Citation Information :
Branco BC, Mobily M, Rhee P, Wynne JL, Friese RS, Kulvatunyou N, Joseph B, Tang AL, O'Keeffe T. Does Money Matter? Relationship between Household Income and Mortality after Trauma. Panam J Trauma Crit Care Emerg Surg 2019; 8 (2):91-95.
Background: Previous studies have demonstrated an association between lack of insurance and outcomes after trauma. However, it is not clear if this is merely a surrogate for socioeconomic status. The purpose of this study is to investigate the relationship between household income and mortality among injured patients.
Methods: The Arizona Inpatient State Database was used to identify all trauma patients over a representative 1-year period. Demographics, clinical data, and outcomes were extracted. Median household income (MHI) for patients’ domiciliary zip code was extracted. Patients were divided into four quartiles according to MHI (lowest, low, high, and highest). The standard statistical analysis was used to compare groups.
Results: A total of 58,743 were available for analysis (lowest: 27.6%; low: 25.9%; high: 26.3%; and highest: 20.2%). There was a decrease in the proportion of males as MHI increased (lowest: 53.4%, low: 48.8%, high: 49.2%, and highest: 48.7%, p <0.001). Similarly, there was a decrease in the proportion of Hispanics and Native Americans (Hispanics: lowest: 23.6%, low: 14.9%, high: 12.9%, and highest: 5.9%, p <0.001; Native Americans: lowest: 10.8%, low: 2.5%, high: 2.9%, and highest: 0.8%, p <0.001). There was also a decrease in the incidence of penetrating trauma as MHI increased (lowest: 9.6%, low: 8.4%, high: 7.6%, and highest: 6.6%, p <0.001), in particular for gunshot wound (GSWs) (lowest: 5.7%, low: 5.4%, high: 5.0%, highest: 4.5%, p <0.001). After adjustment for demographics and clinical data, when outcomes were analyzed, there was a stepwise decrease in mortality as MHI increased (Log rank = 0.002).
Conclusion: Patients with low MHI have a higher adjusted mortality rate after trauma. To address health-related disparities, socioeconomic disparities must be ameliorated. Further evaluation of these results is warranted.
Centers for Disease Control and Prevention. Fast Stats: Death and Mortality. Available at: http://www.cdc.gov/nchs/fastats/deaths.htm. Accessed February 17, 2013.
Bolorunduro OB, Haider AH, et al. Disparities in trauma care: are fewer diagnostic tests conducted for uninsured patients with pelvic fracture? Am J Surg 2013;205(4):365–370. DOI: 10.1016/j.amjsurg.2012.10.026.
Coburn N, Fulton J, et al. Treatment variation by insurance status for breast cancer patients. Breast J 2008;14:128–134. DOI: 10.1111/j.1524-4741.2007.00542.x.
Cram P, Pham HH, et al. Insurance status of patients admitted to specialty cardiac and competing general hospitals: are accusations of cherry picking justified? Med Care 2008;46:467–475. DOI: 10.1097/MLR.0b013e31816c43d9.
de Bosset V, Atashili J, et al. Health insurance-related disparities in colorectal cancer screening in Virginia. Cancer Epidemiol Biomarkers Prev 2008;17:834–837. DOI: 10.1158/1055-9965.EPI-07-2760.
Englum BR, Villegas C, et al. Racial, ethnic, and insurance status disparities in use of posthospitalization care after trauma. J Am Coll Surg 2011;213:699–708. DOI: 10.1016/j.jamcollsurg.2011.08.017.
Franks P, Clancy CM, et al. Health insurance and mortality. Evidence from a national cohort. JAMA 1993;270:737–741. DOI: 10.1001/jama.1993.03510060083037.
Greene WR, Oyetunji TA, et al. Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma. Am J Surg 2010;199:554–557. DOI: 10.1016/j.amjsurg.2009.11.005.
Haas JS, Goldman L. Acutely injured patients with trauma in Massachusetts: differences in care and mortality, by insurance status. Am J Public Health 1994;84:1605–1608. DOI: 10.2105/AJPH.84.10.1605.
Haider AH, Chang DC, et al. Race and insurance status as risk factors for trauma mortality. Arch Surg 2008;143:945–949. DOI: 10.1001/archsurg.143.10.945.
Nirula R, Nirula G, et al. Inequity of rehabilitation services after traumatic injury. J Trauma 2009;66:255–259. DOI: 10.1097/TA.0b013e31815ede46.
Rhee PM, Grossman D, et al. The effect of payer status on utilization of hospital resources in trauma care. Arch Surg 1997;132:399–404. DOI: 10.1001/archsurg.1997.01430280073010.
Rosen H, Saleh F, et al. Downwardly mobile: the accidental cost of being uninsured. Arch Surg 2009;144:1006–1011. DOI: 10.1001/archsurg.2009.195.
Sabharwal S, Zhao C, et al. Pediatric orthopaedic patients presenting to a university emergency department after visiting another emergency department: demographics and health insurance status. J Pediatr Orthop 2007;27:690–694. DOI: 10.1097/BPO.0b013e3181425653.
Sacks GD, Hill C, et al. Insurance status and hospital discharge disposition after trauma: inequities in access to postacute care. J Trauma 2011;71:1011–1015. DOI: 10.1097/TA.0b013e3182092c27.
Salim A, Ottochian M, et al. Does insurance status matter at a public, level I trauma center? J Trauma 2010;68:211–216. DOI: 10.1097/TA.0b013e3181a0e659.
Taghavi S, Jayarajan SN, et al. Does payer status matter in predicting penetrating trauma outcomes? Surgery 2012;152:227–231. DOI: 10.1016/j.surg.2012.05.039.
Weygandt PL, Losonczy LI, et al. Disparities in mortality after blunt injury: does insurance type matter? J Surg Res 2012;177:288–294. DOI: 10.1016/j.jss.2012.07.003.
Federal Reserve Bank of San Francisco. 2006. Available at: http://www.frbsf.org/news/speeches/2006/1106.html. Accessed February 17, 2013.
United States Census Bureau. Income, Poverty and Health Insurance coverage in the United States. Available at: http://www.census.gov/prod/2011pubs/p60-239.pdf. Accessed February 17, 2013.