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December 2, 2009

Trauma and Insurance
Posted by Jim Macdonald at 10:52 PM * 28 comments

Thanks to Liberal Oasis for this story.

In a 2008 study published in the Archives of Surgery, Race and Insurance Status as Risk Factors for Trauma Mortality (pdf), looking at around 400,000 trauma (excluding burns) patients between the ages of 17 and 64 who were alive when they reached the hospital, and sorting on race and insurance status, the study’s authors found a couple of things.

First, non-hispanic Caucasians had a better chance of survival than Hispanics and African-Americans. Second, insured patients had a better chance of survival than uninsured patients. But, surprisingly, insurance status was a better predictor of outcome than race. Insured African-Americans and insured Hispanics had lower mortality rates than uninsured non-hispanic Caucasians. Overall, the mortality rate in the uninsured was twice the mortality rate among the insured.

The authors of the study comment:

Lack of medical insurance is most often associated with worse baseline health status, with increased and poorly recognized comorbidities. It is known that preexisting medical conditions are associated with poor outcomes after trauma, suggesting that an uninsured patient would do worse after traumatic injury. This may partially explain our finding that the adjusted odds of death substantially increased for all uninsured patients, even when we controlled for injury severity and other factors known to affect trauma outcomes.
They also say:
This work suggests that quality of care issues for trauma patients are worthy of investigation. In a statewide study of trauma patients in Massachusetts, uninsured patients were less likely to receive an operation, less likely to receive rehabilitative therapies (in-house physical therapy), and more likely to die in the hospital.
The authors caution:
Our study likely provokes more questions than it provides answers for. It may be that insurance status is a surrogate for other factors that affect mortality in a critically injured patient (eg, health education, awareness and management of comorbidities, substance abuse, and risk-taking behaviors). In brief, insurance represents more than just the ability to pay a bill.
Yet still they conclude:
These data suggest that addressing disparities in health insurance status would have a significant effect on outcomes of traumatic injuries for African American, Hispanic, and white patients.

A couple of concepts that you should understand before reading the original article:

Comments on Trauma and Insurance:
#1 ::: abi ::: (view all by) ::: December 03, 2009, 07:26 AM:

I would also be very interested to see a comparison of trauma severity between the two populations, the insured and uninsured. I'm aware that this survey controlled for that, but I bet that the insured patients sought treatment sooner and for lesser (= more likely to have a good outcome) trauma than the uninsured ones. So the controlled study would throw out a bunch of good outcomes (fixable traumas fixed) for insured patients that weren't matched by similar uninsured patients.

In other words, the difference is probably even worse for the broad populations of the insured vs the uninsured.

#2 ::: Chris Johnson ::: (view all by) ::: December 03, 2009, 02:26 PM:

This observation is true across many disease categories. For example, children without insurance who end up in a pediatric intensive care unit are more likely to die than are insured children with the exact same disease entity, corrected for severity of disease.

#3 ::: dcb ::: (view all by) ::: December 03, 2009, 02:40 PM:

And once again I'm glad I live in a country with a National Health Service, where they don't ask whether you're insured before starting to treat you...

#4 ::: The Sailor ::: (view all by) ::: December 03, 2009, 03:25 PM:

abi, I believe they used trauma because trauma means there was no question of the person going to the emergency room, probably by ambulance.

#5 ::: C. Wingate ::: (view all by) ::: December 03, 2009, 04:11 PM:

Am I correct in reading that "blunt trauma" tends to mean car wrecks and falls, while "penetrating trauma" tends to mean knifings and shootings? (Obviously penetrating trauma occurs in car wrecks too.) I'm a little thrown off by the difference between the two groups because they seem to indicate that it makes a difference, but for example they didn't give an indication of how much it mattered. If morbidity is higher in general for penetrating trauma, it would have been interesting to see everything broken out by those categories too.

#6 ::: Lori Coulson ::: (view all by) ::: December 03, 2009, 04:30 PM:

C. Wingate @5, I'd say your reading is correct, but blunt force trauma can kill as quickly as penetrating (snapped c-spine or broken femur, for example).

I thought I saw an article about this last week, and the majority of the penetration wounds were either caused by knife or gunshot.

