M. Cerullo1, M. Michailidou1,2, Z. G. Hashmi1, A. T. Lwin1, E. B. Schneider1, A. H. Haider1 1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2University Of Arizona,Tucson, AZ, USA
Introduction: Prior research has demonstrated the efficacy and safety of non-operative management for splenic injuries in children. In addition, repeated studies have documented an association between insurance status and hospital course. Though every state has set up its own State Children’s Health Insurance Program (SCHIP), enrollment rates have varied. Our study aims to determine how enrollment influences the effect of insurance status on in-hospital management of pediatric splenic injury (PSI).
Methods: PSI surgical intervention (splenectomy and splenorrhaphy) was evaluated as the primary outcome measure. Enrollment into SCHIP from 1999 to 2011 was calculated using state-level data from the US Census Bureau’s Current Population Survey. The Savitzky-Golay smoothing algorithm was applied to yearly ratios of uninsured to publicly insured children to calculate the rate of enrollment in SCHIP by state. To evaluate the effect of insurance status on interventions, discharge records of patients aged less than 18 years with ICD-9 codes for non-penetrating splenic injury (865.-) from the Kids’ Inpatient Database for 2009 were used. Design weights were applied at the discharge level to produce national-level estimates. Logistic regression was used to evaluate the effect of insurance status on management of PSI after adjusting for confounders including age, sex, race, new injury severity score (NISS), income quartile, abdominal anatomic injury severity (AIS), and hospital characteristics (e.g. urbanicity, teaching status, management, children’s hospital designation). A hierarchical model was then constructed to evaluate the latent effect of enrollment rates on the effect of insurance status.
Results: A total of 2843 patients with pediatric splenic injury in 39 states met inclusion criteria. Mean age of children with PSI was 13.4 years (SE: 4.4). Most were male (71.4%), white (76.5%), above median income (52.9%), and treated in urban teaching hospitals (72.0%). Adjusted odds of mortality was higher in children who underwent operative management compared to children who underwent non-operative management (OR=7.96, 95% CI: 4.51-14.07). Lack of insurance was not associated with mortality, (OR=1.37, 95% CI: 0.62-3.05), though uninsured children had 1.4 (95% CI: 1.16-2.91) times greater adjusted odds of undergoing operative management compared to insured children, and they continued to demonstrate greater odds of undergoing operative management even when clustering by state was controlled for in the hierarchical model (OR: 1.83; 95% CI: 1.09-3.10). Faster state-specific enrollment rate resulted in lower odds of operative management (p<0.05).
Conclusion: Uninsured children are more likely than insured children to receive operative management for blunt splenic injury, regardless of their state’s rate of enrollment into SCHIP. However, children in faster enrolling states are less likely to undergo operative management overall, highlighting the importance of measures aimed at increasing insurance uptake.