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BACKGROUND: Disparities in outcomes for uninsured trauma patients have been well documented. This study investigates whether failure to rescue (FTR) is a driver of mortality disparities after injury and whether patients treated at hospitals with a large volume of uninsured patients are more likely to die after complication.

METHODS: A retrospective cohort study that analyzed patient records included in the National Trauma Data Bank from years 2008 to 2010 was performed. Hierarchical logistic regression was used to examine the probability that insurance type would be associated with complications, FTR, and in-hospital mortality while controlling for injury severity, mechanism of trauma, age, sex, race, comorbidities, head injury, hypotension, and hospital clustering. Additional regression models that stratified insurance subgroups and hospital subgroups were also performed.

RESULTS: The uninsured patients had the lowest likelihood of developing a complication, and publicly insured patients were most likely to develop a complication compared with privately insured patients (uninsured odds ratio [OR], 0.86; government OR, 1.44). Despite having a lower risk of complication, the uninsured group was significantly more likely to experience FTR than publicly or privately insured patients (OR, 1.34). There was no significant difference in the FTR outcome between private and publicly insured patients. Both the uninsured and publicly insured patients were significantly more likely to die in the hospital than privately insured patients (uninsured OR, 1.26l; government OR, 1.17). There were no differences in complications, FTR, or mortality between safety net and non-safety net hospitals.

CONCLUSION: The uninsured patients are more likely to experience FTR than the privately insured patients. Resources should be focused on this patient population to prevent complications and to study the reasons for higher mortality in these patients after they experience a complication.

LEVEL OF EVIDENCE: Prognostic study, level III.

(C) 2013 Lippincott Williams & Wilkins, Inc.