#7 ::: B. Durbin ::: (view all by) ::: December 03, 2009, 05:07 PM:

From a statistical POV, I am interested to see if there are more trauma injuries to people who are uninsured, on the theory that they may be in situations where trauma is more likely.

Theory A: White-collar jobs are more likely to have insurance; low-grade physical labor jobs are less likely to. (High-risk physical labor generally carries its own insurance.)

Theory B: People who choose to not wear seatbelts are more likely to get into accidents; it appears to be a personality thing. If someone is stressed because they don't have insurance, might they get into more accidents? (Not to mention the associated "dangers of poverty" category which increases the exposure to physical violence.)

Theory C: I make enough money for insurance, therefore I make enough to get a safer car. Someone who is barely eking by might have a clunker with a frame that isn't quite right anymore.

It's probably impossible to test, much like my question if car seats for kids have reduced car sickness (because by raising them up where they can see the road, the discrepancy between visual and balance is reduced.) But I am interested.

#8 ::: Jim Macdonald ::: (view all by) ::: December 03, 2009, 06:47 PM:

All other things being equal, the mortality rate for people with the same ISS or the same RTS should be equal, regardless of whether the trauma was blunt or penetrating.

#9 ::: C. Wingate ::: (view all by) ::: December 03, 2009, 07:01 PM:

That "should" was a testable hypothesis in this study, though, as they could have looked within, for example, insured whites and compared blunt vs. penetrating trauma morbidity etc.

#10 ::: thomas ::: (view all by) ::: December 03, 2009, 07:17 PM:

B.Durbin@7:

I am interested to see if there are more trauma injuries to people who are uninsured, on the theory that they may be in situations where trauma is more likely.

Theory D: Young people, especially men, are less likely to have insurance (partly because they are less likely to need it). They are also more likely to have major trauma.

#11 ::: thomas ::: (view all by) ::: December 03, 2009, 07:34 PM:

abi@1:

So the controlled study would throw out a bunch of good outcomes (fixable traumas fixed) for insured patients that weren't matched by similar uninsured patients.

In other words, the difference is probably even worse for the broad populations of the insured vs the uninsured.

An excellent point. They miss out on the benefit from insurance due to it making you more likely to get treated.

The fact that they are looking at mortality reduces the impact of this: fatal injuries are fairly likely to end up in hospital at some point, even if it's too late. If they were looking at whether the accidents lead to chronic pain or disability there would be a much larger bias.

#12 ::: Jim Macdonald ::: (view all by) ::: December 03, 2009, 07:35 PM:

See also:


Disease and Disadvantage in the United States and in England

Health Insurance and Mortality in US Adults

Both are cited in the Liberal Oasis post linked above.

As to RTS being a predictor of mortality across mechanisms of injury, I expect that work has been done in other studies.

#13 ::: thomas ::: (view all by) ::: December 03, 2009, 07:38 PM:

B.Durbin@7:

I am interested to see if there are more trauma injuries to people who are uninsured, on the theory that they may be in situations where trauma is more likely.,

Actually, we can tell from the proportions in the paper. 47% of the patients were uninsured, which is substantially higher than the proportion of the population uninsured, even taking age into account. The insurance coverage rate is well above 53% even in people under 35, everywhere except the south Texas border region.

#14 ::: Jim Macdonald ::: (view all by) ::: December 03, 2009, 07:43 PM:

Uninsured patients are more likely to be discharged home rather than discharged to rehabilitation facilities.

Also: untreated chronic disease can complicate recovery from trauma. A person with uncontrolled diabetes is more likely to have a poor outcome than that same person with the same injury would have with the diabetes under control. Same for heart disease, asthma, etc. By observation, a person without insurance is less likely to get the regular checkups that would detect underlying disease processes and would be less likely to have them under control.

In the recent past I've seen two where diabetes was diagnosed postmortem. In one, the patient had a syncopal episode, vomited, aspirated, and died. In the second, the patient had a heart attack and died. Neither of those patients had health insurance (although both were employed).

#15 ::: thomas ::: (view all by) ::: December 03, 2009, 08:01 PM:

I was thinking that some students in my survey analysis course in spring might want to look into these data further, but then I looked at the conditions for (non-profit, research) access:

First, you have to agree
All Information derived from the NTDB from The American College of Surgeons, Committee on Trauma shall remain the full and copyrighted property of The American College of Surgeons, Committee on Trauma and shall be so noted in educational material, website presentations, and publications., that is, you have to agree that the information that uninsured patients have twice the mortality rate is copyrighted by the ACS. This is ludicrous. Even claiming copyright on the raw data would be ambitious, especially as the information transfer agreement with the participating hospitals doesn't mention copyright.

