Trauma/original research
Factors Affecting the Likelihood of Presentation to the Emergency Department of Trauma Patients After Discharge

https://doi.org/10.1016/j.annemergmed.2011.04.021Get rights and content

Study objective

We determine the rate at which trauma patients re-present to the emergency department (ED) after discharge from the hospital and determine whether re-presentation is related to race, insurance, and socioeconomic factors such as neighborhood income level.

Methods

Trauma patients admitted to a Level I trauma center between January 1, 1997, and December 31, 2007, were identified with the hospital's trauma registry. These patients were linked to administrative data to obtain information about re-presentation to the hospital. Neighborhood income was obtained with census block data; multiple imputation was implemented to account for missing income data. Logistic regression analysis was used to determine the predictors of re-presentation.

Results

There were 6,675 patients who were included in the study. A total of 886 patients (13.3%) returned to the ED within 30 days of discharge from the hospital. Uninsured patients (odds ratio [OR]=1.64; 95% confidence interval [CI] 1.30 to 2.06) and publicly insured patients (OR=1.60; 95% CI 1.20 to 2.14) were more likely to re-present to the ED than those with commercial insurance. Residing in a neighborhood with a median household income less than $20,000 was associated with a higher odds of re-presentation (OR=1.77; 95% CI 1.37 to 2.29). Only 13.2% of patients who came to the ED were readmitted to the hospital.

Conclusion

A substantial number of trauma patients return to the ED within 30 days of being discharged, but only a small proportion of these patients required readmission. Re-presentation is associated with being uninsured or underinsured and with lower neighborhood income level.

Introduction

Nonmedical factors such as race, insurance, and socioeconomic status have a profound effect on health care quality and outcomes. Within the field of trauma, several studies have shown that race and insurance are related to measures such as the likelihood of inhospital mortality, the amount of care received, and length of stay.1, 2, 3, 4, 5, 6 Yet despite these findings, little is known about how these factors influence the interactions of trauma patients with the health care system immediately after discharge from the hospital.

The few articles published on the subject of postdischarge care after a traumatic injury describe the influences of both race and insurance. A large study using a national sample showed that uninsured individuals were less likely to receive recommended follow-up care after an unintentional injury.4 For patients discharged after a traumatic brain injury, 2 previous studies demonstrated that both race and insurance affected rehabilitation placement.7, 8 However, a study of orofacial injury patients has shown that although unemployed black patients were most likely to miss follow-up appointments, health insurance was not a substantial predictor.9 None of the previous studies controlled for broad indicators of socioeconomic status such as neighborhood income level, which is likely a confounder in the relationship of insurance status with postdischarge care.

One particular issue that, to our knowledge, has not been addressed in previous literature is emergency department (ED) utilization after the discharge of admitted trauma patients. This is important to know not only to assess the full effect of the previously described disparities but also to more completely understand the differences in the economic costs and resource use associated with these patients. Furthermore, the effect of nonclinical socioeconomic factors, such as neighborhood income level, on ED utilization should be assessed. Because of the findings of previous studies, we hypothesize that factors such as race, disposition, and injury type are associated with differences in ED re-presentation rates among trauma patients. Furthermore, we believe that socioeconomic status indicators, specifically neighborhood income levels, will be a substantial predictor of these differences.

Section snippets

Study Design and Setting

Using a nonconcurrent retrospective cohort design, the analysis examined trauma patients admitted to a state-verified, urban Level I trauma center during a 10-year period beginning January 1, 1997, and ending December 31, 2007.

Selection of Participants

Patients admitted to the adult trauma service at the Johns Hopkins Hospital in Baltimore, MD, were identified with the hospital's trauma registry. Patients younger than 18 years and older than 65 years were excluded, as were patients who died during their initial hospital

Results

A total of 7,925 trauma admissions that met all inclusion criteria were identified in the trauma registry. There were 764 (9.6%) patient visits that were not included because of recidivism during the study period. Of the remaining sample, 275 (3.8%) patients could not be matched to the administrative database on the basis of medical record number, birth date, and admission/discharge dates and were excluded from the analysis. Another 211 (2.9%) patients were excluded because of missing

Limitations

Our sample population consisted solely of patients at a single urban, academic Level I trauma center and is not necessarily representative of trauma institutions nationwide. This was evidenced by the fact that the patients in our sample were predominantly black, uninsured, and male. Also, a substantial percentage of patients in the study had experienced a penetrating trauma (41.2%). Therefore, our findings might not be easily extrapolated to trauma care throughout the country. These differences

Discussion

Our study found that 13.3% of patients discharged after a traumatic injury returned to the ED within 30 days. Furthermore, the analysis demonstrates that there are certain identifiable populations who are more likely to re-present to the ED after a trauma. With respect to insurance, uninsured and publically insured patients were more likely than commercially insured patients to re-present to the ED. Residing in a neighborhood with lower median household income was also associated with increased

References (41)

  • J.J. Doyle

    Health insurance, treatment and outcomes: using auto accidents as health shocks

    Rev Econ Stat

    (2005)
  • J. Hadley

    Sicker and poorer—the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income

    Med Care Res Rev

    (2003)
  • J. Hadley

    Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition

    JAMA

    (2007)
  • C. Marquez de la Plata et al.

    Ethnic differences in rehabilitation placement and outcome after TBI

    J Head Trauma Rehabil

    (2007)
  • S. Shafi et al.

    Ethnic disparities exist in trauma care

    J Trauma Injury Infect Crit Care

    (2007)
  • H. Quan et al.

    Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data

    Med Care

    (2005)
  • Overview ICD-9 provider & diagnostic codesOverview of ICD-9 provider & diagnostic codes

  • F.M. Chen et al.

    Geocoding and linking data from population-based surveillance and the US census to evaluate the impact of median household income on the epidemiology of invasive streptococcus pneumoniae infections

    Am J Epidemiol

    (1998)
  • A.J. Karter et al.

    Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes

    Diabetes Care

    (2000)
  • M.T. Bassett et al.

    Social class and black-white differences in breast cancer survival

    Am J Public Health

    (1986)
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    Supervising editors: Brendan G. Carr, MD, MS; Judd E. Hollander, MD

    Author contributions: KSL, JHY, DKN, and AHH conceived the study. KSL and DKN gathered and matched the various data sets used. KSL performed the statistical analysis. DKN, JHY, and AHH provided oversight and guidance. KSL drafted the article, and all authors contributed substantially to its revision. KSL takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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    Publication date: Available online June 19, 2011.

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