决定是复杂且多因素的,患者的保险状况有可能影响决策。
■要确定患者保险类型(私人保险,医疗补助,并且没有保险)与在美国创伤中心护理的严重受伤成年人的WLST时间有关。
这项基于回顾性注册的队列研究包括来自美国外科医师学会创伤质量改善计划(TQIP)注册的I级和II级创伤中心的报告数据。参与者包括在2017年1月1日至2020年12月31日期间受伤的成年创伤患者,需要在重症监护病房住院。如果患者在到达或在急诊科死亡或先前存在不复苏指令,则将其排除在外。分析于2023年12月12日进行。
■保险类型(私人保险,医疗补助,无保险)。
■对保险状态与WLST时间之间的关联进行了调整的事件时间分析,分析考虑到医院的聚类。
■这项研究包括307731名患者,其中160809人(52.3%)有私人保险,88233(28.6%)有医疗补助,58689人(19.1%)没有保险。平均(SD)年龄为40.2(14.1)岁,232994(75.7%)为男性,59551(19.4%)是非裔美国人或黑人患者,白人患者为201012例(65.3%)。总的来说,12962例(4.2%)患者在入院期间接受了WLST。与有私人保险的患者相比,没有保险的患者更有可能接受更早的WLST(HR,1.54;95%CI,1.46-1.62)和医疗补助(HR,1.47;95%CI,1.39-1.55)。这一发现对于敏感性分析是稳健的,不包括在出现48小时内死亡的患者,以及将非停药死亡作为竞争风险。
■在这项针对美国严重受伤的成年创伤患者的队列研究中,与有私人或医疗补助保险的患者相比,没有保险的患者接受了较早的WLST.根据我们的发现,患者的支付能力可能与WLST的决策转变有关,提示社会经济学对患者预后的影响。
UNASSIGNED: Withdrawal of life-sustaining therapy (WLST) decisions for critically injured trauma patients are complicated and multifactorial, with potential for patients\' insurance status to affect decision-making.
UNASSIGNED: To determine if patient insurance type (private insurance, Medicaid, and uninsured) is associated with time to WLST in critically injured adults cared for at US trauma centers.
UNASSIGNED: This retrospective registry-based cohort study included reported data from level I and level II trauma centers in the US that participated in the American College of Surgeons Trauma Quality Improvement Program (TQIP) registry. Participants included adult trauma patients who were injured between January 1, 2017, and December 31, 2020, and required an intensive care unit stay. Patients were excluded if they died on arrival or in the emergency department or had a preexisting do not resuscitate directive. Analyses were performed on December 12, 2023.
UNASSIGNED: Insurance type (private insurance, Medicaid, uninsured).
UNASSIGNED: An adjusted time-to-event analysis for association between insurance status and time to WLST was performed, with analyses accounting for clustering by hospital.
UNASSIGNED: This study included 307 731 patients, of whom 160 809 (52.3%) had private insurance, 88 233 (28.6%) had Medicaid, and 58 689 (19.1%) were uninsured. The mean (SD) age was 40.2 (14.1) years, 232 994 (75.7%) were male, 59 551 (19.4%) were African American or Black patients, and 201 012 (65.3%) were White patients. In total, 12 962 patients (4.2%) underwent WLST during their admission. Patients who are uninsured were significantly more likely to undergo earlier WLST compared with those with private insurance (HR, 1.54; 95% CI, 1.46-1.62) and Medicaid (HR, 1.47; 95% CI, 1.39-1.55). This finding was robust to sensitivity analysis excluding patients who died within 48 hours of presentation and after accounting for nonwithdrawal death as a competing risk.
UNASSIGNED: In this cohort study of US adult trauma patients who were critically injured, patients who were uninsured underwent earlier WLST compared with those with private or Medicaid insurance. Based on our findings, patient\'s ability to pay was may be associated with a shift in decision-making for WLST, suggesting the influence of socioeconomics on patient outcomes.