Downwardly Mobile The Accidental Cost of Being Uninsured
Downwardly Mobile The Accidental Cost of Being Uninsured
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DOI：
10.1001/archsurg.2009.195
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发表时间：
2009-11-01
影响因子：
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通讯作者：
Gawande, Atul A.
中科院分区：
文献类型：
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作者：
Rosen, Heather;Saleh, Fady;Gawande, Atul A.
假设：鉴于广泛的证据表明，由于保险状况而导致筛查、入院、治疗和结果方面存在差异，因此，尽管有预防性规定（例如《紧急医疗治疗和积极分娩法》），未投保的创伤患者（院内死亡）的结果可能存在差异。设计：数据收集自 2002 年 1 月 1 日至 2006 年 12 月 31 日的国家创伤数据库（7.0 版）。我们使用多元逻辑回归来比较按保险状态划分的死亡率。设置：国家创伤数据库包含来自 900 多个美国创伤中心的 270 万名创伤性损伤患者的信息，包括人口统计数据、病史、损伤严重程度、结果和费用。患者：对具有相似年龄、种族、损伤严重程度、性别和损伤机制的患者（年龄 >= 18 岁；n=687 091）的数据进行了评估，以了解按付款人状态划分的死亡率差异。结果测量：钝性或穿透性创伤后院内死亡。结果：粗略分析显示未投保患者的死亡率较高（比值比 [OR]，1.39；95% 置信区间 [CI]，1.36-1.42；P < .001）。控制性别、种族、年龄、伤害严重程度评分、修订后的创伤评分和伤害机制（根据医院聚类进行调整）后，未投保患者的死亡率最高（OR，1.80；95% CI，1.61-2.02；P < .001）。对不太可能患有合并症的年轻患者进行的亚组分析显示，未投保患者的死亡率较高（OR，1.89；95% CI，1.66-2.15；P < .001），对头部受伤患者（OR，1.65；95% CI，1.42-1.90；P < .001）和患有 1 种或多种合并症的患者（OR， 1.52；95% CI，1.30-1.78；P < .001）。结论：未投保的美国人在创伤后的调整死亡率较高。治疗延迟、不同的护理（通过接受较少的诊断测试）和健康素养下降是可能的机制。
Hypothesis: Given the pervasive evidence of disparities in screening, hospital admission, treatment, and outcomes due to insurance status, a disparity in outcomes in trauma patients (in-hospital death) among the uninsured may exist, despite preventive regulations ( such as the Emergency Medical Treatment and Active Labor Act).Design: Data were collected from the National Trauma Data Bank from January 1, 2002, through December 31, 2006 ( version 7.0). We used multiple logistic regression to compare mortality rates by insurance status.Setting: The National Trauma Data Bank contains information from 2.7 million patients admitted for traumatic injury to more than 900 US trauma centers, including demographic data, medical history, injury severity, outcomes, and charges.Patients: Data from patients ( age, >= 18 years; n=687 091) with similar age, race, injury severity, sex, and injury mechanism were evaluated for differences in mortality by payer status.Main Outcome Measure: In-hospital death after blunt or penetrating traumatic injury.Results: Crude analysis revealed a higher mortality for uninsured patients (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.36-1.42; P < .001). Controlling for sex, race, age, Injury Severity Score, Revised Trauma Score, and injury mechanism (adjusted for clustering on hospital), uninsured patients had the highest mortality ( OR, 1.80; 95% CI, 1.61-2.02; P < .001). Subgroup analysis of young patients unlikely to have comorbidities revealed higher mortality for uninsured patients (OR, 1.89; 95% CI, 1.66-2.15; P < .001), as did subgroup analyses of patients with head injuries (OR, 1.65; 95% CI, 1.42-1.90; P < .001) and patients with 1 or more comorbidities (OR, 1.52; 95% CI, 1.30-1.78; P < .001).Conclusions: Uninsured Americans have a higher adjusted mortality rate after trauma. Treatment delay, different care (via receipt of fewer diagnostic tests), and decreased health literacy are possible mechanisms.