Evidence map›Paper›PMID 39026325›Full record

Observational studyCritical care (London, England)2024

Influence of health insurance on withdrawal of life sustaining treatment for patients with isolated traumatic brain injury: a retrospective multi-center observational cohort study.

Armaan K Malhotra, Husain Shakil, Ahmad Essa, Francois Mathieu, Shaurya Taran, Jetan Badhiwala, Yingshi He, Eva Y Yuan, Abhaya V Kulkarni, Jefferson R Wilson and 2 more

Abstract readObservational StudyMulticenter Study
PubMed Full text at PMC Publisher
In one paragraph

Observational study in Critical care (London, England), 2024. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 7 papers.

0numbers the graph read from it
0cells of the map it votes in
7citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

7 citing papers in PubMed.

  1. Article
  2. Article
  3. Review
  4. Review
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  7. Review
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

12 authors.

Armaan K MalhotraDivision of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
Husain ShakilDivision of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
Ahmad EssaDivision of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
Francois MathieuDivision of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
Shaurya TaranInstitute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
Jetan BadhiwalaDivision of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Yingshi HeDivision of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
Eva Y YuanDivision of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
Abhaya V KulkarniInstitute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
Jefferson R WilsonDivision of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
Avery B NathensInstitute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
Christopher D WitiwDivision of Neurosurgery, Unity Health Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. christopher.witiw@unityhealth.to.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundHealthcare inequities for patients with traumatic brain injury (TBI) represent a major priority area for trauma quality improvement. We hypothesized a relationship between health insurance status and timing of withdrawal of life sustaining treatment (WLST) for adults with severe TBI.

methodsThis multicenter retrospective observational cohort study utilized data collected between 2017 and 2020. We identified adult (age ≥ 16) patients with isolated severe TBI admitted participating Trauma Quality Improvement Program centers. We determined the relationship between insurance status (public, private, and uninsured) and the timing of WLST using a competing risk survival analysis framework adjusting for baseline, clinical, injury and trauma center characteristics. Multivariable cause-specific Cox regressions were used to compute adjusted hazard ratios (HR) reflecting timing of WLST, accounting for mortality events. We also quantified the between-center residual variability in WLST using the median odds ratio (MOR) and measured insurance status association with access to rehabilitation at discharge.

resultsWe identified 42,111 adults with isolated severe TBI treated across 509 trauma centers across North America. There were 10,771 (25.6%) WLST events in the cohort and a higher unadjusted incidence of WLST events was evident in public insurance patients compared to private or uninsured groups. After adjustment, WLST occurred earlier for publicly insured (HR 1.07, 95% CI 1.02-1.12) and uninsured patients (HR 1.29, 95% CI 1.18-1.41) compared to privately insured patients. Access to rehabilitation was lower for both publicly insured and uninsured patients compared to patients with private insurance. Accounting for case-mix, the MOR was 1.49 (95% CI 1.43-1.55), reflecting significant residual between-center variation in WLST decision-making.

conclusionsOur findings highlight the presence of disparate WLST practices independently associated with health insurance status. Additionally, these results emphasize between-center variability in WLST, persisting despite adjustments for measurable patient and trauma center characteristics.

Indexed as

Brain Injuries, TraumaticInsurance, HealthWithholding TreatmentAdultAgedCohort StudiesFemaleHumansInsurance CoverageMaleMiddle AgedRetrospective StudiesCritical careEnd of life careEquityInsurance statusSevere traumatic brain injuryWithdrawal of life sustaining treatment

Identifiers

PMID39026325
PMCPMC11264615

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.