Study: Lack of insurance contributes to trauma deaths

By Karen Kaplan
Los Angeles Times

Patients who lack health insurance are more likely to die from car accidents and other traumatic injuries than people who belong to a health plan – even though emergency rooms are required to care for all comers regardless of ability to pay, according to a study to be published today.

An analysis of 687,091 patients who visited trauma centers nationwide between 2002 and 2006 found that the chances of dying after an accidental injury were almost twice as high for the uninsured as for the patients with private insurance, researchers reported in Archives of Surgery.

Trauma physicians said they were surprised by the finding, even though a slew of studies had previously documented the ill effects of going without health coverage. Uninsured patients are less likely to be screened for certain cancers or be admitted to specialty hospitals for procedures such as coronary-bypass surgery. Overall, about 18,000 deaths each year have been traced to a lack of health insurance.

But insurance status isn’t supposed to be a factor for trauma patients. The Emergency Medical Treatment and Active Labor Act, passed by Congress in 1986, guarantees that people brought to emergency rooms get all the necessary treatment no matter what kind of insurance they have – or don’t have.

The research team from Harvard University and Brigham and Women’s Hospital in Boston used information from 1,154 U.S. hospitals that contribute to the National Trauma Data Bank. The team found that patients enrolled in commercial health plans, health-maintenance organizations or Medicaid had equal risks of death from traumatic injuries when the patients’ age, sex, race and severity of injury were taken into account.

The risk of death was 56 percent higher for patients covered by Medicare, perhaps because the government health plan includes many people with long-term disabilities, said Dr. Heather Rosen, who led the study while she was a research fellow at Harvard Medical School.

However, the risk of death was 80 percent higher for patients without any insurance, according to the report.

The researchers also did a separate analysis of 209,702 trauma patients between the ages of 18 and 30 because they were less likely to have chronic health conditions that might complicate their recoveries. Among these younger patients, the risk of death was 89 percent higher for the uninsured, the study found.

Rosen, now a surgical resident at the Keck School of Medicine at the University of Southern California, said the group expected to find at least some disparity based on insurance status. But she said the group was surprised at the size of it.

The researchers offered several possible explanations. Despite the federal law, uninsured patients often receive fewer services such as CT and MRI scans and are less likely to be transferred to a rehabilitation facility.

Patients without insurance may have higher rates of untreated underlying conditions that make it harder to recover from trauma injuries, the researchers said. They also may be more passive with doctors and nurses since they don’t interact with them as often. All of these factors could influence whether a trauma patient is able to recover from injuries.

But the link also could be coincidental, the authors acknowledged.

Perhaps the hospitals that have fewer resources also happen to see the most uninsured patients, they said.

The types of injuries may differ too, said Dr. Frank Zwemer, chief of emergency medicine for the McGuire Veterans Administration Medical Center in Richmond, VA. Stabbing and gunshot victims were much more likely to die from their wounds than other trauma patients tracked in the study. These people are generally uninsured, but the type of injury – not insurance status – is the reason for their higher fatality rates, he said.

More research is needed to figure out whether lack of insurance actually harms trauma patients or whether the data simply reflect a correlation, said Dr. A. Brent Eastman, chair of trauma at Scripps Memorial Hospital in San Diego.