Disparities In Length Of Stay Research Articles

Racial Disparity in Length of Stay Following Implementation of a Bariatric Enhanced Recovery Program

IntroductionEnhanced Recovery Programs (ERPs) mitigate racial disparities in postoperative length of stay (LOS) for colorectal populations. It is unclear, however, if these effects exist in the bariatric surgery population. Therefore, this study aimed to evaluate the racial disparities in LOS before and after implementation of bariatric surgery ERP. MethodsA retrospective cohort study was performed using data from a single institution. Patients undergoing minimally invasive sleeve gastrectomy or Roux-en-Y gastric bypass from 2017 to 2019 (pre-ERP) or 2020-2022 (ERP) were included. Chi-square, Kruskal–Wallis, and analysis of variance were used to compare groups, and estimated LOS (eLOS) was assessed via multivariable regression. ResultsSeven hundred sixty four patients were identified, including 363 pre-ERPs and 401 ERPs. Pre-ERP and ERP cohorts were similar in age (median 44.3 years versus 43.8 years, P = 0.80), race (53.4% Black versus 56.4% Black, P = 0.42), and preoperative body mass index (median 48.3 versus 49.4, P = 0.14). Overall median LOS following bariatric surgery decreased from 2 days pre-ERP to 1 day following ERP (P < 0.001). Average LOS for Black and White patients decreased by 0.5 and 0.48 days, respectively. However, overall eLOS remained greater for Black patients compared with White patients despite ERP implementation (eLOS 0.21 days, P = 0.01). ConclusionsImplementation of a bariatric surgery ERP was associated with decreased LOS for both Black and White patients. However, Black patients did have slightly longer LOS than White patients in both pre-ERP and ERP eras. More work is needed to understand the driving mechanism(s) of these disparities to eliminate them.

Racial Disparities in Length of Stay Among Severely Ill Patients Presenting With Sepsis and Acute Respiratory Failure

Although racial and ethnic minority patients with sepsis and acute respiratory failure (ARF) experience worse outcomes, how patient presentation characteristics, processes of care, and hospital resource delivery are associated with outcomes is not well understood. To measure disparities in hospital length of stay (LOS) among patients at high risk of adverse outcomes who present with sepsis and/or ARF and do not immediately require life support and to quantify associations with patient- and hospital-level factors. This matched retrospective cohort study used electronic health record data from 27 acute care teaching and community hospitals across the Philadelphia metropolitan and northern California areas between January 1, 2013, and December 31, 2018. Matching analyses were performed between June 1 and July 31, 2022. The study included 102 362 adult patients who met clinical criteria for sepsis (n = 84 685) or ARF (n = 42 008) with a high risk of death at the time of presentation to the emergency department but without an immediate requirement for invasive life support. Racial or ethnic minority self-identification. Hospital LOS, defined as the time from hospital admission to the time of discharge or inpatient death. Matches were stratified by racial and ethnic minority patient identity, comparing Asian and Pacific Islander patients, Black patients, Hispanic patients, and multiracial patients with White patients in stratified analyses. Among 102 362 patients, the median (IQR) age was 76 (65-85) years; 51.5% were male. A total of 10.2% of patients self-identified as Asian American or Pacific Islander, 13.7% as Black, 9.7% as Hispanic, 60.7% as White, and 5.7% as multiracial. After matching racial and ethnic minority patients to White patients on clinical presentation characteristics, hospital capacity strain, initial intensive care unit admission, and the occurrence of inpatient death, Black patients experienced longer LOS relative to White patients in fully adjusted matches (sepsis: 1.26 [95% CI, 0.68-1.84] days; ARF: 0.97 [95% CI, 0.05-1.89] days). Length of stay was shorter among Asian American and Pacific Islander patients with ARF (-0.61 [95% CI, -0.88 to -0.34] days) and Hispanic patients with sepsis (-0.22 [95% CI, -0.39 to -0.05] days) or ARF (-0.47 [-0.73 to -0.20] days). In this cohort study, Black patients with severe illness who presented with sepsis and/or ARF experienced longer LOS than White patients. Hispanic patients with sepsis and Asian American and Pacific Islander and Hispanic patients with ARF both experienced shorter LOS. Because matched differences were independent of commonly implicated clinical presentation-related factors associated with disparities, identification of additional mechanisms that underlie these disparities is warranted.

