Downwardly mobile: the accidental cost of being uninsured

Arch Surg. 2009 Nov;144(11):1006-11. doi: 10.1001/archsurg.2009.195.


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, >or=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.

Publication types

  • Comparative Study

MeSH terms

  • Adult
  • Aged
  • Confidence Intervals
  • Databases, Factual
  • Female
  • Health Care Surveys
  • Healthcare Disparities / economics*
  • Healthcare Disparities / statistics & numerical data
  • Hospital Mortality / trends*
  • Humans
  • Injury Severity Score
  • Insurance Coverage / statistics & numerical data
  • Logistic Models
  • Male
  • Medically Uninsured / statistics & numerical data*
  • Middle Aged
  • Multivariate Analysis
  • Odds Ratio
  • Probability
  • Quality of Health Care
  • Reference Values
  • Survival Analysis
  • Trauma Centers / economics
  • Trauma Centers / statistics & numerical data
  • United States
  • Wounds and Injuries / diagnosis
  • Wounds and Injuries / economics*
  • Wounds and Injuries / mortality*
  • Wounds and Injuries / therapy