Monday, November 30, 2009

Okay, I'm just gonna have to go all Doctor on you now

No, it doesn't mean that I'm going to charge you for reading this. :-)

I've talked about healthcare reform over and over again (I don't see how Joan does it every day without going insane). I've talked about healthcare from an emotional standpoint and from an American legislative standpoint. I've talked about all the benefits of healthcare reform. Well, I'd like to take a different tactic. I would like to review the medical literature. I've picked several studies which I will describe over the next several days. The one thing that all of these studies have in common is that they point out that health insurance is a predictor of outcome. On Wednesday or Thursday, I'm going to review an article from the Journal of the American Medical Association which clearly states that having a unified health program has survival benefits (we don't have a coordinated, organized healthcare system in the United States).
As a trauma surgeon, I don't like to talk "shop" with people who are not in the medical profession. As soon as you start mentioning cytokines and mitochondria DNA, most people's eyes glaze over. But, with watered-down legislation creeping through the Senate at a glacial pace, I thought it was important for me to go over some of this literature. The literature makes approximately the same point that Keith Olbermann made approximate monthly go when he talked about having health insurance being life-and-death.

In trauma, we, trauma folks, would like to think that we treat patients all the same. Many states have trauma systems, in which an injured patient, is shunted away from small hospitals that probably cannot help that patient and toward trauma centers who have the expertise and the manpower to help. This move has been shown to save lives. Most, if not all trauma centers have protocols which are then individualized for a particular patient. We have found through numerous studies that these protocols help save lives. Therefore, you would figure that the outcome of a patient who was seriously injured in a car crash would be directly related to his or her injuries which is true for the most part. A recent study has thrown a wrench in this.

A study, which was published in The Archives of Surgery in 2008, investigated over 400,000 patients which had been entered into the National Trauma Databank. One thing that we have known for years is that socioeconomic status does influence your outcome. As expected, mortality rates for Black and Hispanic patients were higher than those of White patients. Patients with insurance had a mortality rate of approximate half of those without insurance. Now, for the shocker -- both Blacks and Hispanics with insurance who were injured had a mortality rate less than Whites without insurance.
This was a very surprising result. Numerous studies in trauma patients over the years have shown differences in outcomes amongst the races. As more and more studies have been done, it is clear that race is a surrogate for multiple other factors including eating habits, living conditions, and other things that can affect outcome. It is also clear that insurance acts as a surrogate for those same kind of factors. People with insurance have jobs. People with jobs drink less than people without jobs. People with jobs tend to live in better conditions than people without jobs. What was surprising is how strong insurance is as an indicator of lifestyle.

So, if every American has health care coverage will they all have better outcomes from trauma? Well, this question is somewhat hard to answer. On one hand, just having insurance does not get you to live in a better house, in a better neighborhood with better indoor plumbing and a refrigerator that works all the time. On the other hand, one of the huge problems that we have in the trauma community is that we have to send many people home from the hospital, after their hospital stay is over, when they should go to a rehabilitation center for more therapy but they can't qualify because they don't have insurance. These patients will instantly do better. Getting adequate health care coverage to all Americans is a step towards better equality.

I would like all members of Congress to read this article. This is important. This is what we're fighting for. We're fighting for a more equitable society. I'm not trying to take away any healthcare from anybody but instead, I want to add healthcare to those who don't have it.

Tomorrow, I'm going to review an article called health insurance and mortality in United States adults. This article expands on the concept that insurance is a marker for outcome.


Robert M said...

this is a great article and post. Please stop making sense.
Congradulations on being a poster here.

The Angry Independent said...

Excellent piece Dr. Thompson...

Measuring trauma stats may be tricky, because you have to take into account who is coming to the ER with the worst injuries to begin with. Those who are poor and Black are disproportionately exposed to certain kinds of injuries, at least in big urban centers. I don't know about NC.

In other words, one thing that this can't really take into account are the social and cultural problems that lead Blacks to sustain injuries from assault (guns, knives, beatings) at a higher rate. Insurance can't fix that.

But you are correct.... that better access tends to lead to better outcomes.

There was one study that claimed that the outcomes aren't that much better for the poorest (and I can't recall that study at the moment)...but there are so many other variables that effect outcomes.... doesn't mean that more access doesn't improve care and outcomes when the patient takes advantage of that access. The person still has to go to the doctor, still has to take their medications, still has to make appointments, etc. Other variables such as lacking transportation, being homeless, having too many untreated pre-existing conditions, drinking, smoking, and drug use, sometimes skew the numbers.

But for most people.... better access would extend life...and improve quality of life.