Insurance Status Biases Trauma-System Utilization and Appropriate Inter-Facility Transfer: The Reverse Disparity of the ‘Wallet Biopsy'
Cheryl K. Zogg*, Kevin M. Schuster*, Adrian A. Maung*, Kimberly A. Davis
Yale School of Medicine, New Haven, CT
Objective: To identify potential associations between insurance and the probability of Emergency Department (ED) transfer-vs-admission for severely-injured patients presenting to non-trauma centers (NTC). Analogous assessment was conducted across the spectrum-of-care (Level II-III TCs). At the state-level, NTC patients were longitudinally-followed to determine where they were transferred and whether in-hospital mortality/major-morbidity differed based on transfer-status.
Methods: Nationally-weighted data from the Nationwide Emergency Department Sample (2010-2014) and state-level data from the California inpatient and ED databases (2009-2011) were used to identify adult (18-64y) and pediatric (0-17y) trauma patients with ISS≥15. Risk-adjusted logistic regression determined differences in the relative odds of direct admission-vs-transfer, outcome measures.
Results: Nationwide, 138,138 adult and 18,896 pediatric NTC patients were identified. For both groups (Table), insured patients were more likely to be admitted (e.g. private-vs-uninsured OR[95%CI]: adult-1.54[1.40-1.70], pediatric-1.95[1.45-2.61]). The trend persisted across Level II-III TCs (e.g. Level II private-vs-uninsured adult-1.83[1.30-2.57]). Among transferred NTC patients at the state-level, 28.5% of adult and 34.1% of pediatric patients were not transferred to Level I-II TCs. An additional 44.2% (adult), 50.9% (pediatric) of all NTC patients were never transferred. Directly-admitted patients experienced higher morbidity (19.6-vs-8.2%, OR[95%CI]:2.74[2.17-3.46]) and mortality (3.3-vs-1.8%, 1.85[1.13-3.04]).
Conclusions: Severely-injured patients evaluated at NTCs and Level II-III TCs were less likely to be transferred if insured. Such a finding could result in suboptimal trauma care for better-insured patients and questions the success of transfer-guideline implementation.
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