title: The Association of Insurance Status and Race With Transfers of Patients With Traumatic Brain Injury Initially Evaluated at Level III and IV Trauma Centers.
abstract: OBJECTIVE
  To investigate the association of lack of insurance and African American race with the probability of transfer to level I/II trauma centers after evaluation in the emergency department of level III/IV trauma centers for traumatic brain injury (TBI).
  
  
  BACKGROUND
  The influence of nonmedical factors on the disposition of TBI patients initially seen in less specialized institutions is debated.
  
  
  METHODS
  We conducted a retrospective cohort study involving TBI patients who were registered in the National Trauma Data Bank between 2009 and 2011. Regression methods were used to investigate the association of insurance status and race with the disposition of TBI patients evaluated in less specialized trauma centers.
  
  
  RESULTS
  During the study period, there were 26,031 TBI patients who were registered in the National Trauma Data Bank and met inclusion criteria. Of these, 10,572 (35.9%) were transferred to a higher level of care institution. Multivariable logistic regression after coarsened exact matching demonstrated an association of uninsured patients with an increased possibility of transfer (odds ratio [OR] = 1.22; 95% confidence interval [CI], 1.05-1.42). On the contrary, there was no association of African Americans with transfers (OR = 1.27; 95% CI, 0.99-1.62). Those with Glasgow Coma Scale score above 8 (OR = 1.22; 95% CI, 1.08-1.39) or Injury Severity Score below 16 (OR = 1.33; 95% CI, 1.13-1.56) had a higher possibility of transfer.
  
  
  CONCLUSIONS
  In TBI patients, lack of insurance was associated with an increased possibility of transfer to higher level of care institutions after evaluation in a level III or IV trauma center emergency department. Regardless of insurance status, this transfer pattern was also observed for African Americans, but only for those with milder injuries.
authors.affiliation: Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Kimon
authors.initials: K
authors.lastname: Bekelis
authors.affiliation: Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA.
authors.forename: Symeon
authors.initials: S
authors.lastname: Missios
authors.affiliation: Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.|Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.|The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.
authors.forename: Todd A
authors.initials: TA
authors.lastname: Mackenzie
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data*; D001930:Brain Injuries / Q000628:therapy*; D016208:Databases, Factual; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D055815:Young Adult