8: In Pediatric Trauma, Does Insurance Play a Role In Transfer of Patients to OR, ICU or Another Institution?

Abstract

Previous studies on disparities in pediatric trauma patients have demonstrated increased mortality in uninsured patients compared to insured. Reasons for this disparity remain unclear and may be related to location of initial care. To determine if there are any mortality differences in transfers from ED to OR, ED to ICU and transfers out of the institution based on insurance status. We utilized the National Trauma DataBank (v.6.2) and extracted the following variables: Insurance type (self pay, Medicaid [Mcaid], insured [BCBS, HMO, MCO]); age (0-18); ISS >8; injury type (blunt); systolic BP >0; ED disposition; length of stay; and ICU days. All cases with missing variables excluded. 7240 uninsured, 19462 insured and 14975 Medicaid children analyzed. Overall mortality rates were higher in uninsured (5.3%) compared to insured (1.8%) and Mcaid (3.3%) patients [p<0.001]. Uninsured were more likely to be transferred (5.3%) compared to insured (2.9%) and Mcaid (2.9%) [p<0.001]. Uninsured were less likely to go to the OR (14.3%) compared to insured patients (20.4%) or Mcaid (16.5%), despite higher overall ISS scores in uninsured patients (uninsured ISS 15.84, insured ISS 14.63, Mcaid ISS 15.12) [p<0.0001]. Uninsured taken to OR had significantly higher ISS scores (OR ISS 17.53) compared to insured (OR ISS 13.95) and Mcaid (OR ISS 15.49) [p<0.0001]. Although ISS scores were slightly higher in uninsured patients going to ICU (ICU ISS 19.69 compared to 19.09 for insured and 18.93 for Mcaid (p<0.001)), uninsured ICU children were more than twice as likely to die (ICU uninsured mortality 9.4% compared to insured 3.8% and Mcaid 6.3%, p<.001). Although uninsured children have higher ISS scores, they are less likely to receive OR care, and more likely to be transferred to an outside facility. Additionally, uninsured patients taken to the OR have higher ISS scores. These differences may contribute to the disparities in mortality observed in uninsured trauma patients.