Clinicians must “uncomfortably” examine bias in life-and-death decisions, says expert
https://www.medpagetoday.com/criticalcare/generalcriticalcare/111230
Critically injured trauma patients without insurance had a higher risk of being taken off life-saving care sooner than their insured counterparts, according to findings from a retrospective cohort study of more than 300,000 U.S. adults.
After adjustment for patient and hospital characteristics, those without insurance had significantly earlier withdrawal of life-sustaining therapy (WLST) when compared with Medicaid recipients (HR 1.53, 95% CI 1.45-1.62) or the privately insured (HR 1.57, 95% CI 1.49-1.65), reported researchers led by Graeme Hoit, MD, of the University of Toronto.
In contrast, no such difference in time to WLST was observed between the Medicaid and privately insured groups (HR 1.03, 95% CI 0.98-1.08). Unadjusted numbers showed mean times to WLST of 6.5 days in the uninsured group, 8.9 days in the Medicaid group, and 7.8 days for the privately insured group.
“Our study suggests that a patient’s ability to pay may be associated with a shift in decision-making for WLST,” the group wrote in JAMA Network Openopens in a new tab or window.
This would appear to go against the Emergency Medical Treatment and Labor Act, which requires that all critically ill patients in hospitals receive optimal care regardless of insurance status or financial means.
But more than two-thirds of uninsured trauma patients are at risk of catastrophic health expenditures, noted Hoit and colleagues, and if these patients are unable to pay, the financial responsibility may shift to the institutions caring for them. One study from 2013opens in a new tab or window estimated a $2.8 billion annual tab for uninsured trauma care in the U.S.
Under ideal circumstances, the decision to WLST involves a shared decision between clinicians and a patient’s surrogate or substitute decision-maker (SDM), the researchers pointed out.
“However, the nature of severe traumatic injury means that trauma patients are typically younger, less likely to have preexisting care directives, more likely to be estranged from their families and SDMs, and more likely to belong to marginalized social populations compared with the general critical care population,” they wrote. “These factors complicate WLST decisions and may increase the likelihood of practitioner, caregiver, or institutional biases impacting decisions and timing.”
The new findings, said Hoit and colleagues, build on prior trauma studies linking uninsured status with increased mortality.
“When presented with decisions about whether or not to proceed with tests, procedures, or care continuation, institutions and/or SDMs may both have concerns with the cost of care and be less likely to pursue extensive measures, resulting in earlier mortality,” they wrote.
In an accompanying commentaryopens in a new tab or window, Zara Cooper, MD, MSc, a trauma surgeon at Brigham and Women’s Hospital and Harvard Medical School in Boston, said “it is incumbent upon individual clinicians and health systems to closely and uncomfortably examine how bias either creeps or marches into the life-and-death decisions we make for everyone under our care.”
In fact, she suggested, meaningful differences between the study groups — namely alcohol or substance use and mental health disorders — may have influenced WLST decisions. Self-inflicted injuries, for example, were associated with a greater risk of earlier WLST (HR 1.54, 95% CI 1.36-1.73), “suggesting that even though depression is a treatable disorder, comorbid depression may have biased clinicians and surrogates toward WLST.”
But Cooper added that “one of the more important findings in this study is that having any insurance vs no insurance is more important than having public vs private insurance in terms of risk of treatment withdrawal.”
An estimated 12% of American adults ages 18 to 64 do not have insurance, according to recent CDC dataopens in a new tab or window, with the highest rates among Hispanics, those of lower income, and people living in non-Medicaid expansion states (all but 10 states — mostly in the south — have expanded Medicaid accessopens in a new tab or window under the Affordable Care Act).
Compared with injured adults in non-expansion states, noted Cooper, people in expansion states “are more likely to survive hospitalization, have shorter hospitalizations, and are more likely to receive rehabilitation postdischarge.”
The study from Hoit’s team included 307,731 critically ill trauma patients ages 18 to 64 admitted to an intensive care unit (ICU) in the U.S. from 2017 to 2020. Data were captured from level I and level II trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP) registry. Analyses excluded patients who died on arrival or in the emergency department, as well as individuals with a “do not resuscitate” order.
Mean age was 40 years, three-fourths were male, about two-thirds were white, and 19% were Black. The most common mechanism of injury was motor vehicle collision (35%), followed by falls (22%), firearms (12%), and motorcycle (10%) or pedestrian (9%) accidents. More than three-fourths of the injuries were unintentional, while 15.8% were related to assaults and 2.8% were self-inflicted.
A majority (52%) of the cohort had private insurance, while 19% were uninsured, and the rest were insured through Medicaid.
Uninsured patients tended to be younger than those with private insurance (37.8 vs 41.7 years); were more likely to be male (82.6% vs 73.2%), have a history of substance abuse (12.5% vs 0.8%), and be victims of assault (24.2% vs 7%); they were less likely to be white (56.1% vs 73.8%) and generally had lower rates of chronic illness. The uninsured population was more similar to the Medicaid group.
Hoit’s team noted that TQIP defined life-supporting interventions as ventilator support (with or without extubation), kidney replacement therapy, medications to support blood pressure or cardiac function, and surgical, interventional, or radiological procedures.
Overall, 12,962 patients (4.2% of the total cohort) underwent WLST during their ICU admission, including 5% of those without insurance, 4.2% of those with Medicaid, and 3.9% of those with private insurance. Overall, the average time to WLST was 7.8 days.
Besides self-inflicted injuries, another variable associated with earlier withdrawal of care was firearm injuries (HR 2.01, 95% CI 1.79-2.27). WLST was less common in Asian, Black, and Hispanic patients (as compared with whites) and for those treated at teaching or for-profit hospitals.
Study limitations cited by the authors included a lack of variables captured in the TQIP registry — including income, religious/spiritual beliefs, marital status, language ability, and education level — that may have influenced decisions related to WLST. Also, researchers did not assess the types of care that had been provided before it was withdrawn.
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