Uninsured Less Likely to Receive Surgery Than Insured Pediatric Trauma Patients, Despite Greater Severity of Injuries

Nancy A. Melville

October 07, 2010

October 7, 2010 (Las Vegas, Nevada) — Uninsured children in trauma departments are less likely to receive operating room care and more likely to be transferred to outside facilities, despite having higher levels of illness or injury than insured children, according to research presented here at the American College of Emergency Physicians 2010 Scientific Assembly.

Among uninsured children who do make it to surgery, Injury Severity Scores (ISS) are typically higher, according to the study. The findings offer important insights into reasons behind the higher rates of mortality that have been reported in uninsured pediatric trauma patients in previous studies, according to lead author Wael Hakmeh, DO, an emergency medicine physician at St. John Hospital and Medical Center in Detroit, Michigan.

Using information on 7,240 uninsured, 19,462 insured, and 14,975 Medicaid-insured children from the National Trauma Data Bank (version 6.2), the researchers analyzed data such as insurance type, age, injury type, length of stay, and days in the intensive care unit (ICU).

As has been shown in earlier studies, mortality rates were higher in uninsured children (5.3%) than in insured (1.8%) and Medicaid-insured children (3.3%; P < .001).

"We did a study earlier this year [Acad Emerg Med. 2010;17:809-812] showing that both insurance and race were independent predictors for mortality in pediatric trauma patients, and a lack of insurance was the biggest marker," said Dr. Hakmeh.

"In that study, we showed that uninsured children were almost 3 times more likely to die than their insured counterparts; this study showed basically the same mortality rate." He added that "this study is meant to explore the possible contributors to those figures."

The new study showed that uninsured patients were more likely to be transferred to other facilities (5.3%) than insured (2.9%) and Medicaid-insured patients (2.9%; < .001).

Despite having higher overall ISS (uninsured, 15.84; insured, 14.63, and Medicaid-insured, 15.12), uninsured patients were less likely to go to the operating room than insured or Medicaid-insured patients (14.3%, 20.4%, and 16.5%, respectively; P < .0001).

"This is important because when you look at the uninsured, they're either as sick as the rest of the population or even sicker. Despite that, they were less likely to go into the operating room," Dr. Hakmeh said.

Uninsured patients who were taken to the operating room had significantly higher ISS than insured or Medicaid-insured patients (ISS odds ratio [OR], 17.53 for uninsured; 13.95 for insured; and 15.49 Medicaid-insured; P < .0001).

Even though ISS were slightly higher in uninsured patients going to the ICU (19.69) than in insured ( 19.09) and Medicaid-insured (18.93) patients (P < .001), the uninsured ICU children were more than twice as likely to die than the insured and Medicaid-insured patients, with ICU mortality rates of 9.4% for uninsured, 3.8% for uninsured, and 6.3% for Medicaid-insured children (P < .001).

"This study raises the concern that perhaps these factors contribute to that 3-fold increase in mortality in uninsured pediatric trauma patients," Dr. Hakmeh said.

There are numerous other factors, however, that could explain some of the study's figures, according to Jill M. Baren, MD, director of pediatric emergency medicine education in the Department of Emergency Medicine at the Hospital of the University of Pennsylvania in Philadelphia, and moderator of the session.

"This study did not really examine other possible covariates of uninsured children," she noted.

"For example, noninsurance might also be a marker for generalized lack of access to medical care. It's possible that the uninsured children in the study had other types of comorbidities that may have made them more susceptible to poor outcomes."

In addition, the findings suggest that clinical decisions might be made based on patients' insurance status, yet emergency department physicians typically have no knowledge of the patient's insurance status, Dr. Baren said.

"Most of the time physicians are not aware of insurance status when they're actually making clinical decisions," she said. "So if insurance really does play a role, it is unclear from the study why that is the case."

Dr. Hakmeh and Dr. Baren have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2010 Scientific Assembly: Abstract 8. Presented September 28, 2010.


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