Disparities in Trauma Outcomes: The Impact of Insurance Status and Trauma Center Level on Discharge Practices

Introduction: This study aimed to investigate the distribution of insurance status across level 1 and non-level 1 trauma centers and assess its influence on discharge outcomes in spinal trauma patients.

Methods: Data from the National Trauma Databank (2017-2022) were analyzed. Patients with spinal fractures were categorized by insurance status (insured vs. uninsured/underinsured) and trauma center level (level 1 vs. non-level 1). Insurance status was defined as uninsured/underinsured (Medicaid, Not Billed, Self-Pay) and insured (Private/Commercial Insurance, Medicare, Other Government). Outcomes included length of stay (LOS), injury severity scores (ISS), and hospital discharge disposition. Multinomial logistic regression assessed the relationship between insurance status, ISS, trauma center level, and outcomes.

Results: The proportion of uninsured/underinsured patients treated at non-Level 1 centers increased from 40% in 2017 to 46% in 2022 (p = 0.02). The ratio of uninsured/underinsured patients treated at non-level 1 relative to level 1 centers significantly increased from 1.025 in 2017 to 1.125 in 2022 (R² = 0.777, p = 0.02). Uninsured/underinsured patients had higher ISS scores than insured patients (mean ISS: 15.42 vs. 13.09, p < 0.001) and experienced longer ICU stays (8.24 vs. 7.2 days, p < 0.001) and hospital stays (11.34 vs. 9.17 days, p < 0.001) at non-level 1 compared to level 1 centers. Despite greater injury severity, uninsured/underinsured patients had lower odds of being discharged to rehab (OR: 0.39, p < 0.001) or SNF (OR: 0.21, p < 0.001). These odds were further reduced at non-Level 1 centers, with uninsured/underinsured patients having 11% lower odds of discharge to rehab and 36% lower odds to SNF compared to Level 1 centers (p < 0.001).

Conclusion : Uninsured/underinsured patients with more severe injuries are increasingly treated at non-Level 1 trauma centers and experience longer hospital stays. Despite this, they are more frequently discharged home, highlighting disparities in discharge practices based on insurance status.