Americans without health insurance appear more likely to die following admission to the hospital for trauma than those with health care coverage, according to a report in the November issue of Archives of Surgery, one of the JAMA/Archives journals.
In 2007, 45.7 million Americans were uninsured, according to background information in the article. "Uninsured patients currently face health-related disparities in screening, hospital admission, treatment and outcomes," the authors write. "Uninsured adults have a 25 percent higher risk of mortality than insured adults, accounting for approximately 18,000 deaths per year in excess. Evidence regarding the effects of lack of insurance on traumatically injured patients suggests that they are at added risk."
Heather Rosen, M.D., M.P.H., of Children's Hospital Boston and Harvard Medical School, and colleagues analyzed records from the National Trauma Data Bank, which contains information from 2.7 million patients admitted for traumatic injury to more than 900 U.S. trauma centers. Demographic, medical history, injury severity, outcomes and charges were assessed for 687,091 patients age 18 and older admitted between 2002 and 2006. Patients were divided into five insurance categories: uninsured, a managed care organization, commercial indemnity insurance, Medicare or Medicaid.
Overall, uninsured patients had the highest rate of death following admission for trauma, even after controlling for age, sex, race and severity and mechanism of injury. An analysis of patients age 18 to 30 -- selected because they were less likely to have co-occurring illnesses -- revealed that uninsured patients in this group still had the highest odds of death. The same was true in a subanalysis of only patients with head injuries and in another analysis of those with one or more co-occurring illnesses.
Lack of insurance may increase the risk of death after trauma in several ways, the authors note. Uninsured patients may experience treatment delay; receive different care, including fewer diagnostic tests; or possess a lower rate of health literacy.
"Most recent research has concentrated on decreased (or lack of) access to care as a result of being uninsured," the authors write. "However, we found that, even after admission to a hospital, trauma patients can have worse outcomes based on insurance status. This concerning finding warrants more rigorous investigation to determine why such variation in mortality would exist in a system where equivalent care is not only expected but mandated by law."
"In addition, treatment often is initiated before payer status is recognized; thus, this provokes the question of whether differences exist in processes of care during the hospital stay," they conclude. "We can only speculate as to the mechanism of the disparities we have exposed; the true causes are still unclear. Although the lack of insurance may not be the only explanation for the disparity in trauma mortality, the accidental costs of being uninsured in the United States today may be too high to continue to overlook."
- Heather Rosen; Fady Saleh; Stuart Lipsitz; Selwyn O. Rogers, Jr; Atul A. Gawande. Downwardly Mobile: The Accidental Cost of Being Uninsured. Arch Surg, 2009; 144 (11): 1006-1011 [link]
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