Racial and Ethnic Disparities in Length of Stay for Common Pediatric Diagnoses: Trends From 2016 to 2019.

Inequities in pediatric illness include unequal treatment and outcomes for children of historically marginalized races/ethnicities. Length of stay (LOS) is used to assess health care quality and is associated with higher costs/complications. Studies show LOS disparities for Black and Hispanic children in specific diagnoses, but it is unclear how broadly they exist or how they change over time. We examined the association between race/ethnicity and LOS longitudinally for the most common pediatric inpatient diagnoses. We used the 2016 and 2019 Kids' Inpatient Databases. The 10 most frequent diagnoses in 2016 were determined. For each diagnosis in each year, we assessed the association between race and LOS by fitting a generalized linear mixed effects model with a negative binomial distribution, accounting for clustering and confounding. Using descriptive statistics, we compared associations between the 2 years for trends over time. Our analysis included >450 000 admissions and revealed significantly longer LOS for Black, Hispanic, and/or Asian American or Pacific Islander, Native American, and other children in 8 of the 10 diagnoses in 2016, with mixed changes over time. Three new disparities emerged in 2019. The largest disparities were for Black children in most diagnoses. Kids' Inpatient Database data showed longer LOS for children of historically marginalized race/ethnicity with common pediatric inpatient diagnoses, which largely persisted from 2016 to 2019. There is no plausible biological explanation for these findings, and inequities in social needs, access to care, and quality of care likely contribute. Future directions include further study to understand and address contributing factors.

Disparities in Hospital Length of Stay Across Race and Ethnicity Among Patients With Heart Failure.

Reducing hospital length of stay (LOS) has been identified as an important lever for minimizing the burden of heart failure hospitalization, yet the impact of social and structural determinants of health on LOS has received little attention. We investigated disparities in LOS across race/ethnicity and their possible drivers. We analyzed patients hospitalized for heart failure from 2017 to 2020 using the Get With The Guidelines-Heart Failure registry. We characterized LOS differences across race/ethnicity by insurance and disposition, adjusting for demographics, comorbidities, and clinical severity. Effects of hospital-level clustering on LOS across race/ethnicity were assessed using hierarchical mixed-effects models. We evaluated the association between LOS and discharge rates of guideline-directed medical therapy. Three thousand three seven hundred thirty patients hospitalized for heart failure were identified. After excluding inpatient deaths, the adjusted LOS for Black (5.72 days [95% CI, 5.62-5.82]), Hispanic (5.94 days [95% CI, 5.79-6.08]), and Indigenous American/Pacific Islander (6.06 days [95% CI, 5.85-6.27]) patients remained significantly longer compared with non-Hispanic White patients (5.32 days [95% CI, 5.25-5.39]). This pattern was driven by LOS differences among patients discharged to hospice or nursing facilities. After accounting for variability between hospitals, associations of race/ethnicity with LOS either were attenuated or reversed in direction. Guideline-directed medical therapy rates on discharge did not differ significantly across race/ethnicity despite longer LOS for Black, Hispanic, and Indigenous American/Pacific Islander patients. Differences between hospitals drive LOS disparities across race/ethnicity. Longer LOS among Black, Hispanic, and Indigenous American/Pacific Islander patients was not associated with improved quality of care.

Association Between Limited English Language Proficiency and Disparities in Length of Stay and Discharge Disposition After Total Shoulder Arthroplasty: A Retrospective Cohort Study.

