Department of Surgery, Howard-Hopkins Center For Outcomes Research, Howard University College of Medicine, 2041 Georgia Avenue Northwest, Washington, DC 20060, USA.
Am J Surg. 2013 Apr;205(4):365-70. doi: 10.1016/j.amjsurg.2012.10.026. Epub 2013 Jan 31.
Research from other medical specialties suggests that uninsured patients experience treatment delays, receive fewer diagnostic tests, and have reduced health literacy when compared with their insured counterparts. We hypothesized that these disparities in interventions would not be present among patients experiencing trauma. Our objective was to examine differences in diagnostic and therapeutic procedures administered to patients undergoing trauma with pelvic fractures using a national database.
A retrospective analysis was conducted using the National Trauma Data Bank (NTDB), 2002 to 2006. Patients aged 18 to 64 years who experienced blunt injuries with pelvic fractures were analyzed. Patients who were dead on arrival, those with an injury severity score (ISS) less than 9, those with traumatic brain injury, and patients with burns were excluded. The likelihood of the uninsured receiving select diagnostic and therapeutic procedures was compared with the same likelihood in the insured. Multivariate analysis for mortality was conducted, adjusting for age, sex, race, ISS, presence of shock, Glasgow Coma Scale (GCS) motor score, and mechanism of injury.
Twenty-one thousand patients met the inclusion criteria: 82% of these patients were insured and 18% were uninsured. There was no clinical difference in ISSs (21 vs 20), but the uninsured were more likely to present in shock (P < .001). The mortality rate in the uninsured was 11.6% vs 5.0% in the insured (P < .001). The uninsured were less likely to receive vascular ultrasonography (P = .01) and computed tomography (CT) of the abdomen (P < .005). There was no difference in the rates of CT of the thorax and abdominal ultrasonography, but the uninsured were more likely to receive radiographs. There was no difference in exploratory laparotomy and fracture reduction, but uninsured patients were less likely to receive transfusions, central venous pressure (CVP) monitoring, or arterial catheterization for embolization. Insurance-based disparities were less evident in level 1 trauma centers.
Uninsured patients with pelvic fractures get fewer diagnostic procedures compared with their insured counterparts; this disparity is much greater for more invasive and resource-intensive tests and is less apparent in level 1 trauma centers. Differences in care that patients receive after trauma may be 1 of the mechanisms that leads to insurance disparities in outcomes after trauma.
其他医学专业的研究表明，与有保险的患者相比，没有保险的患者在治疗上会出现延迟，接受的诊断性检查较少，健康素养也更低。我们假设，在经历创伤的患者中，这些干预措施的差异并不存在。我们的目的是使用国家数据库检查接受创伤性骨盆骨折治疗的患者接受的诊断和治疗程序的差异。
使用国家创伤数据银行（NTDB）进行回顾性分析，时间为 2002 年至 2006 年。分析了经历钝性创伤合并骨盆骨折且年龄在 18 至 64 岁之间的患者。排除了到院前已死亡、损伤严重程度评分（ISS）<9、有创伤性脑损伤和烧伤的患者。比较了无保险患者和有保险患者接受特定诊断和治疗程序的可能性。对死亡率进行了多变量分析，调整了年龄、性别、种族、ISS、休克状态、格拉斯哥昏迷评分（GCS）运动评分和损伤机制等因素。
21000 名患者符合纳入标准：其中 82%有保险，18%无保险。ISS 无临床差异（21 对 20），但无保险患者更有可能休克（P<.001）。无保险患者的死亡率为 11.6%，有保险患者为 5.0%（P<.001）。无保险患者更不可能接受血管超声检查（P=.01）和腹部 CT（P<.005）。胸部 CT 和腹部超声检查率无差异，但无保险患者更可能接受 X 光检查。剖腹探查术和骨折复位率无差异，但无保险患者较少接受输血、中心静脉压（CVP）监测或动脉导管栓塞。在 1 级创伤中心，基于保险的差异不太明显。
与有保险的患者相比，骨盆骨折的无保险患者接受的诊断性检查较少；对于更具侵入性和资源密集性的检查，这种差异更大，在 1 级创伤中心差异较小。创伤后患者接受的护理差异可能是导致创伤后保险结果差异的机制之一。
