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J Pediatr Surg. 2009 Oct;44(10):1952-7. doi: 10.1016/j.jpedsurg.2008.12.026.

Lack of insurance negatively affects trauma mortality in US children.

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  • 1Department of Plastic and Oral Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA.



Uninsured children face health-related disparities in screening, treatment, and outcomes. To ensure payer status would not influence the decision to provide emergency care, the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, which states patients cannot be refused treatment or transferred from one hospital to another when medically unstable. Given findings indicating the widespread nature of disparities based on insurance, we hypothesized that a disparity in patient outcome (death) after trauma among the uninsured may exist, despite the EMTALA.


Data on patients age 17 years or younger (n = 174,921) were collected from the National Trauma Data Bank (2002-2006), containing data from more than 900 trauma centers in the United States. We controlled for race, injury severity score, sex, and injury type to detect differences in mortality among the uninsured and insured. Logistic regression with adjustment for clustering on hospital was used.


Crude analysis revealed higher mortality for uninsured children and adolescents compared with the commercially or publicly insured (odds ratio [OR] 2.97; 95% confidence interval [CI], 2.64-3.34; P < .001). Controlling for sex, race, age, injury severity, and injury type, and clustering within hospital facility, uninsured children had the highest mortality compared with the commercially insured (OR, 3.32; 95% CI, 2.95-3.74; P < .001], whereas children and adolescents with Medicaid also had higher mortality (OR, 1.19; 95% CI, 1.07-1.33; P = .001).


These results demonstrate that uninsured and publicly insured American children and adolescents have higher mortality after sustaining trauma while accounting for a priori confounders. Possible mechanisms for this disparity include treatment delay, receipt of fewer diagnostic tests, and decreased health literacy, among others.

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