Background: Limited English language proficiency in patients undergoing total shoulder arthroplasty (TSA) may make treatment more challenging. Purpose: We sought to investigate the potential association between TSA patients' use of a language interpreter and 2 outcomes: hospital length of stay (LOS) and discharge disposition. Methods: We conducted a retrospective cohort study comparing LOS and discharge disposition after TSA for patients who required interpreter services and patients who did not at a single institution in an urban setting between 2016 and 2020. Consecutive patients requiring interpreter services who underwent TSA were matched 1:1 to patients who did not require an interpreter by age, body mass index (BMI), sex, and procedure. Multivariate regression models controlling for age, BMI, sex, smoking, opioid use, white or non-white race, procedure, and diagnosis were constructed to determine associations between interpreter use, LOS, and discharge disposition. Results: Forty-one patients were included in each cohort, exceeding the minimum number required per an a priori power analysis. Mean hospital LOS was longer in the interpreter cohort than in the non-interpreter cohort (2.8 ± 2.4 vs 1.8 ± 1.0 days, respectively). Multivariate linear regression demonstrated interpreter use was the strongest predictor of LOS, with the effect estimate indicating an additional 0.88-day LOS per patient. A greater proportion of patients from the interpreter cohort were discharged to an acute/subacute rehabilitation facility than patients from the non-interpreter cohort (n = 8 [19.5%] vs n = 2 [4.9%], respectively). Patients from the interpreter cohort were 454% more likely to be discharged to acute/subacute rehabilitation facilities. Conclusions: Our retrospective analysis of patients undergoing TSA suggests that the need for interpreter services may be associated with increased LOS and discharge to a facility. More rigorous study is needed to identify the factors that influence these outcomes and to avoid disparities in hospital stay and discharge.

Association Between Patient Diversity in Hospitals and Racial/Ethnic Differences in Patient Length of Stay.

Hospitals serving a disproportionate share of racial/ethnic minorities have been shown to have poorer quality outcomes. It is unknown whether efficiencies in inpatient care, measured by length of stay (LOS), differ based on the proportion patients served by a hospital who are minorities. To examine the association between the racial/ethnic diversity of a hospital's patients and disparities in LOS. Retrospective cross-sectional study. One million five hundred forty-six thousand nine hundred fifty-five admissions using the 2017 New York State Inpatient Database from the Healthcare Cost and Utilization Project. Differences in mean adjusted LOS (ALOS) between White and Black, Hispanic, and Other (Asian, Pacific Islander, Native American, and Other) admissions by Racial/Ethnic Diversity Index (proportion of non-White patients admitted to total patients admitted to that same hospital) in quintiles (Q1 to Q5), stratified by discharge destination. Mean LOS was adjusted for patient demographic, clinical, and admission characteristics and for individual intercepts for each hospital. In both unadjusted and adjusted analysis, Black-White and Other-White mean LOS differences were smallest in the most diverse hospitals (Black-White: unadjusted, -0.07 days [-0.1 to -0.04], and adjusted, 0.16 days [95% CI: 0.16 to 0.16]; Other-White: unadjusted, -0.74 days [95% CI: -0.77 to -0.71], and adjusted, 0.01 days [95% CI: 0.01 to 0.02]). For Hispanic patients, in unadjusted analysis, the mean LOS difference was greatest in the most diverse hospitals (-0.92 days, 95% CI: -0.95 to -0.89) but after adjustment, this was no longer the case. Similar patterns across all racial/ethnic groups were observed after analyses were stratified by discharge destination. Mean adjusted LOS differences between White and Black patients, and White and patients of Other race was smallest in most diverse hospitals, but not differences between Hispanic and White patients. These findings may reflect specific structural factors which affect racial/ethnic differences in patient LOS.

Characterizing social and policy determinants of hospital length of stay among paediatric inpatients with diabetes using linked population-based data.

