Insurance Coverage Status Affects Mortality Rate in Pediatric Trauma Patients

A study led by Heather Rosen, MD, MPH, research fellow in the Department of Plastic Surgery at Children's Hospital Boston and Harvard Medical School, found that uninsured children were over three times more likely to die from their trauma-related injuries than children who were commercially insured, after adjustment for other factors such as age, gender, race, injury severity and injury type in an analysis of data from the National Trauma Data Bank. Moreover, publicly-insured children were 1.19 times more likely to die from trauma when compared with commercially-insured children.

According to the federal Emergency Medical Treatment and Active Labor Act (EMTALA), all hospitals are required to treat patients until they are medically stable, regardless of insurance status. "We have this idea that everyone is treated equally, yet the mortality rate after trauma among uninsured children is much higher when compared to children with commercial insurance," says Rosen.

The study, involving researchers from Children's, Harvard Medical School, and Brigham and Women's Hospital, collected and analyzed data from the National Trauma Data Bank, a consortium of more than 900 trauma centers across the country.

The researchers examined data from 174,921 trauma patients aged 17 years and younger. Patients were divided into three groups: uninsured, publicly insured, and commercially insured.

After adjusting for factors such as race, age, gender, injury type and injury severity, results showed that uninsured trauma patients were over three times more likely to die after trauma than patients who were commercially insured by plans such as Blue Cross/Blue Shield and worker's compensation. Furthermore, patients with public insurance, including Medicaid and the State Children's Health Insurance Program (SCHIP), were 1.19 times more likely to die than commercially insured patients.

Because the study was retrospective, the researchers cannot say definitively why insurance status may affect mortality rate in spite of EMTALA. "This paper provokes more questions than it answers," says Rosen, who is currently doing her residency in general surgery at the University of Southern California's Keck School of Medicine. "Should we be more vigilant about investigating whether EMTALA laws are being violated? Is this happening more often than we care to admit?"

The researchers speculate about several possible explanations for their findings. One is that trauma patients with public insurance or no insurance may be transferred from one hospital to another, causing a delay in definitive treatment. Uninsured patients may also undergo fewer medical tests, leading to inadequate diagnoses or missed injuries. In addition, if uninsured patients do not speak English as their first language or are less educated overall, they may be less able to communicate with medical providers about their medical history and quality of care after sustaining an injury.

"This study suggests that there may be a direct effect of possessing insurance. We need to work harder to get to the point where every person has access to health care in this country," Rosen says.

Because emergency trauma treatment should theoretically begin before providers know a patient's insurance status, researchers insist that further investigation is needed to determine why these health disparities exist. For the future, Rosen would like to conduct a prospective study of the processes involved in pediatric trauma care according to insurance status, looking at differences in quality of care in real time.

The article, "Lack of Insurance Negatively Affects Trauma Mortality in U.S. Children," is published in the October issue of the Journal of Pediatric Surgery.

Children's Hospital Boston is home to the world's largest research enterprise based at a pediatric medical center, where its discoveries have benefited both children and adults since 1869. More than 500 scientists, including eight members of the National Academy of Sciences, 13 members of the Institute of Medicine and 12 members of the Howard Hughes Medical Institute comprise Children's research community. Founded as a 20-bed hospital for children, Children's Hospital Boston today is a 396-bed comprehensive center for pediatric and adolescent health care grounded in the values of excellence in patient care and sensitivity to the complex needs and diversity of children and families. Children's also is the primary pediatric teaching affiliate of Harvard Medical School. For more information about the hospital and its research visit: www.childrenshospital.org/newsroom.