title: Downwardly mobile: the accidental cost of being uninsured.
abstract: OBJECTIVE
  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).
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: Department of Plastic and Oral Surgery, Children's Hospital Boston; Department of Plastic and Oral Surgery, Harvard Medical School, Boston, Massachusetts, USA. heather.rosen@childrens.harvard.edu
authors.forename: Heather
authors.initials: H
authors.lastname: Rosen
authors.forename: Fady
authors.initials: F
authors.lastname: Saleh
authors.forename: Stuart
authors.initials: S
authors.lastname: Lipsitz
authors.forename: Selwyn O
authors.initials: SO
authors.lastname: Rogers
authors.forename: Atul A
authors.initials: AA
authors.lastname: Gawande
mesh_terms: D000328:Adult; D000368:Aged; D016001:Confidence Intervals; D016208:Databases, Factual; D005260:Female; D019538:Health Care Surveys; D054625:Healthcare Disparities / Q000191:economics* / Q000706:statistics & numerical data; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D015601:Injury Severity Score; D019458:Insurance Coverage / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011336:Probability; D011787:Quality of Health Care; D012016:Reference Values; D016019:Survival Analysis; D014193:Trauma Centers / Q000191:economics / Q000706:statistics & numerical data; D014481:United States; D014947:Wounds and Injuries / Q000175:diagnosis / Q000191:economics* / Q000401:mortality* / Q000628:therapy