BackgroundEvidence is limited on the non-medical factors influencing hospital length of stay (LOS) among paediatric inpatients with diabetes, notably potential social and policy correlates. This study aimed to characterize the associations of socioeconomic status and health policy environment with diabetes-attributable LOS to help inform accountability monitoring of a provincial comprehensive diabetes strategy aiming to minimize time in hospital among this high-risk population.Data and methodsThis retrospective population-based study drew on multiple linked administrative and geospatial databases among all children aged 18 and under with a diabetes-related hospitalization in the province of New Brunswick, Canada, during the four-year period following implementation of an insulin pump funding program. Multiple linear regression was used to assess the role of access to the public insulin pump resourcing scheme and relative neighbourhood deprivation as predictors of days spent in acute care, controlling for age, sex, and place of residence.ResultsAmong the paediatric inpatient population (N = 386), 21% had accessed social resources made available through the insulin pump funding policy and 42% resided in the most materially deprived neighbourhoods. Diabetes-related hospital stays averaged 3.87 days. Paediatric inpatients having accessed resources through the social insurance policy spent significantly fewer days in hospital (1.34 days less [95% CI: 0.63–2.05]) than those who had not, all else being equal. Observed differences in LOS by neighbourhood socioeconomic deprivation were not found to be statistically significant in the multivariate analysis.ConclusionFindings from this context of universal medical coverage suggested that public policy for supplemental financing of assistive technologies among children with diabetes may be associated with reduced burden to the hospital system. The causes of socioenvironmental disparities in LOS require further investigation to inform interventions to mitigate preventable patient-level variations in hospital-based health outcomes.

Racial and Ethnic Disparities in Hip Fracture Surgery Care in the United States From 2006 to 2015: A Nationwide Trends Study

Racial and ethnic disparities in the surgical treatment of hip fractures have been previously reported, demonstrating delayed time to surgery and worse perioperative outcomes for minority patients. However, data are lacking on how these disparities have trended over time and whether national efforts have succeeded in reducing them. The aim of this study was to investigate temporal trends in racial and ethnic disparities in perioperative metrics for patients undergoing hip fracture surgery in the United States from 2006 to 2015. The National Inpatient Sample was queried for White, Black, Hispanic, and Asian patients who underwent hip fracture surgery between 2006 and 2015. Perioperative metrics, including delayed time to surgery (≥2 calendar days from admission to surgical intervention), length of stay (LOS), total inpatient complications, and mortality, were trended over time. Changes in racial and ethnic disparities were assessed using linear and logistic regression models. During the study period, there were persistent disparities in delayed time to surgery for White versus Black, Hispanic, and Asian patients (eg, White versus Black: 30.1% versus 39.7% in 2006 and 22% versus 28.8% in 2015, Ptrend> 0.05 for all). Although disparities in total LOS remained consistent for White versus Black patients (Ptrend= 0.97), these disparities improved for White versus Hispanic and Asian patients (eg, White versus Hispanic: 4.8 days versus 5.3 in 2006 and 4.1 days versus 4.4 in 2015, Ptrend < 0.05 for both). Racial and ethnic disparities were persistent in time to surgery and discharge disposition for hip fracture surgery between White and minority patients from 2006 to 2015 in the United States. These disparities particularly affected Black patients. Although there were encouraging signs of improving disparities in the LOS, these findings highlight the need for renewed orthopaedic initiatives and healthcare reform policies aimed at reducing perioperative disparities in orthopaedic trauma care.

Ethnicity, Spatial Segregation and Length of Stay in Emergency Medicine Departments: The Case of Israel

The present paper examines the sources of disparities between Arabs and Jews and between residents of the periphery and residents of the urban center in the length of stay (LOS) in emergency departments (ED) in Israeli hospitals. Israel is a society where all residents are covered by National Health Insurance and have equal access to emergency medicine; thus, no disparities in emergency treatment are expected. Data were obtained from the 2015 “Survey of Satisfaction with Hospitalization in Emergency Medicine Departments” in Israel. The analysis reveals that LOS is considerably shorter for Arabs than for Jews and among residents of the periphery than residents of the urban center. After considering patterns of residential segregation (as well as socio-demographic attributes and indicators of the medical condition) and controlling for perceived waiting time (triage), the LOS disparity between Arabs and Jews vanishes. The findings lead to the conclusion that disparities in LOS in Israeli EDs do not stem from differential treatment by the medical staff but can be fully attributed to patterns of spatial segregation. Differential allocation of medical resources by the state to urban-center regions, compared to peripheral regions, seems to be the source of LOS disparities in emergency departments in Israeli hospitals.

