Pediatric trauma care: a profitable enterprise?

Insurance-based inequities in emergency interhospital transfers: an argument for the prioritisation of patient care

Currently there is an inequity in transfer rates of uninsured patients versus their insured counterparts. While this may vary by hospital system, studies indicate that this is a national trend, especially in emergency situations, and represents a prioritisation of profits over ethical obligations. This creates a variety of ethical issues for patients and society that generates a concordance between deontological and utilitarian viewpoints, two generally opposed schools of thought. The prioritisation of profit maximisation in order to provide better care for a select population is insufficient to justify deleterious health outcomes, stress and financial burden on patients. Current policy regarding patient transfers in the emergency department is insufficient to protect the uninsured and must be reevaluated.

Association Between Insurance and Transfer of Injured Children From Emergency Departments

OBJECTIVES

To determine if injured children presenting to nondesignated trauma centers are more or less likely to be transferred relative to being admitted based on insurance status.

METHODS

We conducted a cross-sectional study by using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Pediatric trauma patients receiving care in emergency departments (EDs) at nontrauma centers who were either admitted locally or transferred to another hospital were included. We performed logistic regression analysis adjusting for injury severity and other confounders and incorporated nationally representative weights to determine the association between insurance and transfer or admission.

RESULTS

Nine thousand four hundred and sixty-one ED pediatric trauma events at 386 nontrauma centers met inclusion criteria. EDs that treated a higher proportion of patients with Medicaid had higher odds of transfer relative to admission (odds ratio [OR]: 1.2 per 10% increase in Medicaid; 95% confidence interval [CI]: 1.1-1.4), resulting in overall higher odds of transfer among patients with Medicaid compared with patients with private insurance (OR: 1.3; 95% CI: 1.0-1.5). A patient's insurance status was not associated with different odds of transfer relative to admission within individual EDs after adjusting for the ED's proportion of patients with Medicaid (Medicaid OR: 1.0; 95% CI: 0.8-1.1).

CONCLUSIONS

Injured pediatric patients presenting to nondesignated trauma centers are slightly more likely to be transferred than admitted when the ED treats a higher proportion of Medicaid patients. In this study, ongoing concerns about inequities in the delivery of care among hospitals treating high proportions of children with Medicaid are reinforced.