title: Association of insurance status with health outcomes following traumatic injury: statewide multicenter analysis.
abstract: BACKGROUND
  Recognizing disparities in definitive care for traumatic injuries created by insurance status may help reduce the higher risk of trauma-related mortality in this population. Our objective was to understand the relationship between patients' insurance status and trauma outcomes.
  
  
  METHODS
  We collected data on all patients involved in traumatic injury from eight Level I and 15 Level IV trauma centers, and four non-designated hospitals through Arizona State Trauma Registry between January 1, 2008 and December 31, 2011. Of 109,497 records queried, we excluded 29,062 (26.5%) due to missing data on primary payer, sex, race, zip code of residence, injury severity score (ISS), and alcohol or drug use. Of the 80,435 cases analyzed, 13.3% were self-pay, 38.8% were Medicaid, 13% were Medicare, and 35% were private insurance. We evaluated the association between survival and insurance status (private insurance, Medicare, Medicaid, and self-pay) using multiple logistic regression analyses after adjusting for race/ethnicity (White, Black/African American, Hispanic, and American Indian/Alaska Native), age, gender, income, ISS and injury type (penetrating or blunt).
  
  
  RESULTS
  The self-pay group was more likely to suffer from penetrating trauma (18.2%) than the privately insured group (6.0%), p<0.0001. There were more non-White (53%) self-pay patients compared to the private insurance group (28.3%), p<0.0001. Additionally, the self-pay group had significantly higher mortality (4.3%) as compared to private insurance (1.9%), p<0.0001. A simple logistic regression revealed higher mortality for self-pay patients (crude OR= 2.32, 95% CI [2.07-2.67]) as well as Medicare patients (crude OR= 2.35, 95% CI [2.54-3.24]) as compared to private insurance. After adjusting for confounding, a multiple logistic regression revealed that mortality was highest for self-pay patients as compared to private insurance (adjusted OR= 2.76, 95% CI [2.30-3.32]).
  
  
  CONCLUSIONS
  These results demonstrate that after controlling for confounding variables, self-pay patients had a significantly higher risk of mortality following a traumatic injury as compared to any other insurance-type groups. Further research is warranted to understand this finding and possibly decrease the mortality rate in this population.
authors.affiliation: Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, Phoenix, Arizona.
authors.forename: Vatsal
authors.initials: V
authors.lastname: Chikani
authors.affiliation: Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, Phoenix, Arizona.
authors.forename: Maureen
authors.initials: M
authors.lastname: Brophy
authors.affiliation: Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, Phoenix, Arizona.
authors.forename: Anne
authors.initials: A
authors.lastname: Vossbrink
authors.affiliation: Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, Phoenix, Arizona.
authors.forename: Khaleel
authors.initials: K
authors.lastname: Hussaini
authors.affiliation: West Valley Hospital, Goodyear, Arizona.
authors.forename: Chistopher
authors.initials: C
authors.lastname: Salvino
authors.affiliation: Banner Good Samaritan Medical Center, Phoenix, Arizona.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Skubic
authors.affiliation: Arizona Department of Health Services, Bureau of Emergency Medical Services and Trauma System, Phoenix, Arizona.
authors.forename: Rogelio
authors.initials: R
authors.lastname: Martinez
mesh_terms: D000328:Adult; D001130:Arizona / Q000453:epidemiology; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; 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*; D006278:Medicare; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012042:Registries; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000191:economics / Q000453:epidemiology*