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Local Access to Care Programs Increase Trauma Patient Follow-up Compliance
Tiffany L. Overton, MPH Shahid Shafi, MD Rajesh R. Gandhi, MD PhD
PII: S0002-9610(14)00145-7
DOI: 10.1016/j.amjsurg.2013.11.008
Reference: AJS 11121
To appear in: The American Journal of Surgery
Received Date: 13 September 2013
Revised Date: 22 October 2013
Accepted Date: 22 November 2013
Please cite this article as: Overton TL, Shafi S, Gandhi RR, Local Access to Care Programs IncreaseTrauma Patient Follow-up Compliance, The American Journal of Surgery (2014), doi: 10.1016/j.amjsurg.2013.11.008.
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Local Access to Care Programs Increase Trauma Patient Follow-up Compliance
Running head: LACP FOLLOW-UP COMPLIANCE
Authors:
Corresponding Author:
Tiffany L. Overton, MPH
O: 817-702-5913
F: 817-702-5162
Trauma Services
JPS Health Network
1500 S. Main St.
Fort Worth, Tx 76104
Shahid Shafi, MD
JPS Health Network
Rajesh R. Gandhi, MD PhD
JPS Health Network
Abstract: Background: Inadequate follow-up of uninsured trauma patients after
discharge remains a major challenge for trauma programs. Local Access to Care
Programs (LACPs) have been developed to improve access to health care to the
uninsured. We hypothesized that enrollment in LACP would improve post-discharge
follow-up of uninsured trauma patients. Methods: Study population consisted of
5,830 uninsured trauma patients from 2006 to 2011, treated at a large urban Level I
trauma center. Patients with burn injuries, transfers to another acute care facility,
and those who died or who left against medical advice, were excluded. Patients who
enrolled in our LACP were compared to those who did not, to determine the
relationship between enrollment in LACP and post-discharge follow-up, while
controlling for injury severity, demographics, and discharge disposition. Results:
Patients in LACP were significantly more likely to schedule follow-up appointments
after discharge (OR=1.78, 95%CI 1.51-2.10) and to comply with them
(OR=2.44,95%CI 1.98-2.99). However, 30-day re-admission rates were similar in
two groups (1.1% vs. 1.9%). Conclusions: Enrollment in the LACP was associated
with improved post discharge follow-up but not re-admissions.
Keywords: local access to care programs; trauma; follow-up compliance;
uninsured; patient centered medical home
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Background: Inadequate follow-up of uninsured trauma patients after discharge remains
a major challenge for trauma programs. Local Access to Care Programs (LACPs) have
been developed to improve access to health care to the uninsured. We hypothesized that
enrollment in LACP would improve post-discharge follow-up of uninsured trauma
patients. Methods: Study population consisted of 5,830 uninsured trauma patients from
2006 to 2011, treated at a large urban Level I trauma center. Patients with burn injuries,
transfers to another acute care facility, and those who died or who left against medical
advice, were excluded. Patients who enrolled in our LACP were compared to those who
did not, to determine the relationship between enrollment in LACP and post-discharge
follow-up, while controlling for injury severity, demographics, and discharge disposition.
Results: Patients in LACP were significantly more likely to schedule follow-up
appointments after discharge (OR=1.78, 95%CI 1.51-2.10) and to comply with them
(OR=2.44,95%CI 1.98-2.99). However, 30-day re-admission rates were similar in two
groups (1.1% vs. 1.9%). Conclusions: Enrollment in the LACP was associated with
improved post-discharge follow-up but not re-admissions.
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Summary:
The primary finding of this study is that enrollment of uninsured patients in our local
access to care program was associated with a significant improvement in follow-up after
discharge from the hospital. This suggests that adverse effects of lack of health insurance
on post-discharge follow-up may be mitigated by local access to care programs. The main
implication of our findings is that implementation of a local access to care program may
improve post-discharge care for trauma patients.
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Keywords: local access to care programs; trauma; follow-up compliance; uninsured;
patient centered medical home
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BACKGROUND
Significant improvements have been made in trauma patient management with a focus on
prehospital and hospital care. However, trauma patients’ continued care after hospital discharge,
an important component of comprehensive care, continues to lag behind.(1) The importance of
adequate follow-up after discharge from hospital has been well documented; it ensures proper
treatment and management of conditions,(2) reduces risk of readmission,(1) and improves short
and long-term outcomes,(3) while failure to follow-up contributes to worsening outcomes.(4) In
order to improve post-hospital care, the American College of Surgeons Committee on Trauma
recommends that trauma centers monitor discharged patients’ complications leading to hospital
readmission.(5) Transitioning to primary care providers and integrating care between hospital
discharge and follow-up has shown to increase outpatient follow-up rates.(6) Approaches such as
patient centered medical homes have also been shown to reduce emergency room visits,(7) fewer
avoidable hospitalizations,(8) improved access to care, and higher patient satisfaction.(9)
This issue is of particular importance for the uninsured patients who experience more
difficulty in obtaining outpatient care,(10) are more likely to return to an emergency department
within 30 days of hospital discharge,(11) or forego follow-up care altogether.(10, 12) Limited
access to appropriate follow-up care may impede not only physical rehabilitation after traumatic
injury, but psychological and social components related to quality of life as well. To address the
needs of the uninsured population, Local Access to Care Programs (LACPs) have been
developed that provide low-cost access to medical care in lieu of insurance.(13) LACPs are not
insurance providers, but entities with enrollment mechanisms, eligibility requirements, and
defined benefits and provider networks administered by local nonprofit agencies. LACPs are
designed to facilitate access to health services to the uninsured and underinsured and are
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characterized by having a formal enrollment process, eligibility requirements, a network of
providers, and offering free or reduced health care services. In 2008, twenty-seven states had
existing LACPs, with a total of forty-seven separate programs.(13) A LACP implemented by
Virginia Commonwealth University showed a reduction in emergency department an inpatient
costs and use.(14)
The purpose of this study was to determine if our LACP improved follow-up after
discharge in trauma patients. We hypothesize that uninsured patients enrolled in the LACP were
more likely to follow-up after hospital discharge than uninsured patients who did not enroll in
the program.
