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The Accidental Cost of Being Uninsured

Heather Rosen, MD, MPH; Fady Saleh, MD, MPH; Stuart Lipsitz, ScD; Selwyn O. Rogers Jr, MD, MPH; Atul A. Gawande, MD, MPH

Arch Surg. 2009;144(11):1006-1011.

Hypothesis  Given the pervasive evidence of disparities in screening, hospital admission, treatment, and outcomes due to insurance status, a disparity in outcomes in trauma patients (in-hospital death) among the uninsured may exist, despite preventive regulations (such as the Emergency Medical Treatment and Active Labor Act).

Design  Data were collected from the National Trauma Data Bank from January 1, 2002, through December 31, 2006 (version 7.0). We used multiple logistic regression to compare mortality rates by insurance status.

Setting  The National Trauma Data Bank contains information from 2.7 million patients admitted for traumatic injury to more than 900 US trauma centers, including demographic data, medical history, injury severity, outcomes, and charges.

Patients  Data from patients (age, 18 years; n = 687 091) with similar age, race, injury severity, sex, and injury mechanism were evaluated for differences in mortality by payer status.

Main Outcome Measure  In-hospital death after blunt or penetrating traumatic injury.

Results  Crude analysis revealed a higher mortality for uninsured patients (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.36-1.42; P < .001). Controlling for sex, race, age, Injury Severity Score, Revised Trauma Score, and injury mechanism (adjusted for clustering on hospital), uninsured patients had the highest mortality (OR, 1.80; 95% CI, 1.61-2.02; P < .001). Subgroup analysis of young patients unlikely to have comorbidities revealed higher mortality for uninsured patients (OR, 1.89; 95% CI, 1.66-2.15; P < .001), as did subgroup analyses of patients with head injuries (OR, 1.65; 95% CI, 1.42-1.90; P < .001) and patients with 1 or more comorbidities (OR, 1.52; 95% CI, 1.30-1.78; P < .001).

Conclusions  Uninsured Americans have a higher adjusted mortality rate after trauma. Treatment delay, different care (via receipt of fewer diagnostic tests), and decreased health literacy are possible mechanisms.

Author Affilations: Department of Plastic and Oral Surgery, Children's Hospital Boston and Department of Plastic and Oral Surgery, Harvard Medical School (Dr Rosen), and Center for Surgery and Public Health (Drs Rosen, Saleh, Lipsitz, Rogers, and Gawande), Division of Burn, Trauma, and Critical Care, Department of Surgery, (Dr Rogers), and Division of General and Gastrointestinal Surgery, Department of Surgery (Dr Gawande), Brigham and Women's Hospital, Boston, Massachussetts; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles (Dr Rosen); and Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada (Dr Saleh).

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