840 Reducing healthcare disparities using enhanced recovery after surgery for cesarean delivery

Enhanced recovery after surgery programs aim to achieve impartial surgical healthcare through the utilization of standardized protocols. Our objective was to compare disparities in hospital length of stay (LOS) by race-ethnicity before and after the implementation of an enhanced recovery after surgery for cesarean delivery (ERAS-CD) program. An ERAS-CD program was implemented at our institution in October 2018. Using a healthcare analytics platform, we compared disparities in LOS after delivery (calculated from time of delivery to discharge) and 30-day readmission rates (defined as any inpatient hospitalization within 30 days of delivery) based on race-ethnicity before (October 2017 – September 2018) and after (November 2018 – October 2019) ERAS-CD implementation. We excluded any outliers, defined as a LOS >25 days using the Academic Medical Center model, and any patients without reported race-ethnicity. Student’s T test and Chi square were used for comparison with p<0.05 considered statistically significant. Continuous data are expressed as mean +/- standard deviation. After applying exclusion criteria, 1520 patients underwent cesarean delivery in the pre-ERAS-CD group and 1522 in the post-ERAS-CD group. Before ERAS-CD implementation, Asian, Black, Hispanic and patients of other race-ethnicity all had a significantly longer mean LOS after cesarean delivery as compared to White patients. After ERAS-CD implementation, this disparity was no longer seen (Table 1). 30-day readmission rates were similar pre- and post-ERAS-CD in patients of all race-ethnicities. After the implementation of an ERAS-CD program, we saw a reduction in healthcare disparity as it relates to hospital LOS, without an increase in readmission rates. We believe that consistent patient education and multidisciplinary standardized guidelines contributed to this effect. Although our findings show promise in addressing known healthcare disparities, one must equally practice cultural competency and patient-centered care to achieve truly impartial surgical healthcare.

620: Enhanced recovery after surgery for cesarean delivery: Reducing healthcare disparity

Enhanced recovery after surgery (ERAS) programs aim to achieve impartial surgical healthcare through the utilization of standardized protocols. Our objective was to compare disparities in hospital length of stay (LOS) by insurance payer status before and after the implementation of an ERAS protocol for cesarean delivery (CD). An ERAS-CD program was implemented at our institution in October 2018. Using a healthcare analytics platform, we compared disparities in LOS after delivery (calculated from time of delivery to discharge) based on insurance payer status before (January-June 2018) and after (January-June 2019) ERAS implementation. Student’s T test and Chi square were used for statistical comparison with p< 0.05 considered statistically significant. Continuous data are expressed as mean +/- standard deviation. 883 patients underwent CD in the pre-ERAS group, 763 (86.4%) of whom had private insurance and 120 (13.6%) of whom had Medicaid. In the post-ERAS group, 892 patients had a CD; 783 (87.8%) were privately insured and 109 (12.2%) had Medicaid. Pre-ERAS, patients with Medicaid had a significantly longer mean LOS after CD than those with private insurance (3.33 +/- 1.15 days vs 3.15 +/- 0.90 days, p=0.05). After ERAS implementation, this disparity was no longer seen (2.87 +/- 1.09 days vs 2.69 +/- 0.87 days, p=0.18). Re-admission rates were similar pre- and post-ERAS; 10.8% vs 9.2%, p=0.69 for patients with Medicaid and 3.0% vs 4.0%, p=0.29 for privately insured patients. After the implementation of an ERAS-CD program, we saw a reduction in healthcare disparity as it relates to hospital LOS among patients with Medicaid vs private insurance. We believe that patient education and multidisciplinary, standardized guidelines contributed to this effect. Although our findings show promise in addressing known healthcare disparities, one must equally practice cultural competency and patient-centered care so as to achieve truly impartial surgical healthcare.

