Insurance coverage could impact survival of patients after spinal cord injury

The care of people seriously harmed by spinal cord injury can cost hundreds of thousands of dollars, and a new analysis suggests that ability to pay influences how long a patient remains on life support.

In a study of more than 8,400 U.S. adults with severe spinal cord injury, "uninsured patients had greater odds of withdrawal of life-supporting treatment," compared to those who had private insurance, researchers said.

The findings were published in the journal JAMA Surgery.

According to background information in the study, an estimated 1.3 million people in North America have been affected by a spinal cord injury, which can often result in irreversible paralysis. Other medical issues, such as trouble with respiration, can also occur.

Caring for these individuals can require a large staff and complex, expensive technologies.

All of that can mean big medical bills: "In the U.S., the cost of acute care for spinal cord injury has been estimated to be between $92,220 and $337,400, with the higher end of the range reported to correspond to higher neurologic levels of injury."

The new study was led by Dr. Christopher Witiw, an assistant professor of surgery at the University of Toronto. His team wondered if time spent on life support was affected by the level and type of insurance coverage a U.S. patient might have.

To find out, they looked at 2013–2020 data from the American College of Surgeons. It covered patient outcomes and insurance status for 8,421 people aged 16 and older, all of who were treated for a spinal cord injury. Data came from 498 different trauma centers.

Most of the patients (80%) were male and they averaged 49 years of age.

Over the course of the study, patients who had no insurance coverage were 49% more likely to be taken off life support compared with the privately insured, Witiw's team found.

Patients who had no insurance coverage were also 98% more likely to die over the study period compared with the privately insured, the research showed.

Put another way, of 940 patients without insurance, just over 22% were taken off of life support and just under 34% died.

For the privately insured, those numbers were 14.3% and 21.5%, respectively.

Rates for people on public insurance (Medicaid, Medicare) lay somewhere between those of the privately insured and the uninsured, the study found. The privately insured fared significantly better than the publicly insured in terms of lower rates of complications while in hospital, as well as longer hospital stays.

All of these findings "highlight potential insurance-related disparities in outcomes after complete cervical spinal cord injury," Witiw's group concluded.

Decisions to withdraw life support are, of course, heart-wrenching and of life-or-death importance, since "97.5% of patients who had withdrawal from life support ultimately died," the researchers noted.

"The decision for withdrawal from life support is complex and requires shared decision-making between patients, families and practitioners, with respect for patient autonomy being paramount," the authors said.

Does the ability to pay mounting medical bills play a role in these decisions?

The researchers noted that it was difficult to untangle economic barriers from other factors that might influence decisions around life support, such as the cultural or religious beliefs of patients and their doctors and "expectations about recovery."

Still, Witiw's group said, "future work is needed to incorporate patient perspectives and identify strategies to close the quality gap [in spinal cord injury care] for the large number of patients without private insurance."

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