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Ann Surg. 2018 Jun;267(6):1093-1099. doi: 10.1097/SLA.0000000000002254.

Cured into Destitution: Catastrophic Health Expenditure Risk Among Uninsured Trauma Patients in the United States.

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Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA.
Department of Surgery, Beth Israel Deaconess Hospital, Boston, MA.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA.
Yale School of Medicine, New Haven, CT.
Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA.
Massachusetts Eye and Ear Infirmary, Department of Otolaryngology and Office of Global Surgery, Boston, MA.



To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk.


Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measures of economic hardship are insufficient and exclude those at greatest risk.


We performed a retrospective review, using data from the 2007-2011 Nationwide Inpatient Samples of all uninsured nonelderly adults (18-64 yrs) admitted with primary diagnoses of trauma. We used US Census data to estimate annual postsubsistence income and inhospital charges for trauma-related admission. Our primary outcome measure was catastrophic health expenditure risk, defined as any charges ≥40% of annual postsubsistence income.


Our sample represented 579,683 admissions for uninsured nonelderly adults over the 5-year study period. Median estimated annual income was $40,867 (interquartile range: $21,286-$71.733). Median inpatient charges were $27,420 (interquartile range: $15,196-$49,694). Overall, 70.8% (95% posterior confidence interval: 70.7%-71.1%) of patients were at risk for CHE. The risk of CHE was similar across most demographic subgroups. The greatest risk, however, was concentrated among patients from low-income communities (77.5% among patients in the lowest community income quartile) and among patients with severe injuries (81.8% among those with ISS ≥ 16).


Over 7 in 10 uninsured patients admitted for trauma are at risk of catastrophic health expenditures. This analysis is the first application of CHE to a US trauma population and will be an important measure to evaluate the effectiveness of health care and coverage strategies to improve financial risk protection.

[Indexed for MEDLINE]

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