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. 2023 Jul 11:382:e074289.
doi: 10.1136/bmj-2022-074289.

Association between Medicare eligibility at age 65 years and in-hospital treatment patterns and health outcomes for patients with trauma: regression discontinuity approach

Deepon Bhaumik  1 , Chima D Ndumele  2 , John W Scott  3 , Jacob Wallace  2
Affiliations

Association between Medicare eligibility at age 65 years and in-hospital treatment patterns and health outcomes for patients with trauma: regression discontinuity approach

Deepon Bhaumik et al. BMJ. .

Abstract

Objective: To determine whether health systems in the United States modify treatment or discharge decisions for otherwise similar patients based on health insurance coverage.

Design: Regression discontinuity approach.

Setting: American College of Surgeons' National Trauma Data Bank, 2007-17.

Participants: Adults aged between 50 and 79 years with a total of 1 586 577 trauma encounters at level I and level II trauma centers in the US.

Interventions: Eligibility for Medicare at age 65 years.

Main outcome measures: The main outcome measure was change in health insurance coverage, complications, in-hospital mortality, processes of care in the trauma bay, treatment patterns during hospital admission, and discharge locations at age 65 years.

Results: 1 586 577 trauma encounters were included. At age 65, a discontinuous increase of 9.6 percentage points (95% confidence interval 9.1 to 10.1) was observed in the share of patients with health insurance coverage through Medicare at age 65 years. Entry to Medicare at age 65 was also associated with a decrease in length of hospital stay for each encounter, of 0.33 days (95% confidence interval -0.42 to -0.24 days), or nearly 5%), which coincided with an increase in discharges to nursing homes (1.56 percentage points, 95% confidence interval 0.94 to 2.16 percentage points) and transfers to other inpatient facilities (0.57 percentage points, 0.33 to 0.80 percentage points), and a large decrease in discharges to home (1.99 percentage points, -2.73 to -1.27 percentage points). Relatively small (or no) changes were observed in treatment patterns during the patients' hospital admission, including no changes in potentially life saving treatments (eg, blood transfusions) or mortality.

Conclusions: The findings suggest that differences in treatment for otherwise similar patients with trauma with different forms of insurance coverage arose during the discharge planning process, with little evidence that health systems modified treatment decisions based on patients' coverage.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at https://icmje.org/disclosure-of-interest/ and declare: no support from any organization for the submitted work; support from the Agency for Healthcare Research and Quality for JWS as principal investigator (grant K08-HS028672) and as a co-investigator (grant R01-HS027788). JWS also receives salary support from Blue Cross Blue Shield of Michigan through the collaborative quality initiative known as Michigan Social Health Interventions to Eliminate Disparities (MSHIELD), outside the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Changes in health insurance, treatment intensity, and health outcomes after age 65 years. The mean of outcomes is plotted by age (in years) for the study period. For illustrative purposes, a line of best fit is plotted based on a local linear regression, with the optimal bandwidth selected by the study’s regression discontinuity model. Dashed line denotes Medicare eligibility threshold, and open circle represents the expected mean of the outcome at age 65 in the absence of Medicare eligibility
Fig 2
Fig 2
Changes in composition of length of stay after age 65 years. The plot presents local linear regression discontinuity (RD) estimates of the adjusted discontinuity between age and discrete indicators for different lengths of stay. Encounters with lengths of stay of 15 days or longer are grouped together
See this image and copyright information in PMC

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