Authors: Erica L W Lester, Justin E Dvorak, Patrick J Maluso, Leah C Tatebe, Sandy Widder, Faran Bokari
Journal: Annals of Surgery
Published Date: November 2020
PMID: 33214468
DOI: 10.1097/SLA.0000000000004635


Analyze the impact of the ACA on trauma outcomes at a population level and within at-risk subgroups.


Trauma disproportionately affects the uninsured. Compared to the insured, uninsured patients have worse functional outcomes and increased mortality. The goal of the Affordable Care Act (ACA) was to increase access to insurance.


An interrupted time series (ITS) was conducted using data from the National Inpatient Sample (NIS) database between 2011-2016. Data from Alberta, Canada was used as a control group. Mortality, length of stay (LOS), and probability of discharge home with or without home health care was examined using monthly time intervals, with January 2014 as the intervention time. Single and multiple group ITS were conducted. Subgroup analyses were conducted using income quartiles and race.


After the intervention, there was a monthly reduction in mortality of 0.0148% (p < 0.01)in the American cohort: there was no change in the Canadian cohort. The white subgroup experienced a mortality reduction: the non-white subgroup did not. There was no significant change in LOS or discharge home rate at a population level. There was a monthly increase in the probability of discharge with home health (0.0247%: p < 0.01); this was present in the lower income quartiles and both race groups. The white subgroup had a higher rate of utilization of home health pre-ACA, and this discrepancy persisted post-ACA.


The ACA is associated with improved mortality and increased use of home health services. Discrepancies amongst racial groups and income quartiles are present.