Unisured Trauma Victims Face High Death Rates

(Nov. 16) — It’s federal law: All seriously
injured emergency and trauma patients
must be given equal lifesaving care,
whether or not they can pay for it. But
that’s not happening, according to a new
report. The study, conducted by
Children’s Hospital Boston research
fellow Dr. Heather Rosen and colleagues
from three other hospitals, found that
uninsured trauma victims ages 18 to 30
are dying at an annual rate 89 percent
higher than insured victims with identically
severe injuries.
As the health reform tornado continues to
swirl on Capitol Hill, the data could
provide fresh ammunition for those
pushing for expanded health insurance
coverage.
The study, published today in the
Archives of Surgery, examines the
survival rates for patients brought to
about 900 U.S. trauma centers between
2002 and 2006, analyzing some 690,000
patients who had suffered penetrating
trauma — such as wounds inflicted by a
gun or knife — or blunt trauma from
vehicle crashes and falls. Earlier research
found 18,000 extra deaths a year among
uninsured victims of such injuries. Rosen
and the other researchers chose to focus
on the 18-to-30-year-old subset because
they had fewer existing conditions —
comorbidity — that muddy the evaluation
of the cause of death.
Courtesy of Heather Rosen
Dr. Heather Rosen, a research fellow at
Children’s Hospital Boston who authored
the study.
The study concludes that there is
“pervasive evidence of disparities in
screening, hospital admission, treatment
and outcome due to insurance status.”
Overall, uninsured patients had the
highest rate of death, even after
controlling for age, sex, race, and severity
and mechanism of injury.
In an e-mail interview, Rosen puts it more
plainly: “Uninsured patients in the United
States have a higher risk of dying after
trauma, even though there is universal
access to emergency care.”
That the absence of insurance leads to
preventable deaths of patients with
cancer, diabetes, respiratory and other
chronic diseases is by now accepted
wisdom among medical professionals.
But existing policy is supposed to protect
victims of trauma and other acute medical
events, for whom instant medical
intervention makes the difference
between survival and death. In 1986, in
http://www.sphere.com/article/trauma-victims-face-far-worse-odds-when-uninsured-study-says/19261879
2
response to widespread dumping of
uninsured critically injured or ill patients
onto the street or on lesser hospitals,
Congress passed the Emergency Medical
Treatment and Active Labor Act. It
mandated that hospitals and ambulance
services provide care to anyone who
needs emergency treatment, regardless
of citizenship, legal status or ability to
pay.
But if the law is not preventing uninsured
trauma patients from receiving
substandard care, as Rosen’s study
indicates, the question becomes why.
Trauma is well-studied, and the specific
steps that must be taken to keep the
lethal dominoes from falling are wellestablished.
Dr. R Adam Cowley, one of
the fathers of the field, sermonized on the
importance of the “Golden Hour” that
exists between an injury and getting the
patient definitive treatment. “Who’s paying
the bill is the last thing we have time to
worry about,” he liked to say. Trauma
doctors and nurses insist that mentality
continues to govern today, even as the
high cost of trauma care and ICU followup
— which can run to hundreds of
thousands of dollars for a single patient
— have brought trauma centers in Los
Angeles, Miami and other urban areas to
the edge of bankruptcy and created
pressure to cut costs.
Interviewed over the weekend, nine
members of five different trauma units
who had read the study all had the same
message: “Not in my shop.” “They will tell
you they don’t even know the funding
status of most of their patients until after
they’ve been hospitalized for some time,”
says Dr. Harold Sherman, a retired
trauma surgeon in Pittsburgh. “They take
and treat all comers equally as required
by their ethics and the law, and certainly
don’t actively discriminate on the basis of
insurance status.”
Some trauma specialists I spoke with
recall representatives from the hospital
billing departments sometimes hovering
at the fringes of the bloody ballet to save
a life. But as a trauma social worker from
Washington, D.C. — who declined to
allowed her name to be used because
she isn’t authorized to speak to reporters
— puts it: “They would never be foolish
enough to tell a trauma surgeon to not
order this or that test, or cancel a scan or
expensive lab work because they found
no insurance card in the patient’s wallet.”
“What surgeon, ER doc or nurse would
risk their license and violate federal law to
keep the billing office happy?” the social
worker adds.
The problems, Sherman explains, creep
in after patients leave trauma care. “Postdischarge
care certainly does vary with
insurance status. It is a constant irritant to
trauma surgeons.”
Dr. Gregory Jurkovich, chief of trauma for
Seattle’s Harborview Medical Center,
claims his hospital had not seen the
disparity in treatment described in
Rosen’s report, but he too says that
follow-up efforts are falling short. For the
underinsured, he says, “there is
http://www.sphere.com/article/trauma-victims-face-far-worse-odds-when-uninsured-study-says/19261879
3
decreased access to rehabilitation and
chronic care services.”
Such anecdotal evidence squares with
another finding of Rosen’s study: Even
when everything else was equal,
“uninsured patients received significantly
fewer radiographic studies and were less
likely to be admitted compared with
insured patients with similar diagnoses.”
In a comment published with the journal
article, Dr. Brent Eastman, a trauma and
vascular surgeon from Scripps Memorial
Hospital in San Diego who was just
elected chairman of the Board of Regents
of the American College of Surgeons,
noted that emergency rooms and trauma
centers “are the safety net for many
communities.” He called for Rosen’s
conclusions to be taken seriously.
Rosen cautions that the definitive cause
for the higher death rate for uninsured
people remains to be determined. Still,
the hard number — the nearly 90 percent
jump in mortality rates for uninsured
accident victims — speaks loudly on its
own. “Although the lack of insurance may
not be the only explanation,” she says,
“the accidental costs of being uninsured
in the United States today may be too
high to continue to overlook.”
2009 AOL Inc. All Rights Reserved