Second, you have to
Indemnify the American College of Surgeons, its Committee on Trauma and their employees and agents from any and all liability, loss, or damage suffered as a result of claims, demands, costs, or judgments arising out of use of NTDB information.

The university would be responsible for me, as long as I didn't do anything outrageous, but not for a student, and I can't really ask students to indemnify the American College of Surgeons even if the risk is vanishingly unlikely.

#16 ::: thanate ::: (view all by) ::: December 03, 2009, 10:19 PM:

BDurban@7 (& thomas@10):

Theory E (similar to B & possibly D): People who are flying without insurance because they don't feel like they need it are more likely to get themselves into dangerous situations by working on the assumption that they're not going to get hurt.

#17 ::: Jim Macdonald ::: (view all by) ::: December 03, 2009, 11:39 PM:

The theories are ... beside the point. The point is: Q. Two people are seriously injured. Which one dies? A. The one without insurance.

#18 ::: Lila ::: (view all by) ::: December 04, 2009, 09:14 AM:

Re discharge plans: on my first clinical rotation I treated an uninsured patient who'd been stabbed in the heart and, through the resultant blood loss, sustained permanent brain injury. He was cortically blind (that is, though his eyes were functioning normally, his visual cortex was damaged and his brain wasn't interpreting visual input), ataxic (=severely uncoordinated), and like many brain-injured patients, impulsive and erratic in his behavior. He could walk, slowly, if two people held his hands, and he could feed himself and I think dress himself with assistance, but that was about it.

He was 21 years old. We couldn't find any nursing home or rehab facility that would accept him, so he stayed in the hospital for many months.

He was also an illegal immigrant. His only relative stateside (I don't know if he was here legally or not) was not able to care for him. His mother offered to come up from their country of origin to care for him here, but they wouldn't let her out. Initially, country-of-origin also refused to let him back in. Eventually they relented. A special medical flight had to be chartered to take him home and he was released into the custody of his mother. I often wonder if he survived.

Needless to say, the long hospital stay plus the very expensive chartered flight rang up WAY more expenses for this patient that would have been required if he'd been insured and could have been discharged to a nursing home.

#20 ::: A.J. Luxton ::: (view all by) ::: December 04, 2009, 10:20 PM:

I have heard stories of uninsured people getting forcibly discharged from hospitals once their condition could be said to be other than a "medical emergency" - even if it would kill them in several days without treatment.

It would not surprise me at all if lack of follow-up care in situations where emergency and non-emergency care are both required has caused some of these deaths.

#22 ::: Lee ::: (view all by) ::: December 05, 2009, 12:20 AM:

Jim, #21: And it's an inaccurate portrayal. The character labeled "America" should instead be tagged "American big-business-owned media and political pundits"; polls continue to show that 60% or more of actual Americans WANT a public health-care plan.

#23 ::: David Harmon ::: (view all by) ::: December 05, 2009, 08:52 AM:

And at some risk of digression, a quiz dedicated to morbidity... but no, it doesn't ask about insurance.

#24 ::: Lila ::: (view all by) ::: December 05, 2009, 11:44 AM:

A.J. @ #20, you mean like this story?

#25 ::: Tae Kim ::: (view all by) ::: December 05, 2009, 12:00 PM:

dcb @3: "And once again I'm glad I live in a country with a National Health Service, where they don't ask whether you're insured before starting to treat you..."

But we don't ask about insurance status before we treat critical patients. Besides, EMTALA guarantees evaluation and treatment regardless of ability to pay.

#26 ::: TexAnne ::: (view all by) ::: December 05, 2009, 01:40 PM:

Tae Kim: the only time I've ever had to take a friend to the ER, they copied his driver's license and insurance card before he was seen.

#27 ::: TexAnne ::: (view all by) ::: December 05, 2009, 02:04 PM:

Tae Kim: I'm sorry, I missed the word "critical."

#28 ::: eric ::: (view all by) ::: December 11, 2009, 01:15 AM:

And then there's this: Matter of life and Death.


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