METHODS
Our Level I trauma center is part of a publicly funded, integrated network of a large
urban hospital (a Level I trauma center) and multiple outpatient facilities (primary care and
specialty clinics), that provide comprehensive inpatient and outpatient care to the entire county
of two million people. The network also offers a local provider-based LACP to low- income,
uninsured patients treated at our Level I trauma center including the assignment of a medical
home within the network. To qualify, patients must be at or below 300% Federal Poverty Line,
and either don’t qualify for or are rejected by third party payers. Counselors screen all uninsured
patients for eligibility, and enroll eligible patients in the LACP during their inpatient stay.
Patients’ medical bills are covered under the LACP 90 days prior to the date of enrollment, and
enrolled patients receive discounts on outpatient medical visits within the network, medications,
and aren’t turned away if they are unable to afford copayments. Patients are required to re-enroll
on a yearly basis, but may stay in the program as long as they qualify.
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We retrospectively reviewed data collected from the trauma registry maintained at an
urban level I trauma center for patients presenting between 2006 and 2011. Inclusion criterion
was lack of health insurance. Patients with burns, transfers out to an acute care facility, and those
who died or who left against medical advice were excluded from analysis. Demographic, injury
specific (e.g. injury severity score, mechanism of injury), discharge information (e.g. condition
on discharge, discharge setting), and complications were abstracted from our trauma registry.
Patients were classified into two groups based on their insurance status at discharge: self-pay
(uninsured), or LACP (enrolled in our hospital network program described above). The primary
outcomes were scheduling and compliance with follow-up appointments up to 60 days after
hospital discharge. A secondary outcome was 30-day re-admission rates. This study was
approved by our hospital’s Institutional Review Board.
Data analysis was conducted using SPSS version 20. Descriptive statistics were
performed to characterize demographic information. Binary logistic regression was used to
evaluate significant predictors of scheduling and follow-up compliance. Primary predictor of
interest was insurance status at discharge while controlling for age, sex, race, discharge
disposition, Glasgow Outcome Score (GOS), injury severity, and length of stay.
RESULTS
Of 11,725 trauma patients during the study period, 5,830 (50%) were uninsured and met
our inclusion and exclusion criteria. Of these, 4,504 (77%) were self-pay at discharge, and 1,326
(23%) were enrolled in the LACP program (Figure I). Overall, follow-up appointments were
scheduled for 4,515 (77%) of patients. Both groups of patients had similar racial/ethnic makeup,
suffered primarily blunt injuries, and had similar Glasgow Coma Scale scores at admission and
Glasgow Outcome Scores at discharge. Patients enrolled in the LACP were somewhat older, had
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higher injury severity scores, and longer hospital length of stay. Self-pay patients were more
predominately male and more likely to be discharged home without professional assistance
(Table I). Patients enrolled in LACP were significantly more likely to schedule a follow-up
appointment than self pay patients (84% vs. 76%, p <0.001) and significantly more likely to
comply with it (89% vs. 77%, p <0.001) (Figure I).
Multivariate regression analysis yielded that after adjusting for age, gender,
race/ethnicity, ISS, hospital length of stay, discharge disposition, and GOS, patients enrolled in
LACP program were 78% more likely to schedule a follow-up appointment and more than twice
as likely to comply with it than self pay patients (Table II). Other independent predictors of
scheduling a follow-up appointment included younger age, increasing ISS, and those who were
discharged home without assistance. The only independent predictors of compliance with follow-
up appointment were participation in LACP, increasing ISS, and increasing hospital length of
stay (Table II). Additionally, 83 (1.4%) of our uninsured patients had unplanned readmissions
over a 30-day period after discharge, and rates were similar between LACP enrollment status
(1.9% Self-Pay vs. 1.1% LACP).
DISCUSSION
The primary finding of this study is that enrollment of uninsured patients in our LACP
was associated with a significant improvement in follow-up after discharge from the hospital.