Regional Variation in Mortality, Major Complications, and Cost After Left Ventricular Assist Device Implantation in the United States (2009 to 2014)

The objective of this analysis was to provide evidence on regional differences in outcomes, cost and disposition among patients who undergo continuous-flow LVAD implantation. Using data from the National Inpatient Sample and US Census Bureau, annual national estimates in utilization, in-hospital mortality, major complications, cost, length of stay (LOS), and disposition were estimated for years 2009 to 2014. Main outcomes and complications were identified using patient safety indicators and International Classification of Diseases-Ninth Revision, Clinical Modification codes. We analyzed a total of 3,572 (weighted = 17,552) patients with LVAD implants among the 4 Census regions of the United States. The patient population in the Southern region was younger with higher percentage of African-Americans. Overall, the comorbidity burden was higher in the Midwest. The risk-adjusted rate of in-hospital mortality did not differ significantly among the geographical regions (p = 0.8). With the exception of cardiac tamponade rates which were higher in the Northeast and West, all other post-operative complications did not differ between regions. LOS was higher in the Northeast (median 32 days) and lower in the South (median 27 days). The cost analysis suggested higher median cost in the West (median $246,292) and lowest in the Northeast region (median $192,604). Finally, higher percentages of patients were transferred to an extended care facility in the Northeast, whereas more patients were discharged to home in the Western region. We identified region disparities in LOS, cost and disposition but not in-hospital mortality and complications, among patients who underwent LVAD implantation between 2009 and 2014.

Abstract 2623: Racial Disparities in Hospital Length of Stay among Native Hawaiians and other Pacific Islanders with Ischemic Stroke

Introduction: Native Hawaiians and other Pacific Islanders (NHPI) with ischemic stroke are younger and have more comorbidities compared to other major racial-ethnic groups. However, their impact on hospital length of stay (LOS) after ischemic stroke has not been studied. Hypothesis: We assessed the hypothesis that NHPI race is associated with a longer hospital LOS after ischemic stroke. Methods: Data from 2004 to 2010 were retrospectively obtained from the Get With the Guidelines-Stroke (GWTG-Stroke) database from The Queen’s Medical Center, the only primary stroke center for the state of Hawaii. Multivariable analyses were performed using a stepwise linear regression model to identify factors predictive of hospital LOS after ischemic stroke. Results: A total of 1921 patients hospitalized for ischemic stroke (NHPI 20%, Asians 53%, whites 24%, blacks 0.8%, others 2%) were studied. Univariate analyses showed that NHPI were younger (mean ages, NHPI 60±14 vs. Asians 72±14, p &lt;0.0001; vs. whites 71±14, p &lt;0.0001) and had higher prevalence of diabetes (NHPI 53% vs. Asians 67%, p &lt;0.0001; vs. whites 22%, p &lt;0.0001), hypertension (NHPI 82% vs. whites 22%, p &lt;0.0001), prior stroke or TIA (NHPI 30% vs. Asians 23%, p =0.01), smoking (NHPI 19% vs. Asians 14%, p =0.01), dyslipidemia (NHPI 43% vs. whites 34%, p &lt;0.01), and longer hospital LOS (NHPI 11±17 days vs. Asians 7±9 days, p &lt;0.0001; whites 8±17 days, p &lt;0.05). After adjusting for age, race, gender, and risk factors with predefined significance ( p &lt;0.1), independent predictors for hospital LOS were NHPI race (parameter estimate, 2.67; 95% CI, 1.09 - 4.22, p =0.001), atrial fibrillation/atrial flutter (parameter estimate, 2.22; 95% CI, 0.53 - 3.90, p =0.01), and age (parameter estimate, -0.04; 95% CI, -0.09 - -0.002, p =0.04). Conclusions: Native Hawaiians and other Pacific Islanders with ischemic stroke have a longer hospital length of stay compared to Asians and whites. Further studies are needed to assess if other socioeconomic factors contribute to the observed differences.

