Study: Injured uninsured more likely to die in ER

[Moonglow]

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By CARLA K. JOHNSON, AP Medical Writer – Mon Nov 16, 4:00 pm ET

CHICAGO – Uninsured patients with traumatic injuries, such as car crashes, falls and gunshot wounds, were almost twice as likely to die in the hospital as similarly injured patients with health insurance, according to a troubling new study.

The findings by Harvard University researchers surprised doctors and health experts who have believed emergency room care was equitable.

"This is another drop in a sea of evidence that the uninsured fare much worse in their health in the United States," said senior author Dr. Atul Gawande, a Harvard surgeon and medical journalist.

The study, appearing in the November issue of Archives of Surgery, comes as Congress is debating the expansion of health insurance coverage to millions more Americans. It could add fodder to that debate.

The researchers couldn't pin down the reasons behind the differences they found. The uninsured might experience more delays being transferred from hospital to hospital. Or they might get different care. Or they could have more trouble communicating with doctors.

The hospitals that treat them also could have fewer resources.

"Those hospitals tend to be financially strapped, not have the same level of staffing, not have the same level of surgeons and testing and equipment," Gawande said. "That also is likely a major contributor." Gawande favors health care reform and has frequently written about the inequities of the current system.

The researchers took into account the severity of the injuries and the patients' race, gender and age. After those adjustments, they still found the uninsured were 80 percent more likely to die than those with insurance — even low-income patients insured by the government's Medicaid program.

"I'm really surprised," said Dr. Eric Lavonas of the American College of Emergency Physicians and a doctor at Denver Health Medical Center. "It's well known that people without health insurance don't get the same quality of health care in this country, but I would have thought that this group of patients would be the least vulnerable."

Some private hospitals are more likely to transfer an uninsured patient than an insured patient, said Lavonas, who wasn't involved in the new research.

"Sometimes we get patients transferred and we suspect they're being transferred because of payment issues," he said. "The transferring physician says, 'We're not able to handle this.'"
Federal law requires hospital ERs to treat all patients who are medically unstable. But hospitals can transfer patients, or send them away, once they're stabilized. A transfer could worsen a patient's condition by delaying treatment.

The researchers analyzed data on nearly 690,000 U.S. patients from 2002 through 2006. Burn patients were not included, nor were people who were treated and released, or dead on arrival.

In the study, the overall death rate was 4.7 percent, so most emergency room patients survived their injuries. The commercially insured patients had a death rate of 3.3 percent. The uninsured patients' death rate was 5.7 percent. Those rates were before the adjustments for other risk factors.

The findings are based on an analysis of data from the National Trauma Data Bank, which includes more than 900 U.S. hospitals.

"We have to take the findings very seriously," said lead author Dr. Heather Rosen, a surgery resident at Los Angeles County Hospital, who found similar results when she analyzed children's trauma data for an earlier study. "This affects every person, of every age, of every race."

 

[Cerberus]

By CARLA K. JOHNSON, AP Medical Writer – Mon Nov 16, 4:00 pm ET

Without having read the research paper myself, from the article one thing that stuck out at me was "The researchers took into account the severity of the injuries and the patients' race, gender and age." What about comorbidid conditions? It's much more likely that the uninsured pt is going to have untreated comorbidities, or other factors that would increase morbidity/mortality than the insured patients. If we are comparing Joe LiverBomb who gets hit by a car while crossing the street because he is intoxicated with someone who was hit by a car while training for a triathlon, we can't say it's Joe's insurance status that caused him to have higher mortality in the ED.

 

[RxnMan]

Without having read the research paper myself, from the article one thing that stuck out at me was "The researchers took into account the severity of the injuries and the patients' race, gender and age." What about comorbidid conditions? It's much more likely that the uninsured pt is going to have untreated comorbidities, or other factors that would increase morbidity/mortality than the insured patients. If we are comparing Joe LiverBomb who gets hit by a car while crossing the street because he is intoxicated with someone who was hit by a car while training for a triathlon, we can't say it's Joe's insurance status that caused him to have higher mortality in the ED.

My thoughts exactly.

But something tells me that no amount of insurance is going to save a guy named Joe LiverBomb.

 

[docB]

In the study, the overall death rate was 4.7 percent, so most emergency room patients survived their injuries. The commercially insured patients had a death rate of 3.3 percent. The uninsured patients' death rate was 5.7 percent. Those rates were before the adjustments for other risk factors.

I think that releasing a claim like this without looking at any of the confounders makes it more of a political statement than a scientific one.

 

[Seville]

Without having read the research paper myself, from the article one thing that stuck out at me was "The researchers took into account the severity of the injuries and the patients' race, gender and age." What about comorbidid conditions? It's much more likely that the uninsured pt is going to have untreated comorbidities, or other factors that would increase morbidity/mortality than the insured patients. If we are comparing Joe LiverBomb who gets hit by a car while crossing the street because he is intoxicated with someone who was hit by a car while training for a triathlon, we can't say it's Joe's insurance status that caused him to have higher mortality in the ED.

Honestly, this was my thought as well. Most of my uninsured patients don't go see any sort of primary care provider to do health maintenance check ups.

 

[docB]

Interestingly our preliminary consensus here, that the uninsured are probably less healthy to begin with and therefore fare worse in trauma, fits both our agenda of deflecting blame away from the ED and the agenda of the authors to show that we need universal coverage.

You don't do a study of outcomes in the insured and the uninsured with the intent of finding no difference.

 

[RxnMan]

From the article:

...We performed subgroup analyses on the following 3 groups of patients: (1) those aged 18 to 30 years (to investigate patients with a lower prevalence of comorbidities), (2) those with information in the NTDB on 1 or more preexisting comorbidities,...

These are important groups for our discussion because the both would remove or equalize the effect of multiply-comorbid Joe LiverBomb, respectively. The results are in table 3. Young patients do equally well, regardless of insurance status (OR = 0.99, 0.99-1.01).

Comorbid uninsured patients do worse with increasing age (right hand side of table 3). But is subgroup #2 just all patients with comorbidities lumped together, regardless of quantity? In the lower-right hand corner of table 3 you see that # of comorbidities is a significant risk factor for mortality - but is this matched to insurance status and age? I'd really want to know if a 64 y/o male with 3 comorbidities and insurance does better/worse/same as a 64 y/o male with 3 comorbidities w/o/insurance. Maybe I'm just not interpreting the table right.

You can read the article for free here.

 

[docB]

I'd really want to know if a 64 y/o male with 3 comorbidities and insurance does better/worse/same as a 64 y/o male with 3 comorbidities w/o/insurance.

I'd imagine he would. All 64yoMs with 3 comorbidities aren't =. A guy with heart disease, diabetes and htn who is compliant with meds, has a normal EF and a baseline Cr of 1 will do better in a Trauma ICU than the guy with an EF of 15% and a creatinine of 3.

 

[GeneralVeers]

Also is it likely that the uninsured will tend be in more densely populated urban areas, thus present to already overcrowded county hospitals?

Think MLK......

 

[MSTigER]

Densely populated urban areas=more uninsured=more likely to have fatal high velocity trauma