This suggests that adverse effects of lack of health insurance on post-discharge follow-up may be
mitigated by LACPs.
These findings are consistent with prior studies demonstrating the ability of LACPs to
facilitate access to health care for uninsured patients. A program implemented by Virginia
Commonwealth University showed a reduction in emergency department and inpatient costs and
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use, and the decrease was more pronounced in patients enrolled in the program for longer periods
of time.(14) Similarly, having a usual source of care is associated with lower rates of unmet
medical needs, problems, and delays in getting care.(15)
The main implication of our findings is that implementation of LACP may improve post-
discharge care for trauma patients. We did not find any relationship with readmission rates which
were low for both groups. This is also borne by the fact that in 2011, our hospital was penalized
only 0.07% by Medicare for hospital readmissions after discharge, compared to 0.74% and
0.57% at other regional hospitals. Overall, trauma patients are at low risk for readmission, with
surgical site infection as the only identified risk factor for risk of readmission.(16) Additionally,
over three years of enrollment in the Virginia Commonwealth program, average total costs per
enrollee fell from $8,899 to $4,569 (approximately 50 percent). However, it may take several
years of enrollment for hospitals to see significant health care savings.(14) Second, establishment
of a medical home is important for continuity of care, and even though healthcare coverage for
the poor fluctuates frequently,(17) patients enrolled in medical homes may continue to use the
services when they are insured.(18) Trauma centers nationwide should explore the option of
implementing a LACP to see if it would be suitable for the long-term follow-up needs of their
respective populations.
This study has a few limitations that should be recognized. First, patients discharged to a
facility (such as a nursing home or rehabilitation center) may have received follow-up care at
those locations, limiting our ability to track follow-up compliance. Additionally, without follow-
up data for all patients (insured and uninsured) we are unable to accurately predict the degree to
which enrollment in our LACP increases compliance compared to usual health insurance.
Hospital readmission rates were only followed thirty days out from hospital discharge date, and
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research has shown only 23% of readmissions were to the same hospital.(19) Finally, without
information about long-term patient outcomes, we are unable to evaluate whether or not
improved post-discharge follow-up was associated with improvement in other outcomes such as
complications, quality of life, and functional outcomes.
In conclusion, enrollment in local access to care program was associated with improved
post-discharge follow-up among uninsured trauma patients but not readmission rates. Such
programs for trauma patients may improve their long term outcomes.
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Table I. Patient Demographics by Insurance Coverage Status (IQR=Interquartile range, LACP=Local Access to Care Program)
LACP
(n = 1,326)
Self-Pay
(n = 4,504)
p-value
Age (years, median, IQR) 38 (26 to 49) 30 (23 to 43) <0.001
Gender (% male) 74% 78% <0.001
Race/Ethnicity (% white) 51% 49% NS
Injury Severity Score (median, IQR) 9 (4 to 11) 5 (4 to 10) <0.001
Mechanism of Injury (% blunt) 84% 82% NS
Glasgow Coma Scale (median, IQR) 15 (15 to 15) 15 (15 to 15) NS
Hospital Length of Stay (days, median, IQR) 3 (1 to 6) 2 (1 to 4) <0.001
Glasgow Outcome Score (% good recovery) 94% 93% NS
Discharged to (% home without assistance) 86% 89% <0.01
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Table II. Independent Predictors of follow-up appointment scheduling and Compliance
Follow-up Appointment
Scheduling
Follow-up Appointment Compliance
Odds Ratio (95% CI) p-value Odds Ratio (95% CI) p-value
Age (years) 0.99 (0.98 – 0.99) <0.001 0.99 (0.99 – 1.00) NS
Gender (% male) 0.86 (0.73 – 0.99) NS 0.95 (0.79 – 1.13) NS
Race (White vs. Other) 0.91 (0.80 – 1.03) NS 0.98 (0.84 – 1.13) NS
Injury Severity Score 1.02 (1.01- 1.03) <0.001 1.02 (1.00 – 1.03) <0.01
Hospital Length of Stay (days) 1.01 (0.99 – 1.02) NS 1.02 (1.01 – 1.03) <0.05
Glasgow Outcome Score (Good Recovery vs. Other)
.99 (0.76 – 1.31) NS 0.94 (0.67 – 1.32) NS
Discharge Disposition (Home without assistance vs. Other)
1.49 (1.22 – 1.83) <0.001 1.19 (0.91 – 1.54) NS
LACP vs. Self-Pay 1.78 (1.51 – 2.10) <0.001 2.44 (1.98 – 2.99) <0.001
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Figure I. Uninsured Patient Flow Diagram
Uninsured Patients
n = 5,830
Local Access to Care Prgram
n = 1,326
23%
Scheduled Follow-up
n = 1,112
84%
Follow-up
n = 989
89%
Lost to Follow-up
n = 123
11%
No Scheduled Follow-up
n = 214
16%
Self-Pay
n = 4,054
77%
Scheduled Follow-up
n = 3,403
76%
Follow-up
n = 2,607
77%
Lost to Follow-up
n = 796
23%
No Scheduled Follow-up
n = 1,101
24%