Racial Disparities in Hospital Length of Stay for Asthma: Implications for Economic Policies

Asthma is one of the most common health burdens on American families. An understanding of how the costs of asthma are distributed across communities is essential to realizing cost savings from preventative care. We model the household’s utilization of hospital services using Grossman’s health production framework. We then test for differences in asthma-related hospitalizations by race using inpatient records from the Massachusetts Division of Health Care Finance. On average black and nonwhite-Hispanic patients stayed between one-third and one-fourth of a day less than similar white patients which translates into a difference in expenditures of $8 million over 1994–2002. The difference in expenditures raises questions for market-based methodologies to value health and for policies directed at reducing inequalities in health outcomes.

Relationship of Insurance Status to Hospital Length of Stay after Traumatic Injury: Patients with Publically Funded Insurance Have the Longest Lengths of Stay and Uninsured Patients Are Discharged the Earliest

Introduction: Research has consistently shown that insurance status significantly impacts health care, including resource use, morbidity, and mortality. Data from several medical specialties demonstrate that patients without insurance have fewer physician visits, receive fewer procedures, and have shorter lengths of hospital stay leading to worse clinical outcomes. Uninsured hospitalized trauma patients are also known to have worse mortality outcomes; however, the impact of insurance on hospital stay in trauma is unknown. Objective: To examine the impact of insurance status on hospital length of stay (LOS) in the setting of acute trauma. Methods: Trauma patients, age 18-64, included in the National Trauma Data Bank (NTDB) between 2002-2006 were analyzed. Patients were categorized in three insurance groups: 1) Private insurance (HMO, PPO, MCO, Workers Comp, No Fault, and other commercial plans), 2) Publically funded insurance (Medicaid & Medicare), and 3) Uninsured (self pay or private charity). In unadjusted analyses Student's t-test were applied to determine the bi-variate relationship between insurance and LOS. In order to control for differences in injury severity and case mix between insurance groups, generalized linear models, an extension of multiple linear regression, were used, and adjusted estimates of LOS calculated. Covariates adjusted for included: age, gender, race, injury severity score (ISS), presence of shock (SBP<90) on ED arrival, GCS motor score, mechanism of injury (motor vehicle collision, motorcycle collision, fall, etc), type of injury (blunt vs. penetrating), intention of injury, presence of severe head and/or extremity injury, and year of admission. Results: 542,171 patients in the NTDB met inclusion criteria and had complete data for analysis. Unadjusted median hospital LOS for Uninsured patients was 2 days. Private and Publically insured patients had a median LOS of 3 days (respective mean LOS: 4.4, 5.3, and 6.9, p<0.001). After adjusting for covariates, mean length of stay for Uninsured patients was the lowest followed by Private insurance and then Publically insured patients (see figure). On analysis of patients with moderate to severe injuries (ISS>9), LOS for Uninsured, Privately insured, and Publically insured patients were 12.7, 13.5, and 15.7 days, respectively. Similarly among the most severely injured patients (ISS>15), the respective LOS were 13.3, 14.6, and 17.7 days. The differences between adjusted LOS for each insurance group were significant (p<0.001) across all injury severities. Conclusion: The ability to pay is directly linked to length of hospital stay in acute trauma patients. Those without insurance are discharged the earliest whereas those with publically funded insurance are kept in hospital the longest. These disparities in LOS are even more pronounced among the more severely injured patients with even longer hospital stays. These data become increasingly important given the current debate over health care reform. As a next step towards improving health care disparities after trauma, the relationship between LOS, quality of care, and outcomes needs to be further explored.